In the year since the Fourth High Level Meeting on NCDs and Mental Health (HLM4), the focus of the global NCD community has rightly been on how the promises of the political declaration are delivered on by governments. Amid debates on the future of global health architecture and declining overseas development assistance, governments are grappling with growing NCD burdens, while facing an unprecedented squeeze on public health budgets.

Most people reading this will be familiar with what a vital tool health taxes (levied on tobacco, alcohol and sugar sweetened beverages) can be. They provide a “triple-win”: reducing harmful consumption, generating revenue for governments, and reducing pressure on health systems. But despite this, implementation of health taxes worldwide remains patchy.

Cancer Research UK’s International Cancer Prevention programme has supported tobacco tax reform in numerous countries in recent years. But our partners have often found that when making the case for health taxes, it’s not enough to present compelling data on their potential impact. The pathway to tax reform is not just technocratic; it is political. If domestic political dynamics are not carefully navigated, then even the most brilliantly designed health tax policies are at risk of stalling, unravelling, or being reversed under intense pressure from health-harming industries.

To better understand these political realities, we recently commissioned a comparative political economy analysis by Kivu International across Kenya, Uganda, Tanzania and Zambia. The countries all have unique political characteristics, with varying levels of commitment to health taxes. But regardless of the context, a clear set of questions should be considered by policymakers:

• Are the fiscal rewards of health taxes clear enough? Ministries of Finance usually wield more political influence than Ministries of Health. It’s important for health policymakers to present health taxes as practical instruments for strengthening domestic resource mobilisation, improving fiscal resilience and supporting national development priorities rather than treating them as a standalone public health initiative.
• Have you considered product-specific dynamics? Sometimes, it’s not advantageous to attempt collective reform of tobacco, alcohol and SSB taxes at the same time. Political economy analysis can help policymakers identify what reforms are most politically feasible, helping them sequence these in ways that maximise their chances of success.
• Is the timing right within the political cycle? Elections, fiscal crises and budget negotiations all influence whether there’s an opportunity for reform. Understanding these political cycles means policymakers can sequence reforms more effectively, using quieter political periods to build evidence, strengthen consensus and prepare legislation.
• Is there a strong pro-reform coalition? If policy reform is to be sustainable, it needs broad public consent and demand. Embedding reform within domestic coalitions makes it more resilient to electoral change and industry pressure. Policymakers need to publicly make the case for reform beyond government and avoid shutting out civil society from the policy reform process.
• Do the public understand the benefits of health taxes? If tax rises are clearly linked to national health priorities (e.g. the Philippines’ health taxes funding UHC initiatives) they have much greater support from the public. Too often though, health taxes can generate revenue for a government without subsequent increases in the health budget. Policymakers should embed earmarking in health tax legislation, and frame this as a way of building the political case for health tax reform.

If governments are to show long term leadership in acting on NCDs, expanding health taxes is essential. But understanding and confronting political challenges – and supporting civil society’s engagement in the reform process – is crucial if health tax reform is to last. In the run up to the delayed Manila NCD financing dialogue, we urge policymakers and advocates alike to commit to building the political strategies that will turn health taxes into a sustainable reality.