Tobacco kills one-third to one-half of all people who use it, on average 15 years prematurely. The World Health Organization (WHO) has a target of a 30% reduction in smokers by 2025; but this is one target that would be great to exceed. Alcohol-attributable cancer, liver cirrhosis, and injury caused 1.5 million deaths globally in 2010.
Recently, the representatives of ministries of finance and ministries of health, as well as a host of civil society organizations and international organizations, met in Manila to consider lessons to be drawn from the international experience surrounding so-called sin taxes.
Photo courtesty Creative Commons
For those of us who have been impacted by the death of loved ones due to the negative health consequences of smoking, the recent announcement by Larry Merlo, the CEO of the U.S. pharmacy chain CVS, to stop selling tobacco products in the chain’s 7,600 stores, was a ray of hope and a step toward a future when public health concerns trump short-term profit motives.
I usually criticize development wonks who come up with yet another ‘if I ruled the world’ plan for reforming everything without thinking through the issues of politics, power and incentives that will determine which (if any) of their grand schemes gets adopted. But it’s been a hard week, and today I’m taking time out from the grind of political realism to rethink aid policy.
Call it a thought experiment. Suppose we started with a blank sheet of paper, and decided which issues to spend aid money on based on two criteria – a) how much death and destruction does a given issue cause in developing countries, and b) do the rich countries actually know how to reduce the damage? That second bit is important – remember Charles Kenny’s book ‘Getting Better‘, which argues powerfully that since we understand how to improve health and education much better than how to generate jobs and growth, aid should concentrate on the former.
It is common to hear officials from countries and international agencies talk about the multiple challenges that impede intersectoral work for health. The concern is valid: while ministries of health and related institutions are organized and funded to improve the “health” of the population, other ministries do not have such a mandate. In most cases, this has led to a certain paralysis characterized by lofty aspirations in the health sector about the potential benefits of intersectoral action, but with little collaboration and action involving other sectors.
The scaling up of voluntary medical male circumcision, particularly in high HIV prevalence settings, is a highly cost-effective intervention to fight the epidemic—randomized controlled trials have found a 60% protective effect against HIV for men who became circumcised.
But, the supply of this medical service is just one part of the picture. Without active involvement from individuals and communities to deal with social and cultural factors that influence service acceptability, the demand for this common surgical procedure will be low.
Indeed, on a recent visit to Botswana, a country with high HIV prevalence and low levels of male circumcision, my World Bank colleagues and I had a good discussion with the National HIV/AIDS Commission about ways to address the low uptake of voluntary, safe male circumcision services in spite of a well-funded program by the government. It was obvious to all that if the demand for, and uptake of, this service were not strengthened through creative mechanisms that foster acceptance, ownership, and active participation of individuals and community organizations, the program would not help control the spread of HIV through increased funding of facilities, equipment, and staff alone.
So, what do we need to do to ensure that need, demand, utilization, and supply of services are fully aligned to improve health conditions?
The scientific evidence is overwhelming. As Robert Beaglehole and colleagues at the World Health Organization (WHO) pointed out years ago, tobacco is the only consumer product that eventually kills half of its regular users if they follow its manufacturers’ recommendations.
Given this dire reality, it is clear that Africa is now at a crossroads. On one hand, the countries in this region have become an attractive and under-tapped market as tougher regulations, high taxes, and greater consumer awareness of the dangers of smoking in developed countries are “closing the door” to tobacco imports and leading to significant drops in consumption. And on the other hand, cigarettes are becoming increasingly affordable as incomes rise in several African countries due to the rapid economic growth of recent years. Indeed, African countries are experiencing the highest increase in the rate of tobacco use amongst developing countries--the number of smokers in sub-Saharan Africa is projected to increase 148 percent by 2030, to 208 million smokers or one-fifth of the total population.