Political Economy Analysis of Health Taxes (Tobacco, Alcohol Drink, and Sugar Sweteened Beverage): Case Study of Three Provinces in Indonesia

Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This study takes a problem-driven political economy analysis (PEA) approach to investigate the challenges and opportunities surrounding health tax implementation, with a particular focus on sub-national government in Indonesia, where the decentralization context of health tax remains understudied. Employing a qualitative methodology by collecting data from a total of twelve focus group discussions (FGDs) conducted in three provinces—Lampung, Special Region of/ Daerah Istimewa (DI) Yogyakarta, and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs), and alcoholic beverages—we explore the multifaceted dynamics of health tax policies. These FGDs involved 117 participants, representing governmental institutions, non-governmental organizations (NGOs), and consumers. Our findings reveal that while health tax policies have the potential to contribute significantly to public health, challenges such as a lack of consumer awareness, bureaucratic complexities, and decentralized governance hinder implementation. Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardized packaging. Addressing these challenges is critical for realizing the full potential of health tax policies. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by Universitas Indonesia through International Indexed Publication Grant (Hibah Publikasi Terindeks Internasional/ PUTI Q1). Grant Number: NKB-299/UN2.RST/HKP.05.00/2023 ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study received approval from the Ethical Review Board of Universitas Katolik Indonesia Atmajaya (Approval No. 00061/III/PPPE.PM.10.05/07/2022) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All original data is accessible to the public by contacting the corresponding author. The original data for editorial and reviewer teams has been enclosed within the system (as a supporting information)