New health taxes in Ghana: a qualitative study exploring potential public support

In the context of a fiscal crisis and health pressures, Ghana's government has been exploring additional pro-health taxes. The World Health Organization and World Bank support health taxes as 'win-win' policies that can, if designed effectively, simultaneously improve health and raise revenue for health spending. However, international evidence shows that health taxes can meet political and public opposition. Yet, there is little research that empirically examines public views of health taxes. We compared policy stakeholders' perceptions of Ghanaian public support for health taxes with public views, seeking to understand the basis for potential public opposition, the extent to which evidence can shape public views, and whether tax framing and design influences public support. We undertook 28 semi-structured key informant interviews with stakeholders (from government, advocacy, and business groups) and five focus groups with 38 members of the public (purposefully selected for diversity in gender, age, ethnicity, occupation, and social background). We employed an innovative deliberative design for the focus groups, which enabled us to explore how public views responded to contrasting health tax 'frames'. Stakeholders generally believed public support for health taxes was low, especially for more widely consumed products. Yet, most focus group participants expressed strong support for health taxes, especially those targeting (more widely-consumed) sugar-sweetened beverages. Support increased when health taxes were framed as measures to improve public health and/or create a fairer tax system, and when commitments were made to using resulting revenue for health spending (known as 'earmarking' or hypothecation). However, stakeholders and members of the public shared a concern that business influence in Ghanaian politics presents a key barrier to implementing effective health taxes sustainably. Overall, our findings suggest that health taxes with a clearly-framed health rationale could command strong Ghanaian public support but likely require effective advocacy to overcome political barriers.