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Featured case: Sin Taxes and Health Financing
in the Philippines

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The case

Who – the protagonist

Dr Enrique Ona, a top surgeon in the Philippines. After working in the US and UK, he returned to the Philippines in 1970 to set up a vascular and transplant surgery programme at the University of Philippines’ College of Medicine. In 2010, he was appointed Secretary of the Department of Health.



Benigno Aquino became president of the Philippines in 2010. Despite being a smoker, he supported raising taxes on tobacco products (‘sin taxes’) to discourage smoking and generate new revenues for health care. He instructed Health Secretary Enrique Ona to prioritize the tax increase and expand health insurance coverage for poor Filipinos.


Nearly one-third of Filipino adults smoked, and cigarette prices in the Philippines were among the lowest in the world. Despite heavy opposition from tobacco interests, Enrique Ona worked with the finance department, civil society groups, and others to raise tobacco taxes and earmark new revenues for health insurance subsidies and health facility upgrades. The new law passed in December 2012 and subsequently adult smoking prevalence fell to 25%, and an increasing number of poor Filipinos obtained government-sponsored health insurance.


The Republic Act 10351, known as the ‘sin tax reform act’ was finally signed into law on 19 December 2012, with higher tax rates taking effect from 1 January 2013.


The Philippines is a Southeast Asian country in the Western Pacific made up of more than 7,000 islands. The country gained independence from the US in 1946 and became the Republic of the Philippines.


Key quote

‘This was probably the most important role I played: to make it very clear to everybody to forget about it being a tax measure and focus instead on it being a health measure.’ – Enrique Ona

What next?

Enrique Ona had resigned from his post as Secretary of the Department of Health in 2014, but he was still concerned about the impact of the ‘sin tax’ reforms on smoking levels and healthcare access. Could the initial decline in smoking be sustained into the future? And would the tax revenue have the impact on national health that he’d hoped for?

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The authors

Amy Madore, Julie Rosenberg and
Rebecca Weintraub







Amy, Julie and Rebecca describe meeting their protagonist in Manila and the complex issues he faced with determination and passion.

Winning the battle

We met former Health Secretary of the Philippines Enrique Ona over delicious Filipino pastries at a quiet café in Manila, where he and an activist he’d worked closely with proudly described ‘how the sin tax battle was won’. The Ministerial Leadership Program at Harvard (MLIH) saw in Ona a determined and passionate leader who was able to overcome incredible political and transnational hurdles to improve health. We feel it’s important to share with other health ministers across the globe his experience and the role of fiscal policy in health care delivery.


Challenging and invigorating

Being in Ona’s shoes is challenging and invigorating for students. Ona holds tremendous power as a political leader; he’s a strategic leader, and he has a big evidence base to support his cause, but he’s also fighting strong opposition from national and local tobacco interests. Students stand in Dr Ona’s shoes as he navigates this intensely political issue and builds relationships with a variety of stakeholders. Students also grapple with how to allocate and maximise the new tax revenues given the many pressing needs facing the health system.

Strategic and tactical

This is a great case for health and finance professionals as it explores the links between health and finance policy and highlights the importance of collaboration between government agencies working in these realms. Public health and advocacy professionals in particular will benefit from analysing the strategic and tactical steps sin tax reform advocates took and how they addressed challenges along the way.

Widely applicable

The lessons learned from this case are applicable beyond the Philippines and include the need to understand the issues and stakeholders involved in policy making and the importance of data collection and analysis in advocating for and maintaining sound health policies.

A fun case to write

This was a fun case to write. We had the opportunity to speak with Filipinos from many different walks of life, from a cab driver who works 22-hour days and had switched to a cheaper cigarette brand in response to higher taxes, to a former tobacco tycoon who carries gold-plated business cards and has a pet Siberian tiger. Everyone who helped achieve tax reform spoke with great pride about the effort, no matter how modest their role, and beamed about its collaborative, multisectoral nature.  

This case is one of 36 in our Global Health Delivery collection, all of which are available free. The collection brings unique perspective and an interdisciplinary lens to health policy and the intersection of health and financing.

About the authors

Amy Madore is Senior Case Writer at The Global Health Delivery Project at Harvard.
e amadore@globalhealthdelivery.org

Julie Rosenberg is Director of Research and Publications at The Global Health Delivery Project at Harvard.
e julie@globalhealthdelivery.org

Rebecca Weintraub is Assistant Professor at Harvard Medical School and Faculty Director at The Global Health Delivery Project at Harvard.
e rebecca@globalhealthdelivery.org


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