• Policy discussions on preventing NCDs/malnutrition on updated/innovative approaches to address gaps in food market conditions, marketing campaigns, inflationary factors and consumer awareness

In a context where 83% of all deaths in Sri Lanka are the results of non-communicable diseases (NCDs), with diabetes being the second highest cause of deaths recording 58.5 deaths per 100,000 persons, NCDs remain a growing health concern in the country. Even though various policy efforts have been made over the years to combat NCDs, due to various reasons, the country is yet to satisfactorily achieve and maintain the results of those policy efforts. Market conditions, marketing campaigns, inflation and awareness among consumers remain matters that require updated and improved approaches in this discussion.

These are some of the central points that were discussed during a recent discussion titled “Policy Dialogue on Strengthening Policies for Controlling NCD Risk Factors and Malnutrition” which was organised by the Institute of Policy Studies of Sri Lanka (IPS), where the findings of several studies pertaining to preventing NCDs, healthy food environments and combating malnutrition were discussed. The event also paid attention to the existing and necessary policies regarding these matters, and their applicability and effectiveness were discussed by health and policy experts.

Discouraging high sugar foods

During the discussion, the findings of a study on the efficacy of the sugar sweetened beverages tax and the traffic light labelling system in reducing sugar sweetened beverage consumption were discussed. Presenting the study findings, Research Economist at the IPS, Priyanka Jayawardena, explained that this study was conducted in a context where the prevalence of NCDs has increased, with the highest rate of increase being reported for diabetes, and NCD risk factors, such as unhealthy food habits including the high consumption of sugar, fat, and salty food and sugar sweetened beverages, and physical inactivity, being on the rise. At the same time, the effectiveness of sugar sweetened beverages control policies has not been formally evaluated.

She noted that as per the NCD Control National Multi-Sectoral Action Plan (NMAP), one important action for reducing sugar sweetened beverages consumption in the country is reviewing and adjusting sugar sweetened beverages tax rates. The sugar sweetened beverages tax not having changed to account for the prevailing inflation, and providing limited coverage, i.e. excluding milk based beverages, were also noted. At present, the sugar sweetened beverages tax excludes 80% of sweetened beverages.

Presenting the findings of the study regarding the sugar sweetened beverages tax’s effectiveness in Sri Lanka, Jayawardena explained that a 10% price increase of soft drinks could reduce the consumption of the same by 30%, while a 10% price increase of fruit drinks could reduce the consumption of the same by 17.7%. It was noted that the impact of the sugar sweetened beverages tax has declined, as tax rates are not adjusted in line with inflation. As per the study findings, only 66% of the people are aware of the traffic light labelling system, and consumer awareness differs by population groups. Findings with regard to the impact of the traffic light labelling on sugar sweetened beverages related choices showed that awareness of the traffic light labelling system is clearly associated with making healthy sugar sweetened beverages related choices, and that those who are aware of the traffic light labelling use their knowledge when making sugar sweetened beverages related choices. They further showed that consumers are more likely to choose a healthy sugar sweetened beverage and avoid an unhealthy sugar sweetened beverage when the traffic light labelling appears on the packaging of a product.

In conclusion, the study said that the sugar sweetened beverages tax is effective in Sri Lanka, although the potential effects have come down, which the report noted indicates the importance of reviewing and adjusting the sugar sweetened beverages tax rates as identified in the NCD-NMAP. It further concluded that the traffic light labelling system helps consumers to make low sugar sweetened beverages choices, and that consumers’ awareness of the traffic light labelling system is significantly associated with making healthy sugar sweetened beverages choices. In terms of policies, it was noted that the sugar sweetened beverages tax should be adjusted periodically for inflation and affordability to protect the real value, and that the sugar sweetened beverages tax and regulations should be strengthened to cover a wider range of products, particularly sweetened milk based beverages. Also explaining that awareness on traffic light labelling is key to promoting healthy sugar sweetened beverages related choices, Jayawardena added that awareness raising campaigns targeting different groups of people are necessary in order to increase consumer awareness of the traffic light labelling system. Such programmes should target low income groups and community driven programmes have a significant role in raising awareness of traffic light labelling among consumers in rural areas, according to the study.

The study had been conducted through surveys conducted with and data gathered from consumers and supermarkets and similar establishments, based in 14 Districts in all nine Provinces of the country. It had taken into account three main factors, i.e. the beverage category, traffic light labelling and prices.

Food environment in the current economy

In addition, the findings of more new studies regarding NCDs were presented by Research Economist at the IPS, Sunimalee Madurawala, and Research Officer at the IPS, Usha Perera. These studies focused on the political economy of the food environment and the influence of the food environment on NCD risk factors. Madurawala explained that political economic factors are closely interconnected in shaping the food environment in a country, and that there are multiple targeted policies and programmes to prevent NCDs and to improve the food environment.

Explaining the findings of the study with regard to policy framing and the policy content, she added that NCDs are well recognised and well framed as policy issues. She noted a lack of attention to crucial elements such as funding sources and financing mechanisms, governance considerations, gender sensitivity, and stakeholder identification. Limited recognition in policies from other sectors has also been observed by the study, regarding which she noted that NCDs, nutrition and food environment related issues as well as health and agriculture sectors showed more recognition. She discussed findings related to policy development and policy implementation as well. With regard to policy development, she explained the importance of several matters including recognising NCDs as a significant health challenge, the relationship between nutrition and NCDs being well recognised, and affordability, availability and accessibility being major concerns in the food environment. Regarding policy implementation, she pointed out industry responses, which include lobbying for tax reductions, requesting grace periods, reformulating products, introducing new products and heavy advertising, and also the consumer response, regarding which she pointed out a reduction in demand. In this regard, the study said that consumer awareness is not sufficient and that intensive marketing by the industry highlights the need for improved awareness. In addition, industry influence, poor representation by the civil society, and coordination and communication related gaps among stakeholders were discussed with regard to the main findings pertaining to policy developments, and also limited influence during policy implementation, implementation gaps caused mainly by resource constraints, unaddressed issues from policy developments hindering effectiveness, and the lack of monitoring and evaluation mechanisms.

Madurawala presented a number of recommendations in terms of policy development and policy implementation so as to address the abovementioned concerns. Under policy framing and content, she said that the prioritisation of NCDs and nutrition in policy framing should continue and the coverage of crucial policy elements should be ensured. With regard to stakeholder engagement, she said that the country should promote active and continuous participation of all stakeholders throughout the policy development stage and the policy role. Addressing technical and legal issues is also a key recommendation, under which proactively addressing technical and legal considerations during the policy development stage was pointed out. In terms of policy implementation, it was recommended to create awareness, increase Government involvement and political commitment, and to close implementation related gaps. Managing industry interferences and responses was a major recommendation, under which steps such encouraging positive industry actions, exposing and minimising unethical interferences and promoting industry participation and addressing concerns, were recommended.

Meanwhile, Perera discussed the influence of the food environment on NCD risk factors in underserved settlements in the Colombo District. According to the study, a decline in the sale of cooked food items has been observed, while the sale of carbonated sugary drinks, fried rice and kottu has also reduced. Consumers have switched to cheaper food alternatives, and regular customer bases have been lost. People’s meals have been compromised with the decline in their ability to purchase the necessary food items, the report noted. The reduced food consumption is a result of both the economic crisis and the Covid-19 pandemic. Although it leads to the risk of malnutrition, undernutrition and a lack of micronutrients, it also reduces the risk of diabetes, cholesterol, high blood pressure and certain other specific NCD risk factors.

She presented several recommendations in this regard, noting that some of the NCD-NMAP recommendations for promoting the consumption of fruits and vegetables are not applicable to the urban poor. While some consumers did not have the space to cultivate, to some, it could be too costly to buy them from the pola (weekly fairs) as they buy several times a week. In this context, the country can look into raising awareness, promoting mobile vendors to take fruits and vegetables, and empowering women within underserved settlements to prepare healthy snacks from fruits and vegetables.