Sunday, June 02, 2019

糖税能治肥胖?


如果您近期逛超市,应该很难不注意到很多含糖饮料正做折价促销。那不是意外,也不纯粹是开斋节要来临。商家和厂方为了要应付即将要在71日落实的含糖饮料税(以下简称为糖税),现在就抛售倾销旧货。这个新征的税务项目针对含糖饮料制成品,是在去年的财政预算案正式提出。凡是每100毫升的饮品拥有超过5克附加糖将被征税每公升40仙;至于果汁或蔬菜汁有更高的征税糖份顶限(超过12克),奶制品则是超过7克。这个政策点子其实早在两年前就率先由卫生部倡议。落实新征税的日期原本是41日,后来关税局给予3个月的通融期,让饮料制造公司能及时调整生产作业和登记征税户口。笔者感到有些意外,因为不少饮料制造商似乎已准备好,早已跟随政策把糖份含量调整降至5克以下。如此一来,新税务都还没正式起跑,看来政府已有初步成功的迹象。

相信不少人对这糖税政策的成效有所保留或存疑,特别是当政府以减少痴肥和糖尿病病例为宗旨和出发点。也有人认为这又是个美其名扩大财政收入来源的政策。针对直接的经济效益,笔者找不到有关糖税的今年官方收入估计数目。但根据2019年度财政预算案有关其他类别(非酒精非香烟)的特殊货物税(excise tax)收入预算,若糖税纳入其中同时其他类别税务收入保持不变,那么糖税在今年预料最高可征收大约5000万令吉。而笔者根据2014年大马成年人营养调查(Malaysian Adult Nutrition Survey, MANS)报告的饮用量结果计算税收,全年最高应可达1.12亿令吉。因此这笔糖税收入数目相当可观。

国人摄糖量过高

尽管世界卫生组织在2015年建议每人每日不宜食用超过50克糖。MANS报告里也指出国人摄取糖分相当高。仅仅是砂糖本身,食客每日就平均吃掉20克(见图表)。饮料当中最严重的是麦芽饮料,大约60%受访者每日平均就饮用160毫升,而一般人印象中的祸首——汽水仅获45.7%人青睐,每日平均饮用81.1毫升。如果根据美禄所建议的冲饮方式及可口可乐食品成分标签计算,以上的饮用量分别已含10克与9克糖。国人若不减糖,岂有不肥的道理?
MANS报告也展示了市面上各种各样的饮食品,这些都可能是某些人摄取糖份的来源,工厂制成的含糖饮料或仅是一部分而已。如今特别潮流风行的奶茶文化,那些现做的甜滋滋饮料,其实并不包含在被征税的物品种类。


笔者较关注的是,到底哪个群体最有可能因为这个新税务而改变他们的日常饮食习惯?如果饮品即刻贵了大约40仙,是否还是一般饮客可负担、无痛痒的代价?糖税到底有没有阻遏作用,促使他们改变习惯、改喝低糖免附加税的饮品?反之,笔者担心大部分人宁愿给多一点钱喝他们喜欢的甜度,然后继续导向痴肥和糖尿病。

就拿汽水为例,虽说汽水广受欢迎,几乎不分年龄和收入阶层,但MANS报告结果也显示较多年轻人有喝汽水的习惯,同时较富裕的人士比较少饮用。另一份2017年的调查报告则发现大约37%的中学生承认至少每天都饮用一罐/瓶汽水,23.6%的中学生不分城乡在学校内购买含糖饮料(包括汽水)。这意味著这些饮料相对廉宜又成功让幼小心灵上瘾。如果糖税能起正面的作用,那么首先就必须对准来自较低收入的家庭,特别是那些拥有未成年孩子的家庭。原因是后者还没有经济基础,若能减少他们购买高糖饮品同时转购低糖替代品,相信就能有效地减少这些孩童每日的糖份摄取量,抑制和改换他们对高糖的口味。

改变民众甜舌口味
笔者本身的研究也发现,由于最低家庭收入的40%阶层(B40)每月明显花费更多在饮食(25.5%的月入),糖税或可让他们重新调整每月家庭支出预算,减少购买高糖饮料。

糖税政策对国家好吗?在一些国家例如墨西哥,糖税的确对国民健康起著正面作用。一般良性的政策结果包括征税饮品销售量下跌、成人与孩童减少摄取高热量食品及体重递减、以及国库收入增加。笔者也预料饮品制造商会推出和销售更多低糖免糖税的替代品。这肯定不是坏事,因为糖税本来并非要民众放弃某些饮品,而是自行调整他们的口味和思维,让他们普遍认为太甜的饮品不止是更昂贵,同时也不健康。糖税政策能达到这点就难能可贵,可说取得了一半的胜利。如果民众的甜舌口味逐渐改变,大家已著重健康,届时饮食业业者也会随著调整他们准备食物使用的糖、盐和食用油份量。

要改变社会习性,不可能仅靠税收制度里的财务奖励和惩罚为手段就可达到目的。若真属实可以那么简单,当一些国家对酒精和香烟征收更高的罪恶税的时候,这些产品的销售量在这些市场理应下降,但很多时候却事与愿违。因此,一些国家实施了糖税后能取得成就,其实胥视其他伴随著有效的公共卫生政策与宣导。

刊登于《東方日報》東方文薈版2019年6月2日

東方日報FB po 文留言链接在此

Make drug price transparent


Glad to contribute my thoughts on the resolution on drug price transparency passed in the recent 72nd World Health Assembly. Thank you The Star for the interview.
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//...Research institute Penang Institute in KL’s senior analyst Dr Lim Chee Han says that given budget constraints, the WHO resolution will strengthen the government’s position in setting appropriate indicative prices for drug procurement open tender bids.
This will enable the government to secure the best value from the bids and purchase more needed health products with the limited funds, he says.
The resolution will also help private patients to reduce their out-of-pockets expenditure on drugs, thus reducing the incidence of medical impoverishment after catastrophic illness, he says.
Lim says that the medicines that require the ministry to intervene and request transparency on are single-source originator medicines that are new in the market.
“This is where the market price data and information about the medicine are often lacking to determine the value, most likely subjected to unreasonable pricing,” he says.
In the current practice when calling for a tender, the ministry will compare prices with median prices of medicine in countries with a similar development status, says Lim.
“With this new resolution, all member states can urge pharmaceutical companies to declare the relevant information before accepting the list price set by the company.
“This can deter some companies from abusing their patent monopoly position to set unreasonably high benchmark/reference prices in different markets,” he says. //

The news article can be accessed here.

My full media response is below:
The resolution passed in the WHA72 to improve the transparency of markets for medicines, vaccines and other health products, is a long-awaited victory for the global citizens. Certainly this news benefits Malaysia by and large, as the issue about rising healthcare cost especially concerning drug price is gaining more public attention.  What the resolution actually compels the health authority in the member states to do is to publicly share information about: i) net prices of health products, ii) costs of clinical trials (for the drug development) carried out, iii) sales performance of health products, iv) patent status and market approval status, v) help improve national capacities especially in developing countries and low- and middle-income countries. The net effect of (i) to (iv) would be, the pharmaceutical companies have to justify their pricing by declaring the specific costs incurred in the drug development, considering if the profit of the drug sales have already recouped their investment, and lastly health authority in the member states as well as public would be made aware of the drug patent status while anticipating the entry of generic drugs in the competition to bring the drug price even lower. After the scrutiny of various global health authorities, health advocacy groups and general public, these information would certainly increase the market transparency and social responsibility of pharmaceutical companies in setting the drug price in an acceptable and reasonable range.

Granted, drug price transparency does not equate to drug price control.  However, opaque, unaccountable or simply arbitrary drug price-setting behaviour by some pharmaceutical companies should not be the way how a free market works. Freedom of information must come hand-in-hand, for a buyer to be fully aware of the product information therefore could determine/evaluate what is a fair value. Otherwise it can lead to abuse of legal-monopoly position (by the virtue of being a patent holder) in setting unreasonable and unethical pricing.

Medicine is not ordinary market commodity. When the patent period is still on, there would have no other substitute for the patients. They could be desperate and probably could not live without those life-saving drugs. Sometimes the only obstacle/barrier that denies their access to the drug is not the availability, but affordability of the drug[1].

In 2017, RM2.382 billion had been set aside for medicine procurement for MOH health facilities, which was about 10% of the total operating expenditure of the MOH. As much as the government would like to help the public patients to access the treatments, given the budget constraint, every drug procurement using this pool of funding poses opportunity cost to others.

The WHA72 resolution would strengthen the hands of the government in setting the appropriate indicative prices for drug procurement open tender bids, thus ultimately the government would secure the best value from the procurement bids and be able to squeeze more from the limited fund to purchase more needy health products. Drug price transparency would also help the private patients to reduce their out-of-pockets expenditure on drugs, thus reduce the incidence of medical impoverishment after catastrophic illness.


[1] There is often a phenomenon for originator cancer drugs to be priced higher. According to the Medicine Prices Monitoring 2017 report published by the MOH, the three selected standard cancer treatment originator products cost in the range of RM3,807.2 to RM19,520.5 or 107.6 to 551.7 days of minimum wage, as compared to all drugs in other categories, where their treatment cost was typically in the low multiply of hundreds.

回應卡迪耶欣的言論

那天988電台電訪我要我回應卡迪耶欣的言論(表現不好的部長應自動辭職退位)。以下是我當時的答復。可惜週四早上播出時我已錯過了。

***
Kadir 是首相馬哈迪的媒體通訊顧問,從他過去的言論就像扮演著類似馬哈迪的非正式代言人或喉舌,所以他的談話或帶出馬哈迪欲傳達意思或訊息。所以聽他發言時,難免不聯想到這個長久以來他的角色本位。
馬哈迪在被詢及整體內閣表現評分的時候,10分他打5分,意味著也許接近一半的部長表現欠理想。可惜馬哈迪和Kadir都沒有給部長的KPI標準。到底怎樣的表現才算合格,失敗還是特優呢?是否有出席內閣會議、遵循內閣整體議決就是好?是否包括落實希盟競選宣言?是否勤力走動國內國外活動開會拍照打卡就是有做事的證明?還是愛開記者會發表言論,在網媒很積極,公共輿論和印象很“紅”,就是有表現?沒人曉得。
重組內閣本來就是首相的權力,可是Kadir卻催促那些“表現不好”的人自動辭職,耐人尋味。請問誰會自招自己表現不好到需要辭職自動退位?要知道馬來西亞政府沒有辭職的文化。
再說,內閣本身各職位的安排本來就是各成員黨密室談判角力的結果,無論是成員黨之間或黨內部派系。這本來就不是一個選賢與能的決定。比如說,誠信黨獲得最高內閣部長職位的是末沙布,應該沒有人會認定他就是希盟中選議員裡最好的國防部長人選吧?他在位,因為他是誠信黨主席,就如林冠英是財長因為他是行動黨no.1秘書長。萬一末沙佈的表現真的不好,馬哈迪有可能會敢敢動他把他撤換嗎?
所以Kadir才扮演那個喉舌的角色,叫那些成員黨表現“不理想”的部長成員知難而退。如果是他自家土團黨的部長,這個就很簡單了因為馬哈迪在黨內大權在握,根本不需要Kadir出來放話。有天如果Kadir不再需要這樣出來代言,就代表馬哈迪身為首相的權力地位已完全鞏固,土團黨已主導政府,其他成員黨只有附屬的份。你有看過國陣時代,首相的發言人有這樣對成員黨喊話?
目前要內閣重組撤換部長是件複雜麻煩的事。預料如果有成事,應該不是因為該部長真的表現不好,而是黨內的決鬥,黨內老大不保那人而要換上其他的自己人。