> For the complete documentation index, see [llms.txt](https://research.ambitiousimpact.com/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://research.ambitiousimpact.com/reducing-diet-related-disease-through-taxes-on-sugary-drinks/reducing-diet-related-disease-through-taxes-on-sugary-drinks/7-implementation.md).
# 7 Implementation
This section discusses implementation factors that we think are of relevance for both 1) deciding whether we should recommend the ideas, and 2) the entrepreneurs considering taking the idea to scale.
## 7.1 What operating this charity would look like
Figure 2 notes how we would characterize this proposed idea along an explore-exploit continuum[^1]. We think that this intervention is on the exploit end of the spectrum, as SSB taxation has been implemented in many countries before, and the World Health Organization provides a manual on SSB tax policy.
Figure 2: Explore-exploit
The [manual](https://www.who.int/publications/i/item/9789240056299) on SSB tax policy provided by the WHO outlines the following key steps that a policy advocacy organization might follow:
1. Building a case for taxing SSBs—conducting situational analyses
1. Understanding the health and economic burdens of the country
2. Assessing complementary interventions
3. Examining the political environment of the country
2. Assessing the technical, administrative, and political feasibility of a tax for the country
3. Building a coalition among key stakeholders, including civil society and academia
4. Determining how to best frame the issue to garner public support
1. Framing should also anticipate and counter opposition from the food and beverage industry
5. Designing an appropriate tax instrument for the country’s situation
6. Assisting with monitoring and enforcement after the passing of the tax
7. Countering industry lobbying to roll back the new tax
In terms of determining how to best frame the issue, qualitative research by [Lwin et al. (2023)](https://gh.bmj.com/content/8/Suppl_8/e012955) indicates that the new charity would need to be flexible in highlighting different benefits of the tax to different audiences. Specifically, based on studies of health taxes across eight LMICs, they find that no one best practice dominates when it comes to choosing between an emphasis on the health benefits of the tax, or the fiscal and economic benefits: “Researchers, advocates and policymakers may generate greater support for health taxes by developing multiple frames that resonate with different types of values rather than searching for a single strong frame that is universally applicable across contexts." Nevertheless, meta-analyses indicate that emphasizing how the revenues of the tax can be reinvested towards health initiatives tends to carry a particularly high chance of success, at least in framing the matter to the general public ([Elliot et al., 2022](https://www.ijhpm.com/article_3910.html); [Hattersley et al., 2023](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802843)).
Other potential strategies include those outlined in the Global Health Advocacy Incubator (GHAI)’s “path to policy change” framework—as utilized in the successful SSB tax advocacy in Ghana ([Laar et al., 2023](https://gh.bmj.com/content/8/Suppl_8/e012154)).
The [World Cancer Research Fund](https://www.wcrf.org/policy/our-publications/building-momentum-series/lessons-implementing-robust-sugar-sweetened-beverage-tax/) study highlights the following key questions to be considered when designing an SSB tax, to take into account country contexts and local jurisdictions:
* What types of products should be taxed?
* What type of tax should be used?
* How high should the tax be?
* Who should the tax be levied on?
* Should it be a general or an earmarked tax?
A new charity working on this issue should fully flesh out its answers to each of these questions in order to determine the precise SSB tax it should advocate for.
## 7.2 Key operational factors
This section summarizes our assessment of potential concerns related to implementing this idea through a new charity.
**Table 12: Implementation concerns**
| Factor | Level of concern |
| ------------------------------------------ | ---------------- |
| Talent | Moderate |
| Access to information | Low |
| Access to relevant stakeholders | High |
| Feedback loops / monitoring and evaluation | Moderate |
| Execution difficulty / tractability | High |
| Complexity of scaling | Moderate |
| Risk of harm | Low |
### Talent
We think that a team of strong generalists could have success with this ToC. Given the policy focus, founders would need to be excited about policy advocacy, which generally includes longer timelines, less obvious feedback loops, and a significant amount of networking and relationship management. Progress in this space often depends on being able to identify, access, and persuade the right decision-makers.
Our main concern relates to local context and connections. Therefore, a local founder or a strong local first hire would likely be essential to gain access to relevant networks and support effective engagement with policymakers.
The following backgrounds, skills, or profiles would likely be useful for the co-founders or early hires at this organization:
* Background in lobbying
* Language proficiency in the official language of the country they choose to advocate in, or at least one team member who does
* Established networks among the government/civil society in their chosen country
* Experience in communications/framing policy advocacy messaging
### Access
“Access” refers largely to the ease with which a newcomer can gain traction with stakeholders or get information that is necessary to design or evaluate the intervention.
#### Information
We do not expect access to information to be a barrier.
#### Relevant stakeholders
We think that it is likely that access to decision-makers will be a barrier, which is part of the reason why policy advocacy has a low chance of success. This expectation is already “priced in” to our thinking on cost-effectiveness and the theory of change.
### Feedback loops / monitoring and evaluation
Monitoring progress for this intervention will likely focus on the following indicators:
* In the short term, policy proposals submitted or meetings conducted
* In the long term, the creation of a new SSB tax
* Changes in sugar intake in the population post-reform (pre-/post-studies)
* Reformulation of beverages post-reform
We find it very likely that an organization can reliably monitor these changes.
However, given the nature of this work, it is worth noting that evaluating the specific contribution of policy advocacy to eventual policy changes is particularly challenging. It is rarely possible to determine with high confidence what would have happened in the absence of advocacy efforts. That said, strong and rigorous evaluations should be able to narrow down and plausibly estimate a non-profit’s contribution to policy change. Founders and funders working in this space should be comfortable operating under this degree of uncertainty.
### Tractability
We think that failure to introduce the policy is more likely than success. Consistent with this, we believe that advocating for government action—particularly when it affects the food and beverage industry—is inherently difficult. We expect strong opposition to any proposed SSB tax, with lobbying efforts likely to focus on arguments such as:
* There is no evidence to demonstrate that SSB taxes will reduce obesity, diabetes, or diet-related NCDs
* SSB taxes unfairly target the beverage and sugar industries, even though many other foods are high in sugar
* Individuals should be responsible for their health, including deciding what to eat and drink, not governments
* SSB taxes are regressive and disproportionately affect and harm poor people
* SSB taxes will harm the economy and cause job losses
* SSB taxes give money to ineffective and corrupt government agencies
All of these arguments can be easily rebutted (see [GHAI 2021](https://assets.advocacyincubator.org/uploads/2021/08/Evidence_to_Support_SSB_Taxes.pdf)), and we think that it is possible to beat this counter-lobby. However, we expect it to make advocacy significantly more difficult and to slow progress. But, change is clearly possible; SSB taxes have already been successfully implemented in 44 countries (see the [OEH](https://www.obesityevidencehub.org.au/collections/prevention/countries-that-have-implemented-taxes-on-sugar-sweetened-beverages-ssbs) and [WASSH](https://www.worldactiononsalt.com/worldaction/reformulation/sugar-reduction/taxes/) databases).
Based on this, we give this intervention a 9% probability of success. This assessment of difficulty is priced into our estimations in this investigation.
### Complexity of scaling
Although policy change is challenging, we think that it could become easier with each new country. A Vital Strategies policy brief of lessons from South Africa’s SSB tax advocacy highlights that “international evidence of effectiveness of taxes as implemented by other countries is crucial in building the case for a soda tax – which would suggest that advocacy becomes easier over time, and that past success rates are an underestimate” ([Cullinan et al., 2020](https://www.vitalstrategies.org/lessons-from-south-africas-campaign-for-a-tax-on-sugary-beverages/)). Moreover, a comparative policy analysis of the institution of SSB taxes in 16 countries between 2016 and 2019 ([Mulcahy et al., 2022](https://academic.oup.com/heapol/article/37/5/543/6542480)) finds evidence for a diffusion effect, where evidence and political will generated by early adopters of SSB taxes facilitated the adoption of similar taxes in other countries.
On the other hand, because successful policy advocacy is highly relationship-based, a new charity may essentially need to start from scratch in each country, building and cultivating new relationships.
We also think it is worth highlighting that enforcement is especially important for SSB taxes, as we expect compliance to be low without oversight by the charity, so this may limit how quickly a new organization can scale.
### Risk of harm
The overall risk of harm from this intervention is low.
We discuss potential negative externalities in [Section 3.5](/reducing-diet-related-disease-through-taxes-on-sugary-drinks/reducing-diet-related-disease-through-taxes-on-sugary-drinks/3-quality-of-evidence.md). The most significant concern is substitution, as this may have its own health implications depending on what consumers substitute toward (see [Section 3.5.3](/reducing-diet-related-disease-through-taxes-on-sugary-drinks/reducing-diet-related-disease-through-taxes-on-sugary-drinks/3-quality-of-evidence.md)). However, we expect the overall effect of substitution to be net positive.
## 7.3 Remaining uncertainties
* What tax rate will ultimately be implemented by target governments. While a new charity would advocate for a 20% tax in line with WHO recommendations, many countries have implemented lower tax rates in practice.
* The level of enforcement a new SSB tax would achieve, and therefore how much effort a new charity would need to devote to supporting enforcement following successful advocacy.
* The extent to which consumers would substitute away from SSBs toward ASBs or other beverages, and how harmful these substitutions may be, given the high uncertainty and heterogeneity in the existing evidence.
* It is also unclear which artificial sweeteners cause the most harm.
* The share of products that would reformulate to avoid the new tax, and how this would influence consumption.
[^1]: Our recommendations can be characterized along a spectrum between exploration and exploitation—ideas closer to exploration require more research and design, and involve riskier bets and wider confidence intervals; ideas closer to the exploit side of things usually have narrower confidence intervals and rely more on replication/expansion of well-developed and concrete interventions.
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