The soaring prevalence of obesity, and the non-communicable diseases (NCDs) associated with it, is increasingly becoming one of the main public health threats in the world. Once considered an ailment of the rich, overweight and obesity are no longer a health concern only in wealthy countries. Their prevalence continues to grow in low- and lower-middle-income countries (LMICs), and is pervasive even in countries where undernutrition persists. To face this challenge, many countries have designed and implemented comprehensive strategies and standalone policies to curb the epidemic. However, most documentation around the process to design and implement these policies come from high-income countries, and only recently have there been some efforts aimed at understanding the process and experiences in middle-income countries. This work aims to help fill this knowledge gap. This case study is part of a series of country case studies commissioned to better understand the process of designing and implementing policies to prevent and control obesity. The series provides an overview of the contextual factors and political processes in which these policies were introduced and the roles of the stakeholders in moving the policies forward from design to implementation.
Development Challenge and Intervention
This case study centers in understanding how taxes on sugar-sweetened beverages (SSBs) and advertising regulations were defined and designed as policy instruments, how such policies gained traction for enactment in Mexico, how the policies were implemented, specifically considering market and political interests, and the future prospects of such policies, given the dynamic political environment. More generally, the case looks at the difficulties and gaps emerging from a well-established strategy on paper to its actual implementation in the political reality.
Mexico has one of the highest prevalence of overweight and obesity in the world. Obesity is a risk factor for various chronic conditions and creates significant costs for healthcare systems. The Mexican government has recognized the urgency for action. In 2013, the federal government published the Strategy to Prevent and Control Overweight, Obesity and Diabetes (hereinafter, the Strategy), which provided a multifactorial framework to develop policies to combat obesity. This case study examines the enactment and implementation of two policies that are part of the Mexican Strategy. More specifically the case study focuses on the regulations on the advertising of foods/beverages on television (during programming directed to children) and the taxes on sugar-sweetened beverages (SSBs) with no nutritional value. Such instruments sought to reduce consumption of foods/beverages with no nutritional value and are intended to modify the obesogeneity of the contextual environment.
Delivery Challenges and attempts to confront them
The key delivery challenge faced by health authorities was a distorted market structure, in which the pricing system was not leading to desirable outcomes due to market failures such as asymmetries of information and externalities. In terms of the externalities, it is known that foods frequently account only for its private cost which is different from the social one, leading to an increased consumption that does not account social side effects such as increased health care costs. This led authorities to use different policy instruments, among them fiscal incentives and regulations, which would modify choices of individuals by affecting relative prices and influencing consumer preferences through massive marketing strategies. However, enacting such types of polices would cause significant consequences for the food and beverages industry. For the tax on beverages with added sugars, a key challenge was the potential for patronage and opposition, as the food industry actively used its resources to induce political interference. For screen regulations (i.e., TV and movie theaters), two important challenges were the absence of consensus among stakeholders and debatable nutritional indicators to establish which foods and beverages could be advertised.
The Mexican Strategy to Combat and Prevent Overweight, Obesity and Diabetes resulted from prior policy attempts to address obesity from a multi-sectorial perspective. However, three key aspects determined the enactment and implementation of specific polices: (i) the scientific evidence, and a local community of experts able to communicate such knowledge to key policy stakeholders; (ii) the voice of civil society, which was key in demanding to government actions and in forming coalitions; and (iii) the right political timing that allowed the issue to be placed on the political agenda.
While having a Strategy has been a relevant political step, the specific policies stemming from it have areas that can be improved. An example is the lack of a harmonized set of nutritional criteria. For example, while it was not addressed in this case study, the 8 percent ad valorem tax on junk food, seems to have potential contradictions with the advertising regulations. This is something that needs to be further studied so that in the future, policies combating obesity will be congruent in terms of their nutritional standards, which should be set by non-partisan processes (i.e., limiting the participation of the food industry).
In addition, nothing guarantees that polices will remain when the administration changes. This lack of continuity in the strategies to prevent and combat obesity could pose important threats to the public health benefits already achieved (both in political and public health terms). SSB taxes are better equipped to face electoral cycles because they are legally binding; they are a special tax on production and services (IEPS for its acronym in Spanish), whose modification needs to be discussed and approved by Congress. On the other hand, regulations on food advertisement have a weaker design since they are mainly linked to the Strategy to Prevent and Control Overweight, Obesity and Diabetes, which is a non-legally binding document of the executive branch of government, leaving it open to modification as a result of political maneuvering.
Considering such challenges, civil society organizations and NGOs, academia and international organizations have an important role in negotiating with the government to increase the chances that such policies survive electoral cycles and can be improved. They also have an important role in collaborating with the government in overseeing the implementation and monitoring process.
As highlighted by the experience of the ANSA and the Guidelines for the Sale or Distribution of Foods and Drinks in Primary School Facilities, monitoring mechanisms are key in the future of the policies. However, monitoring mechanisms linked to policies to combat obesity and overweight should be free of conflict of interest.