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WHAT IS THE PROBLEM?

Alcohol harm is a two-fold problem: a) harm due to alcohol is a major contributor to the global burden of disease and disability; and b) even though high-impact, evidence-based, cost-effective solutions are available, inertia to develop and implement alcohol policy solutions persists.

Major contributor to the global burden of disease and disability

Alcohol is one of the leading causes of premature death, disease, injury and disability, and loss of quality of life years. The damage caused by the alcohol reaches far beyond health concerns, affecting human beings’ potential, families’ wellbeing, communities’ resilience, socio-economic prosperity, social capital, sustainable development and global justice and Human Rights.

The majority of the global adult population lives free from alcohol consumption. Nevertheless, the products and practices of the alcohol industry result in a severe and pervasive health, social, economic and Human Rights burden on people, communities, and society at large. Globally, alcohol contributes to 2.8 million deaths (5.1% global death) each year, as well as to the disabilities and poor health of millions of people suffering from chronic diseases and nonfatal injuries.

• Alcohol is a psychoactive substance with toxic, carcinogenic, teratogenic, and dependence-producing properties.
• The death rate due to alcohol is higher than the death toll caused by tuberculosis, HIV/AIDS, and diabetes.
• Alcohol consumption is a causal factor in more than 200 disease and injury conditions.
• ”Alcoholic beverages are carcinogenic to humans.” – established the International Agency for Research on Cancer (IARC) in 1988.
• Alcohol causes a range of mental and behavioral disorders, and other Non-communicable conditions, such as cancer, cardiovascular disease, diabetes, as well as injuries.
• Alcohol also is a risk factor for infectious diseases, such as tuberculosis, HIV/AIDS, and COVID-19.

Alcohol remains one of the leading risk factors contributing to the global burden of disease. And alcohol’s contribution to global deaths and disease has increased, not declined, over the past two decades.

• Alcohol is the 8^th leading preventable risk factor of disease.
• The contribution of alcohol to the global disease burden has been increasing year by year from 2.6% DALYs in 1990 to 3.7% DALYs in 2019.
• In high income countries, alcohol use is the 2^nd fasted growing risk factor and in Low- and Middle-Income Countries (LMICs) it is the 4^th fastest rising risk factor.

Alcohol harm is a tremendous burden on the children and youth of the world:

• Alcohol is the 2^nd largest risk factor for disease burden in the age group 10-24 years.
• Alcohol is the largest risk factor for disease burden in the age group 25-49 years.

Beyond health consequences to the individual alcohol consumer, alcohol harm has an social dimension. People other than the alcohol user experience harm in the form of violence, crime, road traffic fatalities, reduced workplace productivity, and harm to the fetus.

Alcohol causes significant social and economic loss to people, communities and societies at large. Alcohol’s harm to others affects family members, friends, co-workers and strangers. Some examples are emergency room staff, police, taxi drivers, children of households with alcohol problems, children born with fetal alcohol syndrome, road traffic victims of driving under the influence of alcohol, or victims of alcohol violence – especially gender-based, domestic and intimate partner violence. 

• A recent worldwide overview showed: the economic costs of harm due to alcohol amount to 1306 Int$ per adult, or 2.6% of the GDP. About one-third of costs (38.8%) were incurred through direct costs, while the majority of costs were due to losses in productivity (61.2%).
• When the second-hand harms and the damage  to alcohol users are combined, the total harm from alcohol is about double that from tobacco.

This illustrates the need to make the response to alcohol harm a priority commensurate with the burden it actually is.

Inertia to develop and implement alcohol policy solutions persists

In 2010, the World Health Assembly adopted the WHO Global Alcohol Strategy unanimously. The moment signified global recognition of the need to accelerate action on alcohol harm as public health priority. Twelve years later, in May 2022, the World Health Assembly adopted the WHO Global Alcohol Action Plan. The moment signified a reckoning with the lack of progress in the last decade to protect more people from alcohol harm.

With some notable exceptions, most countries have failed to develop public health oriented alcohol policy solutions in the last decade.

Overall, trends in alcohol consumption, alcohol’s contribution to the global burden of disease, and progress towards global targets are all pointing the wrong direction – with the most severe consequences of this inertia being faced by people and communities in low- and middle-income countries.

1. Without action, Africa could see an increase in both the absolute number and proportion of people consuming alcohol, the amount consumed per capita and heavy episodic alcohol use.
2. Southeast Asia has seen a 29% increase in per capita alcohol use since 2010.
3. Out of 51 countries in the WHO European Region, only 16 reached the target of a 10% reduction of overall alcohol consumption between 2010-19. But 17 countries saw increases in alcohol use. Almost no progress was achieved since 2016 in the implementation of Best Buys alcohol policy solutions.
4. Alcohol remains highly affordable in the WHO Americas region. Between 2012-16, per capita consumption among alcohol users only increased, with 1 in 5 alcohol users consuming heavily.

Progress in the formulation and implementation of national and local alcohol policy solutions has been insufficient. Most countries, especially low- and middle-income countries (LMICs), have NOT implemented a comprehensive set of alcohol policies. No low-income country has reported increasing resources for implementing alcohol policy in the last decade. Many countries are failing to implement the alcohol policy best buy solutions, with LMICs more likely to have fewer evidence-based and cost-effective policies.

Positive examples of potential

To raise  alcohol taxes means adding a few  cents to the price of alcohol that can have the  price of saving a life.

In Botswana, only 7 months after introducing the alcohol excise tax, alcohol-related road crashes reduced by 12%. In the UK, only a 10% alcohol tax increase could save 1300 lives and prevent 61,000 hospital admissions annually.

In the Philippines, the budget of the Department of Health has tripled after the introduction of tobacco and alcohol excise taxes in 2012. The majority of these resources have been used to cover national health insurance premiums for poor families and benefit packages in both public and private facilities, as well as maintenance of healthcare facilities.Thanks to earmarked revenues, the number of families receiving subsidised health insurance increased from 5.2 million to 15.3 million poor families and senior citizens between 2012 and 2015.

WHY IS MORE FINANCING NEEDED? 

More financing is needed 

1. to facilitate evidence-based action, using high-impact, cost-effective solutions to protect more people from alcohol harm and in doing so promote health, improve quality of life, and drive sustainable development;
2. to unlock the potential of alcohol policy in general and alcohol taxation in particular;
3. to elevate the public discourse about alcohol harm and the potential of alcohol taxation to prevent and reduce that harm;
4. to empower civil society advocacy for public health-centered alcohol policy solutions; and
5. to enhance government capacity to develop and implement public health-centered alcohol excise taxes.

For example: Keeping people healthy reduces health costs, increases productivity and leads to longer and healthier lives, according to a recent report by the World Health Organization.
The “Saving lives, spending less: the case for investing in noncommunicable diseases” report focuses on 76 low- and lower-middle-income countries. The report explains the NCD Best Buys and shows how every dollar invested in scaling up Best Buy actions in these countries could generate a return on investment.
The report also highlights alcohol and tobacco taxation specifically, as high-impact measures to finance NCDs prevention.

Regarding the return on investment, the report shows that the alcohol policy Best Buy solutions are the second best set of options among all 16 NCD Best Buys.

But very few countries actually act on this evidence. While 95% of reporting countries implement alcohol excise taxes, according to the WHO, few use such taxes as a public health policy to reduce consumption and harm.Less than half use price strategies such as adjusting taxes to keep up with inflation and income levels, imposing minimum pricing policies, or banning selling below cost or volume discounts. 

WHY IS ALCOHOL TAXATION THE BEST OPTION TO DO THE MOST GOOD WITH THE RESOURCES AVAILABLE TO US

WHO’s Global Alcohol Strategy, adopted by the World Health Assembly in 2010, continues to be the most comprehensive international policy document with guidance on preventing and reducing alcohol harm at all levels. The Global Alcohol Strategy contains the  three alcohol policy best buys - the most cost-effective alcohol policy solutions that hold the potential to  save millions of lives, when implemented well. They are: increasing taxes on alcohol, reducing physical availability, and banning alcohol advertising. 

An alcohol policy best buy is an intervention that is not only highly cost-effective but also cheap, feasible and culturally acceptable to implement. A highly cost-effective intervention is one that, on average, provides an extra year of healthy life (equivalent to averting one DALY) for less than the average annual income per person. Analysis by the World Health Organization (WHO) has identified a set of affordable, feasible and cost-effective intervention strategies and its study estimates a global price tag for implementing these measures.

A highly cost-effective intervention is one that, on average, provides an extra year of healthy life (equivalent to averting one DALY) for less than the average annual income per person.

The most effective and cost-effective of these three measures is alcohol taxation that leads to  alcohol affordability reductions. The more expensive  alcohol is, the less it is consumed - and these protective effects are greatest for the most vulnerable, often marginalized groups.

The advantage of this alcohol policy solution is that 95% of countries do already have alcohol taxation in place but do not (yet) properly pursue  public health purposes. 

Evidence-based alcohol taxation is a triple win policy: it would not only generate revenues for the national budget but also reduce overall alcohol use and harm, and improve and save lives.

INFO BOX: A 20% increase in the price of alcohol could accumulate as much as 9 trillion US$ in increased revenues globally over a 50 years period and would avert nine million premature deaths.

Public health-centered alcohol excise taxation has a triple-win effect: 

1. it generate revenues for the national budget,
2. it reduce overall alcohol use and harm, and
3. it improve and save lives.

Compared with tobacco taxation, the potential for domestic resource mobilization through alcohol taxation could be even bigger since taxes on alcohol tend to be lower in most countries.

A study of 42 high-, middle- and low-income countries found that raising excise duties on alcohol to at least 40% of the total retail price would increase tax revenue in these countries by 80% to US$ 77 Billion.

Expressed as a proportion of total current spending on health, it is low-income countries that have most to gain (additional receipts would amount to 38% of total current spending on health). 

At the same time, evidence shows that alcohol’s pervasive harm is preventable.

That means alcohol policy best buy implementation in general, and alcohol excise taxation in particular yield returns on investment by reducing the alcohol burden and costs; they also improve health, well-being, and economic productivity, and they generate additional revenue that can be reinvested in health promotion.

WHAT ARE THE ALCOHOL TAXATION CHALLENGES? 

There are four broad challenges to develop and implement public health centered alcohol excise taxation: public discourse, civil society capacity, government capacity, and alcohol industry opposition and interference.

Public discourse and recognition of alcohol harm:

When consumers are aware of the negative health effects associated with their consumption of alcohol they still tend to underestimate the long-term harm from consumption, discounting the costs which often do not occur until later in life, and later regretting their decisions, according to the Task Force on Fiscal Policy for Health, 2019. This is exacerbated in the case of addictive substances like tobacco and alcohol because consumers cannot know how their preferences will change after beginning to consume these products and are likely to overestimate their ability to quit or reduce consumption once they start (Akerlof 1991; Gruber and Kőszegi 2001).

Therefore a public discourse about the full extent of alcohol harm on individual, community, and societal level is important. It helps increase recongntion of the alcohol burden and the potneital of alcohol policy solutions, such as alcohol taxation.

The challenge is to overcome misinformation and congntive dissonance with value-based messaging, story telling, involving people with lived experience and always rooted in the best available evidence.

Civil society capacity:

Community mobilization plays an important role for policy support, and maintaining political commitment to olicy implementation and improvement. But civil society capacity has been lacking in the area of alcohol policy in general and in the field of alcohol taxation in particlualr. Supporting advocacy champions and strengthening civil society and community-based organizations helps strengthen advocacy as well as the public discourse, but has positive effects for fostering active citizenship and democacry overall.

The challenge is to foster understanding of the benefits of alcohol taxation across different sectors, to stimulate a whole-of-society coalition for alcohol taxation.

Government capacity:

Implementing health taxes is a test of government effort and resolve. Industries vigorously oppose tax increases with false or misleading statements related to revenues, employment, illicit trade, and impacts on the poor. Most of this criticism fails to stand up to analysis; none of it justifies inaction – according to the Task Force on Fiscal Policy for Health, 2019.

Governments, especially in low- and middle-income countries need support in overcoming alcohol industry interference, and more so with technical knowledge about alcohol tax development, tax collection, and other technical issues. Governments might also need support for staffing and arranging strategic meetings with stakeholders to foster a whole-of-government approach.

Alcohol industry opposition and interference:

Evidence to support the implementation of effective health taxes on tobacco and alcohol is strong. However, governments face strong opposition to taxes from producers and their allies who persistently raise concerns about the impact of raising taxes on revenues, employment, illicit trade, and the poor. Evidence from around the world demonstrates that these arguments are either false or greatly exaggerated, and none justify inaction.

But the challenge of alcohol industry opposition and interference is real and severe. That is why the first three challenges need to be addressed. In addition stratgeies and know-how is essential to protect alcohol taxation development process from conflicts of interest.

WHAT COULD A NEW PHILANTHROPIST DO?

A new philanthropist could support an ambitious, high-impact charity intervention to advance alcohol taxation in concrete countries, based on an evidence-rooted theory of change (see below).

IMPORTANCE: HOW MANY INDIVIDUALS ARE AFFECTED BY THIS PROBLEM, AND BY HOW MUCH?

Consumption of alcohol imposes costs on others, i.e., negative externalities.

Every 10 seconds a human being dies due to alcohol. Almost 3 million people die each year due to alcohol, 5 percent of deaths worldwide. Alcohol harm derives from the volume of alcohol consumed and patterns of alcohol consumption. 

Alcohol causes both immediate (e.g., injury) and longer-term harms (e.g., liver cirrhosis, mental health problems). 

Alcohol-related deaths and disability impact younger populations:

• Alcohol is the 2^nd largest risk factor for disease burden in the age group 10-24 years.
• Alcohol is the largest risk factor for disease burden in the age group 25-49 years.

People other than alcohol users themselves are often the victims of alcohol harm, such as traffic crashes, homicides, assaults, rapes, child abuse, and spousal abuse. Alcohol use during pregnancy results in a variety of complications for infants and can affect a child’s health later in life. 

Illustrating the pervasive effects of alcohol, a 2019 landmark study conducted a meta-analysis of 24 unique studies and 1416 unique children and youth with fetal alcohol spectrum disorder. The study found that approximately 8 of 1000 in the general population had fetal alcohol spectrum disorder, and 1 of every 13 pregnant women who consumed alcohol during pregnancy delivered a child with fetal alcohol spectrum disorder. The prevalence of fetal alcohol spectrum disorder was found to be notably higher among special populations. The prevalence of fetal alcohol spectrum disorder among children and youth in the general population exceeds 1% in 76 countries.

According to the WHO Global Alcohol Status Report, in 2016, an estimated 283 million people aged 15+ years had an alcohol use disorder (representing 5.1% of adults).

Spending on alcohol not only harms household members’ health but also can divert spending from other goods or services that promote health, such as nutritious foods, education, or good quality housing. 

Furthermore, wherever healthcare expenditures are pooled through public insurance mechanisms or tax-financed health services, non-consumers bear some part of the costs of treating illness and injury due to alcohol. For instance: A first of its kind study has quantified the secondhand alcohol harm in Australia. It amounts to nearly AUD$20 billion in 2016.
Bystanders bear almost 90% of the costs of harm caused by others’ alcohol use, while the government footed the rest of the bill.

over two-thirds of Australians have been harmed by secondhand effects due to alcohol. The total cost amounted to AUD$19.81 billion, in 2016. This includes tangible costs of $11.45 billion and intangible costs of $8.36 billion.

The cost of the harm caused to others is about the same as the cost of the harm caused by alcohol users to themselves and to response agencies serving them. This brings the total cost of the alcohol burden in Australia to about $40 billion.

In any year, about 40% of adults worldwide consumed at least some alcohol in the past year and approximately 16 percent of these alcohol users engage in heavy episodic

Alcohol consumption (WHO 2014a). While there is large variation in the use of alcohol across countries and regions, alcohol sales have increased worldwide and are predicted to continue to rise, with the largest growth in lower-middle-income countries.

Consumption of alcohol imposes large health care costs and reduces economic productivity. The annual economic costs from alcohol consumption were estimated at over 1 percent of GDP in middle-and high-income countries in 2009 (about US$600 billion). A recent worldwide overview showed: the economic costs of harm due to alcohol amount to 1306 Int$ per adult, or 2.6% of the GDP. About one-third of costs (38.8%) were incurred through direct costs, while the majority of costs were due to losses in productivity (61.2%).

Costs vary considerably across countries. For example, total costs of alcohol use in South Africa were estimated at 10% to 12% of the 2009 GDP (between US$30 and US$36 billion) (Rehm et al. 2009).

In this Special Feature, Movendi International has detailed the economic harm due to alcohol in the OECD, and in concrete countries, such as Norway, Australia, Canada, Germany, Sweden, France, the Netherlands, New Zealand, the UK, the United States, as well as low- and middle-income countries, such as Sri Lanka and India. The Special Feature also explores concrete types of economic harm, such as workplace harm and productivity loss, as well as loss of economic growth, healthcare spending and more.

Reducing consumption of alcohol can also avoid impoverishment when households are exposed to high healthcare costs associated with NCDs, according to the Task Force on Fiscal Policy for Health, April 2019.

Hundreds of millions of people are directly affected by the harm due to alcohol consumption. Millions, if not billions of people are affected by the secondhand harm due to alcohol.

WHO IS ALREADY WORKING ON IT?

Neglectedness: Who else is working on this problem? Why are other funders not pursuing the strategies you think are most promising?

Already in 2010, in its World Health Report, the WHO presented evidence for the under-utilized potential of alcohol taxation:

Raising taxes on alcohol to 40% of the retail price could have an even bigger impact than a 50% increase in tobacco taxation.

Estimates for 12 low-income countries show that consumption levels would fall by more than 10%, while tax revenues would more than triple to a level amounting to 38% of total health spending in those countries

However,  a decade later, alcohol is becoming  more affordable, not less, because countries do not implement public health oriented alcohol taxation and fail to adjust alcohol taxes to their GDP, disposable income and inflation.

Based on our analysis, there is no charity that  focuses its work on advancing alcohol taxation. There are several reasons that can be summarized as lack of capacity, alcohol industry opposition, lack of funding, and lack of commitment:

• Alcohol taxation advocacy demands targeting ministries of finances that often protect interests of private sector including the alcohol industry;
• Capacity building of governments, including ministry of health;
• Civil society advocates have not had resources to build their capacity to effectively advocate for alcohol taxation and be an equal partner in the conversation with the ministry of finances;
• Funders supporting civil society organisations in the field of alcohol harm prevention and reduction would not finance policy advocacy work;
• Lack of official development aid in the field of alcohol policy, other than small funding from Norway and Sweden.

Alcohol taxation is the single most cost-effective alcohol policy solution but it also requires the most knowledge and capacity to engage in this policy discussion.

Bloomberg Philanthropies - the biggest supporter of health promotion in the field of NCDs risk factors - has committed almost US$1 billion to support initiatives to reduce tobacco use in LMICs since 2006. But they invest zero dollars in efforts to reduce alcohol use in LMICs.

Movendi International is the global civil society leader and sole voice committed to advancing alcohol taxation, with advocacy work on all levels since 2015 to build civil society capacity, support governments, and increase recognition of the potential of alcohol taxation for health promotion and sustainable development financing.

The Center for Global Development has conducted research in the area of alcohol taxation and issued a report.

The World Health Organization has a technical unit on fiscal policy that has only limited capacity to support countries in alcohol excise tax development.

The United Nations Development Program (UNDP) is working with WHO and the UN Interagency Task Force on NCDs to develop alcohol policy investment cases and alcohol tax revenue projection modeling for countries. But this work is underfunded, despite big demand from countries.

COST-EFFECTIVENESS ANALYSIS

Tractability: How can a philanthropic funder help to make progress on this problem? Can you estimate what impact per dollar you would expect for different types of interventions?

Most countries do not tax alcohol at high enough levels to significantly reduce consumption and related harm, according to the Task Force on Fiscal Policy Health Policy. For instance, average cigarette excise taxes account for about one-third of price (32%) in low- and middle-income countries, and about one-half (48%) of price in high-income countries (WHO 2017b). For comparison, alcohol excise taxes tend to be much lower than tobacco taxes, averaging less than 20% of retail price (among 74 countries reporting to WHO in 2012; WHO 2014a).

The Task Force on Fiscal Policy for Health reported in 2019: Extensive evidence shows that increasing tobacco and alcohol prices reduces demand. On average, in low- and middle-income countries, a 10% increase in price results in a 5% decline in tobacco consumption (NCI 2016), a 6% decline in alcohol consumption (Sornpaisarn et al. 2013). 

Higher alcohol prices and taxes lead to reductions in motor vehicle crashes and fatalities; deaths from liver cirrhosis and alcohol dependence; cases of sexually transmitted diseases; homicides, rape, robbery, child abuse, and spousal abuse; and workplace accidents. One review of 50 studies that examined the impact of taxes and prices on various harms caused by alcohol concluded that a 10% increase in alcohol taxes was associated with a 3.5% decline in all harms associated with alcohol-related disease and injuries (Wagenaar et al. 2009).

For alcohol, experience raising taxes is more limited compared to tobacco taxation, but the existing evidence suggests significant opportunities for health and revenue impact. Few interventions have the power to save this many lives with a relatively simple policy instrument, and the projected additional revenues from tax increases are substantial.

• Increasing taxes on alcohol will avert 9 to 22 million premature deaths over the range of tax increases studied (Table 2). Alcohol taxes can bring in the most additional revenue in large part because alcohol taxes are currently low and consumption is widespread.
• Over 50 years, a tax that increases alcohol prices by 20% over current levels could generate almost US$9 trillion in additional revenues in present discounted value; for a 50% increase, the gain could be almost US$17 trillion in additional revenues – 3 times more than the BRICS country governments collected in revenues in 2017 (US$5.4 trillion).

Cost-effectiveness analysis for the case of Sri Lanka

We have identified several promising countries to launch a program for raising public health-centered alcohol taxation, including Sri Lanka, South Africa and Burundi (for full exercise see here) and after talking to experts from both the effective altruism and alcohol policy field, we decided to model our first intervention for the case of Sri Lanka.

In Sri Lanka, alcohol causes more than 270.000 DALYs and places  a heavy  burden on the health system. According to a study published in 2018, the estimated present value of current and future economic cost of alcohol-related conditions for Sri Lanka in 2015 was USD 885.86 million, 1.07% of GDP. The direct cost of alcohol related disease conditions was USD 388.35 million, which was 44% of the total cost, while the indirect cost was USD 497.50 million, which was 66% of the total cost. 

We have calculated  the cost-effectiveness of our intervention - promoting, imposing or increasing alcohol excise taxes. This is consistent with the World Health Organization’s best buys to prevent and reduce alcohol harm in which they rank Alcohol Taxation as number one.

Some important assumptions in our CEA are the following:

• Increase in excise tax rate by 50% (in June 2019, government indicated a need to index taxes in relation to inflation and make the excise tax public health oriented instead of revenue oriented)
• Alcohol price elasticity of -0.50 (i.e. 10% increase in price, decreases consumption by 5%)
• It takes between 3-5 years to pass alcohol taxation legislation
• We assume our initiaitive would be responsible for 75% that such legislation is passed
• A probability of success in Sri Lanka (reflected in our geographic assessment too) is 30%
• Other figures can be consulted in the CEA
• A moral weight equating 2.8 years of income to one DALY

Info BOX: All of the above suggest that our intervention has the potential to be highly cost-effective. In Sri Lanka, we could avert 25,700 DALYs for $128 per DALY with a Benefit:Cost ratio $83.94.

Cost-effectiveness analysis for Sri Lanka shows that  our intervention (raising alcohol excise taxes) has the potential to be highly cost-effective with a Benefit:Cost ratio of $83.94. We could avert 25,700 DALYs for $128 per DALY.

See CEA: https://docs.google.com/spreadsheets/d/16gleyq3OybCkkvMHqYH9llO0HXG1j9FnxTBeF6vUucM/edit#gid=1968067396 

POSSIBLE INTERVENTIONS

The intervention is to  advance high-impact alcohol taxation. To do this, we want to work with the triple E for triple win of alcohol taxation approach.

1. Elevate the public discourse about alcohol harm and alcohol taxation as solution. Here we plan to apply evidence-based insights and strategies from social psychology and behavioral economics to shape a public discourse that fosters understanding of the harm due to alcohol and the potential of alcohol taxation as the single most cost-effective intervention.
2. Empower civil society advocacy: community-based and other civil society organizations need more capacity to voice their concerns and create political commitment to develop high-impact alcohol taxation. Here we plan to foster advocacy rooted in the evidence of value-based health promotion messaging, framing, and communication.
3. Enhance government capacity for alcohol taxation: we plan to collaborate with WHO and UNDP to improve the evidence base underpinning alcohol taxation in concrete countries, for example through developing investment cases for alcohol taxation, revenue projections, and reports about current and future tax structures and tax shares of product prices. These deliverables will be used to create a whole-of-government approach to alcohol taxation.

We are prepared to face and overcome  potential opposition from some government sectors and the alcohol industry.  But the time is now to advance alcohol taxation as a public health priority solution. Growing focus on promoting sustainable development, achieving Universal Health Coverage and building back better after the COVID-19 pandemic, is causing greater interest, need and commitment to explore and unlock the potential of alcohol taxation to mobilize domestic resources.

This intervention is designed to advocate for more effective public health centred alcohol taxation to prevent death and harm, improve health and foster economic growth. We aim to become the global center of excellence in the field of developing and implementing alcohol taxation. Our ambition is to provide partnership to governments, assistance to local civil society advocates and thought leadership to advance alcohol taxation and increase recognition of its potential. 

Our intervention is based on a combination of three public policy making models: Kingdon's multiple-streams framework, the “Stages Model” of public policy making and the Triangle that moves the mountain.

By combining the three models we have developed our tailor-made, innovative and comprehensive approach for the advancement of alcohol taxation in low income countries.

Urgency - Demand - Response

Through the work of Movendi International, we understand that there is growing demand from governments for capacity building and technical support in alcohol taxation. The matter is becoming urgent but there is insufficient response to government needs and demand. For example, the WHO has very long decision-making processes about which country to support and how to engage. Moreover, the WHO also lacks resources. 

This intervention is designed to respond swiftly to this demand. Our work to quickly respond and provide support will highlight  that there is a need for capacity building and technical support for alcohol taxation.

Working for the biggest impact - saving lives

There is currently no organisation that is dedicated to advancing alcohol taxation on the national level. This intervention can focus exclusively on the most effective alcohol policy solution to make the biggest difference possible through a targeted and proven intervention. 

Creating momentum

This interventions is designed to work exclusively on one issue in one country to solve one problem (respond to the demand) proving that it can be done to advance alcohol taxation and save lives in doing so. By that, this intervention will create more demand and also enable more impact which will lead to the mobilisation of more resources for the cause - domestically and likely also internationally. The intervention seeks to create this type of momentum for alcohol taxation.

Preparing the ground

Bigger initiatives that go beyond alcohol taxation and for example work with the whole WHO SAFER technical package for alcohol policy can come in as countries have mobilised resources for more action/prevention/health promotion through alcohol taxation improvements, facilitated by this intervention.

Theory of change

Our ultimate goal is to save lives by preventing and reducing alcohol harm in three dimensions:

• improved individual health,
• reduced societal externalities, and
• improved economic outcomes.

In order to achieve this, we aim to reduce alcohol consumption by reducing alcohol affordability (i.e. increasing taxes). In supporting and assisting alcohol taxation legislation processes all the way from the initial idea to the implementation we need to generate political action.

We assume the primary bottleneck to be the Ministry of Finance. We plan to address it through similar measures as tobacco prevention advocates applied in their advocacy campaign. For example, they pointed at the deficit in the state budget and calculated how much of that would be covered by proper tobacco tax. They partnered with other civil society organisations representing different groups, such as teachers unions who were harmed by the budget deficit and together created pressure on the ministry to act in the best interest of the people and not the tobacco industry.

Another approach we plan to apply in our advocacy is to expose the practices of the alcohol industry  and to raise awareness about conflicts of interest regarding alcohol industry involvement in alcohol policy making processes.

This intervention will primarily advocate towards and partner with governments, especially ministries of health and finance. If social mobilisation is needed, we will cooperate with various established civil society organisations that represent the needs and voices of beneficiaries. To generate the data  and evidence needed for compelling advocacy initiatives, we will collaborate with academic institutions.

The knowledge base will include (case study for one country, applicable to all intervention countries):

​​1.    The current alcohol taxation system in Sri Lanka

2.   Acts and regulations related to alcohol taxation

3.   What are the government departments/ministries that have the authority to take decisions on alcohol taxation?

4.   Number of alcohol manufactures in the country and the market share of each company and number of liters manufactured each year.

5.   What factors they consider when deciding the tax?

6.   What taxes determine  the price of alcoholic products?

7.   What is the taxation system for local liquor and foreign liquor?

8.   What is the formula, mechanism or a methodology applied for deciding the amount of tax?

9.   Tax increase in last three years?

10. Is there a different taxation system for different alcoholic beverages such as beer, arrack, toddy, and others?

11. What tax reductions were given for alcoholic beverages in the past and what made the government to grant such tax reductions?

12. Current alcohol harm in Sri Lanka? How much does it cost?

13. What would a tax increase mean for the country? What would the benefits be?

a.   When would the tax reform start bringing fruits?

b.   How many lives would be saved?

c.   How many DALYs saved?

D. Which SDGs would be positively affected?

14. How much would the Sri Lanka government need to pay for the tax reform and enforcement?

You can access our full Logical framework here.

Geographic focus

We have conducted  a thorough country ranking analysis to determine where to focus our intervention in three steps.

First, we took into consideration, among others, population, alcohol use per capita among users, DALYs and deaths caused by alcohol harm and alcohol consumption in all countries of Sub-saharan Africa and South Asia.

The top 25 countries from the first step were processed in the second step in which we examined the landscape for alcohol policy regulation. We scored countries considering corruption index, democracy index, ease of doing business but also for the policy conditions such as next election date, alcohol industry interference  and civil society capacity and readiness.

In the final, third step, we discussed with experts in the field of alcohol policy advocacy who have indicated that some countries may be particularly keen to introducing or increasing excise taxes on alcohol (e.g. Sri Lanka article) and learnt that some countries would be targeted by larger grants (GiveWell through Vital Strategies; Norwegian government supporting a WHO SAFER country mission) and need greater investment in order to successfully introduce an effective alcohol taxation system. We have excluded these countries from the final selection.

Through these three steps, we have identified several promising countries, including Sri Lanka, South Africa and Burundi (for full exercise see here) and after talking to experts from both the CE and alcohol policy field, we decided to start our first intervention in Sri Lanka.