Challenges and way forward for implementation of sugar taxation in the Middle East and North Africa (MENA)

Background: Over consumption of added sugar beyond the World Health Organization (WHO) recommended level of 10% of daily energy intake has well-established negative health consequences including oral diseases. However, the average consumption of added sugar in the Middle East and North Africa region (MENA—World Bank's regional classification) is 70% higher than the WHO recommended level. Imposing taxes on added sugar has been proposed by the WHO to decrease its consumption. Yet, only 21.6% of the total MENA population are covered by taxation policies targeting added sugar. Challenges: Well-recognized challenges for the implementation


| SUG AR TA X ATI ON P OLI CIE S IN THE MENA REG I ON
Refined sugar, commonly known as 'added sugar', is a commodity that has been described as addictive in the neuroscience literature. 1,2[8][9] Over consumption of sugar is strongly linked with noncommunicable diseases (NCDs), including oral diseases, and can be tackled with different public health interventions including fiscal measures such as targeted sugar taxes of ultra-processed foods and sugar-sweetened beverages (SSB-the most common source of added sugar intake). 9,10practical manual to guide SSB taxation policies was issued by the WHO in 2022. 11Yet, only seven (Morocco, Tunisia, Saudi Arabia, United Arab Emirates (UAE), Qatar, Bahrain and Oman) out of the 19 MENA countries (36.8%) have imposed SSB targeted taxation (Figure 1). 12-14This covers 21.6% (n = 102.9 million) of the MENA population (n = 475.4 million), 3 leaving MENA as the third least covered region by SSB taxation policies after North America and East Asia. 13Moreover, taxes on ultra-processed food rich in fat, sugar and salt is greatly overlooked in MENA with only Tunisia implementing it. 15

| CHALLENG E S IN IMPLEMENTING SUG AR TA X ATI ON P OLICIE S AND THE 3i FR AME WORK
There are many challenges facing the implementation of sugar taxation policies in the MENA region (Figure 2).These may be fitted within the 3-i policy development framework (3iF): Interest, Ideas and Institution which was previously used in exploring the policies for human immunodeficiency virus (HIV) control and prevention. 16,17terests are the agendas of stakeholders.If powerful stakeholders would gain from a policy, the policy is likely to be implemented.Ideas include perspectives on actual or hoped-for realities as understood by the stakeholders.Whether and how much the ideas are translated into policies is affected by cultural attributes, and for professional groups is affected by education and training.Institutions include the organizational factors through which policies are implemented including the type of government and the control different units within the government have on policy implementation.In this context, path dependence, which refers to processes where past events or decisions constrain later events or decisions, or simply put 'the resistance to change', is an important aspect that affects institutional commitment to change.Institutions are more likely to continue a policy path if there is a high cost for changing this policy. 16oking at the 'interest' domain, one of the standard challenges refers to the powerful food and beverage (F&B) industry influence on policy making through lobbying, research spending and generally using the 'SCARE tactics' (S: sowing doubt by discrediting science and diverting attention, C: court and legal threats, A: anti poor rhetoric, R: revenue instability, and E: employment impact for the F&B industry workers) to argue against added sugar taxation policies. 11e additional MENA-specific hurdle to implementing added sugar taxation could be the policy makers' hesitancy and/or inherent fear of protests and civil unrests in reaction to increasing the prices of basic commodities.For example, in 1977 in Egypt, riots occurred when the government increased the prices of sugar, rice, cooking gas, tea, cooking oil and bread. 18The government quickly reversed these policies to contain the riots. 19In January 2011, protesters in Jordan took to the streets to express their frustration with the increasing prices of sugar, flour and rice. 20Similar protests for the same reasons at the same period were observed in Tunisia, Algeria and Libya. 20,21me of these demonstrations turned into a massive uprising and a revolutionary movement labelled 'The Arab spring' in 2011 in Tunisia, Egypt, Libya, Syria and Yemen. 22Other public outcries over increased price of sugar occurred in Egypt in 2016 and 2024 23,24 and in Iraq and Tunisia in 2022. 25,26These incidents might lead policy makers to avoid risk by not imposing targeted added sugar taxation to maintain political stability in an already unstable region, 27 especially considering the high degree of government mistrust, limited official information sharing and low health literacy among the MENA population. 27,28Also, considering the income diversity within MENA, it seems that income-wealthy Gulf Cooperation Council (GCC) countries are ahead in implementing targeted sugar taxes compared to other lower-income countries in the region, except for Morocco and Tunisia (Figure 1).Theoretically, this could be partly attributed to the relative affluence and higher incomes in the GCC countries that may lead to more modest concerns and public reactions to the rising prices of refined sugar products through taxation in these societies compared to those in poorer countries.
Focusing on the 'ideas' domain, the cultural habits and lifestyle in many MENA countries may be seen as supportive of sugar consumption, thereby presenting a challenge for sugar taxation policies implementation.MENA is the third leading region, after the Americas and Europe, in obesity among adults 29 and the leading region in diabetes. 30,31Ultra-processed foods and SSBs are considered essential and affordable treats in a resources-limited region despite their health risks. 8,32These consumption behaviours can be further fuelled by attractive marketing strategies utilized by F&B industry (such as reduced price for super-size servings). 33Moreover, the SCARE tactics can mobilize and amass a negative public sentiment health policy, Middle East, North Africa, public health dentistry, sugar-sweetened beverage, taxation towards any proposed taxation. 1,2,11On the contrary, (oral) healthcare providers in the MENA region receive minimal training on health policies during their undergraduate studies. 34This hinders them from advocating for sugar taxation policies as they do not consider it a professional responsibility.
The institutional domain of the 3iF may shed further light on the limited progress among MENA countries in implementing sugar taxation.In some countries, such as Egypt, governments have traditionally used subsidies to ensure the availability and affordability of added sugar.This has continued even after the current economic crisis and currency devaluation, and added sugar is currently available at prices below the international average. 24,35Path dependence and population expectations would further hinder policies that increase added sugar price through taxation after decades of keeping its price low.This is especially relevant during the current global economic and geopolitical turbulence and food supply chain F I G U R E 1 Existence of tax on sugar-sweetened beverage (SSB) in the Middle East and North Africa (MENA).Data source: World Health Organization's (WHO) Global Health Observatory (GHO) 2021 data, and the World Bank 2023 data.*There was conflicting evidence on whether Iran is covered by SSB targeted taxation.The World Health Organization's (WHO) Global Health Observatory (GHO) 2021 data showed that Iran was covered by at least one form of SSB-targeted taxation without mentioning the details about this form of tax. 12On the contrary, the World Bank 2023 data showed that Iran was not covered by any form of SSB targeted taxation. 13,14I G U R E 2 Summary of the challenges and ways forward for implementation of sugar taxation in the Middle East and North Africa (MENA) based on the 3i framework.instability that has already led to increased prices for basic commodities including sugar. 23,24

| WAY FORWARD FOR IMPLEMENTING SUG AR TA X ATI ON IN THE MENA REG I ON
The above-mentioned challenges indicate that implementing sugar taxation will be a 'hard sell' in the MENA region, but the 3iF can also help with deciding the way forward to address these challenges (Figure 2).On the 'ideas' front, it is important to raise public awareness about the health and oral health risks of over consumption of added sugar in the local lay language/dialect to help counter the misinformation and distrust of scientific evidence.This may be particularly relevant in rural populations that are generally characterized by lower educational level and higher consumption of SSB compared to urban populations in the MENA region. 6,36At the same time, (oral) healthcare professionals need training on science communication and policy advocacy so that they are better equipped to engage with policymakers and the public.Ideally, science communication should also be informed by evidence about the expected health/oral health benefits of sugar taxation derived from studies conducted in the local setting.
To stimulate the 'interest' of stakeholders, transparency is needed during policy development by informing the public about the driving factors behind the proposed tax and future spending of the collected revenues. 37Interest and ownership can also be promoted by fostering a free and safe environment for a community dialogue to further facilitate stakeholder interest and ownership and build a civil coalition to drive taxation policy implementation. 11Last, 'institutional' support requires using an appropriate political window of opportunity to introduce the sugar tax while considering the economic situation.It is also essential to enact clear and strict conflict of interest regulations that promote transparency in the public debate and limit any undue influence of commercial players on health policy.All these require the strong commitment and support of a healthoriented political leadership.
The influence of F&B industry on added sugar taxation policies is undeniable.However, the MENA region has further specific challenges that hinder the implementation of targeted sugar taxation policies in the region.Although there are differences across MENA countries in both sugar consumption patterns and instigation of sugar taxation policies, some regional commonalities exist.A general political hesitancy to introduce bold public health policies and tendency to maintain the status quo, even to the extent that governments commit to subsidize added sugar are challenges specific to the MENA that need to be addressed.These are further compounded by cultural barriers and consumption behaviour towards added sugars, and the general lack of health policy advocacy among (oral) healthcare providers.
There are feasible ways forward and political leadership is essential.After all, population health is a political issue affected by a wide range of policies, far extending the healthcare system.