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HEALA: 2022 Division of Revenue Proposals

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Submission to Standing Committee on Appropriations

1. Background

Introduced in 2018, the Health Promotion Levy (HPL) is a tax designed to precisely target the sugar content added to sugar sweetened beverages (SSBs) beyond acceptable thresholds. This lowers overall sugar consumption via SSBs through incentivising companies towards reformulating their products and affecting a reduction in demand and consumption of such goods by consumers. This levy is essential to enforce industry accountability for public health in the South African context; where excessive and increasing consumption of SSBs, driven by aggressive market behaviour, significantly contributes to our spiralling rates of obesity and diet-related non-communicable-diseases (NCDs) such as type 2 diabetes, cardiovascular diseases, certain cancers and tooth decay.

Despite its relatively short period of existence, and the watered-down rate at which it was introduced, its positive impact on sugar consumption is already evident. By arresting this trend, the longer-term effects will bring a massive saving of lives, as well as billions in healthcare costs and related economic burdens otherwise incurred.

While not the primary goal of the HPL, the additional positive impact is the raising of significant revenue for the state budget. For a struggling healthcare system that is increasingly financially constrained and overburdened, the availability of such funding is invaluable. However, the potential impact of these funds is currently limited by a lack of dedicated and effective oversight as to their use. Within the context of many competing socio-economic needs, policymakers are obligated to prioritise usage of the revenue raised in a manner that can most effectively advance rights to health and wellbeing of the most vulnerable people living in South Africa.

2. Assessment of Current HPL Collections & Usage

Currently, the HPL sets a levy-free threshold of four grams of sugar per 100ml in non-alcoholic SSBs produced or imported for domestic consumption (excluding certain items such as fruit juices and dairy products), levying a fixed rate per gram of sugar that exceeds this. National Treasury commendably raised this rate by 4.5% to 2.31 cents per gram in 2022 – while further consultations may see the welcomed inclusion of fruit juices and reduction of levy-free threshold. In practice, this amounts to a tax of 10% to 11% on the price of 1 litre of the average sugar-sweetened beverage.

From its inception to March 2021, the cumulative revenue raised from both domestically produced and imported SSBs amounts to R7.9 billion. This represents a collection of R3.2 bn, R2.5bn and R2.1bn across financial years 2018/19, 2019/20, and 2020/21 respectively. Declines in revenue collected are potentially expected as producer and consumer behaviour respond positively to the HPL. The impact of COVID-19 on the market also played a significant factor in the decrease over the previous two years. National Treasury estimates annual HPL collections to increase over the coming financial years due to market recovery and growth; increasing up to R2.8bn by 2024/25.

Here, we should note that the compromise with business to reduce the levy rate from the proposed 20% to 11% has meant not only massively restricting its positive impact on public health, but also forfeiting billions in potential revenue.

Nonetheless, even the current rate produces a substantial source of revenue; annually accounting for around 0.2% of the state’s total budget revenue. Yet the ongoing concern is the use thereof.

At present, neither the entirety nor simply a portion of this tax revenue is earmarked for any particular purpose, going instead to the National Revenue Fund for general government expenditure. Treasury’s explanation for this is that “the legislative earmarking of revenue is not supported as it will introduce rigidities in the budgeting process”.5 Rather it can be referred to as being ‘soft ring-fenced’. In this, the government has stated commitment for additional budgetary support for health promotion and chronic disease prevention programmes, as identified by the National Department of Health (NDoH). Presumably supported from this revenue, the 2021 Medium Term Expenditure Framework raised NDoH’s budget allocation for health promotion to around R50 million per annum. By 2021, actual expenditure under health promotion totalled a mere R34 million over 2019/20 and 2020/21.

It is deeply inadequate that from the Health Promotion Levy raising R7.9 billion over 3 years, the very justification for its existence receives such a miniscule budget allocation; which is then underspent at that. Meanwhile, the entire health budget faces cuts of over R50 billion in real terms over the next 3 years. This needs to be changed.

3. A More Comprehensive Approach to Health Promotion

Restructuring how the tax revenue from the HPL is allocated and spent, whether partially or entirely, is a necessary, beneficial and strategic consideration. The presence of unallocated funding in the National Revenue Fund may be seen as desirable for potential rainy days or administrative ease. Yet policymakers are obligated to weigh this choice against tangible alternatives to evaluate which route, or what compromise between them, best protects South Africans’ Constitutional rights while prioritising the most vulnerable.

South Africa struggles with a double burden of malnutrition – especially seen in children. The reality is that 1 in 4 children (27%) are stunted (chronically malnourished) which is coupled with an increasing child and adolescent overweight and obesity – all increasing the growing burden of NCDs. The need to intervene early is vital. The first 1000 days from conception to two years old is a critical time to address immediate undernutrition and consequent overweight or obesity later in life. Although this time is vital for long term results, addressing the current issue of childhood hunger must be prioritized. Positive results of good nutrition during early childhood may be reversed by poor nutrition
during adolescence. The reality is that 30% of South African children live in households living below the food poverty line – where adequate nutrition needed for optimum growth and development is out of their reach.7 The NIDS-CRAM reports, found that during the pandemic child hunger had risen to 14% (1 in 7 people indicated a child in their household had gone hungry in the prior week) and that 400 000 children lived in households that experience perpetual hunger (hunger every day or almost every day) during each of the waves.

The need to invest in food and nutrition security initiatives in South Africa that can protect children from both under and over nutrition is pertinent to creating a thriving population that can reach their physical, mental and economic potential. This can be done through increasing funding of existing interventions such as the National School Nutrition Programme (NSNP) to expand the programme and provide more meals to school learners and expanding existing social protection measures.

These alternatives should be identified by their alignment with the holistic intent of the HPL, and furtherance of its goals. This entails not only support for the NDoH’s health promotion programme, but other high impact areas that can contribute to decreasing the burden of obesity and diet related NCDs. Effectively, by linking the majority expenditure of HPL collections from the goals of the HPL itself, we are creating a far more comprehensive policy that can more directly funnel resources from unhealthy economic and behavioural activities into opposingly healthier ones for much greater overall impact. This strengthens the HPL into a far more impactful policy with greater measurable benefits. An inevitable result of this is the deepening of public trust in and support for the HPL and policy-makers’ intentions behind it; an invaluable resource in the event of widening or raising the HPL.

4. Potential Strategies for Utilisation

Proactive dedication of the levy’s revenue offers many benefits, but how and where. Our key proposals are as follows:

Proposed Strategies:

  • Increasing support for NSNP
  • Supporting nutrition of children in the critical first 1000 days: Maternity Grant
  • Improving nutrition in households: Basic Income Support
4.1 Increasing Support for the National School Nutrition Programme (NSNP)

The National School Nutrition Programme (NSNP) is a lifesaving feeding scheme that benefits over 9 million learners aged four and above every day. The programme’s objectives include providing all learners one nutritious meal to enhance learning, strengthening nutrition education in schools to promote healthy lifestyles with the use of food production initiatives (school gardens). This programme allows learners to realise their constitutional rights to basic nutrition (Section 28(1)(c)) and basic education (Section 29(1)(a)) and aims to improve their ability to learn through reducing hunger, combating malnutrition and improving school attendance. The NSNP is an effective poverty alleviation intervention, reaching some of the most vulnerable children in South Africa by targeting schools in the socio-economic quintiles one, two and three or the “no fee-paying schools”).

The NSNP is guided by a conditional grant framework (CGF) with specific budget allocations according to the following, at least 96% of the budget should be spent on school feeding and purchasing cooking, education including deworming should be a minimum of 0.5%and administration a maximum of 3.5%.

Although the NSNP can improve punctuality, school attendance, mental concentration, and learners’ general well-being – it has fallen short in implementation. In 2017, the Legal Resources Centre compiled an analysis of the NSNP in the Eastern Cape. The daily nutritious meal should provide 30% of the recommended daily allowance (RDA) of energy; however, the report found that the meals served only provided 16% of the RDAs – equivalent to a snack rather than a meal. The Department of Education (DOE) evaluation of the implementation of the NSNP in 2016 found that only half of the schools received balanced meals including three food groups (starch, protein, and vegetables) and 42.4% of schools only served two food groups, often omitting vegetables.

Schools argue that they cannot meet the NSNP’s nutrition requirements without sufficient funding, while most Provincial DBEs have underspent on their budgets for the NSNP implementation. In order to be a more effective program and meet the nutritional needs of many vulnerable children, the NSNP should be expanded to also include breakfast. Evidence shows that breakfast has positive benefits for children’s academic performance and attention in school. Using the funds from the HPL to strengthen and expand this existing national intervention could be an effective way to address child hunger.

Providing nutritious meals to learners contributes to the children’s health in the long term. Effectively decreasing socio-economic impacts of poor childhood nutrition such as non communicable diseases. Thus, decreasing the burden on the state’s public health burden. Consequently, investing in childhood nutrition also provides financial benefit to the state in the long term.

4.2 Supporting nutrition in the critical first 1000 days (Maternity Support Grant)

Intervening in a child’s nutrition in the first 1000 days can have positive lifelong results. Stunting arises from chronic malnutrition in pregnancy and the early years of life and impairs the physical and cognitive development of young children. Stunting from macro and micronutrient deficiencies in pregnancy and the early years of life casts a long shadow on children’s health, education and employment prospects across their life course. Improving the wellbeing and nutritional status of pregnant women during this critical period when the growth of the developing foetus is wholly dependent on the nutritional status of the mother, would go a long way towards shifting the needle on stunting in South Africa. At present however, pregnancy poses significant health, social and economic challenges for women. Many women working in the informal sector (which is where the majority of poor women work) have to give up paid work during pregnancy, while incurring additional costs related to the increased volume and variety of food they need to consume to support pregnancy, travel costs for healthcare and costs of a new child. Local surveys find that as many as forty percent of pregnant women report going to bed hungry, 15% of babies are born with low birth weight and 40% of poor children do not access the child support grant in the first year of life. Extending the Child Support Grant into pregnancy, in the form of a Maternal Support Grant, would help ensure that poor and vulnerable pregnant women have access to much needed income support to enable attendance of antenatal check-ups, healthy nutrition and improved mental health. In addition, enabling uptake of income support during pregnancy would support seamless transition to the Child Support Grant once the baby is born and mitigate against the access barriers to the Child Support Grant many poor and vulnerable women face immediately after their baby is born.

The idea of a Maternal Support Grant is not a new one. Different types of pregnancy support are available in many other countries. Maternity and early childhood support is presently provided in over 30 countries. Such support has also been discussed for at least a decade in South Africa.

An investment case on the MSG estimates that extending the CSG into pregnancy will cost a maximum of R2, 227 million at current CSG levels. This constitutes only 1,2% of the total grant budget. Considering that economic models suggest that stunting places a penalty of 9% of GDP per capita on African and Asian, the return on investing in extending the CSG into pregnancy and reducing SA’s high stunting prevalence, would far outweigh the costs.

4.3 Improving nutrition in households: Basic Income Support

Globally, Social safety net programmes that provide sufficient levels of cash transfers over long periods can be effective in breaking the intergenerational cycle of poverty, improving the living standards of the poor, reducing food insecurity, and can improve undernutrition outcomes. These programs have the potential to reach millions of people that can spend the money given on nutritious food and have better access to health care including nutritional and health education. In turn, social support can help reduce the risk of childhood undernutrition, obesity, and non-communicable diseases (NCDs).

Poverty, inequality and unemployment are not mere challenges, they are the most profound crisis confronting democratic South Africa. These are all drivers for the double burden of malnutrition we see in children. Households struggle to afford nutritious food, leaving their children and members hungry. Social grants are vital in mitigating the effects of poverty for households and children.

The South African government needs to create a society of greater equality by strengthening the social protection system. One that will guarantee sufficient nutrition for all families and provide access to quality healthcare and education. Cash grants reduced hunger and malnutrition and improved food sufficiency. The evaluations of Basic Income Support a Case for South Africa showed that grant recipients were significantly more likely to have enough income for their daily food needs than those in the control group. The grants also led to more varied diets, with greater relative consumption of fruit and vegetables. The number of households that reported that their income was sufficient for their food needs increased from about 50% in the baseline to about 78% and a further 82%. Lastly, income grants were associated with an improvement in children’s weight-for-age, with the most considerable effect being among young girls.

During the pandemic – Although the R350 was not enough to make households and beneficiaries food secure, those who did not receive it, and those who received it late, experienced hunger and food insecurity more frequently (Black Sash Social protection in a time of COVID Lesson for Basic Income Support). The Department of Social Development has acknowledged that the COVID-19 SRD grant was primarily used to buy food.

The implementation of a Basic Income Support (BIS) in South Africa is feasible, affordable, would contribute to economic growth and job creation, and similar to social grants. The BIS would ensure many households in the country have improved food security, health and educational outcomes, resulting in long-term impact on poverty reduction.

The Black Sash and HEALA demand that the government implement a permanent Basic Income Support for those aged 18 to 59 years who have no or little income that meets the upper-bound poverty line (R1335 per month). Unemployed Caregivers who receive the CSG must also qualify. Although the extension of the COVID-19 Social Relief of Distress (SRD) grant is welcomed, it must be increased to at least the Food Poverty Line (R624) until social assistance for the unemployed is made permanent.

5. Way Forward

If we are to improve the health of all South Africans – we need to start with helping our children thrive into their best potential. As there are limited funds it is not a possibility to embrace new programmes however there are existing effective programmes that reach millions of hungry children everyday such as the NSNP and child support grant. In order to address the food and nutrition insecurity that our children experience we must prioritise; including breakfast in the NSNP more children will reach their daily nutritional needs, addressing the intergenerational transfer of malnutrition through the expansion of the child support grant into pregnancy & acknowledging that households that include vulnerable children and women need additional resources through basic income support.

6. Recommendations

By directly confronting excess sugar consumption, the Health Promotion Levy currently serves as one key preventative policy against rampant health conditions such as obesity, type 2 diabetes and other diet related NCDs. Its ability to create effective impact is already evident despite its constraints. Yet without strengthening the levy, along with introducing additional measures, South Africa is unlikely to resist its current trajectory towards increasingly catastrophic loss of life and crippling economic costs.

To do so, requires not only raising the levy and widening its scope, but finding ways to maximise the use of funds it raises to protect and enhance South Africans’ rights to health, nutritious food and a decent quality of life. To this end, we propose that:

  • Usage of HPL tax revenue as general revenue must be reprioritised via earmarking the entirety or majority thereof towards projects in line with the HPL’s vision.
  • Regulate and subsidise daily staple and healthy foods and reduce food prices.
  • Key projects to be considered for this should include:
    • Increasing support for NSNP
    • Supporting nutrition of children in the critical first 1000 days: Maternity Grant
    • Improving nutrition in households: Basic Income Support
7. About HEALA

HEALA is a coalition of civil society organisations that advocate for equitable access to affordable, nutritious food in South Africa by building a more just food system.

For further information contact:

HEALA: Nzama Mbalati
Email: Nzama@heala.org
Cell phone: 082 734 5414

Rural Health Advocacy Project: Nathan Taylor
Email: NTaylor@rhap.org
Cell phone: 082 406 1208

Grow Great: Dr Kopano Matlwa Mabaso
Email: kopano@growgreat.co.za
Cell phone: 071 861 5796

Black Sash: Hoodah Abrahams-Fayker
Email: hoodah@blacksash.org.za
Cell phone: 072 252 0333

Section27: Baone Twala
Email: twala@section27.org.za
Cell phone: 081 464 3033

South African Council of Churches: Reverend Parkson Mohlala
Email: lechipishaparksonm@gmail.com
Cell phone: 082 547 6434

SACSoWACH: Pumla Dlamini
Email: pdlamini@vitaminangels.org
Cell phone: 079 806 5406

TAC: Ngqabutho Mpofu
Email: ngqabutho.mpofu@tac.org.za
Cell phone: 061 807 6443

Equal Education: Nontsikelelo Dlulani
Email: ntsiki@equaleducation.org.za
Cell phone: 073 469 8750


Download the presentation

Stacey, N., Edoka, I., Hofman, K., Swart, E. C., Popkin, B., & Ng, S. W. (2021). Changes in beverage purchases following the announcement and implementation of South Africa’s Health Promotion Levy: an observational study. The Lancet Planetary Health, 5(4), e200-e208.

Manyema M, Veerman LJ, Tugendhaft A, Labadarios D, Hofman KJ. Modelling the potential impact of a sugar sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa. BMC Public Health 2016;16(1):405

Question to the Minister of Finance Standing Committee – NW1300 | PMG

Budget Review 2021

Final Response Document on the 2017 Rates and Monetary Amounts and Amendment of Revenue Laws Bill – Health Promotion Levy

Kristie L. Watkins, Donald A. P. Bundy, Dean T. Jamison, Günther Fink, and Andreas Georgiadis “Evidence of Impact of Interventions on Health and Development during Middle Childhood and School Age”, pages 99 – 106

South African Child Gauge 2020: Food and nutrition security

NIDs CRAM Wave 5: Synthesis Report

National School Nutrition Programme – SECTION27

Hazell E. Report on the Implementation Evaluation of the National School Nutrition Programme. Pretoria: JET Education Services. 2016

National Treasury, (2015), Frameworks for conditional grants to provinces. Government Gazette, 38869, 12 June 2014: Part 2: 126-127
Bulman A. Realising Every Child’s Right to Nutrition: An analysis of the National School Nutrition Programme in the Eastern Cape. Grahamstown: Legal Resource Centre. 2017.

Hazell E. Report on the Implementation Evaluation of the National School Nutrition Programme. Pretoria: JET Education Services. 2016

Hazell E. Report on the Implementation Evaluation of the National School Nutrition Programme. Pretoria: JET Education Services. 2016

The effects of breakfast on behavior and academic performance in children and adolescents

Basic Income Support. 2020. Black Sash.

Key data from the February 2022 Household Affordability Index

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The February 2022 Household Affordability Index, which tracks food price data from 44 supermarkets and 30 butcheries, in Johannesburg (Soweto, Alexandra, Tembisa and Hillbrow), Durban (KwaMashu, Umlazi, Isipingo, Durban CBD and Mtubatuba), Cape Town (Khayelitsha, Gugulethu, Philippi, Langa, Delft and Dunoon), Pietermaritzburg and Springbok (in the Northern Cape), shows that:

  • In February 2022: The average cost of the Household Food Basket is R4 355,70.
  • Month-on-month: The average cost of the Household Food Basket decreased by R45,33 (-1%), from R4 401,02 in January 2022 to R4 355,70 in February 2022.
  • Year-on-year: The average cost of the Household Food Basket increased by R354,52 (8.9%), from R4 001,17 in February 2021 to R4 355,70 in February 2022.

Food prices dropped marginally in all areas tracked. Most foods in the basket came down in February 2022 – and across most staples, meats, and vegetables, with the exception of oils and fats: cooking oil, margarine and cremora.

Statistics South Africa’s latest Consumer Price Index for January 2022 shows that Headline inflation was 5,7%, and for the lowest expenditure quintiles 1-3, it is 6,7%, 6,1% and 5,6% respectively. CPI Food inflation was 6,2%.

Workers

The National Minimum Wage for a General Worker in February 2022 is R3 470,40. Transport to work and back will cost a worker an average of R1 280 (36,9% of NMW), and electricity an average of R731,50 (21,1% of NMW). Together transport and electricity, both non-negotiable expenses, take up 58% (R2 011,50) of the NMW, leaving R1 458,90 to secure all other household expenses. Workers families will underspend on food by a minimum of 51,8%, this month, based on PMBEJDs basic nutritional food basket which stands at R3 029,23 for a family of four persons.

Productivity in the workplace and learning quality in classrooms, and whether we have to visit a health centre or not, are all dependent on the food we eat.

Women and children

In February 2022, the average cost to feed a child a basic nutritious diet was R771,95. Year-on-year, the cost to feed a child a basic nutritious diet has increased by R61,20 or 8,6%.

In February 2022, the Child Support Grant of R460 is 26% below the Food Poverty Line of R624, and 40% below the average cost to feed a child a basic nutritious diet of R771,95.

In its annual adjustments, Government chose to increase the Child Support Grant by R20 from April 2022. This is an increase of 4,3%.

The R20 increase will move the Child Support Grant of R480 from 26% below the Food Poverty Line of R624, to 23% below the Food Poverty Line.

by  the PMBJED group

Vacancy: Communications manager

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Are you an exceptional communicator with at least five years’ experience in journalism or communications? Are you committed to social justice and health equality?

We are looking for a communications manager to implementation of HEALA’s communication strategy and to develop, implement, monitor and evaluate communications to support HEALA’s primary policy advocacy campaigns.

This person must have the ability to think strategically, handle ambiguity, and problem solve in a fast-paced, limited-structure, multicultural environment.

HEALA is a coalition of civil society organisations advocating for equitable access to affordable, nutritious food in South Africa by building a more just food system.
HEALA’s mission is to create a platform for communities to organise and mobilise around policy and the realisation of the right to affordable, nutritious food.
Find out more on our website.

Role specifics

  • Fixed term position – 1 year contract.
  • Location – Rural Health Advocacy Project – Rosebank Johannesburg.
  • Closing date 25 April 2022.

What we’re looking for

This work is all about conveying information to various audiences, including a range of cultures and international partners, donors and NGOs. The skills we’re looking for include:

  • Fluent written and spoken English as well as one other South Africa language.
  • Sound knowledge of the South African media sector, including news production cycles and outlets.
  • Basic knowledge of social media and website metrics, including Twitter and Facebook.
  • Experience with web content management systems and newsletter delivery systems such as Mailchimp is a plus.
  • Proven ability to translate health and/or scientific research jargon into easy-to-understand language; experience in helping researchers and experts do the same is an added advantage.
  • Excellent oral and written communications skills, including the ability to communicate about complex issues in sensitive and compelling ways.
  • Willingness to travel nationally or internationally as required.

What the role looks like

Key performance areas include:

  • Designing, writing and editing advocacy communications materials for the HEALA coalition and specific policy advocacy campaigns
  • Managing the content and co-ordination the reporting for all of HEALA’s digital platforms including the WordPress website, MailChimp and social media channels (Facebook, Twitter and LinkedIn)
  • Facilitating effective communication within the HEALA coalition and with external stakeholders
  • Building and maintain relationships with the media
  • Overseeing event management
  • Effective self-management and performance ownership

Find out more

You can find further information at the full job spec.

How to apply

Accepted applications will comprise of two parts:

  1. Your CV detailing all relevant experience and education
  2. A cover letter answering these three questions:
    • Please describe a piece of communications work that you are proud of and provide links where possible. What was your role in creating this work?
    • What are three important values you would embody as the communications manager for HEALA, and can you give examples of how you embody them already?
    • What are two concrete learnings from your experience working in communications sector that you would bring to HEALA?

Please email your CV and cover letter to nboomgaard@witshealth.co.za with the subject line: RHAP-Comms Manager before 15 March 2022.

WHO report unmasks the deceitful marketing of the $55 billion formula milk industry

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On Wednesday 23rd February 2022, Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) and partners launched a new report, ‘How the marketing of formula milk influences our decisions on infant feeding’. This report – the largest of its kind to date – draws on the experiences of over 8,500 women and 300 health professionals across eight countries, including South Africa. It exposes the aggressive and manipulative marketing practices used by the formula milk industry and highlights the negative impacts on families’ decisions about how to feed their babies and young children.

The largest formula milk producing company has had a century and a half of experience perfecting the marketing of an inferior child feeding product. How? By positioning its formula milk as the closest formulation to human breastmilk, and by using trusted and credible health professionals to endorse and recommend formula milk as a suitable replacement to breastmilk. The infant formula industry has mastered the art of manipulation by using product marketing strategies to convince mothers that infant formula ‘is just like breastmilk’. But the established scientific body of evidence has illustrated that breastmilk is far superior to formula milk and that child health costs due to inappropriate formula feeding are multiple, robbing children of optimal health and cognitive development while fuelling the obesity epidemic in childhood and adulthood, and increasing the risk of children dying of pneumonia and diarrhoea. And while industry profits, these costs are carried predominantly by the public health system.

As a society, we must recognize how efforts to increase infant formula sales undermine breastfeeding. As Phil Baker pointed out in the United Nations University IIGH webinar: Infant and Young Child Feeding: Policy, Power and Politics – as the formula industry has globalized so has its “power of marketing”. Exposure to such marketing reduces breastfeeding initiation, duration, and exclusivity irrespective of context. Without significant and purposeful interventions to protect, promote and support breastfeeding, many countries, particularly here in Africa, will see a steady decline in breastfeeding rates and a concurrent rise in malnutrition, with more pronounced childhood obesity and its associated health conditions of non-communicable diseases like hypertension, diabetes, and cardiovascular diseases. While we may think of these as adult diseases, their origins lie in early inappropriate infant feeding.

This is why South Africa committed to protecting, promoting, and supporting breastfeeding at Tshwane in 2011 and introduced Regulations relating to Infant and Young Child Feeding, R991 to protect mothers and caregivers from the inappropriate and misleading marketing of formula milk. Yet despite these efforts, the 2016 Demographic Health Survey found that one in four infants under the age of six months has never received breastmilk (25%), while only one in three is exclusively receiving breastmilk (32%), the larger portion of 43% is mixed fed, receiving breastmilk and other feeds, predominantly infant formula. This means that 68% of infants under six months of age are receiving sub-optimal feeding and are not being exclusively breastfed as recommended by the national Department of Health and WHO.

At the same time, the infant formula industry has earmarked low and middle-income countries for market expansion, and Euromonitor reported that the sale of formula milk in South Africa more than doubled from 2000 to 2015. The R991 prohibits the advertising and promotion of infant formula, in any form, on all media platforms. But since then infant formula companies have continued to breach the existing regulations and developed new strategies to promote and market their product. These include below-the-line advertising on social media, the sponsorship of continuous professional development courses for health professionals, sponsorship of conferences and symposiums linked to infant and young child nutrition, funding for students and researchers through industry-affiliated entities like the Nestlé Nutrition Institute, Africa (NNIA) and sponsorship of lecturer positions that specifically teach infant and child nutrition. Without diligent monitoring and reporting, infant formula companies continue to cross the line and test the strength of R991.

In recent years, these formula milk marketing strategies have exploited social media to reach consumers with enticing and misleading health claims and false promises of better growth and development of their children often coaxing mothers with words that conjure up superiority like ‘Opti-pro’, ‘Gold’ and ‘Supreme’. This is in modern terms ‘false advertising’. The survey of pregnant women and mothers that was part of this study found that strikingly almost half of women (49%) believed that formula is very much like breastmilk. These perceptions are clearly aligned with formula companies’ marketing messages said Prof Tanya Doherty from the South African Medical Research Council, one of the researchers assisting with analysis of the South African data.

What is particularly concerning in the context of South Africa’s high levels of poverty, unemployment and food insecurity, is the inability of households to adequately and safely provide infants with sufficient formula milk to ensure good growth and development. One in three children in South Africa live in households below the food poverty line which leaves insufficient money to buy sufficient formula milk to meet the needs of growing children. Ms Pumla Dlamini from Vitamin Angels and Nutrition Lead for the health rights coalition, South African Civil Society for Women’s, Adolescents’ and Children’s Health (SACSoWACH) points out, “What is most frustrating is that Nestlé uses home-grown social protection measures like stokvels to idealize and liken infant formula to breastmilk. This erodes indigenous healthy feeding practices such as breastmilk, rendering them less desirable.”

In 2021, civil society efforts led by HEALA galvanized action through the #NotTodayNestle campaign to stop a Nestle-funded series of mom & child events. The formula milk industry has a track record of violations and underhand tactics, and in this case, Nestlé, a Swiss-based company, chose to exploit the long-held tradition of stokvels – using these community-based savings schemes to market their products to women who can ill-afford formula milk, highlighting the lengths that the profit-focused formula industry employs to ensnare unsuspecting and trusting consumers.

As researchers and food justice activists, we, therefore, call on the government of South Africa, to place children’s health before profits and support WHO’s efforts to protect women from exploitative marketing practices. This can be done by strengthening the enforcement of R991 and to accelerate efforts to gazette the regulations governing the advertising of unhealthy food to children. We call on the whole of society to protect, promote and support breastfeeding. This includes progressive maternity protection and paid maternity leave for six months for all mothers, regardless of employment status; state-funded childcare services; and community-based support for breastfeeding mothers. If South Africa is to turn the tide on childhood obesity, it will have to counteract the aggressive and insidious marketing of infant formula. The health of the nation depends on strategic and decisive leadership to curtail the inappropriate marketing of the $55 billion formula milk industry.

HEALA is a civil society coalition working to advance food justice in South Africa to ensure that communities are able to exercise their right to affordable, nutritious food.

SACSoWACH is a civil society coalition that advocates for the health of newborns, children, adolescents, women and mothers.

For interviews:

Dr Chantell Witten
Lecturer, Faculty of Health Sciences, Division Health Education, University of Free State
SACSoWACH Nutrition Working Group Member
chantell.witten@gmail.com
+27(0)71 485 5893

Angelika Grimbeek
Nutrition Programme Manager for HEALA
angelika@heala.org
+27(0)72 078 3160

Professor Tanya Doherty
Health Systems Research Unit, SAMRC
tanya.doherty@mrc.ac.za

Who is HEALA?

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HEALA is a coalition of civil society organisations that advocate for equitable access to affordable, nutritious food in South Africa by building a more just food system.

Access to nutritious, affordable food is a fundamental human right. Section 27(1)(b) of the South African Constitution guarantees all the right to sufficient food and commits the state to the progressive realisation of this right. Additionally, Section 28(1)(c) states that every child has the right to basic nutrition, shelter, basic health care services and social services.

Still, South Africa suffers from high levels of hunger, food insecurity, and obesity – all of which are consequences of the country’s broken food system.

A healthy and sufficient diet is essential for all people to achieve their full potential.
HEALA believes that only by fixing South Africa’s broken food system will the country be able to guarantee everyone equitable access to affordable, nutritious food.

Click here to view our Fact Sheet.

NEDLAC-commissioned report backs South Africa’s “sugar tax”

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A recently leaked report on the health promotion levy’s economic impacts affirms that the levy can play an important role in financing healthcare in South Africa. However, the Healthy Living Alliance (HEALA) disputes the report’s claims — based on flawed methodology — that the levy will lead to job losses.

In 2018, South Africa introduced a health promotion levy of 11% on sugary drinks with more than 4 grams of sugar per 100 ml to help curb skyrocketing rates of noncommunicable diseases — such as diabetes, high blood pressure and heart disease — linked with increased sugar consumption. Many of these conditions are now among the leading causes of natural death, according to Statistics South Africa.

Nedlac report sugar tax TB

Practically, the levy — also sometimes called a “sugar tax” — adds about 46 cents to the price of an average can of original Coca-Cola, for instance. The levy does not apply to natural fruit juices or sweetened dairy products.

No, the Nedlac report did not argue the sugar tax should be cut

In 2018, the Portfolio Committee on Trade and Industry directed the National Economic Development and Labour Council (Nedlac) to commission a study to assess the levy’s impact on South Africa’s economy.

Although the official report has not yet been released, a leaked copy circulated in June recommended that the levy should continue and that the tax funds be earmarked to support public healthcare. Currently, these funds are not specifically designated for the health budget.

Yet, the research also used what HEALA believes is a flawed methodology to argue that more than 16,000 jobs and an estimated R 653-million in economic investment were lost due to the sugar tax. These calculations fail to account for other forces such as EXAMPLE that are affecting the sugar industry.

The NEDLAC document fails to consider the levy’s proven health benefits

But more glaring is the Nedlac report’s failure to account for the health promotion levy’s economic benefits.

By reducing the amount of sugar people consume, the levy creates a healthier South Africa, reducing the cost of treating noncommunicable diseases and creating a healthier and more productive workforce.

The South African government spent R2.7 billion treating people living with diabetes in 2018, and the costs for 2030 are projected to be R35.1 billion. A 2016 modelling study estimated that an increased health promotion levy of 20% would save R5 billion in healthcare costs in the next two decades.

According to the 2016 research, a health promotion levy of 20% could save 72,000 lives in the next 20 years.

The NEDLAC report lacks transparency

The sugar industry has had a history of misrepresenting the economic impact of a tax on sugar-sweetened beverages. The industry has repeatedly made unproven claims about alleged job losses connected to the sugar tax without backing these up with data, as AfricaCheck found in 2016. The fact-checking organisation also revealed that industry claims downplayed sugary beverage consumption among South Africans and masked inequalities within consumption levels.

Today, there is no publicly available information on how the NEDLAC report authors, Wesbound (PTY) Ltd, were appointed, the timeframe for the research or their terms of reference.

The evaluation appointment process and terms of reference must be made freely available to ensure public confidence in the report. Transparency is crucial for ensuring that the work was independently conducted and free of influence from industry, the Portfolio Committee on Trade and Industry or NEDLAC.

Here’s what we do know about the health promotion levy’s impacts

Since the Portfolio Committee on Trade and Industry’s request for an economic impact evaluation, two local, peer-reviewed published studies assessing the HPL’s impact have found that levy works to reduce harmful sugar consumption.

University of Witwatersrand researchers found that the levy led to a 60% reduction in sugary beverage consumption among people who consumed a lot of sugar in Soweto. In the Langa outside Cape Town,

University of the Western Cape scientists found that adults between 18 and 39 years old slashed their overall sugar intake by almost a third after the levy was introduced.

In short, the levy is working just as intended to  — incentivising people to change the way they consume sugar.

The sugar tax also generated an extra R5.4 billion for the country in its two years.

The Nedlac report is a wasted opportunity

HEALA believes in food justice, or the right of all communities to access nutritious, affordable, and culturally appropriate food. Because of shortcomings in both methodology and transparency, HEALA believes that the NEDLAC report represents a missed opportunity to evaluate a transformative and innovative policy to improve the lives of all South Africans.

HEALA also continues to demand that the National Treasury Department increase the health promotion levy to 20% to ensure the tax keeps pace with inflation and remains effective.

HEALA is sympathetic to the sugar industry’s concerns regarding job loss and fully supports the implementation of the Department of Trade, Industry and Competition’s Sugar Master Plan.

However, South Africa simply cannot afford to rely on sugar consumption at the expense of our current and future health and productivity – nor do we need to. The industry can and should transform to build more diversified revenue streams for sugar producers, including capitalising on global demand for biofuels.

Noncommunicable diseases fuelled in part by dangerous sugar consumption remain a significant risk factor for developing severe COVID-19. Today, COVID-19 has cost more than 200 000 people in South Africa their lives and pushed another two million into poverty.

Government can and should use all the tools at its disposal to help enable and grow a healthy population that can fully realise their potential and contribute to our shared future.

Media Release: Doubling the sugary beverage levy could raise billions for Covid-19 fight

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If South Africa doubled its sugary beverage levy, it could raise billions to help fund the fight against Covid-19.

In 2018, South Africa introduced a health promotion levy of about 11% on sugary beverages to help curb the country’s sugar consumption, which is fuelling a rise in non-communicable diseases, such as diabetes, high blood pressure and obesity. 

Currently, beverages are taxed about 2.21 cents per gram of sugar for anything over a 4-gram threshold. The current levy adds about 46 cents to the price of an average can of original taste Coca-Cola, for instance. The levy does not apply to natural fruit juices or sweetened dairy products.  

Within its first two years, the health promotion levy has generated R5.4 billion for government. This would have been enough to finance South Africa’s down payment for Covid-19 vaccines from the Covax facility almost 20 times over despite the health promotion levy’s relatively small contribution to government’s overall budget. 

If the National Treasury doubled the health promotion levy now, it could net the government around R2 billion to help fund the fight against Covid-19 in the short term, head of the Healthy Living Alliance (HEALA) Lawrence Mbalati says. This estimate is based on current consumption levels and the revenue raised by the levy already.

If Treasury doubled the levy and raised R2 billion, that would be enough to pay for several thousand new nurses and doctors, as well as tens of thousands of community healthcare workers based on average salary ranges. 

“This is a watershed moment for the country,” Mbalati explains. “Government revenues are under immense pressure and funding the fight against Covid-19, including vaccines, remains critical.”

“Policymakers, and in particular the National Treasury, have an opportunity now to decide to increase the health promotion levy to 20% to raise additional revenue in the short-term,” he says. “In the long-term, we know that a health promotion levy of 20% will reduce the amount of sugar people eat, decreasing their chance of developing conditions such as diabetes, obesity and high blood pressure that also put people at a higher risk of dying from Covid-19.”

Globally, being obese has been shown to increase a person’s risk of dying from Covid-19 by almost 50% and more than doubles the risk of being hospitalised, according to a recent analysis published in the journal Obesity Reviews.  

South Africa’s health promotion levy has already led some beverage makers to reduce the amount of sugar in their drinks. One study by PRICELESS SA found that the levy also reduced sugary beverage consumption by 60% among people in Soweto who consumed a lot of sugar.

Meanwhile, there is no evidence to date that the levy has led to job losses in the sugar or beverage industry, contrary to industry claims. 

A health promotion levy of 20% in the long-term could reduce sugar consumption, saving lives both from non-communicable diseases but also Covid-19 as many scientists expect the virus to remain with us in the foreseeable future. 

HEALA is therefore calling on the National Treasury to act now.

“Raising the health promotion levy to 20% is absolutely critical to not only funding the Covid-19 fight but also to saving lives now and in the future.”

For interviews, contact:
Lawrence Mbalati, head of the Healthy Living Alliance (HEALA)
082 734 5414
lawrence@heala.org 

Click here to download and read the pdf

Read more:
What you need to know about South Africa’s health promotion levy

Watch:
Healthy Living Alliance Media Briefing: Increase the HPL to 20%

Fact Sheet: Evidence to support increasing South Africa’s Health Promotion Levy (HPL) to 20% in 2021

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South Africa implemented its Health Promotion Levy, or HPL, in April of 2018. The HPL is a sugar-sweetened beverage (SSB) tax of approximately 11%, based on sugar content. Initial research on the price impact of the HPL has shown prices increased commensurate with the tax for taxed beverages but did not change for non-taxable beverages and reduced consumption.

Click here to download and read the pdf

Embargoed For Release

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Big Food Used Global Pandemic to Aggressively Promote Unhealthy, Ultra-Processed Food & Sugary Drinks

A new report finds that the food and beverage industry giants directly and indirectly blocked. Healthy food policies while putting vulnerable consumers at even greater risk.

WASHINGTON, D.C. – A new report released by the Global Health Advocacy Incubator [GHAI] details how food and beverage corporations – such as Coca-Cola, McDonald’s, Nestlé, and PepsiCo – seized the coronavirus pandemic as a unique opportunity to promote their ultra-processed foods to especially vulnerable populations around the world.

Facing Two Pandemics: How Big Food Undermined Public Health in the Era of COVID-19


Reveals how the lack of healthy food regulations worldwide enabled “Big Food” to use the global COVID-19 crisis, publicly portraying themselves as do-gooders while directly and indirectly influencing policy and putting disadvantaged people at even greater risk. These same corporations – whose ultra-processed food and sugary drinks were already contributing to rising rates of obesity, malnutrition, and diet-related diseases – used the pandemic to position themselves and their unhealthy products as essential and safe, putting those compromised populations at even higher risk of coronavirus complications and mortality. GHAI collected more than 280 examples from 18 countries between March and July 2020.

“Based on the examples we gathered, it quickly became clear that Big Food was working hard to position themselves as a crucial part of the pandemic solution,” said Holly Wong, GHAI Vice President, “while furthering their own gains by hindering the advancement of public health policies.”

The GHAI report outlines key ways “Big Food” exploited the coronavirus pandemic to their advantage:

  • They polished their public images with pandemic “solidarity actions,” while aggressively promoting their junk food and sugary drink brands. They donated ultra-processed products to children in school programs and low-income populations when these people needed nutritious foods. They also donated and promoted baby formula, breaching the International Code of Marketing of Breastmilk Substitutes. In South Africa, Coca-Cola collaborated with a nonprofit to donate “cooldrinks” – soft drinks – to local healthcare centers, including an obesity care center.
  • They touted unhealthy ultra-processed food and drinks as essential, safe products, equating food safety with healthy food. In Brazil, the industry group ILSI (International Life Science Institute) highlights that processed foods are allies in the fight against COVID-19 touting their high safety levels that reduce the risk of chemical and physical contamination.
  • They funded online educational platforms aimed at helping children learn during quarantine, dangerously blending marketing with educational information, and positioning these corporations as reliable sources of health-related information. An online learning platform used by schoolchildren in the US featured junk food advertising.
  • They spun a health and wellbeing narrative publicly while leveraging the pandemic as a way to delay healthy food policy. In México, they attempted to use COVID-19 as an excuse to postpone implementing a new front-of-package warning label law.
  • They promoted junk food as a tonic for tough times, linking unhealthy food with appealing sentiments such as comfort, nostalgia, and family togetherness. In Brazil, Burger King promoted its fast-food delivery service under the guise of helping people to stay safe at home.
  • They linked their ultra-processed food and drinks with charitable causes, helping consumers feel good about unhealthy purchases. In the US, Coca-Cola partnered with Uber Eats to donate one meal to Feeding America for every order placed.

These corporate interventions enabled Big Food to improve their image, strengthen their brands, ally with decisionmakers to gain political influence, and position their businesses as public-health partners during an emergency – even as they used these opportunities to advance their own unhealthy products.

Ultimately, the GHAI report underscores the urgent need for evidence-based healthy food policies and regulations, as well as stronger conflict-of-interest protocols, worldwide.

“This is a wake-up call for governments to implement evidence-based public policies designed to create healthier food environments and to protect the right to adequate food,” said Lawrence Mbalati, Programmes Manager of South Africa’s Healthy Living Alliance.

“Such policies will help consumers make healthier nutritional choices during vulnerable times like these. The bottom line is, governments must prioritize public health above private interests and profits.”

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Click here for the report: https://bit.ly/two-pandemics

For media interviews, please contact Lawrence Mbalati, HEALA Programmes Manager,
082 734 5414; lawrence@heala.org. Please note, in addition to English, Lawrence speaks Xitsonga (first language), Tshivenda, Sepedi, Sesotho/Setswana and can also speak isiZulu and isiXhosa.

About the Healthy Living Alliance (HEALA)

HEALA is a  leading alliance of civil society and academic organisations fighting for every person’s right to healthy food in South Africa. Launched in 2016 by the civil society organisations and academic institutions, HEALA successfully campaigned for the Sugary Drinks Tax implemented by South African Government in April 2018.

HEALA’s current campaigns include advocating for clear warning labels on ultra-processed foods, healthy food environment, marketing restrictions of junk food and sugary drinks to under-age children in South Africa.

Calls for Finance Minister to increase health promotion levy (HPL) and include fruit juices

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The Healthy Living Alliance (HEALA) and Rural Health Advocacy Project (RHAP) call for an increase in the so-called sugar sweetened beverage tax and inclusion of fruit juices to reduce diet-related disease and death, and raise much-needed revenue amidst COVID-19 health demands and budget deficits.

Johannesburg, 4 November: Advocacy groups for healthy food in South Africa have made a strong call backed by scientific evidence for an increase from 11% to 20% of the Health Promotion Levy (HPL), and to include fruit juices in the levy.

Responding to Finance Minister Tito Mboweni’s 2020 Medium Term Budget Policy Statement last week, the Healthy Living Alliance and Rural Health Advocacy Project highlight how South Africa is grappling with both a COVID-19 epidemic and an obesity epidemic.

Nearly 70% of South African women, 31% of men and 13% of children under five are considered overweight. This is fuelling noncommunicable diseases (NCDs) such as type 2 diabetes and heart disease which put people at greater risk of severe COVID-19 illness and death. South Africa has the highest recorded number of cases and deaths in Africa. The collision of the COVID-19 and the NCD epidemics has significantly increased demands on the country’s health system.

“Sugar sweetened beverages (SSBs) such as sodas and fruit juices, as well as ultra-processed foods (industrially made ‘ready to eat and heat’ foods such as cereals and processed meats) contribute to obesity, a key risk factor for type 2 diabetes,” said Mr Lawrence Mbalati, HEALA’s programmes manager.

In 2018, South Africa was the first country in the African Region to introduce a tax on sugary beverages, a strategy which the World Health Organization (WHO) recommends as an effective way to reduce sugar consumption and address NCDs. South Africa’s HPL aimed to address rising rates of overweight, obesity and diet-related NCDs, and raise much needed revenue for health promotion.

According to National Treasury data, the HPL raised R3.195 billion in the first fiscal year (April 2018 – October 2019). While the tax is currently set at 11%, HEALA and RHAP have urged the Finance Minister to increase this to WHO’s recommended rate of 20%, which could drop demand by 24%.

“We don’t know the impact of the HPL because NEDLAC’s study on this has still not been completed. We are repeating our call for fruit juices to be included. Excluding them leads people to believe that juices are healthier, when in fact the sugar content is similarly high to soft drinks. Marketing fruit juice as a ‘healthy alternative’ to children and parents puts them at risk of consuming excessive amounts of sugar. Fresh fruits are fine on their own, but when turned into fruit juice, much more fruit is needed to make up the volume. Our bodies process these additional sugars in the same way as SSBs,” he said.

“Now more than ever, South Africa will benefit from an increased HPL tax for additional revenue and help to reduce risks related to obesity,” concluded Mr Mbalati.

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Issued by Healthy Living Alliance (HEALA) and Rural Health Advocacy Project (RHAP)
For media interviews, please contact Lawrence Mbalati, HEALA Programmes Manager, 082 734 5414

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