the “fat tax” in kerala state, india: a case...

CASE STUDYAugust 2019

PROJECT DATA

PARTNER ORGANIZATION:World Bank

ORGANIZATION TYPE:Multilateral

DELIVERY CHALLENGES:Project Design, Macroeconomic Environment, Coordination, Monitoring

DEVELOPMENT CHALLENGE:Prevention and Control of Obesity

SECTOR:Health

COUNTRY:India

REGION:South Asia

CONTACT

CASE AUTHORS:Arun B Nair, Suresh K Mohammed

TABLE OF CONTENTS

Introduction . . . . . . . . . . . . . . . . . . . . . . 2

Context . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Development Challenge:

Tackling Rising Obesity Rates . . . . . . . . 4

Policy formulation and

implementation . . . . . . . . . . . . . . . . . . . 6

Formulation of the Policy . . . . . . . . . . . 8

Delivery Challenges . . . . . . . . . . . . . . . . 9

Impact of Policy Implementation . . . . 11

Lessons Learned . . . . . . . . . . . . . . . . . 11

Conclusion . . . . . . . . . . . . . . . . . . . . . . 12

Annex 1 Name and Designation

of Interviewees . . . . . . . . . . . . . . . . . . . 13

Annex 2 Timeline . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . 15

AcknowledgmentsThis case study was prepared by Arun B Nair and Suresh K Mohammed as part of a Global ASA report on the Prevention and Control of Obesity. Many people contributed to the preparation of this case study, and thanks are due for their contributions, starting with the stakeholders and experts who graciously gave their time in interviews to help develop the story that became this case study. Suresh K Mohammed, as the Task Team Lead, provided invaluable support in liaising with government counterparts, reviewing drafts, and ensuring a smooth clearance process. The authors thank Mr. Rajeev Sadanandan, Additional Chief Secretary-Health, Government of Kerala (GOK), for his guidance and support to the preparation of this case study. Maria Eugenia Bonilla-Chacin served as the Principal Investigator and provided helpful insights and guidance throughout the preparation of the case study. Linda Brooke Schultz also provided technical oversight, extensive guidance, and review at every stage of the case study. Jacob Bathanti reviewed many drafts and provided guidance during the writing process. On the GDI team, Sruti Bandyopadhyay and Claudio Santibañez provided review and support. Financial support for this work was provided by the Government of Japan through the Japan Trust Fund for Scaling Up Nutrition.

PrefaceThe soaring prevalence of obesity, and the non-communicable diseases (NCDs) associated with it, is increasingly becoming one of the main public

The “Fat Tax” in Kerala State, India: A Case Study

GLOBAL DELIVERY INITIATIVE

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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. The countries included in the series span World Bank regions and income levels, including Brazil, Chile, India, Mexico, Poland, Thailand, Turkey, Sri Lanka, and South Africa. The nine case studies were developed utilizing a casestudy methodology developed by the Global Delivery Initiative (GDI). GDI is a collaborative effort to create a collective and cumulative evidence base of delivery know-how to inform development practice and improve implementation. For each case study, the methodology was tailored to highlight the factors that supported and hindered the design and implementation of obesity prevention policies in each individual country. This series aims to answer three key questions within the analysis: (1) the development challenge, the overall problem the country was aiming to solve; (2) the delivery challenge, the experiences that hindered the policy design and implementation from achieving its full potential; and (3) the inflection points that stalled or progressed the momentum gained throughout the process. Each case study is based on peer-reviewed literature, publicly available government documents, a review of mass media advocacy campaigns, and in-person qualitative interviews with a broad range of key stakeholders.

Maria Eugenia Bonilla-Chacin

IntroductionKerala, the southernmost state of India, has consistently performed well on the human development index (Institute of Applied Manpower Research, Planning Commission, 2011). The health development model of the state in the last few decades has been described as “good health at low cost” (Panikar 1992), producing health outcomes that were on par with more developed and wealthier nations. However, the changing disease profile of the state in the last two decades, with an increasingly high burden of obesity and non-communicable diseases (NCDs), poses a significant challenge to Kerala’s story of human development.

The Kerala government responded to this challenge with a multipronged approach. In 2010, it was one of the first states in India to adopt the national program for control of diabetes, cardiovascular diseases, and stroke (NPCDCS) on a limited basis, and later expanded it to the whole state using its own financial resources. Early diagnosis, treatment, and behaviour change were the corner stones of this program. In 2016, it launched a new program through local self-governments to encourage life style modifications in the population. The latest intervention by the government was the introduction of the “Fat Tax,” a fiscal policy that levied an additional tax of 14.5 percent on purchases of unhealthy food items to disincentivize consumption .

This case study documents the evolution and implementation of the Fat Tax policy in order to understand the context and processes that facilitated or hindered its implementation. The case study examines how the policy was designed and implemented, and documents various stakeholders’ perspectives on it.

ContextNotwithstanding its low rate of economic growth and low per capita income relative to other Indian states, Kerala stands out for its high level of human development and has been ranked first among the states of India on the human development index (Institute of Applied Manpower Research, Planning Commission, 2011). The state’s achievements on health indicators from the 1950s to the 1990s is attributed to diverse factors such as the spread of education, political awareness, development of roads and transportation, social movements, and most importantly, the consistent and unwavering support of successive governments for the development of health infrastructure

The “Fat Tax” in Kerala: A Case Study

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(Kutty 2000). The table below compares a few development indicators of Kerala to the national average.

However, since 1990s Kerala has been passing through a phase of health transition, which is comprised of three elements: demographic, epidemiological, and health care. With a fertility rate of 1.8, which is much below the national fertility rate of 2.2, Kerala is far ahead of India’s other states in demographic transition (International Institute for Population Sciences 2015). The decrease in birth rate and death rate, also has given rise to the phenomenon of “population aging,” an increase in the proportion of people aged above 60 years. Since 1971, the decrease in crude birth rate of Kerala has been much more pronounced than the decrease in crude death rate. Consequently, the percentage of aged population in Kerala is higher than most other states. In 1961, Kerala had an elderly population of 2.2 million which increased to 4.2 million in 2011 and the old age dependency ratio in the state is 10.4 percent (MOSPI 2016). According to the 2011 census, Kerala had the highest proportion of elderly population (12.6 percent) among all states of India.

Along with demographic transition, Kerala is witnessing a change in its disease profile. Over the years, there has been a marked decline in the share of infectious diseases in the overall disease burden of the state (State Planning Board 2015). On the other hand, the prevalence of non-communicable disease has increased compared to communicable diseases. NCDs include cardiovascular disease (which includes heart attacks and stroke), diet-related cancers,

chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma) and diabetes. Among these, cardiovascular diseases (CVD) and diabetes are reported to be very high in Kerala. According to Soman et al. (2010), age-adjusted coronary artery disease (CAD) mortality rates per 100,000 in Kerala were 382 for men which are higher than those of industrialized countries.1 Further in Kerala, 60 percent and 40 percent of CAD deaths in men and women respectively occurred before the age of 65 in the state. Around 35,000 cancer cases are detected every year in Kerala and nearly 100,000 people are under cancer treatment annually (State Planning Board 2015). The number of cancer cases being treated by the Regional Cancer Centre of Kerala alone has increased significantly from 3,696 in 1982 to 14,995 in 2012–12. Various studies have reported that 31 percent, 15.9 percent and 9.8 percent of elderly in Kerala suffer from hypertension, diabetes and heart problems, respectively (State Planning Board 2012). The progressive aging of the population, changing life styles, and migration to other countries have all contributed to this change in disease burden (Panikar 1999).

Kerala is also facing transition in its healthcare sector with rapid growth of the private health care system. In the late seventies and early eighties, the state saw a significant increase in public health infrastructure especially in curative care. However, in the aftermath of economic liberalization2 in the 1990s, there has been an overall decline in the utilization of government health care facilities (Kunhikannan, Aravindan, and Nair 2000; Varatharajan, Sadanandan, and Nair 2002). The non-availability of basic services in government hospitals, especially in rural areas, has been crowding out patients and prompting them to seek care from the private sector (Jeemon 2002). At present, the private sector dominates heath care service delivery in the state with more than 65 percent of the population seeking inpatient and outpatient care services from this sector (NSSO 2015).

1 For example, the mortality rate for coronary artery disease per 100,000 population in Germany for men was 237 in 2013 according to the Global Burden of Disease data.

2 In the year 1991, India faced a balance of payment crisis which forced the government to initiate economic reforms in the country often referred to as ‘economic liberalization.’ The goal of economic reforms was to make the economy more market-oriented and expand the role of private and foreign investment. Liberalization heralded a number of changes including a reduction in import tariffs, deregulation of markets, reduction of taxes, and greater foreign investment. The economic reforms were aimed at ending the licensing system by decreasing the government intervention in the business, thereby pushing economic growth. It discouraged public sector monopoly and paved the way for competition in the market. This policy marked a sharp departure from the socialist public sector led economic policies pursued until then.

Table 1 Comparison of development indicators of Kerala with India – 2011

Development indicator India Kerala

Total Populationa 1,210,854,977 33,400,000

Female Literacy Rateb 65 .50% 95 .07%

Sex ratioc 943 1058

Life expectancy at birthd 67 .9 74 .9

Total Fertility rate (TFR)e 2 .3 1 .8

Source: Census 2011, NITI AYOG,2018a Total Population in absolute numberb Literacy Rate amonge females calculated excluding the population in the age group of 0–6 from the female populationc Number of female per 1000 of male populationd Number of years a newborn infant would live if prevailing patterns of mortality at the time of its birth were to stay the same throughout its lifee The average number of children expected to be born per woman during her entire span of reprodeuctive period, assuming that the age-specific fertility rate to which she is exposed continue to be the same and that there is no mortality


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Development Challenge: Tackling Rising Obesity RatesGlobally, India is ranked 5th for the most number of obese men in the world and 3rd in number of obese women according to the global obesity study published in The Lancet (NCD Risk Factor Collaboration (NCD-RisC) 2016). A recent study published in the New England Journal of Medicine on health effects of overweight and obesity in 195 counties points to the fact that India and China accounted for the highest number of obese children in the world (Gregg and Shaw 2017). Among all the states of India, Kerala is ranked second highest in terms of prevalence of obesity according to the 4th round of the National Family Health Survey held in 2015–16 (International Institute for Population Sciences 2015).3 Table 1 compares the trends of overweight or obesity in Kerala and India as a whole.

In their analysis of the reasons for the increasing obesity in Kerala, Sivasankaran and Thankappan (2013) underscored factors such as a transition in dietary habits of the people,marked by consumption of processed and marketed products high in salt, sugar and saturated fats, and reduced physical activity due to sedentary life styles. The study also highlighted the presence of an “obesogenic environment” in Kerala due to a very high consumption of products high in salt, sugar, and saturated fats. Even though dietary habits differ across regions, religions, and castes, most of the population consumes rice, fish, meat, and dairy products. Coconut and lentils are consumed extensively, as accompaniment to rice based food preparations. The dietary pattern is heavy in saturated fats because of the regular use of fresh, grated coconut and, to a lesser extent, coconut oil.

Another reason for the rising prevalence of overweight and obesity in the state is the fact that majority of Keralites consume at least one dish containing meat or fish every day and their overall calorie consumption has increased by 400 calories in the last three decades (Sivasankaran and Thankappan 2013). Consumption of fish and marine products, although high in the state, has not been credited with any beneficial effect because of the widespread habit of deep-frying. Studies have also documented a very

low per capita consumption of fruits and vegetables in the state. Kerala’s average salt consumption, at 25 to 35 grams per day, is five to six times higher than the WHO recommended level (Maya 2013; Sivasankaran 2013). This is also quite high when compared with the overall Indian average salt consumption of 10.98 grams per day (Johnson et al. 2017).

There is also an increasing trend of consuming traditional bakery products from local bakeries and fast food restaurants, which is contributing to the increasing rate of obesity in the state. (Daivadanam et al. 2015). The food products sold in bakeries have a high trans-fat content as hydrogenated oils are used for their preparation. This can lead to premature hypertension, lipid, and sugar problems early in life and increases the risk of chronic disease (Sivasankaran 2010). Though the Food Safety and Standards Authority of India (FSSAI) has passed a regulation restricting trans-fat to less than 5 percent in hydrogenated oils, there are no regulatory mechanisms to assess and monitor the trans-fat content of bakery products nor are there effective laws to regulate their sale.

The rising burden of non-communicable diseases (NCDs), driven in large part by the high prevalence of obesity, is a major challenge faced by Kerala’s health system. The 71st round of National Sample Survey Organisation (NSSO 2015) reported that both rural and urban areas of Kerala have high levels of morbidity compared to other states with a high prevalence of NCDs (NSSO 2015). Cardiovascular diseases, hypertension, diabetes, and cancer are the leading causes of morbidity in Kerala (NSSO 2015). The overall prevalence of CVD risk factors was 50–100 percent higher in Kerala than the national average, with a narrower urban-rural gradient (Thankappan et al. 2010)anthropometric risk factors with behavioural risk factors; (iii. The Kerala Sasthra Sahithya

3 The NFHS survey considers people having Body Mass Index (BMI) more than 25 kilogram per meter square as overweight or obese. The age range is 15–54 years for men and 15–49 years for women.

Table 2 Trends in overweight or obesity — Comparison between India and Kerala

India Kerala

Males (%)

Females (%)

Males (%)

Females (%)

Rural 14 .3 15 .0 26 .3 31 .5

Urban 26 .3 31 .3 31 .1 33 .5

Total 18 .6 20 .7 28 .5 32 .4

Source: NFHS 4th Round 2015–16 .


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Parishad (KSSP)4 surveys ranked cardiovascular diseases as one of the leading causes of death in Kerala followed by cerebrovascular diseases. Prevalence of diabetes ranges from 11–19 percent in men and 15–22 percent in women with the rural population having paradoxically higher rates of diabetes than urban dwellers (Thankappan et al. 2010)anthropometric risk factors with behavioural risk factors; (iii. Only 20 percent of the diabetics in the state are treated and adequately controlled. The age adjusted prevalence of Type 2 Diabetes Mellitus for the whole of India is 8 percent, but for Kerala, the average is 14.3 percent for men and 17.8 percent for women. As regards hypercholesterolemia, hypertension, and overweight the prevalence for men and women respectively in Kerala are 51.4 percent and 61.5 percent, 33.9 percent and 31.6 percent, and 23.9 percent and 37.5 percent (Daivadanam et al. 2013).

According to the state level disease burden report published as part of the Global Burden of Disease (GBD) study, 74.6 percent of the total disease burden in Kerala in 2016 was attributable to NCDs (ICMR, PHFI & IHME 2017). In terms of Disability Adjusted Life Years (DALYs), Ischemic Heart Disease (12.2 percent), Sense Organ Diseases (4.6 percent), COPD (4.4 percent), Stroke (4.2 percent) and Diabetes (4.0 percent) were the five leading causes. Dietary risks (11.2 percent) and high body mass index (7.6 percent) were amongst the leading risk factors contributing to DALYs in the state.

Treatment of NCDs is much more expensive compared to other diseases due to hospitalization, continuous medication and requirement of diagnostic tests, involvement of specialists, and use of modern technology. The average out-of-pocket expenditure for inpatient treatment for NCDs is two times as compared to that of non-NCDs whether in public or private sector. The State Health Accounts 2013–14 estimates that more than 40 percent of the out-of-pocket expenditure was incurred for treatment of NCDs, of which around 45 percent was incurred during hospitalization and 37 percent during outpatient services (Mukopadhyay et al. 2016).

4 Kerala Sastra Sahitya Parishad (KSSP) literally means “Kerala Forum for Science and Literature” and was founded in 1962. It is a mass based movement for promotion of science and has a membership of around 40,000 drawn from all walks of life. KSSP published the first health study titled “Health and Development in Rural Kerala in 1987. Follow up studies were done in 1996, 2004 and 2011.

Figure 1 Ranking of top ten risk factors contributing to DALYs in Kerala 1990–2016

Source: (Page No 134; India: Health of Nation’s States, ICMR, PHFI & IHME 2017) .

Risk factors 1990

Malnutrition* [17.4%]

All pollution [9.3%]

Dietary risks [8.1%]

High blood pressure [7.9%]

Tobacco use [6.5%]

High fasting plasma glucose [5.9%]

High total cholesterol [4.0%]

WaSH** [3.3%]

Occupational risks [3.0%]

Impaired kidney function [2.8%]


Risk factors 2016

High blood pressure [13.4%]


High fasting plasma glucose [11.1%]

High body-mass index [7.6%]

High total cholesterol [7.0%]

Tobacco use [6.9%]

All pollution [6.2%]

Impaired kidney function [4.8%]

Malnutrition* [4.4%]

Occupational risks [3.7%]

WaSH** [1.3%]

The percent �gure in brackets next to each risk is DALYsfrom that risk out of total DALYs.

* Malnutrition is child and maternal malnutrition.** WaSH is unsafe water, sanitation, and handwashing.

Behavioural Environmental/occupational Metabolic Same or increase Decrease

1

2

3

4

5

6

7

8

9

10

12

1

2

3

4

5

6

7

8

9

10

13


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The high burden of NCDs and the high out-of-pocket expenditure for treatment of these diseases (amounting to catastrophic levels) has prompted several policy responses to prevent and control NCDs in Kerala. One of the most significant among them was the Fat Tax, a fiscal policy that sought to bring about behavioural change in peoples’ food habits by disincentivizing unhealthy foods served in restaurants. This case study looks at the evolution of policies on NCDs in Kerala and does an in-depth analysis of the formulation and implementation of the Fat Tax policy bringing interesting insights into the process. The case study also offers critical lessons for other countries with similar contexts.

Policy formulation and implementationThough the rising burden of NCDs in Kerala was recognized in the late 1980s, no comprehensive policy was put in place to address this. In 2005, the federal government of India launched the National Rural Health Mission (NRHM) which aimed to correct the architectural defects in India’s health care delivery system. The mission’s objective was to provide accessible, affordable, accountable, effective, and reliable health care facilities to rural areas in India. NRHM established an integrated approach to health by bringing the numerous disease control programs under a single umbrella. But the key focus of NRHM was improving maternal and child health while prevention and control of NCDs was not a priority.

However, recognizing the growing burden of NCDs in the country, in 2010–11 the federal government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The primary objectives of the program were: i) prevention and control of NCDs through behaviour and lifestyle changes; ii) early diagnosis and management of NCDs; iii) capacity building at various levels of health care for prevention, diagnosis, and treatment of common NCDs; iv) training of human resources within the public health facilities to cope with the increasing burden of NCDs; and v) establishment of palliative and rehabilitative care (Directorate General of Health Services, Ministry of Health & Family welfare, and Government Of India 2013). The NPCDCS combines population and high-risk strategies to prevent the NCD

burden. Early diagnosis, treatment, and behaviour change are the key strategies of the program.

Kerala was one of the first states to adopt the NPCDCS in 2010. Initially, the program started in one district and later in 2011 was extended to four more districts. Recognizing the magnitude of the unfolding NCD epidemic in the state, in 2012 the government of Kerala expanded the program to all districts using its own financial resources. The program covers all 230 community health centers (CHC), 835 primary health centers (PHC) and more than 5000 sub-centers (HSC) across the state. As part of the program, all adults above 30 years of age are screened for diabetes, hypertension, and body mass index (BMI) at the Primary Health Center (PHC) for early detection of NCDs. In addition to these clinics, there are outreach facilities to cater the population who are unable to reach the health centers. The patients identified through the screening program are provided regular treatment, investigations and follow up free of cost in Primary Health Centers (PHCs). Further, the program aims to generate behaviour change and awareness from childhood itself as part of early prevention strategies through health education activities as part of the School Health Program. So far over 13.1 million adults above the age of 30 years have been screened in Kerala since the inception of the program and over 2.6 million diabetes patients and 2.9 million hypertension patients are enrolled for treatment under the program (Program Statistics, Department of Health 2017).

Later in 2014, an expert committee of the state planning board, the apex body for developing the policy and planning process in the state, was constituted to give recommendations on key health issues in Kerala (State Planning Board 2014). The expert committee had a diverse mix of policy makers, public health experts and representatives of non-governmental organizations. The committee outlined six priority areas for policy reforms; prevention and control of NCDs was among them. The expert committee advocated a greater role for the public health system in providing preventive and curative services to address the NCD burden and thereby reduce the cost of care. It also urged the government to ensure the availability of essential medicines and diagnostics for treatment of NCDs free of cost in public hospitals and strengthen screening for NCDs at primary health care institutions in the state.

At the same time, consultative meetings of the Left Democratic Front (LDF), a coalition of left of the


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centre political parties, were taking place as part of the preparation of the LDF manifesto for general elections in Kerala which were due in 2016. The consultations on health involved members of academia, public health experts, members of local self-governments and representatives of non-government organisations. The outcome of these consultative meetings was the development of key policy recommendations for the health sector in the state.

After state elections in 2016, a new government led by the LDF was elected to power in Kerala. The election manifesto of LDF identified the priority areas in the health sector and highlighted the increasing burden of NCDs in the state and the need of effective strategies to tackle the disease burden. The new government initiated key policy reforms, including interventions aimed at reducing the burden of NCDs in Kerala. As part of these reforms, the Department of Health declared short and medium-term targets for the health sector. The Sustainable Development Goals (SDG) framework, specifically SDG Goal 3 (Health and Well-Being), was chosen as the reference frame for these goals so that targets finalized by Kerala would be aligned to national and global targets. (SDG Goal 3.4 SDSN 2017). Table 3 depicts the SDG goals used by the Department of Health to set specific targets.

Further, the LDF government introduced the Comprehensive Primary Health Care Program (CPHC),

which transformed the existing Primary Health Centers (PHCs) to Family Health Centers (FHCs). The FHCs are envisaged to provide comprehensive primary care services at the community level with an emphasis on NCD prevention and control activities. The Kerala government also launched a unique grassroots-level program for the prevention and control of NCDs in June 2016. As part of this initiative, government teachers and health workers, as well as students from classes VIII to XII from selected local self-governments in every district are trained to encourage lifestyle modifications among the population in their jurisdiction.

Together with and in the context of these health sector reforms, the LDF government introduced the Fat Tax of 14.5 percent on a set of defined unhealthy foods (Government of Kerala 2016). In an interview, the Finance Minister explained that improving food quality and reducing intake of fatty foods was a priority for reducing the burden of obesity and NCDs in the state. The government’s intention, he said, was to promote traditional healthy foods using the revenue generated from Fat Tax.

“When the discussion happened on using taxation to reduce consumption of fatty food it was decided to start with a symbolic gesture which will trigger a message. The Fat Tax on some of the commodities

Table 3 Target for Reduction of NCD Burden in Kerala based on SDG Goals

Sl. No. Target Topic Outcome Target by 2020 Target by 2030

1 Premature mortality from NCD

Relative reduction in deaths from major NCD before 70 years of age

5% 10%

2 Diabetes Relative reduction in prevalence No target Halt the rise

3 Obesity Relative reduction in prevalence among adults No target Halt the rise

Relative reduction in prevalence among children and adolescents

Halt the rise 20%

4 Physical inactivity Relative reduction in prevalence of physical inactivity

10% 20%

5 Raised blood pressure Detection of raised blood pressure 60% 90%

Proper control of raised blood pressure among detected

50% 50%

6 Healthy diet Relative reduction in mean population intake of salt < 5g/day

10% 20%

Relative increase in mean population intake of fruits & vegetables > 5 servings/day

10% 25%

Source: State Sustainable Development Goals NCD Final Document, dated July 13, 2017 .


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will generate revenue for rejuvenation of traditional healthy food like Jack Fruit.”5

The Fat Tax was levied on burgers, pizzas, tacos, doughnuts, sandwiches, pasta, and bread-fillings (similar to sandwiches) sold by restaurants having a brand name or trade mark registered under the Trade Marks Act, 1999 (Government of Kerala 2016b). Restaurant chains such as Kentucky Fried Chicken, Pizza Hut, Dominos, Chic King, French Fried Chicken, Southern Fried Chicken, and McDonald’s were the primary targets of the new policy. The policy was announced in the first budget of the LDF government on 8th July 2016 and become effective from August 2016. The new tax policy was initiated with an objective to cut down the unhealthy food consumption and was expected to generate an additional tax revenue of around INR 100 million (US$1.522 million)6 (Government of Kerala 2016).

The Fat Tax was introduced as a first major step towards raising awareness on unhealthy foods and bringing in a behavioural change in food habits of the people by disincentivizing consumption of unhealthy food. The Fat Tax also aimed to be an alternative revenue generation source for the state government. The case study captures how the Fat Tax policy in Kerala was designed and implemented, and documents the different stakeholders’ perspectives on how far this policy would help in tackling the burden of obesity in Kerala. The case study covers three specific aspects of this policy reform:

1. How the policy of Fat Tax evolved as a measure to reduce the burden of obesity in Kerala;

2. How the policy formulation was influenced by the views of various stakeholders; and

3. What delivery challenges affected policy implementa-tion, and how they were addressed.

Formulation of the PolicySince the manifesto of the Left Democratic Front (LDF) had given prominence to social sectors such as health and education and clearly prioritized the emerging epidemic of NCDs in the state, there were

high expectations of new initiatives to control obesity and NCDs by the newly elected LDF government as it presented its first budget in July 2016.

These expectations were fulfilled. In India, the budget speeches are used by state governments to announce revenue proposals of various departments and new tax proposals for revenue generation.7 In his budget speech on July 8, 2016, the Finance Minister of Kerala announced the introduction of the Fat Tax on branded restaurants which sold fast foods. This announcement was hailed by policy makers, public health experts, and media as an important measure towards maintaining public health and reducing the burden of obesity in the state.

The groundwork for this policy announcement had been nevertheless laid in the preceding months, after the LDF government came to power. Kerala has a tradition of pre-budget consultations with different trade bodies, interest groups, and the community at large; their suggestions and viewpoints are taken into consideration when new programs and policies are introduced. The pre-budget consultative meetings are systematically undertaken in the metro cities of the state involving all major stakeholders. During these consultations, trade and industry representatives as well as stakeholders present their views on the existing tax structures and proposed new tax instruments and its effect on trade and economic growth. The pre-budget meetings also include internal consultative meetings with officials from different departments when new tax proposals and ways to increase the tax revenues of the state are discussed. In May 2016 the pre-budget discussions between the Commercial Taxes Department and the Finance Minister led to a consensus on taking concrete steps to tackle the increasing obesity levels in Kerala. It was decided to use

5 Author Interview with Dr. T.M Thomas Isaac, Minister of Finance Government of Kerala, March 23, 2017, at Thiruvananthapuram, Kerala.

6 US1= INR.65.68 as per the exchange rate of RBI onApril 19, 2018.

7 The financial year for State and Central Governments in India is from April 1 to March 31, and the annual budget is presented in February or March every year. This process requires a great deal of research and the preparation of the budget begins in the month of September when all the stakeholders are informed, and the notification of the budget is issued. Once the timeline is set with a proper outline of the budget, the Finance department begins consultations with other departments regarding their receipts and financial requirements for the upcoming fiscal year. A broad overall goal for the different sectors of the government is determined by the Finance department. Viewpoints and advice of leading stakeholders including industry, representatives of workers, farmers etc. and other economists are solicited and deliberations are held in this stage of information gathering. Once the information received from various surveys and studies in the previous steps are analyzed, the policy for the budget is made. This process is highly confidential and journalists are restricted from writing about the deliberations when the process is being executed. Secrecy is paramount to the budget making process and the new tax proposals and policies are made known only on the day of budget presentation. Once the budget is announced, the proposals are debated in the Assembly and the budget is passed after due deliberation.


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taxation as an instrument to improve health and reduce the burden of obesity in the state. The Secretary of the Commercial Taxes Department described how public pressure helped push the issue to the fore:

“During the pre-budget discussions, we had asked the public for suggestions. They have been sending us mails to do something about fast foods, especially those run by branded multinational restaurants.” Secretary, Commercial Taxes Department, Kerala (Mint)8

However, only a few stakeholders from the food and beverage industry associations were part of the pre-budget discussions that led to the initiation of the new tax policy. Further, the food industry associations were not consulted before the announcement of the policy, and reported that they heard about the Fat Tax when the budget was announced. Nonetheless, most of industry associations and public health experts felt that it was a welcome move and saw it as a positive step toward the control of obesity by the government.9

In response to the introduction of the Fat Tax, the food and beverage industry associations raised concerns as to why the policy only targeted branded food outlets and not local food outlets and traditional food items even though they were also contributing to the obesity epidemic in the state. In our interviews, key officials of the Commercial Taxes Department said that the aim was to start with food items which are easy to monitor and then slowly expand to cover other food items.10 Yet another criticism was that the left-leaning government’s position with regard to multinationals was reflected in the new Fat Tax policy. In an interview with the authors, the Finance Minister clarified that the Fat Tax policy was not targeting any brand, but the trademark registration meant for registered products, such as burgers or pizzas. The Finance Minister felt that a policy change such as imposing taxation on unhealthy food items should be

implemented incrementally. It would be unwise to target food items which are consumed by a large majority of the population in the beginning itself as it would make the policy unpopular and politically untenable.11 Therefore, it was decided to start with branded products and slowly expand to unhealthy food items sold by bakeries and other local eateries. An industry representative, on the other hand, claimed that the government was trying to diminish the expanding presence of fast food chains to rural hinterlands of the state to preserve the traditional food habits of the people.12

After the announcement of the fiscal policy by the finance minister, the Fat Tax policy was widely covered in the local and national media, and generated debate on measures to control obesity among various stakeholders in both government and the private sector. According to the Finance Minister, the Fat Tax gained more publicity than expected.13 This in turn led to discussions about initiatives in different countries to fight obesity, bringing the issue to the fore and making the public aware of the obesity epidemic in the state. He regarded the public debate as a very positive development and according to him:

“It generated a debate out of the narrow context of the state budget to the wider context of global efforts to control obesity, whether such anti-obesity measures were successful in Denmark? Did Mexico try something similar? It was in the international news. So, it achieved its purpose bringing the issue of obesity to the fore and I was thinking that I will expand it to other food items next year.”14

Delivery ChallengesThe Fat Tax policy faced significant delivery challenges both in its planning and conceptualization as well as in its implementation. In the planning and conceptualization phase there were issues in the design and targeting of the tax levies, as well as in the time sequencing of the

8 Interview with Secretary, Commercial Taxes, quoted in newspaper (Live mint) article titled “Kerala imposes fat tax on burgers, pizzas in budget; published on July 9 2016 (http://www.livemint.com/Politics/aLOL6JxQIWVuO0ZYYFkuoN/Kerala-proposes-fat-tax-on-burgers-pizzas.html).

9 Author interview with Mr. Sudhish Kumar Patron, Kerala Hotel and Restaurant Association;16/03/17 at Thiruvananthapuram, Kerala.; Author Interview with Mr. Antony Thomas, Vice Chairman, Kerala Chamber of Commerce and Industries’ 13th March 2017 at Kochin, Kerala.

10 Author Interview with Dr. Rajan.N. Khobragade IAS, Commissioner, Commercial Taxes, Government of Kerala;22nd March 2017 at Thiruvananthapuram, Kerala.

11 Author Interview with Mr. Antony Thomas, Vice Chairman, Kerala Chamber of Commerce and Industries’ 13th March 2017 at Kochin, Kerala.

12 Author Interview with Mr. Antony Thomas, Vice Chairman, Kerala Chamber of Commerce and Industries’ 13th March 2017 at Kochin, Kerala.

13 Author Interview with Dr. T.M Thomas Issac, Minister of Finance Government of Kerala;23rd March 2017 at Thiruvananthapuram, Kerala.

14 Author Interview with Dr. T.M Thomas Issac, Minister of Finance Government of Kerala; 23rd March 2017 at Thiruvananthapuram, Kerala.


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policy reform. In the implementation phase there were challenges in coordination as well as monitoring.

Planning and Conceptualization PhaseOne delivery challenge in the conceptualization phase was that the definition of food items that were covered under the ambit of Fat Tax was based on the type of Food Business Operator (FBO) rather than the energy density or fat content threshold of the food items prepared. The Fat Tax was levied only on multinational chains and branded trademark owners, who comprise less than 10 percent of the FBOs in Kerala. Much of the unhealthy food consumed by the population of Kerala is produced by local FBOs such as bakeries and home-grown fast food chains, who were not covered in the imposition of the Fat Tax. The products manufactured in local FBOs are difficult to tax as they are not standardized and their ingredients are not declared.

Another delivery challenge was the time sequencing of the policy reform. The Fat Tax was announced by the newly elected LDF government of Kerala from the financial year 2016–17 and implemented effective August 2016. However, the federal government of India introduced a taxation reform, the Goods and Services Tax (GST), under which all existing indirect taxes levied on goods and services were replaced by a single country wide taxation policy. The Goods and Service Tax (GST) came into effect from July 1, 2017, following which all the existing state taxes, including Fat Tax, ceased to exist. The Fat Tax was thus implemented for only one year due to the introduction of GST. At the time this case study was prepared (April 2018), the federal government had not included unhealthy foods in the list of items taxed as part of the GST. A Fat Tax policy can be implemented across the states only if the GST Council, which decides the tax rates for various commodities, makes provision for this.

Implementation PhaseWhen the policy was announced the food items which fell in the ambit of Fat Tax were not clearly spelled out. Restaurant owners were unclear on whether or not food items sold by them came under the purview of the Fat Tax. There was also confusion on whether the taxes applied only to branded products or covered all food items including traditional ones. The state government responded by bringing out guidelines on the implementation of the tax policy and the tax collection process, specifying clearly the foods items which fall under the ambit of the new taxes.

Coordination between different departments was another key delivery challenge. The Department of Commercial Taxes of Kerala was responsible for implementing the Fat Tax, while the Department of Health was charged with monitoring the impact of this reform. Ensuring collaboration between these two departments for data collection and monitoring and supervision of the reform was a key challenge. The implementation of the Fat Tax was a major step in convergent action of the Department of Health with the Commercial Taxes Department in reducing the burden of obesity in Kerala. In early 2017, meetings between the Department of Commercial Tax, Department of Food Safety, and the Department of Health on building awareness and on convergent action had not yet taken place.15

The absence of a comprehensive monitoring framework to measure the impact of the policy reform was another significant delivery challenge in the implementation phase. When the Fat Tax policy was initiated, no mechanism to understand the impact of

Delivery Challenges at a Glance

Project Design: The definition of food items covered by the fat tax did not include food produced by local hotels and bakeries.

Macroeconomic Environment: The country wide enactment of the Goods and Services Taxes resulted in all state taxes being an-nulled. As a result, the fat tax could be implemented only for a year.

Coordination: There was scope for better coordination between different departments of the government such as health and commercial taxes in the implementation of fat tax.

Monitoring: There was no mechanism in place to specifically assess the extra revenue generation attributable to fat tax.

15 Author interview with Dr. Bipin Gopal, Nodal Officer, NCD Program; 21/03/2017 at Thiruvananthapuram, Kerala.


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tax collection on affected restaurants was put in place. Data on the volume of sales and tax generated from the imposition of Fat Tax would have been key to understanding whether the tax policy was successful in reducing the consumption of unhealthy food products. But the impact could not be quantified in the absence of mechanisms to collect this data.

Impact of Policy ImplementationThough the Fat Tax policy was implemented for only one year, it resulted in positive outcomes. The most important impact was that it generated a good amount of public discussion on the role of unhealthy food and unhealthy dietary practices in the growing problem of obesity in the state. The discussion was taken up by television news channels, including those broadcasting in Malayalam (the main local and vernacular language of Kerala), and given the high reach and viewership of television, the impact was significant.16

The public discussion and awareness that Kerala’s Fat Tax policy generated has indirectly started having an effect at the national level. The Food Standards and Safety Authority of India (FSSAI) set up a multi member committee to suggest ways to cut unhealthy food consumption and lower the rising burden of lifestyle diseases, such as diabetes and heart disease in India. The committee published a report in May 2017, titled “Consumption of Fat, Sugar and Salt (FSS) and its health effects on India’s population,” in which it recommended additional tax on processed food with high salt and fat content. The recommendation of the committee is as follows (FSSAI 2017, 52):

“Imposing additional tax on the purchase of commodities such as pre-packaged foods with high salt and fat content, sugar sweetened beverages, etc., can be a pragmatic approach to reduce the rising burden of chronic diseases among Indian population. Imposing excise tax on unhealthy eating products can be an endeavor to bring about positive health

effects among population. This exercise can be of great importance in supporting nutrition related programmes by the means of profit generated from taxing unhealthy food products.”

There have been other positive effects as well. The Goods and Services Tax (GST) Council, which includes representatives from both federal and state governments is in the process of deciding the tax rates for various commodities. Even though, the GST Council has not included Fat Tax in the initial list of items to be taxed, the discussions point to the fact that this could be taken up anytime in the future. The GST Council has already recommended imposition of higher taxes on carbonated sweetened soft drinks and the Fat Tax may be considered once GST is fully rolled out. It is not clear whether Fat Tax had any impact on the decision of increased taxation of sugar-sweetened beverages by the GST Council. But the Fat Tax figured in the discussions of the GST Council while deciding the tax of the sugar-sweetened beverages.

A senior official of Department of Commercial Taxes said that the impact of Fat Tax on national taxation policies will be visible in due course of time.

“Small things become big over a period, we don’t hesitate to take a small baby step. So, this is a small step in the direction of controlling obesity and I am sure that we will be able to convince the federal government of India also on bringing out a nationwide Fat Tax.17

Lessons LearnedThe imposition of the Fat Tax as a policy instrument to tackle the burden of obesity and NCDs demonstrates the intent and commitment of the Kerala Government in recognising the problem of obesity and taking convergent actions to tackle it. The case study offers several insights into the policy formulation and implementation process.

One of the lessons emanating from the case study is about the importance of time sequencing of policy. The Fat Tax policy was announced by the Kerala Government at a crucial time when discussions on obesity and its

16 Author interview with Dr. B Ekbal, Member State Planning Board; March 20, 2017 at Thiruvananthapuram, Kerala. Author interview with Dr. D Narayana, Director, Gulati Institute of Finance and Taxation on March 17, 2017 and discussions with C. Maya, leading journalist, on March 26, 2017.

17 Author Interview with Dr. Dr. Rajan N. Khobragade IAS, Commissioner, Commercial Taxes, Government of Kerala; 22nd March 2017 at Thiruvananthapuram, Kerala.


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detrimental effects on the health dominated the public health discourse in the state. From this angle the timing of the policy was opportune, and it succeeded in triggering public attention and discussions about unhealthy foods and the link to obesity. However, the Fat Tax could not be implemented for more than a year, as it became subsumed within the overarching national tax policy reform of GST and ceased to exist before making any impact. From this angle, the timing of the policy was inopportune, suggesting that policymakers should consider sequencing before announcing new reforms.

The name of the policy reform, Fat Tax, was chosen well. The name made an impact in the minds of the people on the ill effects of unhealthy food and unhealthy dietary practices on health. By selecting a succinct and impactful name for the policy reform the Kerala government was successful in creating awareness among the public about the growing threat of obesity in the state.

The case study also suggests that stakeholder consultations with industry associations, trade bodies, public health experts, and researchers would help understand the implementation challenges and strengthen the policy framework. In the case of the Fat Tax, wider stakeholder consultations might have helped in making the roll out of the Fat Tax much more impactful. It may also have led to voluntary compliance by the industry in reducing fats, salt, and sugar.

The design feature of the policy reform was subject to criticism. For instance, the definition of food items which were covered under the ambit of Fat Tax was based on the type of FBO rather than the energy density or fat content threshold of the food items prepared. Thus, high calorie, fat-rich food products sold by local eateries and bakeries were left out. The limited definition not only reduced the impact of the policy reform on health outcomes but was also considered discriminatory commercially. A necessary condition to negate this criticism would be to generate data on average dietary ingredients of different types of food, and taxing those that are above the threshold levels. While this would be difficult to implement it would nudge FBOs to keep the harmful ingredients at acceptable levels.

Another lesson emanating from the case study is the need for clear definition on the food items that come within the ambit of the new taxation policy. A lack of clarity on the food items included within the purview of Fat Tax created confusion among restaurant owners at the beginning of implementation. One way to facilitate

smooth implementation would be to publish guidelines on the tax reform parameters as soon as it is announced.

Though the Fat Tax policy had the dual objective of bringing about behavioural change (discouraging consumption of unhealthy foods) and of revenue generation, the effect could not be measured. There were no baseline studies on current consumption patterns of unhealthy foods or sales of such foods in the state, making it impossible to understand the effect the policy had on consumption patterns. Even figures for revenue generated specifically from Fat Tax could not be ascertained as the Commercial Taxes Department did not put in place a mechanism to disaggregate tax collection data within each broad group of taxable commodities.

The Fat Tax policy shows the importance of interdepartmental coordination for successful policy implementation. The Secretaries of the Department of Health, Finance, and Commercial Taxes were in favour of the taxation policy and took steps for effective implementation. Nevertheless, since the policy was only implemented for one year, coordination between different departments could not be fully achieved. Still, this case study provides some suggestive lessons how different departments could collaborate on policy objectives, targets and call for convergent actions for translating policy into effective action.

Conclusion

The role of the regulation of food products in controlling obesity is well recognized. Many countries have adopted measures to regulate them, either by prescription or through increased taxation. Kerala is one of the states ahead of the epidemiological transition curve and thus facing a serious threat from NCDs. Regulation of food is a powerful tool the government of Kerala has used to control the rising obesity in the state. The Fat Tax was one of the first steps in this direction. While its full impact could not be realized it brought significant attention to the topic. The GST Council which is now in charge of setting tax rates for commodities for the entire country, could explore the fiscal policy measure of taxing unhealthy food. Though the power to tax has been taken away from the states after the implementation of GST, Kerala could engage with Food Business operators for voluntary reduction of trans fat, sugar, and salt in the food products supplied in the state.


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Annex 1 Name and Designation of Interviewees

Name Designation

Mr . Rajeev Sadanandan IAS

Additional Chief Secretary, Department of Health and Family Welfare, Government of Kerala

Dr . R . Ramesh Director of Health Services, Government of Kerala

Dr . Bipin Gopal Nodal Officer, NCD Program, Directorate of Health Services, Government of Kerala

Dr . Rajan N . Khobragade, IAS

Commissioner of Commercial Taxes Government of Kerala

Dr . D . Narayana Director, Gulati Institute of Finance and Taxation

Dr . B . Ekbal Member, KSSP and State Planning Board

Dr . Jayan Jose Thomas

Member, State Planning Board

Prof . K . Ramankutty Professor, Achutha Menon Centre for Health Science Studies; and Member, Expert Committee on Health, State Planning Board

Prof . K . R . Thankappan

Professor and Head of Department Achutha Menon Centre for Health Science Studies (AMCHSS) and Member Committee on State Health Policy

Prof . Vijayakumar Former Professor and Secretary, Health Action by People (HAP); and Member Committee on State Health Policy

Mr . Premal Dave Deputy Director, Confederation of Indian Industries, Kerala Chapter

Mr . Antony Thomas Vice Chairman, Kerala Chamber of Commerce and Industries

Mr . G . Sudhiesh Kumar

Patron, Kerala Hotel and Restaurant Association


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Annex 2 Timeline

Date or Time Event Relevance

1990–2000 Research on the emerging threat of Non-Communicable Diseases (NCDs) burden on Kerala health system .

During this period, there was research and evidence gathering on the increasing burden on NCDs in Kerala . But there was no comprehensive policy for tackling NCDs

2005 Government of India Launched the National Rural Health Mission (NRHM)

Reform program aimed at correcting the architectural defects of India’s health care delivery system . The key focus of the program was on improving maternal and child health indicators . Prevention and control of NCDs was not a priority in the initial phase of the NRHM .

2010 National Control Program for Prevention and Control of Non-Communicable Diseases (NPCDS) program was launched by the Ministry of Health, Government of India .

A comprehensive program for control of NCDs was launched for the first time and was piloted in one district of the Kerala

2011–2013 NPCDS program was expanded to cover the entire state of Kerala

The program was expanded to entire state by the state government of Kerala using its own financial resources

2014 Expert committee of State Planning Board was constituted to give recommendations on key health issues in Kerala

Tackling the burden of NCDs was identified as one of the key priority areas for health planning in the state

2015 Consultative Meetings for development of Manifesto of the LDF coalition .

Important policy recommendations for health sector reforms were laid out in the manifesto of the LDF coalition .

May 2016 Left Democratic Government elected to power in Kerala

June 2016 New policies initiated to tackle the burden of NCDs in Kerala by the newly elected government

Department of Health initiated key policy reforms for reducing the burden of NCDs in Kerala:1 . Kerala set SDG targets for reduction of non-

communicable disease burden .2 . Primary Health Centers were revamped to provide

comprehensive primary care services for NCD prevention and control .

July 8th, 2016– June 30th 2017

‘Fat Tax’ was introduced in the first budget of the new government in Kerala

First of its kind in the country to use fiscal policy as a tool to fight obesity

July 1st 2017 Goods and Service Tax (GST) uniform tax was implemented by the Federal Government of India

‘Fat Tax’ introduced by the Government of Kerala ceased to exist .


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