Sugar, power and policy: The political economy of a health and economic 'win-win' in Fiji's sugar-sweetened beverage tax.

Background: In 2006, the Fiji Government introduced a 0.05FJ$ (0.03USD) per litre excise tax on domestically produced sugar-sweetened beverages (SSBs). Since then, the tax has been abandoned, reintroduced, or adjusted at least ten times, while tariffs on imported SSBs have also undergone reform. These rapid iterations of Fiji's SSB tax raise questions about which interests and motivations underpin the tax, what instigated the multiple adjustments, and implications for its impact on health versus economic and political considerations.

Methods: Using case study methodology, this study maps the history of SSB tax adjustments in Fiji and examines the political economy forces that have shaped, and continually re-shaped, this policy landscape. We used policy analysis and theories of power to analyse the intersection of ideas, interests and institutions, drawing on policy documents (n = 304), key informant interviews (n = 32) and direct observations of socio-political events (n = 7) as data sources.

Results: Findings from this study indicate that the introduction of the SSB tax and subsequent adjustments were motivated more by economic, than health, imperatives. The relationship of mutual dependence between the Fiji Government and domestic SSB industry actors led policymakers to make multiple adjustments, seesawing in an attempt to balance the immediate need for revenue and long-term economic development through strengthened local industries. Early SSB tax lobbying from health actors alone had minimal impact. However, a subsequent alliance between government health actors and politically savvy and well-positioned civil society actors proved persuasive in both increasing the tax rate and ensuring a health and rights focus, arguably achieving a health and economic 'win-win'.

Conclusion: Global adoption of SSB taxes is increasing. Examining the protracted history of Fiji's SSB tax reveals the political ebbs and flows that alter how prospective population health 'wins' are weighed up against other policy imperatives. For health-interested actors, these insights point to important strategic in-roads around the explicit use of political economy analysis to complement technical policy insights. Building and maintaining coalitions that extend beyond government and into civil society also proved pivotal. Health system leadership that champions political thinking and cross-sectoral partnerships holds great promise for enhancing health actors' engagement with SSB tax-specific policy making and other multisectoral reform in Fiji and elsewhere.