Políticas fiscales como herramienta para la prevención de sobrepeso y obesidad

One of three adults in Mexico is obese, therefore, policies to reduce overweight and obesity prevalence in the country were designed. The use of fiscal policy was proposed as a way to discourage the consumption of soft drinks and raise funds to pay health services used by obese patients. The aim of this chapter, published in 2012, was to open the debate on the use of fiscal policy as a tool for the prevention of overweight and obesity in Mexico. Arguments for and against fiscal policies are discussed and outlined. The case of the soft drinks market is examined and the challenges for the design and implementation of a tax policy are discussed. The evidence presented in this chapter shows that tax policies are just one of the many tools that can be used to modify the consumption of unhealthy foods and beverages. However, its effect is limited if not accompanied by other measures, such as improving access and availability of healthy goods, advertising, and product labeling

Efectos heterogéneos en la demanda ante un impuesto al refresco en México

The increasing burden of obesity and related non-communicable diseases in the world has encouraged the design of effective policies in order to contain this trend. Excise taxes on low-nutritious food and sugar-sweetened beverages consumption, such as soft-drinks, have been proposed. Currently, a growing number of studies have calculated potential effects of soft-drinks taxes considering data for average consumers, and have assessed effectiveness of such measure on raising fresh revenues to the government, modifying consumption patterns, and population weight reduction. Nevertheless, there is evidence of heterogeneity of the demand of soft-drinks related to poverty and the level of consumption of soft-drinks. It has also been emphasised the need of examining the possible distributional effects of an excise tax in populations with uneven income distribution. We used Mexican data to discuss effectiveness and equity implications of an excise tax on soft-drinks consumption in populations with heterogeneous demand. We estimated the changes in the quantity purchased and household monthly expenditure on soft-drinks of 8434 households that answered the 2005 Mexican Family Life Survey. Specific price elasticities of the demand for soft-drinks of households grouped by their level of consumption (low, medium and high) and poverty (extreme, moderate and income superior to moderate poverty) were used. Several excise tax rate scenarios were considered: from a conservative level (tax rate: t=20%), to a least conservative level (t=65%) that was defined by the longitudinal analysis of body mass index changes in adults between 2002 and 2005. Effectiveness was evaluated by revenue collection (as a proportion of the cost of a comprehensive obesity prevention strategy), changes of the patterns of consumption and changes in calories related to changes of body mass index. Equity was assessed by concentration curves and indexes of the distribution of tax burden and the distribution of changes of the proportion of food expenditure devoted to soft-drink purchasing. The results suggest although revenues collected with low tax rates (20%) could partially finance a comprehensive obesity prevention strategy for Mexico, effectiveness on changing the patterns of consumption is only observable at tax rates higher than 45%. An excise tax is not effective on modifying population body mass index if tax rates are lower than 65%. Despite the fact that effects are concentrated in high consumption households, regressiveness is a latent problem due to the high tax burden imposed to households on extreme poverty. These results are different from the ones calculated in previous exercises in Mexico, considering average consumers. If governments are considering excise taxes on soft drinks to prevent obesity, heterogeneity of the demand for soft-drinks due to poverty and consumption level should be considered, especially in emergent economies with uneven income distribution. For the Mexican case, in order to design policies that adequately affect the demand for soft drinks, tax rates superior to 45% are recommended, along with redistributional mechanisms to promote equity by compensating households in extreme and moderate poverty, and effective interventions to reduce population weight

Efectos heterogéneos en la demanda ante un impuesto al refresco en México

The increasing burden of obesity and related non-communicable diseases in the world has encouraged the design of effective policies in order to contain this trend. Excise taxes on low-nutritious food and sugar-sweetened beverages consumption, such as soft-drinks, have been proposed. Currently, a growing number of studies have calculated potential effects of soft-drinks taxes considering data for average consumers, and have assessed effectiveness of such measure on raising fresh revenues to the government, modifying consumption patterns, and population weight reduction. Nevertheless, there is evidence of heterogeneity of the demand of soft-drinks related to poverty and the level of consumption of soft-drinks. It has also been emphasised the need of examining the possible distributional effects of an excise tax in populations with uneven income distribution. We used Mexican data to discuss effectiveness and equity implications of an excise tax on soft-drinks consumption in populations with heterogeneous demand. We estimated the changes in the quantity purchased and household monthly expenditure on soft-drinks of 8434 households that answered the 2005 Mexican Family Life Survey. Specific price elasticities of the demand for soft-drinks of households grouped by their level of consumption (low, medium and high) and poverty (extreme, moderate and income superior to moderate poverty) were used. Several excise tax rate scenarios were considered: from a conservative level (tax rate: t=20%), to a least conservative level (t=65%) that was defined by the longitudinal analysis of body mass index changes in adults between 2002 and 2005. Effectiveness was evaluated by revenue collection (as a proportion of the cost of a comprehensive obesity prevention strategy), changes of the patterns of consumption and changes in calories related to changes of body mass index. Equity was assessed by concentration curves and indexes of the distribution of tax burden and the distribution of changes of the proportion of food expenditure devoted to soft-drink purchasing. The results suggest although revenues collected with low tax rates (20%) could partially finance a comprehensive obesity prevention strategy for Mexico, effectiveness on changing the patterns of consumption is only observable at tax rates higher than 45%. An excise tax is not effective on modifying population body mass index if tax rates are lower than 65%. Despite the fact that effects are concentrated in high consumption households, regressiveness is a latent problem due to the high tax burden imposed to households on extreme poverty. These results are different from the ones calculated in previous exercises in Mexico, considering average consumers. If governments are considering excise taxes on soft drinks to prevent obesity, heterogeneity of the demand for soft-drinks due to poverty and consumption level should be considered, especially in emergent economies with uneven income distribution. For the Mexican case, in order to design policies that adequately affect the demand for soft drinks, tax rates superior to 45% are recommended, along with redistributional mechanisms to promote equity by compensating households in extreme and moderate poverty, and effective interventions to reduce population weight

Understanding the heterogeneous nature of the demand for soft drinks in Mexico: why social determinants also matter.

Background. Soft drink consumption is a risk factor for obesity and non-communicable chronic diseases, and policies to reduce it have been proposed around the world, including taxation. Little is known about the role of other social and economic factors on the demand of such goods. In addition, heterogeneity of the demand due to different levels of consumption has been rarely explored. The aim of this study is to analyse the heterogeneous nature of the demand for soft drinks to understand the role of economic and social factors (provision of safe water /local food market conditions) and draw recommendations for the design of obesity prevention. Methods. Population, cross-sectional analysis of household data from the Mexican Family Life Survey, grouped into three consumption groups (low/medium/high consumers, defined by the proportion of total household expenditure devoted to soft drink purchases) and three economic poverty groups (defined by extreme and moderate income poverty lines). Multivariate probit regressions were applied to explore factors associated to the probability to be a consumer, and simultaneous multivariate quantile regressions were used to model the quantity purchased of soft drinks. Heckman’s procedure was used to control for identification bias. Results. The adjusted probability that a household becomes a consumer is significantly higher with male, educated heads of households and higher household income. Living in localities where access to safe water for drinking and cooking needs is not universal significantly increases the probability to consume soft drinks while living in localities with convenience stores and supermarkets (local food market condition) significantly decreases it, especially in households facing extreme poverty. Demand from low-consumption households is price-inelastic (-0.97) compared with high-consumers (-1.2). Yet when the population is grouped by poverty, households in extreme poverty have a higher significant price-elasticity (-1.5) than those above moderate poverty line (-1.3). Conclusions. In order to design policies that adequately affect the demand for soft drinks on high consumers and benefit the poor, social factors should be considered. A comprehensive obesity prevention strategy should complement taxes with policies that affect social determinants such as the local provision of safe water and local food market conditions

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019

"Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru’s healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8–70.3) to 80.3 (77.2–83.2) years. This increase was driven by the decline in under-5 mortality (−80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5–10.1) and reached 7.5 million (6.1–9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

Future and potential spending on health 2015-40 : development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

Background The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings We estimated that global spending on health will increase from US$9.21 trillion in 2014 to$24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and$195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential.Peer reviewe

Future and potential spending on health 2015-40: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

Background: The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods: We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings: We estimated that global spending on health will increase from US$9.21 trillion in 2014 to$24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and$195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation: Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential

Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016–40

Background: Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040. Methods: We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios. Findings: In the reference scenario, global health spending was projected to increase from US$10 trillion (95$20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4–5·1) per year, followed by lower-middle-income countries (4·0%, 3·6–4·5) and low-income countries (2·2%, 1·7–2·8). Despite global growth, per capita health spending was projected to range from only $40 (24–65) to$413 (263–668) in 2040 in low-income countries, and from $140 (90–200) to$1699 (711–3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3–38·6) in Nigeria to 97·9% (96·4–98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030. Interpretation: We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC. Funding: The Bill & Melinda Gates Foundation

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita