Conflicting interests, institutional fragmentation and opportunity structures: an analysis of political institutions and the health taxes regime in Pakistan

Abstract

Pakistan is the world’s fifth most populous country, with large segments of its population at risk from non-communicable diseases caused by consumption of harmful products, including tobacco and sugar-sweetened beverages. Even though evidence exists that increased taxes on harmful products leads to consumption reductions as well as increased revenues, Pakistan’s health taxes remain low. We seek to understand the reasons for the deficient health tax regime. Much of the existing literature emphasises industry tactics, resources and motivations. We take a different approach and instead focus on political institutions in Pakistan which could help explain deficiencies in the health taxes regime. We employed a mixed method design. We conducted: (1) a detailed analysis of media content, (2) semistructured interviews with key stakeholders (and attended relevant meetings) and (3) an analysis of primary and secondary literature, including legal and policy documents. We identify two key aspects of Pakistan’s political institutions which may help explain deficiencies in health taxes. First, we identified structural issues in the design and functioning of key institutions responsible for health taxes, including with respect to federalism, intraelite conflict, interagency coordination and intra-agency fragmentation. Second, we found evidence of an entrenchment of industry interests within governmental institutions, which are characterised by weak frameworks for regulating conflicts of interest. We conclude that gaps and conflict within political institutions, owing to weak design, instability and fragmentation, create political opportunity for industry actors to influence the system to advance their interests. The findings of this research indicate towards needed interventions.

Framing health taxes: learning from low- and middle-income countries

“…Mirza et al analysed political institutions and the health taxes regime in Pakistan and identified two key aspects of the country’s political institutions resisting change 33. The first barrier to health tax policy were structural issues such as federalism, intraelite conflict, interagency coordination and intra-agency fragmentation in the design and functioning of key institutions 33.…”

“…Mirza et al analysed political institutions and the health taxes regime in Pakistan and identified two key aspects of the country’s political institutions resisting change 33. The first barrier to health tax policy were structural issues such as federalism, intraelite conflict, interagency coordination and intra-agency fragmentation in the design and functioning of key institutions 33. The other significant barrier to effective health tax policy was the entrenchment of industry interests within government institutions, exploiting these structural issues and taking advantage of gaps in the governance of conflicts of interest 33.…”

“… 33 The first barrier to health tax policy were structural issues such as federalism, intraelite conflict, interagency coordination and intra-agency fragmentation in the design and functioning of key institutions. 33 The other significant barrier to effective health tax policy was the entrenchment of industry interests within government institutions, exploiting these structural issues and taking advantage of gaps in the governance of conflicts of interest. 33 While tobacco taxes were eventually raised in Pakistan to raise revenue, arguments in favour of health taxes were pre-empted or co-opted prior to being fully formed in deliberative processes.…”

“… 33 While tobacco taxes were eventually raised in Pakistan to raise revenue, arguments in favour of health taxes were pre-empted or co-opted prior to being fully formed in deliberative processes. 33 …”

"Caught In Each Other’s Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry

“… 22 , 48 , 49 Our qualitative data indicates that the lack of political will partly stems from politicians’ motivations to support the growth of the domestic pharmaceutical industry and is influenced by industry lobbying against limitations on marketing or proliferation of active companies. These findings are consistent with a recent analysis in Pakistan highlighting the “entrenchment of industry interests within governmental institutions.” 50 …”