Marcus Richard Keogh-Brown

Background: In March 2016, a tiered tax was announced on industries manufacturing or importing sugar-sweetened beverages in the United Kingdom. The Soft Drinks Industry Levy was implemented in April 2018 with two tiers: £0.18/l on drinks containing ≥ 5 g/100 ml and < 8 g/100 ml of added sugar, £0.24/l on drinks containing ≥ 8 g/100 ml of added sugar, with no levy on drinks containing < 5 g/100 ml of added sugar. The Soft Drinks Industry Levy is a complex intervention that acts as a disruptor in the commercial food system. As such, it demanded an evaluation that went beyond a narrow focus on a single outcome to incorporate assessment of a range of theorised intervention effects and their dynamic inter-relationships, taking a ‘systems’ perspective. Objectives: We undertook formative work over 6 months to underpin the evaluation, leading to five work packages, which aimed to evaluate: Work package 1: impacts on formulation, marketing, prices, purchases and consumption of sugar-sweetened beverages, and early health impacts. Work package 2: estimated impacts on medium- to long-term health outcomes. Work package 3: estimated economic impacts on food and other industries, His Majesty’s Treasury, health and social care systems. Work package 4: impacts on key stakeholders: the public, policy-makers and industry. Work package 5: the wider implications of the Soft Drinks Industry Levy in a synthesis of all findings and other evaluations. Methods: Work package 1 adopted a natural experimental evaluation design and used quantitative methods, including interrupted time series analysis. Work package 2 employed epidemiological modelling to simulate longer-term health outcomes. Work package 3 used micro- and macroeconomic modelling to estimate the net costs and benefits of the Soft Drinks Industry Levy and to simulate longer-term economic outcomes. Work package 4 used qualitative methods to explore acceptability and impacts of the Soft Drinks Industry Levy for diverse stakeholders. Work package 5 synthesised findings from this and other evaluations of the Soft Drinks Industry Levy and identified implications for policy and further research. Results: Our evaluation shows that the Soft Drinks Industry Levy: incentivised reduction in sugar purchased in soft drinks and in food and drinks overall; was associated with reduced inequalities in sugar purchased from soft drinks, with a 1.6% point reduction in prevalence of obesity in Year 6 girls, and with a 12% reduction in hospital admissions for carious tooth extractions in children and adolescents up to 18 years; was viewed favourably by policy-makers and the public; and did not have lasting negative impacts on the economic performance of soft drinks companies. Based on changes in sugar consumption observed, epidemiological modelling suggested that the Soft Drinks Industry Levy will lead to health gains and to net monetary benefit to the health sector, as well as to reductions in health inequalities. The Soft Drinks Industry Levy was forecast to produce a 0.004% cumulative gross domestic product loss to the United Kingdom economy over a 22-year period. Nevertheless, the Soft Drinks Industry Levy represents good value for money when balancing the overall health benefits against the economic impacts. The results of this evaluation are consistent with the results of studies undertaken by others. Limitations: There were limitations of all the studies we undertook, which are detailed in each of the 18 publications referenced in this report. Since we commenced this research, newer methods have become available for evaluations of interventions in complex adaptive systems. We have taken a narrative approach to triangulating and synthesising findings from our diverse range of studies. The use of more formal methods, such as contribution analysis or process tracing, may have strengthened causal inference. Future work: Government is strengthening the Soft Drinks Industry Levy, by reducing the lower levy threshold to 4.5 mg of sugar per 100 ml of soft drink, increasing the levy rates over time in line with inflation, and including milk-based drinks, and the benefits of such changes should, when implemented, be evaluated. The principles underlying the Soft Drinks Industry Levy could be applied to similar levies on other unhealthy foods, and the benefits of these also need to be modelled. Meanwhile, the longer-term impacts of the Soft Drinks Industry Levy, including industry adaptations, should be monitored, including its impacts on the sugar and soft drinks markets in the United Kingdom and globally. Further research is also needed on the implications of rising levels on non-sugar sweeteners in soft drinks and on ways to reduce the sweetness of all foods. Conclusions: The Soft Drinks Industry Levy was a novel, tiered sugar-sweetened beverage tax that incentivised industry reformulation to remove sugar from soft drinks. It was effective in incentivising reformulation and was associated with observed and projected future health benefits. Although it is estimated that the Soft Drinks Industry Levy had costs for the United Kingdom economy, these were mitigated by benefits for the public, the National Health Service and other sectors. The Soft Drinks Industry Levy has been positively received by the public, policy-makers and, to an extent, industry, and offers a model for future fiscal food policy in the United Kingdom and internationally. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.

Background: The United Kingdom Soft Drinks Industry Levy was introduced in April 2018, resulting both in changes in sugar levels in drinks and purchases of drinks. Both mechanisms could impact on the incidence and prevalence of raised body weight, diabetes and diet-related diseases, and therefore, have implications for economic costs to the health sector. Objectives: To model future impacts of the Soft Drinks Industry Levy on population health and health sector costs and to estimate net monetary benefit to the health system. Design and methods: Proportional multistate lifetable modelling study – open and closed cohort analyses. Setting and population: All children and adults in the United Kingdom. Intervention: The Soft Drinks Industry Levy is a two-tier levy of £0.18/l on drinks with between 5 and 8 g of total sugars/100 ml and of £0.24/l on drinks with ≥ 8 g of total sugars/100 ml. Main outcome measures: We evaluated impact of the sugar reduction on: (1) prevalence of overweight and obesity, obesity-related diseases and dental health out to 2050 and (2) lifetime population health (measured in quality-adjusted life-years), change in costs to the health sector and the resulting net monetary benefit. Data sources: We estimated a per person reduction in sugar from a previously published interrupted time series analysis, which found an 8.0 g/household/week (95% confidence interval 2.4 to 13.6) reduction in sugar at 1 year after implementation. Our multistate lifetable model is parameterised using data from population health monitoring surveys, the Global Burden of Disease project, the Human Mortality Database and the Office for National Statistics. Health sector costs were obtained from Department of Health and Social Care budget allocations. Results: The model predicts that the Soft Drinks Industry Levy will reduce the prevalence of overweight and obesity in the United Kingdom by 0.18% points (95% uncertainty interval: 0.059 to 0.31) for males and by 0.20% points (0.064 to 0.34) for females. In the first 10 years of implementation, the reductions in sugar and overweight/obesity are predicted to prevent 270,000 (35,000–600,000) dental caries, 12,000 (3700–20,000) cases of type 2 diabetes, 3800 (1200–6700) cases of cardiovascular diseases and 350 (110–590) cases of obesity-related cancer. For the current United Kingdom population, it is estimated that the Soft Drinks Industry Levy will add 200,000 quality-adjusted life-years (63,500–342,000) over their lifetime and avert £174 million (£53.6–319) in their costs of health care (discounted at United Kingdom Treasury rates). At a United Kingdom Treasury value of £60,000 per quality-adjusted life-year, it is estimated that the Soft Drinks Industry Levy will produce a net monetary benefit of £12.2 billion (£3.88–20.8) for the health system. Limitations: Modelled results assume that the effect of the Soft Drinks Industry Levy remains constant into the future. The longevity of the effect of the Soft Drinks Industry Levy has not been tested. Conclusion: This study of the United Kingdom Soft Drinks Industry Levy tiered tax on sugar content provides further evidence that sugar-sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.

Background: Tuberculosis (TB) imposes a substantial health and economic burden on many populations and countries, but lack of funding has significantly contributed to several countries falling short of global TB reduction targets. Furthermore, existing assessments of the economic impact of TB do not capture the impacts on productivity and economic growth or the pathways by which epidemiology, demography, and the economy interact. Evidence is needed to answer how investment in treatment and control measures may help to mitigate the twin Indian health and macroeconomic burdens of TB over the coming decades. Methods and findings: We develop a fully integrated dynamic macroeconomic-health-demographic simulation model for India, the country with the largest national TB burden, and use it to estimate the macroeconomic return to investment in TB treatment. Our estimated results indicate that, over 2021 to 2040, the health and macroeconomic burdens of TB in India will include over 62.4m incident cases, 8.1m TB-related deaths and a cumulative gross domestic product (GDP) loss of US$146.4bn. Low-income households will bear larger health and relative economic burdens while larger absolute economic burdens will fall on high-income households. Achieving the World Health Organisation’s End TB target of 90% case detection could reduce clinical and demographic disease burdens by 75% to 89% and reduce the macroeconomic burden by US$120.2bn. Developing a 95% effective pan-TB treatment regimen would reduce the same burdens by 25% to 31% and US$35.3bn, respectively, while less effective but immediately achievable scaling-up of existing treatment regimens would reduce burdens by 20% to 25% and US$28.4bn, respectively. If an increase in case detection to 90% could be combined with 95% effective pan-TB treatment, it could reduce clinical and demographic disease burdens by 78% to 91% and reduce the macroeconomic burden by US$124.2bn. In order to develop this complex integrated model framework, some aspects of the epidemiological model were simplified such that the model does not capture, for example, separate modelling of drug susceptible and multidrug-resistant (MDR) cases or separate public/private healthcare provision. However, future iterations of the model could address these limitations. Conclusions: In this study, we find that even our least effective, but most accessible, revised TB treatment regimen has the potential to generate US$28bn in GDP gains. Clearly, the economic gains of increasing case detection rates and implementing improved TB treatment regimens hinges on both the feasibility and timeframe over which they can be achieved in practice. Nevertheless, the revised TB treatment regimen is readily accessible, and our results therefore demonstrate that there is room for undertaking substantial additional investment in control and treatment of TB in India, in order to reduce the suffering of TB patients while maintaining acceptable provision of resourcing elsewhere in the Indian economy.

Objective: To model future impacts of the UK Soft Drinks Industry Levy (SDIL) on population health and health sector costs, and to estimate net monetary benefit to the health system. Design: Proportional multi-state lifetable modelling study Setting: United Kingdom Population: All children and adults Intervention: The SDIL is a two-tier levy of £0.18 per litre on drinks with between 5g and 8g of total sugars per 100mL, and £0.24 per litre on drinks with 8g or more of total sugars per 100mL. We estimated a per person reduction in sugar from previous interrupted time series analysis, which found an 8.0 g/household/week (95% confidence interval: 2.4 to 13.6) reduction in sugar in purchased drinks at one year after implementation. Main outcome measures: W e evaluated impact of the sugar reduction on: (a) prevalence of overweight and obesity, obesity-related diseases and dental health out to 2050; and (b) lifetime population health (measured in quality-adjusted life years [QALYs]), change in costs to the health sector and the resulting net monetary benefit. Results: The model predicts that the SDIL will reduce prevalence of overweight and obesity in the UK by 0.18 percentage points (95% uncertainty interval: 0.059 to 0.31) for males and 0.20 percentage points (0.064 to 0.34) for females, for as long as the sugar-reduction effects of the SDIL are sustained. In the first ten years of implementation, the reductions in sugar and overweight/obesity are predicted to prevent 270,000 (35,000 to 600,000) dental caries, 12,000 (3,700 to 20,000) cases of type 2diabetes, 3,800 (1,200 to 6,700) cases of cardiovascular diseases, and 350 (110 to 590) cases of obesity-related cancer. For the current UK population, it is estimated the SDIL will add 200,000 QALYs (63,500 to 342,000) over their lifetime and avert £174 million (£53.6 to £319) in their costs of health care (discounted at UK Treasury rates). At a UK Treasury value of £60,000 per QALY, it is estimated the SDIL will produce a net monetary benefit of £12.2 billion (£3.88 to £20.8) for the health system. Conclusion: This study of the UK SDIL tiered tax on sugar content provides further evidence that sugar- sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending. What is already known on this topic: Numerous modelling studies have shown that sugar-sweetened beverage taxes are likely to be cost-effective and improve population health, whether the tax is applied on the volume of product or to the sugar content (absolute or tiered), but there have been few modelling studies that have been informed by evaluation of real-world taxes. A volumetric sugar-sweetened beverage tax of 1 peso per litre, implemented in Mexico in 2014, reduced purchases of sugar-sweetened beverages by 7.6% in the first two years, and health economic modelling estimated that it would be cost-effective from a health sector perspective. In the UK, the Soft Drinks Industry Levy (SDIL), announced in March 2016 and implemented in April 2018, was designed as a tiered levy to encourage soft drink manufacturers to reduce sugar content. Follow-up at one year indicates that it has reduced purchases of sugar from drinks by 8.0 g/household/week (95% confidence interval: 2.4 to 13.6). What this study adds: Population health modelling suggests that changes in sugar consumption due to the SDIL will reduce prevalence of overweight/obesity and related diseases and improve dental health in the UK, including 12,000 (95% uncertainty interval: 3,700 to 20,000) fewer cases of type 2 diabetes, 3,800 (1,200 to 6,700) fewer cases of cardiovascular diseases, 350 (110 to 590) fewer cases of obesity-related cancer, and 270,000 (35,000 to 600,000) fewer dental caries, in the first ten years after implementation. Health economic modelling indicates that over the lifetime of the current UK population the SDIL could add 200,000 quality-adjusted life years (63,500 to 342,000) and avert £174 million (£53.6 to £319) in health care costs, leading to a net monetary benefit of £12.2 billion (£3.88 to £20.8) for the health sector. This study of the UK SDIL tiered tax on sugar content provides further evidence that sugar- sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending.

“Coronavirus Disease 2019” (C19) is a respiratory illness caused by “new Coronavirus” SARS-CoV-2. The C19 pandemic, which engulfed the world in 2021, also caused a national C19 epidemic in Pakistan, who responded with initial forced lockdowns (15-30 March 2020) and a subsequent switch to a smart lockdown strategy, and, by 31 December 2020, Pakistan had managed to limit confirmed cases and case fatalities to 482,506 (456 per 100,000) and 10,176 (4.8 per 100,000). The early switch to a smart lockdown strategy, and successful follow-up move to central coordination and effective communication and enforcement of Standard Operating Procedures, was motivated by a concern over how broad-based forced lockdowns would affect poor households and day-labour. The current study aims to investigate how the national Pakistan C19 epidemic would have unfolded under an uncontrolled baseline scenario and an alternative set of controlled non-pharmaceutical intervention (NPI) policy lockdown scenarios, including health and macroeconomic outcomes. We employ a dynamically-recursive version of the IFPRI Standard Computable General Equilibrium model framework (Lofgren, Lee Harris and Robinson 2002), and a, by now, well-established epidemiological transmission-dynamic model framework (Davies, Klepac et al 2020) using Pakistan-specific 5-year age-group contact matrices on four types of contact rates, including at home, at work, at school, and at other locations (Prem, Cook & Jit 2017), to characterize an uncontrolled spread of disease. Our simulation results indicate that an uncontrolled C19 epidemic, by itself, would have led to a 0.12% reduction in Pakistani GDP (−721mn USD), and a total of 0.65mn critically ill and 1.52mn severely ill C19 patients during 2020-21, while 405,000 Pakistani citizens would have lost their lives. Since the majority of case fatalities and symptomatic cases, respectively 345,000 and 35.9mn, would have occurred in 2020, the case fatality and confirmed case numbers, observed by 31. December 2020 represents an outcome which is far better than the alternative. Case fatalities by 31. December 2020 could possibly have been somewhat improved either via a more prolonged one-off 10 week forced lockdown (66% reduction) or a 1-month forced lockdown/2-months opening intermittent lockdown strategy (33% reduction), but both sets of strategies would have carried significant GDP costs in the order of 2.2%-6.2% of real GDP.

Covid-19 requires policy makers to consider evidence on both population health and economic welfare. Over the last two decades, the field of health economics has developed a range of analytical approaches and contributed to the institutionalisation of processes to employ economic evidence in health policy. We present a discussion outlining how these approaches and processes need to be applied more widely to inform Covid-19 policy; highlighting where they may need to be adapted conceptually and methodologically, and providing examples of work to date. We focus on the evidential and policy needs of low- and middle-income countries; where there is an urgent need for evidence to navigate the policy trade-offs between health and economic well-being posed by the Covid-19 pandemic.

[This corrects the article DOI: 10.1371/journal.pmed.1003815.].

Covid-19 requires policy makers to consider evidence on both population health and economic welfare. Over the last two decades, the field of health economics has developed a range of analytical approaches and contributed to the institutionalisation of processes to employ economic evidence in health policy. We present a discussion outlining how these approaches and processes need to be applied more widely to inform Covid-19 policy; highlighting where they may need to be adapted conceptually and methodologically, and providing examples of work to date. We focus on the evidential and policy needs of low- and middle-income countries; where there is an urgent need for evidence to navigate the policy trade-offs between health and economic well-being posed by the Covid-19 pandemic.

Historic levels of funding have reduced the global burden of malaria in recent years. Questions remain, however, as to whether scaling up interventions, in parallel with economic growth, has made malaria elimination more likely today than previously. The consequences of “trying but failing” to eliminate malaria are also uncertain. Reduced malaria exposure decreases the acquisition of semi-immunity during childhood, a necessary phase of the immunological transition that occurs on the pathway to malaria elimination. During this transitional period, the risk of malaria resurgence increases as proportionately more individuals across all age-groups are less able to manage infections by immune response alone. We developed a robust model that integrates the effects of malaria transmission, demography, and macroeconomics in the context of Plasmodium falciparum malaria within a hyperendemic environment. We analyzed the potential for existing interventions, alongside economic development, to achieve malaria elimination. Simulation results indicate that a 2% increase in future economic growth will increase the US$5.1 billion cumulative economic burden of malaria in Ghana to US$7.2 billion, although increasing regional insecticide-treated net coverage rates by 25% will lower malaria reproduction numbers by just 9%, reduce population-wide morbidity by −0.1%, and reduce prevalence from 54% to 46% by 2034. As scaling up current malaria control tools, combined with economic growth, will be insufficient to interrupt malaria transmission in Ghana, high levels of malaria control should be maintained and investment in research and development should be increased to maintain the gains of the past decade and to minimize the risk of resurgence, as transmission drops.