THE OBESITY EPIDEMIC 1

CONTENTS
1


Introduction
– The Worldwide Obesity Epidemic
1

2


Mexico´s 8
approach to controlling obesity and NCDs

3


Fiscal Policies in
Public Health
10

4


Fiscal Policies as an 14
Innovation in Public Health Interventions

5


Why we need
Good Governance
17

6
Conclusions and
Recommendations
20

7 References 22
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The obesity epidemic:

fiscal policies and Good
Governance -the key to
successful public health
interventions
Abstract

The continual increase in obesity constitutes one of the bi-

ggest public health challenges of the 21st Century. On a global

level, rates of obesity have almost doubled during the last thirty

years. One of the countries that face a serious public health

threat from obesity is Mexico and costs for the health care

sector are considered to rise by $1.2 billion by the year 2030.

The introduction of a sugar tax by the Mexican government has

constituted an important step towards the prevention of exces-

sive Sugar Sweetened Beverage consumption and in general it

seems, as fiscal policies for the fight against obesity tend to in-

crease in use. Yet, there are also concerns attached to the idea

of implementing fiscal policies for public health purposes. This

is why we need the concept of Good Governance as a guide to

make fiscal policies effective. The obesity epidemic presents

a big challenge for governments and health professionals but

fiscal policies present a valuable option if their implementation

is governed in an adequate manner.

Keywords: obesity, public policies, taxation, Good Gover-

nance, sugar consumption.

Discussions about the steady increase in obesity prevalen-

ce have offered many perspectives to the question: how to

stop the rise in obesity? In this paper I shall concentrate on four

specific issues, viz., (i) the worldwide obesity epidemic in gene-

ral, (ii) obesity in Mexico, (iii) the use of fiscal policies in public

health, and (iv) the issue of Good Governance. The beginning

of this paper should give the reader an introduction about the

pressing issue of obesity around the world and about its so-

cietal and economic consequences. Followed by this section,

I shall try to present how fiscal policies are increasingly beco-

ming an option for policy makers that try to find solutions to

tackle obesity and its connected health consequences. Even-

tually and at the heart of this paper, I shall try to argue that fiscal

policies in public health can become much more effective if the

concept of Good Governance is applied.

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1. Introduction

– The Worldwide
Obesity Epidemic

The continual increase in obesity in many in fats and sugars, along with a decrease
countries constitutes one of the biggest in physical activity, is related to the increa-
public health challenges of the 21st Cen- sed prevalence of obesity (Popkin, 2001).
tury (Finkelstein et al. 2012; Wang et al. The shift in dietary patterns commenced
2011). Obesity is associated with a number in high-income countries (HICs) and even-
of important health conditions and has im- tually diffused to low-and middle-income
pacts beyond public health and medicine countries, is partially due to the effects of
(Alwan, 2011; Gilbert & Slingerland, 2013; globalization. People have changed their
Vucenik & Stains, 2012; Webber et al., diets from culturally unique diets into a so-
2012). The rapid increase in the prevalence called Western style diet (Popkin, 2001). As
of obesity in many low and middle income a result, obesity has rapidly developed into
countries (LMIC) illustrates the nutrition a global epidemic constituting one of the
transition (Drewnowski & Popkin, 1997; major risk factors for non-communicable
Popkin, 2001). diseases (NCDs) worldwide (Escober et
On a global level, rates of obesity have al., 2013; James, 2008).
almost doubled during the last thirty years Epidemiological patterns, which were
(WHO, 2014). One of the main underlying common for underdeveloped and develo-
causes for the increase in obesity is a shift ping countries (e.g. communicable disea-
in dietary patterns around the world (Drew- ses, malnutrition), have changed in quite
nowski & Popkin, 1997; Popkin, 2001). The dramatic ways uncovering an epidemiolo-
“WHO Action Plan 2008-2013 for the Glo- gical transition in LMICs en route to very
bal Strategy for the Prevention and Control high incidence rates of obesity and NCDs
of NCDs” and the “WHO Global Action Plan (Popkin, 1994; Drewnowski & Popkin,
for the Prevention and Control of NCDs 1997; Popkin, 2001).
2013-2020” identified increasing inactivity, Despite the fact that obesity is a pre-
obesity and unhealthy diets as the major ventable condition, the WHO estimates
contributors for the rise of NCDs, specifi- that 600 million adults are currently obese
cally in LMICs (WHO 2008, WHO 2013). (WHO, 2015). Furthermore, childhood obe-
A steady increase in the production and sity has been on the rise and based on esti-
consumption of energy dense foods, high mations by the World Health Organization,
in 2013, 42 million children under the age burdens on already overburdened and
of five were overweight and at high risk of underfinanced health care systems in.
obesity (WHO, 2015). Increases in numbers of obese patients
Numerous newly established epidemio- and NCDs will have both, an economic
logical patterns seem to be directly linked and societal impact on countries and, in
to the process of globalization, not least particular, on their health care systems
the pattern of obesity in LMICs (Labonté, (Malik, Willet and Hu, 2013).
2001; Labonté & Spiegel, 2013). The so- Politicians are reluctant to address the
called “global production of diets” and its looming increase in obesity and associa-
interconnectedness with intercontinental ted increases in the metabolic syndrome
brands such as Coca Cola has changed the of high blood pressure, CVD, and diabe-
food supply chain towards the unhealthy tes because they do not recognize the
(Chopra & Darnton-Hill, 2004; Labonté, effects that they will have on costs to the
Mohindra & Schrecker, 2011). The shifting health services, productivity and quality
burden of diseases from communicable of life. One reason for this is that obe-
disease to NCDs such as cancer, cardio- se patients do not immediately constitu-
vascular diseases and type 2 diabetes is te a significant challenge to the national
a consequence of the impact of globaliza- health care system because complica-
tion processes (Gushulak & MacPherson, tions occur in later life. Second, the cau-
2004). Globalization has influenced the glo- ses of obesity and NCDs are multifactorial
bal food chain and general global health, and require direct actions encompassing
particularly in LMICs (Swinburn & Boyd, et regulatory actions towards the food and
al., 2011). Globalization is a “constellation beverage industry (Labonté, Mohindra &
of processes by which nations, busines- Schrecker, 2011; adapted from Glasgow,
ses and people are becoming more con- 2005).
nected and interdependent via increased
economic integration and communication UPSTREAM APPROACHES
exchange, cultural diffusion and travel” (La- TO TACKLE THE PROBLEM OF
bonte & Torgerson, 2005). OBESITY AND NCDs

On a global and national level, important
THE PREVENTION AND decisions need to be taken to successfully
CONTROL OF NUTRITION- tackle the problem of obesity and NCDs.
RELATED DISEASES SUCH AS Some solutions are available, but there is
OBESITY AND NCDS a need to come up with new innovative
ways of prevention. One approach is fis-
The prevention and control of nutrition- cal policies; the taxation of nutrients such
related diseases such as obesity and of as sugars and food products like sugars
NCDs is of the utmost importance for the sweetened beverages (SSBs) to reduce
global community. The fight against obe- the consumption of unhealthy foods and
sity has been, and still is, a major challen- drinks. As mentioned in the WHO World
ge for policy makers. Current approaches Health Report, taxing unhealthy food does
to prevent obesity have not been effec- not solely constitute a means to prevent
tive (Escoberet al., 2013; James, 2008). obesity and unhealthy diets, but furthermo-
The shift in epidemiological patterns in re increases ways of augmenting financial
LMICs is taking on a more significant resources for the health care sector to treat
dimension because it will place extra the NCDs (WHO, 2010).

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The problem of obesity is increasing in Mexico implemented a fiscal reform packa-
importance in Latin America, particularly in ge, which includes a tax on junk food (8%
Mexico where 32% of the population are for products containing 275kcal and more
currently obese (Astudillo, 2014). Fiscal per 100g) and sugary beverages (one Mexi-
policy reforms as a public health preven- can peso per litre) (Astudillo, 2014).
tion tool are primarily aimed at prevention In the subsequent sections of this pa-
of obesity but their consequences can be per, the obesity situation in Mexico will
far reaching. Therefore, the key in imple- be discussed, before reviewing the issue
menting fiscal policies for public health of fiscal policies in public health. That is
matters lies within adequate implemen- followed by the main part of this paper;
tation and good governance. Mexico is good governance in relation to fiscal poli-
therefore an example of fiscal policies for cies in public health with a focus on obesi-
public health purposes. The government of ty prevention.
2. Mexico’s

Approach to controlling
obesity and NCDs

Obesity in Mexico is a very serious public cades. The increase in SSBs consumption
health threat. It is costing the Mexican has been accompanied by a reduction in
health care system billions of Mexican pe- consumption of fruits and vegetables (Bar-
sos and costs are considered to raise by quera, Campos & Rivera 2013). The SSBs
$1.2 billion in 2030 (Rtveladze et al., 2014). yield extremely little nutritional value but
Mortality rates attributable to NCDs have are advertised aggressively and are cheap,
increased with increases in the prevalence and highly accessible (Caprio, 2012; Yn-
of obesity (Rivera et al, 2002). The impact gve et al., 2012). Today, Mexicans drink
of obesity and NCDs on health has been more SSBs than any other population (Bar-
considerable. About three quarters of all quera et al., 2008; Barquera et al., 2010).
deaths in Mexico are caused by NCDs (The To combat obesity and NCDs, the Mexi-
Burden of Disease Project, 2010). Almost can government has established a “Natio-
14% of all Mexican deaths were attributa- nal Strategy for the Prevention and Con-
ble to diabetes mellitus since the begin- trol of Overweight, Obesity and Diabetes”
ning of the 21st Century (Rull et al., 2005) (Pilares de la Estrategia Nacional para un
and diabetes has become the dominant México sin Obesidad 2013). The strategy
NCD in Mexico. Between 1980 and 2000, encompasses three closely related pillars,
the number of deaths related to diabetes 1. a focus on public health, 2. provision
mellitus has increased by almost 50% of health care and 3. fiscal policies (Pre-
(Barquera et al., 2003). Direct costs for the sidencia de la República Mexico, 2014).
Mexican health care system, as well as in- The fiscal policies that the Mexican gover-
direct costs for the Mexican economy, will nment has recently introduced includes
therefore constitute a significant problem a fiscal reform package which includes
in the near future (Barquera et al., 2013). a tax on junk food (8% for products con-
Much of the increase in obesity and taining 275kcal and more per 100g) and
NCDs has been attributed mainly to the sugary beverages (one Mexican peso per
increased consumption of Sugar-Sweete- litre) (Astudillo, 2014). Introducing sugar
ned Beverages (SSBs). There has been a taxation constitutes an important step
substantial increase in the consumption towards the prevention of excessive SSB
of SSBs in Mexico during the last two de- consumption. President Pena Nieto an-

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nounced that a significant amount of the (Barquera, Campos and Rivera, 2013). As
sugar tax revenues will be used for further Mexico has been regarded as the leading
prevention programs as well as providing SSB consumer worldwide, implementing a
schools with drinking water fountains (As- tax on sugary beverages reflects an eviden-
tudillo, 2014). ce-based policy. Yet, relying solely on the
The implementation of a fiscal policy fiscal policy will most probably not result
with the aim of tackling obesity can un- in worthwhile outcomes. The Mexican go-
doubtedly be regarded as a success for vernment will need to use its full adminis-
public health. Nonetheless, to achieve trative capacities to win the fight against
positive outcomes, it is of the utmost im- obesity. This will ultimately come back to
portance to determine further actions that the topic of Good Governance, which will
could enhance and support fiscal policies be discussed in subsequent sections.
3. Fiscal Policies

in Public Health

The use of fiscal policies targeting public and generally encompass taxation on pur-
health issues becomes increasingly favou- chased goods and services. Furthermore,
red by governments, as illustrated by the the imposition of direct and indirect taxes
latest example of sugary beverage taxation can have consequences of different natu-
in Mexico (Blakely, Wilson and Kaye-Blake, re, namely being progressive or regressive.
2014; Sassi et al., 2014). Considering the Direct taxes typically foist an equal relati-
history of taxation and fiscal policies world- ve burden on each payer and are, hence,
wide, it seems as that most taxes, at least of progressive nature. On the other hand,
in theory, have been imposed with the aim indirect taxes are known to be regressive,
of increasing the overall welfare of the pa- putting the same financial burden on each
yer. The United Nations (UN) High Level taxpayer without considering their perso-
Summit on NCDs in 2011 emphasized the nal relative capabilities of paying (Britanni-
use of fiscal policies and food taxes for the ca Encyclopaedia, 2014).
prevention and control of NCDs (United One possible way of changing the na-
Nations, 2011). In addition, as the special ture of future anti-obesity policies includes
international public health organization of the application of multi-sectorial actions
the UN, the WHO has advocated the use by governments, including fiscal policies
of fiscal policies in order to “encourage (Gortmaker et al., 2011). An obvious rea-
healthy eating” (WHO, 2009). A significant son for the continuous increase in SSB
number of public health professionals have consumption has been the way the food
stressed the importance of governmental industry has marketed their products
actions to effectively tackle the obesity epi- (Woodward-Lopez, Kao & Ritchie, 2011;
demic (WHO, 2012, Moodie et al., 2013). Pomeranz, 2012). The marketing success
When we talk about fiscal policies and of the food industry consequently led to an
taxation for public health objectives, we increased consumption of SSBs on a glo-
should emphasize the important differen- bal scale (Zenith International, 2013). As
ce between direct and indirect taxes. Di- a further consequence, the increased con-
rect taxes are in general adjusted to the sumption of SSBs had a serious negative
capabilities of a person to pay, whereas impact on the health of millions of people
indirect taxes are non-person adjusted worldwide (Lavin & Timpson, 2013). Fiscal

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policies and the taxation of food products percentage change of the demand and pri-
are worthwhile options for governments ce give an indication whether the demand
complementing the considerably lighter of the product is inelastic (demand decrea-
option of health promotion to prevent ses after price increase; ratio value < 1)
obesity and unhealthy food consumption. or elastic (demand does not decrease af-
Governments, which proactively decide to ter price increase; ratio value > 1). “Cross
implement fiscal policies, might not only price elasticity” is concerned with the de-
increase government revenues, but may mand change of one product after a price
ultimately influence purchasing behaviours change to another product has occurred
of consumers (Moodie et al., 2013). (Principles of Economics, 2011).
The literature on fiscal policies and food A meta-analysis by Escobar and collea-
taxation indicates that it is effective (Andre- gues referring to “evidence that a tax on
yeva, Long & Brownell, 2010). Modelling SSBs reduces the obesity rate” has conclu-
studies, empirical evidence from countries, ded that “an increase in price of SSBs is as-
which have already implemented fiscal sociated with a decrease in consumption;
policies for the fight against obesity and and the higher the price increase, the grea-
NCDs, as well as experimental studies, are ter the reduction in consumption (Escobar
increasingly becoming available. The main et al., 2013)”. Unfortunately, the number
question is, in which way fiscal policies of studies analysing “own price elasticity”
influence the consumption of unhealthy outweigh the number of studies encom-
food products, especially SSBs, and how passing “cross-price elasticity” analyses
governments justify their implementation? (Moodie et al., 2013).
Moreover, with an increase in ill health due Data from observational studies indica-
to SSB consumption, social costs are rising te that a price change of a certain unhealthy
concomitantly, thus supporting the argu- food does not relatively affect the demand
ment of market failure, which reflects the (Andreyeva, Long & Brownell, 2010). A
common consensus of public health pro- number of other studies, which assessed
fessionals, and even economists (Brownell the impact of fiscal policies on unhealthy
et al., 2009). food consumption, concluded that the im-
The cost of food is second to taste in re- pact would be moderate (Chouinard et al.,
gard to decisions about which food to eat 2005; Kuchler, Abebayehu & Harris, 2005).
but “little is known as to whether variations The results of a more recent systematic re-
in food prices account for differences in view of “price, demand and body weight
diet quality or weight status” (Story et al., outcomes”, however, demonstrate that the
2008). The basic underlying idea of taxing demand is to a greater extent price sensiti-
unhealthy foods and drinks is that the in- ve as concluded by previous studies, espe-
creased price of a product leads to a de- cially for the consumption of SSBs (Powell
crease in the consumption of that product. et al., 2013). Moreover, according to a re-
The economic term behind this idea is “pri- view concerning the “Acceptability of a Tax
ce elasticity”. In regard to the taxation of on SSBs” by Lavin and Timpson, “research
unhealthy food, we need to consider two unanimously agrees that the strongest evi-
kinds of price elasticity: “Own Price Elasti- dence is for a tax on SSBs (Lavin & Timp-
city” and “Cross Price Elasticity”. “Own pri- son, 2013). A modelling study in the United
ce elasticity” is solely concerned with one States suggested that taxation of SSBs is
specific product and the eventual change more likely to be effective if the excise tax
in demand after a price change of this spe- is large (20-25% increase in price) (Wang
cific product has occurred. The ratio of the et al., 2012). Wang’s study supports the
evidence of a previous study by Powell and Clark & Rayner, 2012). In addition, the con-
Chaloupka, which concluded that a little sumption of SSBs seems to be particularly
increase in the price of an unhealthy food higher in the lower socio-economic clas-
product would only marginally affect body ses (Lavin & Timpson, 2013). On the other
weight (Powell & Chaloupka, 2009). hand, if SSB consumers from lower socio-
The effectiveness of fiscal policies in economic classes show a more significant
regard to health outcomes is of utmost price sensitivity compared to SSB consu-
importance. Yet, one should not forget the mers from higher socio-economic classes,
significance of their cost effectiveness. the consequent benefits of positive health
The question is not only whether fiscal in- outcomes would be of progressive nature
terventions result in positive public health and the gap of inequalities would eventua-
outcomes but also whether their health lly become smaller between different so-
outcomes justify the costs. Administratio- cio-economic classes (Brownell & Frieden,
nal costs can in theory both outweigh the 2009; Capewell & Graham, 2010; Powell et
revenues of the taxation and the monetary al., 2013; Lavin & Timpson, 2013). Discus-
value of the health outcome. A study by sions about the evidence of fiscal policies
Moodie and colleagues assessed the “cost and taxation strategies repeatedly empha-
effectiveness of fiscal policies to prevent size equality issues in regard to different
obesity”. The authors conclude “that defi- socio-economic classes (Craven, Marlow
nitive conclusions about the value for mo- and Shiers, 2012; Moodie et al., 2013).
ney of fiscal policies for obesity prevention The use of fiscal policies for public
cannot yet be drawn”, despite the fact that health purposes is increasingly becoming
“early indications are that population-level popular on a global level. Regulating SSB
fiscal policies are likely to be potentially consumption has risen up the agenda of
effective and cost-saving” (Moodie et al., necessary public policy initiatives, as seen
2013). in Mexico. The results of such fiscal poli-
Concerns attached to the idea of im- cies are not solely aiming at the financial
plementing fiscal policies for public health aspects of the problem, but are equally
purposes There are a number of concerns important as an educational tool, conside-
attached to the idea of implementing fis- ring it as an educational tax. Altering the
cal policies for public health purposes. The food environment in a way that makes un-
increase in price of one unhealthy product healthy food more expensive will very likely
can lead to the increase in consumption result in an enduring change of food con-
of another unhealthy product (“Cross-Pri- sumption behaviours and thus, decreasing
ce Elasticity”). A number of studies have obesity rates and the prevalence of NCDs
emphasized the issue of compensatory (Osei-Assibey et al., 2012).
food consumption behaviour (Epstein, et It will be important to understand that
al., 2012; Powell et al., 2013) A further is- implementing fiscal policies for one un-
sue arises in regard to the potential finan- healthy product or nutrient may conse-
cial impact of fiscal policies on different quently lead to an overconsumption of
socio-economic classes within a society. other unhealthy products or nutrients. A
On the one hand, it is said that taxes on study by Myrron, Clark and Rayner sugges-
food are of a regressive nature. Hence, ted an extensive application of taxes on
people from lower socio-economic classes a number of distinct unhealthy nutrients.
need to contribute a higher proportion of Moreover, they advised that the minimum
their income as compared to people from level of the tax percentage should be twen-
higher socio-economic classes (Mytton, ty percent (Mytton, Clark & Rayner, 2012).

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Other studies have indicated that fiscal dence is that most studies are based on
policy reforms encompassing unhealthy modelling techniques. Thus, not being able
food taxation should preferably incorpora- to produce real empirical evidence. Excise
te some form of subsidy for healthier food taxes have yielded effective results in the
products (Fletcher, Frisvold & Tefft, 2013; field of tobacco prevention, (Chaloupka,
Lavin & Timpson, 2013). Yurekli & Fong, 2012). This, however, does
In general, it is beneficial if govern- not denote that strategies used for taxing
ments would earmark their fiscal policies, tobacco can be easily transferred to food
precisely indicating for what taxation reve- products. The consumption of food cons-
nues will be used. Overall evidence on fis- titutes a necessity for each individual and
cal policies indicates that fiscal policies are is of high complexity, thus not directly
a potential tool for public health purposes. comparable with tobacco use. Govern-
A disadvantage is, that most studies vary ments will need to assess, which taxation
in methodology, which makes it difficult to strategies will be most appropriate (health
pool the different results. This is especia- outcome, cost-effectiveness, subsidization
lly the case for cost-effectiveness studies of healthy products, equality) and need to
encompassing the topic of unhealthy food adequately govern this process in a way
taxation (Moodie et al., 2013). A further di- that yields the greatest positive results for
sadvantage in regard to the quality of evi- the welfare of the society as a whole.
4. Fiscal policies as an

Innovation en Public Health

Interventions

The utilization of fiscal policies as a preven- health education is most commonly used.
tion tool for public health might be consi- Because of the realization of the relative
dered as some sort of innovation. Before ineffectiveness of health education there
it becomes necessary to explain why good has been a noticeable change in the way
governance of innovations in public health countries try to challenge food-related
is of great importance, we need to elabo- public health problems such as obesity.
rate more on the question of why fiscal This challenge manifests itself in a chan-
policies for the prevention of obesity can ge of prevention techniques towards the
be considered as actual and genuine inno- application of fiscal policies. Yet, the sole
vations. change of prevention techniques does not
“Innovation is the process of making constitute an innovation per se. The ques-
changes to something established by in- tion of whether these changes add value
troducing something new that adds value” still remains to be tested. In regard to pre-
(O´Sullivan, 2008). The first important vious prevention methods, fiscal policies
message, which can be drawn from the seem to be a new approach, not so much
definition by O´Sullivan, is that an inno- in alcohol and tobacco prevention, but cer-
vation does not merely describe the final tainly in the prevention of obesity, including
creation and end of something, but em- fat and SSB consumption. Considering the
bodies the whole process of making the latter, fiscal policies evidently add value in a
creation, thus its whole means to an end. sense that they ought to be more efficient
Second, an important connotation can be in the prevention of SSB consumption and
given to the mentioning of “making chan- thus, might prevent obesity and increase
ges” and “adds value”. If making changes the overall welfare of society. Notwithstan-
and adding value are the core criteria of ding research results ascribing ineffective-
what constitutes an innovation, we need to ness to fiscal policies for the prevention
analyse if this is the case in regard to fiscal of, e.g. SSB consumption and obesity, the
policies for the prevention of obesity. vast majority of recent studies indicates
A number of different prevention that fiscal policies are effective (Escobar et
methods for obesity have been applied du- al., 2013; Lavin & Timpson, 2013; Powell
ring the last decades. First and foremost, et al., 2013; Wang et al., 2012). Essentia-

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lly, the added value of fiscal policies ,for it, and eventually drawing conclusions from
example the prevention of SSB consump- the analysis is the only way of enhancing
tion and obesity, could be measured by re- and ameliorating this knowledge. Second,
ductions in the prevalence of obesity and failures can be a valuable source of infor-
accompanying NCDs, a reduction in health mation, not just for the intrinsic process of
care costs for correlated health complica- the innovation, but also for the institution
tions, and in the decrease of sales of SSBs or organization as a whole. Institutions and
as well as in an increase of the knowled- organizations, which aim at innovating their
ge base of consumers in regard to the un- modus operandi, should consider negative
healthiness of the food product or nutrient outcomes as an excellent opportunity for
in question. continuous learning.
At this point, we conclude that fiscal In spite of the fact that failures carry
policies for prevention of obesity can be some positive connotation, we have a
called an innovation. Apart from the issue pause at this point. It is important to ack-
of change, there are two further domains, nowledge the fact, that there is a differen-
which accompany the nature of innovation, ce between the consequences of failures
namely: “Innovation and Knowledge, and made by a private business company and
Innovation and Society” (O´Sullivan, 2008). by a government. Since fiscal policies are
As an increasing number of countries turn affecting roughly every person in the juris-
to implementation of fiscal policies for the dictional area of the responsible govern-
prevention of obesity, one can definitely see ment, the opportunity of learning from mis-
a transformation in the way public health takes does not mean that any well-meant
prevention methods are applied. The con- policy can be brought into being without
sequential outcomes of implementing fis- a rigorous policy analysis. The aim of a go-
cal policies for obesity prevention ought vernment should always be to keep failu-
to be of positive nature, yet, can also be of res and negative outcomes to a minimum
negative nature. In order to qualify as an to safeguard the public. At the same time,
innovation, the process must add value to mechanisms of continuous surveillance
its means and ends. In practice, this is only of fiscal policy outcomes have to be ins-
possible if positive outcomes outweigh ne- talled by the government. In the end, the
gative outcomes. The important question weighing of positive and negative conse-
at this point is, whether the process of in- quences of a specific fiscal policy depends
novating allows for negative outcomes, relatively exclusive on how good a govern-
and to be outweighed, in respect to fiscal ment governs their policy processes.
policies? As mentioned before in this arti- The last domain of consideration is “In-
cle, the regressive nature of food taxation novation and Society”. By definition and as
may constitute a negative outcome from a mentioned before, fiscal policies are imple-
financial perspective, whereas from a health mented with the underlying aim to even-
perspective, people seem to consume less tually increase the overall welfare of the
amounts of the unhealthy food at stake. To society. If fiscal policies for the prevention
better answer this question, we need to fo- of obesity and accompanying NCDs ultima-
cus on “Innovation and Knowledge”. tely culminate in positive health outcomes,
During the process of innovation, failu- the welfare of the society would undoub-
res and negative outcomes should be tedly increase. A decrease in obesity and
allowed for two reasons. Primarily, making NCDs may result in a decrease of health
failures are a consequence of suboptimal care costs. Furthermore, we could assume
knowledge. Detecting the failure, analysing that the productivity of a country would
rise with a healthier workforce, which may penditures for the government, but rather
eventually lead to an increase of the GDP. indicates an investment, based on the well-
This would effectively imply, that the pre- known saying “health is wealth” (European
vention of obesity does not only reflect ex- Commission, 2007).

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5. Why we need

Good Governance

The concept of Governance is increasing in all people” (Brand, 2007). By describing

importance. It has been a much-discussed how “Good Governance” could be applied
issue, mainly in the fields of political science in the context of Public Health, Brand makes
and global development. The notion of go- use of the “Good Governance” concept de-
vernance as an important element in public veloped by the United Nations Economic
health practice is also increasingly recogni- and Social Commission for Asia and the
sed in health related literature (Dodgson, Pacific (UNESCAP). The UNESCAP concept
Lee & Drager, 2002; Kickbusch & Gleicher, of “Good Governance” has initially been
2012). Governance describes the very spe- designed for the field of development but
cific process of how macro-institutional as has since found broader application. In a
well as micro-institutional activities are ad- nutshell, “Good Governance” according to
ministered and how these institutions exer- the UNESCAP concept encompasses eight
cise their competences at one point in time characteristics, namely: participation, rule
by encompassing time and space related of law, transparency, responsiveness, con-
determinants. In other words, governance sensus oriented, equity and inclusiveness,
explains the process in which administrative effectiveness and efficiency, and accounta-
procedures are determined and how they bility (Figure 2) (United Nations, 2014).
are consequently exercised or not.
Considering the many actions taken by Accountable
Consensus
governments, all could simply be descri- oriented
bed with one word: governance. What we Transparent
Participatory
want to find out in regard to fiscal policies
for the prevention of obesity is, however,
what “Good Governance” implies. Brand Follows the rule
of law Responsive
described Good Governance as “a leading
concept in public administration” with the
Efective and Equitable and
intention of “bringing together administrati- efficient inclusive
ve bodies and all relevant stakeholders (ci-
tizens, NGOs, industry, etc.) to implement Figure 2:
reforms improving the living conditions for Characteristics of Good Governance. (UNESCEP 2014)
 Transparency is one of the most impor-
With respect to fiscal policies for the pre- tant elements in respect to fiscal policies for
vention of obesity, the UNESCEP concept the prevention of obesity. It encompasses,
of good governance constitutes a valuable that all information concerning the policy
guide to make fiscal policies mostly effec- will be made freely available by the gover-
tive. In the following, we will focus at the nment. This includes the application of sim-
eight UNESCEP concept characteristics ple terminology in order to create compre-
and examine what each characteristic en- hension throughout all gradients of society.
tails in regard to fiscal policies for the pre- Adequate coverage by the media, informing
vention of obesity. people about the policy process is prefe-
Participation implies that fiscal policies rable. Furthermore, transparency plays an
for the prevention of obesity should not be immense role when it comes to the earmar-
put into practice without actively including king of fiscal policies. Information with res-
the civil society into the analysis for and pect to how taxation revenues will be used
of policies, which is informed and allowed should be unconditionally transparent and
to freely assemble. Moreover, the poorest comprehensible by everyone.
segment of society and their viewpoints Responsiveness and Accountability are
should be adequately represented in order key components of a well-governed institu-
to attain complete societal participation. tion. Every stakeholder involved in the po-
As mentioned earlier, the highest percen- licy process should be served by the same
tage of obese people are in the lowest so- means and on an equal basis. In this res-
cio-economic classes. We have a duty to pect, the food industry should be treated in
consider their circumstances and perspec- the same way as governmental institutions
tives, and only by doing so, will we be able or NGOs, in terms of timely responses as
to create adequate policies. well as complete disclosure of information.
The Rule of Law, the second characte- Liability in terms of accountability is, howe-
ristic of the “Good Governance” concept, ver, a two-way concept, which effectively
focuses on human rights and fairness. means that each involved stakeholder has
Article 25 of the Universal Declaration of to be accountable for its action. The go-
Human Rights emphasizes that “everyone vernment will have to be accountable for
has the right to a standard of living adequa- its implemented fiscal policies. Moreover,
te for the health and well-being of himself the food industry will have to be accounta-
and of his family, including food” (United ble to the government and to the public in
Nations, 1948). If the food products, which regard to its products and their presumed
significantly foster the development of health effects.
obesity and infringe on the wellbeing of The more stakeholders are involved in
individuals, are considered to be of inade- making policies, the more opinions will
quate standard in regard to Article 25, we flow into the decision-making process. A
either need to ban them or give people well-governed institution should be able to
from lower socio-economic classes the steer the mediation process into a direc-
possibility of purchasing more adequate tion, which eventually reaches a consen-
food products by implementing the right sus of highest value for the welfare of the
policies. The full legal, social and financial society as a whole. Especially in the case
protection of each and every citizen has to of food consumption, obesity and NCDs,
be guaranteed. The implementation of fis- it is very important to incorporate a long-
cal policies can only be justified if it was term perspective into the decision-making
followed in lights of a fair legal framework. process. An adequate consensus can only

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 THE OBESITY EPIDEMIC 19
be reached, if the elements of participation theless, they play important separate parts.
and transparency are guaranteed. A valid By inclusiveness, a well-governed institu-
consensus is solely the result of incorpora- tion should decide upon future policies by
ting all necessary information made availa- including all distinct social segments and
ble through transparency. members. The final public policy should be
The two last elements of the “Good Go- one, which offers the greatest advantage
vernance” concept are Equity and Inclusi- for the worst-off of the society. Only then
veness. Both elements are strongly related can we strive for a world in which equity
to participation and the rule of law. Never- counts as the true prime principle.
6. Conclusions and

Recommendations

This paper sets out to show how public The increasing prevalence of obesity in-
health prevention techniques can change dicates that health education has not been
over time. With regard to continuously in- successful in changing dietary patterns
creasing prevalence of obesity, one may and physical activity. But moreover, there
assume that, at this point in time, global are also reasons to question the implemen-
and national public health is in a particu- tation of fiscal policies. Why should the
lar crisis. Public health practice has new increase in prices of unhealthy products
challenges to deal with. Challenges that change consumer behaviour? As current
can be characterized as being of extreme research indicates, and as described in this
complexity. On the one hand, the rather paper, fiscal policies seem to be effective
novel practice of implementing fiscal po- in lowering SSB consumption. Whether
licies for public health purposes might this will end the obesity epidemic, is a
constitute a valid option in how to best question, which has not yet been answe-
challenge complex public health threats red by research. This brings us to a subse-
such as obesity. On the other hand, it is quent question in which it is inevitable to
likely that even taxation of unhealthy food focus on the core problem of the issue, na-
products will not be the complete solution mely under which conditions the concept
to the obesity crisis. Professionals from a of health is truly established.
number of different disciplines within the Determinants of health are of great im-
field of public health have suggested what portance when it comes to public policy
to eat to stay healthy. Public health educa- making. To create and implement adequate
tion has tried unsuccessfully to counteract public policies requires consideration, not
the development of obesity by informing just of what health professionals consider
citizens about healthy ways of eating and as health, but also focusing on the com-
living and numerous health promotion mon understandings and relevance of how
campaigns have been implemented. Ne- the general public considers and further-
vertheless, they have been relatively ine- more understands health.
ffective, as evidenced by the rising rates Only by applying a holistic framework in
of obesity. The question of why this has which the determinants of health are well
been the case is worth asking. understood, will fiscal policies be more

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 THE OBESITY EPIDEMIC 21
effective. This, eventually, brings us to the ble for the policy (politicians, public health
point of Good Governance – the key to a professionals). This atmosphere of belief
successful public health endeavour. In a and trust can only be created, if Good Go-
democracy, the idea of inclusiveness of vernance is applied as governance encom-
citizens is an unconditional characteristic. passes the eight important characteristics:
Including the general population and their participation, rule of law, transparency, res-
values and beliefs is of utmost importance ponsiveness, consensus oriented, equity
to follow the lines of Good Governance. If and inclusiveness, effectiveness and effi-
fiscal policies are enacted, which do not ciency, and accountability.
represent the characteristics, ideas, values In conclusion, the nature of public
and ultimately, health determinants, of the health has to change and can be guided
general population, Good Governance will by Good Governance. We need to make
fail. This reflects an intrinsic problem bet- public health congruent with democracy.
ween science and evidence based public Until now, public health has predominately
health practice on the one hand, and de- focused on framing their problems as “te-
mocracy as well as citizen inclusiveness on chnical problems which have to be solved
the other hand. Furthermore, it may also through scientific expertise” (Horstman,
indicate “the complicated relationship bet- 2013). However, it is not only about pre-
ween public health, science and democra- senting evidence, giving advice and ma-
cy” (Horstman, 2013). king interventions. It is also about creating
Horstman has emphasized the problem a consistent and fruitful dialogue between
of people not following the advice given citizens and the governing parties. Specifi-
by public health professionals: “In public cally, in the field of public health, this dia-
health, citizens are constructed more as logue should be of great value. In addition,
the object than the subject of policies and qualitative research within the communi-
interventions”; “the gap between policy ties to create empirical evidence of how
and practice”. It seems obvious that health different socio-economic classes think and
professionals are in possession of the ne- feel about implemented policies such as
cessary knowledge on how to preserve the the sugar taxation is badly needed.
health of the people. However, and as we The obesity epidemic presents a big
see more and more people are becoming challenge for governments and health pro-
obese, we start to recognize that a vast fessionals. Fiscal policies may help, if their
number of people tend to ignore the advi- implementation and administrative proces-
ce. At issue here is why some people do ses are governed in an adequate manner,
not follow public health advice. The answer taking into account all possible determi-
might lie in an argument by Horstman, na- nants of the health problem. Since many of
mely, that “It is naïve to assume – as many the determinants of health are beyond the
public health policies and programmes do scope of health professionals, the dialogue
– that experts driven interventions actually with citizens will eventually influence more
result in behaviour change in everyday life than just the health of the people - and lead
on short notice” (Horstman, 2013). The- to an overall increase in the welfare of the
refore, in fiscal policies for the prevention society.
of SSB consumption, it will be pivotal to
make people understand why the taxation
was levied, and second, to create meaning
and a relationship of trust between the ge-
neral population and the people responsi-
7.

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 Universidad Nacional Autónoma de México
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The obesity epidemic: fiscal policies and Good Governance
-The key to successful public health interventions
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