Water security: the key ingredient for soda tax success

Recommended by the World Health Organization, sugar-sweetened beverage taxes have become an attractive policy to reduce the burden of noncommunicable diseases (NCDs). However, in contexts where water safety and security are equally important issues, there is an imperative need to simultaneously promote water sanitation and access policies to ensure the benefits of a soda tax don’t dry up. 

Soda consumption is often high in countries where access to free drinking water is limited. For over half the global population, water insecurity is a daily reality, and so too is the double burden of malnutrition. In 2015, more than 660 million people still lacked access to clean water, most notably in rural areas and in Sub-Saharan Africa. Even for those who have access to water, service is often inadequate or unsustainable, and water from an improved source can still be unsafe to drink.  Additionally, in sub-Saharan Africa, 28% of children under 5 years are underweight with 38% of children under five stunted. Meanwhile, adult overweight and obesity increased approximately 35% from 1992 to 2005 in seven African countries (Burkina Faso, Ghana, Kenya, Malawi, Niger, Senegal and Tanzania) and the prevalence of overweight and obesity among preschool children is expected to increase from 8.5% in 2010 to 12.7% in 2020. Such complex and overlapping issues require responses that address multiple health threats without creating or exacerbating unintended consequences.

Battle of the beverages

When it comes to hydration, water and sugary drinks are in fierce competition, and accessibility is a key determinant of consumption. Mexico has the highest sugary drinks consumption with 745 8oz servings per capita, followed by Chile with 486, and South Africa which is within the 10 leading countries all with 260 servings per capita. This phenomenon has not only occurred as a result of the addictively sweet taste of soda, but also because of high accessibility. In Mexico for example, lack of access to water resulted in the great permeation of sugary drinks that has been recognised as a major cause of obesity and diabetes. In 2014, a soda tax was implemented as a key NCD intervention. Authorities promised the tax revenue would support the introduction of free drinking water fountains in all public schools, reducing the need to buy bottled water – although encouraging, this promise has not yet been realised. Mexico has 206,155 public schools of which 42,617 obtain water from either a water well or a tanker truck, and 6,489 schools lack access to water. Further, the quality of water when available is not guaranteed, and resources to continue water fountain implementation programmes were cut in 2016.

  

Water insecurity dilutes the health and financial benefits of a soda tax  

In support of levies, it has been shown that soda consumption is being replaced mainly by bottled water and other drinks. This is a desirable health outcome. At a macroeconomic level, countries’ health expenditure are expected to decrease, as might families’ out-of-pocket health expenditures for the treatment of chronic diseases related to excessive sugar consumption. However, the impact on every-day expenditure for such families remains to be seen, and it has become apparent that access to free water is a pre-requisite for such benefits and the prevention of hydration insecurity. Without access to free, clean water, two main alternatives arise.

There is a risk of either having to maintain or increase household expenditure through purchasing untaxed commercialised beverages such as juices (non-soda, but often high in added sugar content), or buying bottled water. Alternatively, it may drive people to consume tap water that requires disinfection pre-consumption at a cost, or to hydrate from unsafe sources causing a different type of burden to arise. First, gastrointestinal diseases such as typhoid, cholera, paratyphoid fever, or amoebiasis may become more prevalent. Secondly, exposure to chemicals, pesticides, and other types of non-filterable contaminants present in water may be hazardous to health, with long-term effects. Ultimately, this could offset some of the fiscal benefits of a soda tax by increasing overall health expenditure.

Investing in upstream solutions

Health effects are likely to be higher if collected tax revenue is allocated to nutrition-related health programmes and policies. One strategy is to allocate soda tax resources to introduce and strengthen public water and sanitation systems by collaborating with established organisations and programmes such as WASH. Many mutually beneficial outcomes can arise when the NCD community work with their communicable disease counterparts, especially when issues are closely linked. To achieve this outcome, awareness of the shared determinants and solutions that link these health issues needs to be better communicated among civil society organisations and academia working in this space. A stronger, united public health voice will further increase government accountability in investing in the healthiest source of hydration – water.

At the centre of the soda tax’s success is the need to make global NCD prevention policies responsive to local contexts rather than blindly extrapolating lab-based models – there are many, important variables to consider when applying NCD solutions in the real world. The desired outcome of a soda tax – decreasing consumption of unhealthy beverages by rendering the sugary choice less fiscally appealing – is easier to achieve in high-income countries where alternate hydration choices exist. In many low- and middle- income countries, increasing the accessibility of a free, healthy alternative is the first necessary step to achieving this goal. Ensuring water security will increase the effectiveness of a soda tax, and more broadly the realisation of Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages, and 6: Ensure availability and sustainable management of water and sanitation for all.