How communities in Tonga work together for healthier, longer lives

Tonga has one of the highest rates of non-communicable diseases (NCDs) in the world. NCDs, such as cardiovascular disease, cancers, diabetes and chronic respiratory diseases, account for approximately 80% of deaths in Tonga. Smoking, alcohol consumption, poor diet, and lack of physical exercise have all contributed to the ever-growing burden of disease. However, local communities are coming together to help construct national policies in order to reverse this trend.
 

Evaluating health taxes

NCDs result in increased health care spending and significant economic losses due to the often complex, costly and chronic nature of treatment, as well as to lost productivity. Considering the heavy burden NCDs take on individuals and communities, the government of Tonga asked the World Bank to evaluate the effectiveness of ‘health taxes’ for Tonga’s particular context. Health taxes are primarily intended to disincentivize spending and reduce consumption on unhealthy consumer products, such as tobacco, alcohol and sugary drinks.  The taxes also provide an additional revenue source for the government.

For Tonga, health taxes were imposed on tobacco, alcohol, as well as selected foods and beverages that are considered unhealthy, including mutton flaps, turkey tails, sugar-sweetened beverages, ice cream, instant noodles and more. Together with the government of Tonga, our team from the World Bank conducted a study to determine the effects of the taxes and provide the government of Tonga with policy recommendations to move forward.

Overall, we observed substantial positive changes in consumption habits once the taxes were introduced and spending on taxed unhealthy products decreased. Still, the results were nuanced, and we found significant room for improvement. Most importantly, taxes were applied inconsistently, and primarily to imported products. This left a number of unhealthy local products cheap and affordable.

As a result, people began substituting taxed unhealthy products with cheaper, untaxed unhealthy products. For example, although there was some reduction in tobacco consumption, particularly amongst less wealthy smokers, many people substituted cigarettes with local loose-leaf tobacco or other less expensive brands. Several consumers substituted taxed mutton flaps with untaxed salted beef and corned beef.
 

Working with Communities

Although health taxes influenced the public’s consumption patterns, we recognized that community engagement was critical to the success of the project. Focus groups of both wealthy and poor households, as well as one-on-one interviews with community leaders were held across the country. These discussions provided invaluable insights into cultural habits and attitudes toward food, alcohol and tobacco consumption.

As one participant explained, big meals are part of Tongan culture, “you eat till you can’t fit through the door.” In another instance, mutton flaps and turkey tails are two of the most popular traditional dishes in Tonga – they’re also the fattiest parts of the lamb and turkey, respectively. Reducing Tongan’s consumption of these foods is not just a financial adjustment, it is a cultural one as well.

Currently, the benefits and compromises of the NCD tax are still being debated among the communities. During our focus groups, several Tongans expressed concern that tax increases negatively affect poor communities and the unemployed, who cannot afford healthy food alternatives. That said, communities would be more supportive if the government could demonstrate that revenue from the NCD tax was going to support and promote healthy lifestyles among the population, make healthy food more affordable, and improve health care services.
 

Next steps

The health challenges facing Tonga are substantial – a health tax is just one approach to mitigate these issues. While more work needs to be done to address substitution and ensure there are affordable healthy food alternatives for people, the sociocultural component is just as important. All facets of society have a role to play in addressing the risk factors contributing to the increasing burden of NCDs impacting Tonga. It is only through continued engagement with community members, government, church groups, that real sustainable change will be achieved.

 

For more information see the report