Inter Press ServiceVani S. Kulkarni – Inter Press Service http://www.ipsnews.net News and Views from the Global South Thu, 20 Sep 2018 12:08:34 +0000 en-US hourly 1 https://wordpress.org/?v=4.8.7 Old Age Is a Curse in Indiahttp://www.ipsnews.net/2018/08/old-age-curse-india/?utm_source=rss&utm_medium=rss&utm_campaign=old-age-curse-india http://www.ipsnews.net/2018/08/old-age-curse-india/#respond Tue, 21 Aug 2018 10:19:37 +0000 Pratima Yadav, Raghav Gaiha, and Vani Kulkarni http://www.ipsnews.net/?p=157285 The swift descent of the elderly in India into non-communicable diseases could have various disastrous consequences.

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Old age morbidity is a rapidly worsening curse in India. The swift descent of the elderly in India (60 years+) into non-communicable diseases (NCDs e.g. cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) could have disastrous consequences in terms of impoverishment of families, excess mortality, lowering of investment and consequent deceleration of growth

Credit: Neeta Lal/IPS

By Pratima Yadav, Raghav Gaiha, and Vani S. Kulkarni
NEW DELHI, Aug 21 2018 (IPS)

Old age morbidity is a rapidly worsening curse in India. The swift descent of the elderly in India (60 years+) into non-communicable diseases (NCDs e.g. cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) could have disastrous consequences in terms of impoverishment of families, excess mortality, lowering of investment and consequent deceleration of growth.

Indeed, the government has to deal simultaneously with the rising fiscal burden of NCDs and substantial burden of infectious diseases. As a recent Lancet report (2018) points out, failure to devise a strategy and make timely investment now will jeopardise achievement of SDG 3 and target 4 of a one-third reduction in premature mortality from NCDs by 2030.

Pratima Yadav

NCDs are chronic in nature and take a long time to develop. They are linked to ageing and affluence, and have replaced infectious diseases and malnutrition as the dominant causes of ill health and death in much of the world including India. The four NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) share a set of modifiable risk factors: unhealthy diet, physical inactivity, smoking, excessive use of alcohol and failure to detect and control intermediate risk factors such as high blood pressure, high cholesterol, high blood sugar and excess weight (Bloom et al. 2014).

Of the 56 million deaths worldwide each year, 38 million (68%) are due to non-communicable diseases (NCDs), and 16 million (more than 40%) of these deaths are premature (before 70 years of age).

The four NCDs (cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) account for 42% of all deaths in India. These diseases contribute to 22% of disability-adjusted life-years in India (or DALYs—the combination of years lived with serious illness and those lost due to premature death). So the cost in terms of lives lost is horrendous.

Our analysis with National Sample Survey (NSS) data for 2004 and 2014 highlights some of these concerns in a striking way.

Vani S. Kulkarni

The burden of NCDs rose sharply among the old. It doubled among 61-70 years and 71-80 years and nearly tripled among 80 + years. In sharp contrast, prevalence of communicable diseases also rose but only slightly. So there are strong grounds for an epidemiological transition away from communicable diseases to non-communicable diseases among the old that require longer-term and more expensive solutions.

Between rural and urban areas, the latter had higher prevalence of NCDs and the disparity grew. This gap is largely attributable to greater dependence on processed food, and environmental pollution.

Comparison by gender yields an interesting reversal. In 2004, aged women had higher prevalence of NCDs than aged men, but there was a reversal in 2014. Part of the explanation lies in difference in health-seeking behaviour, with women more restricted in their access to medical care.

Highest prevalence of NCDs was observed among the widowed, followed by the divorced/separated and lowest among never married. Each of these groups recorded higher prevalence except never married who recorded a decline. Ostracised by society, widows often seek solace in slow death.

Raghav Gaiha

Does education make a difference? It does. Among the illiterates and those below primary, the prevalence rose while in all other categories of education it declined. The decline was sharpest among the graduates, followed by those with middle to higher secondary education.

NCDs are often associated with affluence and associated sedentary lifestyle and diets rich in carbohydrates and fats. So we examined the association between per capita income quintiles and NCDs. One striking feature is that both in 2004 and 2014, prevalence rose steadily across these quintiles except in the lowest/least affluent. Besides, prevalence rose more than moderately among the more affluent fourth and fifth quintiles. So the characterisation of NCDs as diseases of affluence is accurate.

Typically, socio-economic hierarchy comprises: the most disadvantaged STs, followed by SCs, OBCs and Others. Prevalence of NCDs was lowest among the STs, higher among the SCs, still higher among the OBCs and highest among the Others in 2004. This pattern remained unchanged in 2014. While the STs experienced a slight reduction, all other groups recorded increases in prevalence of NCDs—especially OBCs and Others.

While the recent National Health Policy 2017 and Niti Aayog have ambitious agenda for curtailing premature death and morbidity due to NCDs, the measly increase in this year’s budget is ironical. Indeed, the neglect of NCDs is worse than tragic given the prediction that cumulative losses in output between 2012 and 2030 due to NCDs may be as high as one-and-a half times of India’s GDP.

 

Pratima Yadav is an independent researcher; Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania; and Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, and Visiting Scholar, Centre for Population Studies, University of Pennsylvania.

This story was originally published in Sunday Guardian

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Excerpt:

The swift descent of the elderly in India into non-communicable diseases could have various disastrous consequences.

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Are Prospects of Rural Youth Employment in Africa a Mirage?http://www.ipsnews.net/2017/11/prospects-rural-youth-employment-africa-mirage/?utm_source=rss&utm_medium=rss&utm_campaign=prospects-rural-youth-employment-africa-mirage http://www.ipsnews.net/2017/11/prospects-rural-youth-employment-africa-mirage/#comments Mon, 13 Nov 2017 17:59:35 +0000 Raghav Gaiha and Vani Kulkarni http://www.ipsnews.net/?p=153004 (Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

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(Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

By Raghav Gaiha and Vani S. Kulkarni
NEW DELHI, Nov 13 2017 (IPS)

Many recent accounts tend to dismiss productive employment of youth in rural areas in Africa as a mirage largely because they exhibit strong resistance to eking out a bare subsistence in dismal working and living conditions. We argue below on recent evidence of agricultural transformation that this view is overly pessimistic, if not largely mistaken.

Raghav Gaiha

The 15–24-year-old age group represents 20% of SSA’s population today and, unlike in other regions, this youth share will remain high and stable (19% in 2050). In absolute terms, SSA’s youth will grow from nearly 200 million in 2015 to nearly 400 million in 2050, and its share in the labour force will remain the highest in the world, even if following a declining trend. Representing 37% today – in comparison with 30% in India, 25% in China and 20% in Europe – it should still account for 30% in 2050 (ILO, 2016).

Agriculture has a substantial role in meeting the youth employment challenge facing Africa. Even in a most optimistic scenario, non-farm and urban sectors are not likely to absorb more than two-thirds of young labour market entrants over the next decade. But there will be vast opportunities for the innovative young people in agricultural systems as they adapt to a range of challenges in the near future. These challenges relate to raising productivity in a sustainable way, integration into emerging high value chains, and healthy diets.

While the challenges are daunting, the potential benefits of addressing them are enormous. Higher prices, more integrated value chains, widening connectivity to markets in some areas, and greater private and public engagement in the sector are creating new opportunities. A major barrier is, however, strong negative preferences/attitudes of the youth towards agriculture.

A survey of rural in- and out-of school young people towards agriculture, based on field-work in two regions in Ethiopia, is remarkably rich and insightful (IDS Bulletin Volume 43 Number 6, 2012). Life as a farmer was tied to life in a village which most respondents saw as hard and demanding. Yet there was considerable heterogeneity in the views of the young. Participants in both regions concurred that agriculture has changed significantly over the last decade. The introduction and adoption of agricultural inputs such as improved seeds, fertilisers and better farming methods (such as slash ploughing, sowing seeds in rows, water pumps, modern beehives) have produced significant increases in productivity and earnings.

There were competing narratives on whether agriculture was becoming more desirable to young people as a result. Participants felt that these developments were making agriculture more and more profitable and therefore more appealing. But they felt that there was a huge obstacle in engaging in it – scarcity of land. Although the dominant view was that young people are disinterested in agriculture, some participants pointed out that this was not always the case.

A slightly more positive attitude towards agriculture was evident among young people who had left school, either failing to complete high school for various reasons or to qualify for higher level education. Although this group of respondents were equally aware of the grimness of traditional agriculture and the life of the common farmer, many were not dismissive of agriculture as a possible future livelihood, while a few even saw it as a preferred livelihood option, under improved conditions.

Recognizing agriculture as a viable employment option is even more challenging when economic and social restrictions related to access to productive resources (eg land, credit and improved seeds) are taken into account. All these limitations are exacerbated for young women who, in general, have no prospect of land access due to rules of inheritance, and who know that they will mainly have to work for their husbands (ILO, 2016).

Although the government considers rural educated youth as instrumental in bringing about a transformation in agricultural skills, knowledge and productivity, it has not effectively addressed either the attitude of many young people towards agriculture or the obstacles preventing their entry into the sector.

To create opportunities commensurate with the number of young people who will need employment, constraints on the acquisition of capital, land, and skills must be removed or relaxed.

A few selected initiatives are delineated below.

Allowing alternative forms of collateral, such as chattel mortgages, warehouse receipts, and the future harvest, can ease the credit constraints-especially for young farmers. The OHADA7 Uniform Act on Secured Transactions, in effect in 17 Sub-Saharan African countries, was amended at the end of 2010 to allow borrowers to use a wide range of assets as collateral, including warehouse receipts and movable property such as machinery, equipment, and receivables that remain in the hands of the debtor. Leasing also offers young farmers some relief, as it requires either no or less collateral than typically required by loans. A case in point is DFCU Leasing in Uganda, which gave more than US$4 million in farm equipment leases in 2002 for items such as rice hullers, dairy processing equipment, and maize milling equipment. Some outgrower arrangements prefinance inputs and assure marketing channels. In Mozambique, Rwanda, Tanzania, and Zambia, Rabo Development (a subsidiary of Rabobank) offers management services and technical assistance to financial institutions, which, in turn, finance supply chains with a range of agricultural clients.

The two aspects of land administration that matter most to young entrants to the labour force are the need to improve security of tenure and the need to relax controls on rental. Land redistribution will also enhance young people’s access to land. In general, policies and measures that help the poor to gain access to land will also help young people.

The growing food demand in Africa is a major avenue for agro-processing, which can easily be developed using small and medium-sized entities (SMEs). This option requires less capital, is more labour intensive and facilitates the proliferation of units in rural boroughs and small towns, offering employment and entrepreneurial opportunities, local value added and new incomes. Agro-processing SMEs can also facilitate the resolution of post-harvest problems, which are a significant issue in SSA resulting in a loss of revenue for farmers.

In the Niger Delta, for instance, the IFAD-supported Community Based Natural Resource Management Programme is promoting a new category of entrepreneur-cum-mentor called the ‘N-Agripreneur’. These N-Agripreneurs own and run medium-scale enterprises at different stages of food value chains. They deliver business development services to producers, especially young people, who are interested in agro-based activities, such as farming as a business, small-scale processing, input supply and marketing.

In order to enable young people to respond to the environmental, economic and nutrition challenges of the future, they must develop suitable capacities. A case in point is ICTs which can develop young people’s capacities, while improving communication and easing access to information and decision-making processes. Investing in extending these technologies to rural areas, in particular targeting young people – who are generally more adaptable to their use – has allowed them to keep themselves up-to-date with market information and new opportunities.

In sum, there is an abundance of remunerative employment opportunities for the youth in rural areas that could dispel the mirage through imaginative government policies.

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Excerpt:

(Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

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Women and Malnutrition in Africahttp://www.ipsnews.net/2017/10/women-malnutrition-africa/?utm_source=rss&utm_medium=rss&utm_campaign=women-malnutrition-africa http://www.ipsnews.net/2017/10/women-malnutrition-africa/#comments Tue, 31 Oct 2017 15:55:42 +0000 Raghav Gaiha and Vani Kulkarni http://www.ipsnews.net/?p=152836 Raghav Gaiha, is (Honorary) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

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Raghav Gaiha, is (Honorary) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

By Raghav Gaiha and Vani S. Kulkarni
NEW DELHI and PHILADELPHIA, Oct 31 2017 (IPS)

Undernutrition is widespread and a key reason for poor child health in many developing countries. In Sub-Saharan Africa, around 40 percent of children under the age of five suffer from stunted growth, that is, severely reduced height-for-age relative to their growth potential. Stunting is a result of periods of undernutrition in early childhood, and it has been found to have a series of adverse long-term effects in those who survive childhood. It is negatively associated with mental development, human capital accumulation, adult health, and with economic productivity and income levels in adulthood.

Raghav Gaiha

Vitamin A deficiency is associated with the higher risk of morbidity and mortality, and ocular disorders such as night blindness, xerophthalmia and blindness, affecting infants, children and women during pregnancy and lactation. African regions account for the greatest number of preschool children with night blindness and for more than one-quarter of all children with subclinical vitamin A deficiency.

The central premise is that agricultural development has enormous potential to make significant contribution in reducing malnutrition and the associated ill health. With its close links to both the immediate causes of undernutrition (diets, feeding practices, and health) and its underlying determinants (such as income, education, access to WASH – water, sanitation and hygiene- and health services, and gender equity), the agriculture sector can play a strong role in improving nutrition outcomes.

Women are vitally important agents, both in their roles as producers and as custodians of household welfare. Their importance, moreover, is generally greater in the lowest-income settings and among households with high dependency ratios—in which a large proportion of household members are nonearning and often nutritionally vulnerable dependents.

The resources and income flows that women control often have positive impacts on household health and nutrition. In some countries, women tend to lack access to economic opportunities outside the domestic sphere to which traditional customs often confine them, especially in rural areas. They are also very often severely constrained by time and the multiple—often simultaneous—roles they play as producers and caregivers. Agricultural programmes and policies that empower and enable women and that involve them in decisions and activities throughout the life of the programme achieve greater nutritional impacts.

Vani S. Kulkarni

Although women comprise more than 50% of the agricultural workforce in most of the Eastern and Southern Africa (ESA) region, the productivity gap between men and women farmers persists. To illustrate how wide the gap is, in Tanzania, Malawi, and Uganda narrowing the gender gap in agricultural productivity has the potential of raising the gross domestic product by USD 105 million, USD 100 million, and USD 65 million, respectively (IFAD,FAO and WFP, 2015). Women farmers typically use lower levels of purchased technological inputs, such as fertilizer and high-yielding seed varieties. That women lack access to these key technological inputs explains a significant portion of the productivity gap. They are often hesitant to adopt these technologies if they do not control the benefits that accrue from adopting. Moreover, women also face unique challenges, due to their lifecycle and reproductive roles, which further influence their participation on- and off-farm.

In Kenya, new varieties of sweet potatoes rich in beta-carotene were introduced to women farmers with an end goal of improving vitamin A intake of young children, thereby preventing vitamin A deficiency. There was a significant increase in the intake of vitamin A-rich foods, among children whose mothers received both the production-focused intervention of planting materials and access to agricultural extension services, and the consumption-focused intervention of nutrition education and training in food processing and preparation. By contrast, there was a decrease in vitamin A intake among children whose mothers received only the production-focused inputs. This example suggests that: (a) women’s farm production offers an entry point for interventions that can improve nutrition; and (b) interventions that increase women’s agricultural productivity and increase their health and nutrition knowledge may yield more benefits than ones that target only productivity or only knowledge.

In Ethiopia, a women-focused goat development project was expanded to include interventions to promote vitamin A intake, nutrition and health education, training in gardening and food preparation, and distribution of vegetable seeds. Goat owning households consumed all produced milk; 87% by the adults as hoja; children in the participating households had slightly more diversified diets; they were also more likely to consume milk more than 4 times a day. As substitutions occur between foods, in the absence of anthropometric indicators, nothing definitive could be inferred about improvements in child nutrition.

Women’s employment in agriculture has positive impacts on nutrition in the household when women have decision-making power over resource allocation. In Uganda, for example, evidence from randomized controlled trials showed positive impacts from biofortified crops, including orange-fleshed sweet potato, on vitamin A status among women and children. Ownership of livestock was associated with better household food security in Kampala. However, there were mixed impacts on the links between women’s empowerment, intrahousehold decision-making, and better nutrition outcomes.

Failure to understand cultural norms and the gender dynamics within the household can result in unanticipated outcomes. In the Gambia, for example, a project geared to increasing women’s rice production was so successful that the land it was grown on was reclassified internally within the household. This resulted in output from that land being sold by men as opposed to women. Women therefore lost their original income stream, but remained committed to increased labour.

Vegetables and legumes are often regarded as women’s crops. Recognizing this, a project in Togo was successful because it promoted the introduction of soybeans as a legume rather than as a cash crop. Promotion as a cash crop would have resulted in the crop switching to male control. Interventions promoting the production of animal source foods also assessed their impact on maternal income or women’s control over income. The results were quite mixed. For example, an intervention involving intensified dairy farming in Kenya showed that an important share of the additional income was controlled by women, whereas in Ethiopia men’s incomes benefited significantly more from intensified dairying than did women’s. Whether women’s income is likely to increase depends on the livestock or aquaculture production system, the nature of the intervention, and cultural beliefs and practices relating to gender. Even if the intervention is targeted to women’s livestock and aquaculture activities, women lose control over the income generated by those activities.

In conclusion, it is arguable that there are improved impacts on nutrition if agricultural interventions are targeted to women and when specific work is done around women’s empowerment (for example, through behaviour change communication), mediated through women’s time use, women’s own health and nutrition status, and women’s access to and control over resources as well as intrahousehold decision-making power. That this may be dismissed out of hand is not unlikely either, given the persistence of male dominance.

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Excerpt:

Raghav Gaiha, is (Honorary) Professorial Research Fellow, Global Development Institute, University of Manchester, England; and Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA).

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The ‘Public’ in Public Healthhttp://www.ipsnews.net/2017/05/the-public-in-public-health/?utm_source=rss&utm_medium=rss&utm_campaign=the-public-in-public-health http://www.ipsnews.net/2017/05/the-public-in-public-health/#respond Mon, 22 May 2017 22:08:43 +0000 Vani Kulkarni http://www.ipsnews.net/?p=150532 Vani S. Kulkarni teaches Sociology at University of Pennsylvania, Philadelphia

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By Vani S. Kulkarni
PHILADELPHIA, May 22 2017 (IPS)

 

The discourse must move beyond a top-down approach to listen to the people and formulate best insurance practices

Much ink has been spilled in documenting the inadequacy of budgetary allocations for public health insurance, specifically for the Rashtriya Swasthya Bima Yojana (RSBY), the world’s largest publicly-funded health insurance (PFHI) scheme. Though the 2017-18 budget allocation has marginally increased from last year’s revised estimates, it has declined relative to last year’s budgeted amount by about ₹500 crore. However, higher budgetary allocation can only constitute a small part of the solution to the scheme’s mixed, if not lacklustre, performance.

Vani S. Kulkarni

Vani S. Kulkarni

Under the scheme, a Below Poverty Line (BPL) family of five is entitled to more than 700 treatments and procedures at government-set prices, for an annual enrolment fee of ₹30. However, even nine years after its implementation, it has failed to cover a large number of targeted families — almost three-fifths of them. Their exclusion has been due to factors like the prevalent discrimination against disadvantaged groups; a lack of mandate on insurance companies to achieve higher enrolment rates; and an absence of oversight by government agencies.

Increase in hospitalisation
True, there has been a substantial increase in hospitalisation rates. However, it is unclear if it has enabled people to access the genuinely needed, and hitherto unaffordable, inpatient care. Often, doctors and hospitals have colluded in performing unnecessary surgical procedures on patients to claim insurance money. For instance, hospitals have claimed reimbursements worth millions of rupees for conducting hysterectomies on thousands of unsuspecting, poor women. Indeed, in the absence of regulations and standards, perverse incentives are created for empanelled hospitals to conduct surgeries. It is thus not surprising that there is no robust evidence of an improvement in health outcomes.

Evidence on the financial protection front is conflicting as well. One study revealed that poorer households in districts exposed to the RSBY and other PFHIs recorded an increase in out-of-pocket (OOP) expenditures for hospital care, and a corresponding rise in incidence of catastrophic expenditure. There is near-consensus that the RSBY has resulted in higher OOP expenditures. Though it is a cashless scheme, many users are exploited by unscrupulous hospital staff.

So, what is the solution? There is a need to bring the ‘public’ back into the discourse on public health to highlight its present culture. The conversation needs to move beyond a top-down approach specifying budget allocation and administrative and technical efficiency. It needs to involve listening to the real public to deliberate on various health practices and policies.

My ethnographic study of the RSBY in Kalaburagi and Mysuru districts between 2014 and 2016 brought to light that a top-down approach on allocation and coverage was important but, by itself, did not translate to expected outcomes. What mattered more was the existing culture of health insurance — how it was perceived, practised and experienced in the everyday, local worlds of the enrolled households. Though they valued aspects like the money available and the number of illnesses covered, they were more deeply affected by how other actors — doctors, local officials, neighbours and even relatives — related to health insurance.

Card not accepted
The disillusionment of Savitri, one of the beneficiaries, after obtaining the plastic card said it all: “If public officials only give us the card without telling us how to use it, the card is just plastic material. Sometimes information is also not correct, making us feel that the card is of no real value if we do not know how to use it.” Further, many hospitals refused to acknowledge the card’s value. Shivakumar’s observation summed it well: “We went to the hospital with the card. Not only could it not be used but also the doctors did not even acknowledge us as patients… We just brought the card home and tossed it to the shelf.” Many bemoaned the absence of public debate on health issues and the RSBY card. Deva’s pithy response was illustrative: “If it is not talked about and debated, we can only think that there is no big value that we should pay attention to.”

Households clearly separated the economic value from social ones. A section saw health insurance as a bad omen, one that announced arrival of illness. Ramesh Kumar, among those in his neighbourhood who refused to enrol, explained: “This card is not a solution for illness, it is a cause of it. You see, when you people knock on our doors to give us the card, it feels like an illness is knocking on our doors. The farther away we are from the card, the further we are from health problems.”

Overall, while the discourse on a greater allocation to RSBY and enhancement of cost-effectiveness are important, a shift of emphasis is needed, bringing the ‘public’ back into the sphere of public health.

The oped first appeared in The Hindu.

The post The ‘Public’ in Public Health appeared first on Inter Press Service.

Excerpt:

Vani S. Kulkarni teaches Sociology at University of Pennsylvania, Philadelphia

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Mind the Treatment Gaphttp://www.ipsnews.net/2017/04/mind-the-treatment-gap/?utm_source=rss&utm_medium=rss&utm_campaign=mind-the-treatment-gap http://www.ipsnews.net/2017/04/mind-the-treatment-gap/#comments Fri, 14 Apr 2017 17:51:06 +0000 Vani Kulkarni and Raghav Gaiha http://www.ipsnews.net/?p=149983 Vani S. Kulkarni teaches Sociology at the University of Pennsylvania, and Raghav Gaiha is (Hon.) Professorial Fellow, Global Development Institute, University of Manchester.

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getty images/ istock photo

By Vani S. Kulkarni and Raghav Gaiha
PHILADELPHIA AND NEW DELHI, Apr 14 2017 (IPS)

Implementation of the Mental Healthcare Act will require a restructuring of health-care services
The Mental Healthcare Bill, 2016, which was passed in the Lok Sabha on March 27, 2017, has been hailed as a momentous reform. According to the Bill, every person will have the right to access mental health care operated or funded by the government; good quality and affordable health care; equality of treatment and protection from inhuman practices; access to legal services; and right to complain against coercion and cruelty. The Bill also empowers a mentally ill person to choose a treatment and her/his nominated representative, decriminalises attempted suicide, prohibits the use of electroconvulsive therapy (ECT) to mentally ill adults without the use of muscle relaxants and anaesthesia, and contains provisions for care, treatment and rehabilitation for those who have experienced severe stress and attempted suicide. While these are laudable and ambitious objectives as they address major concerns of mental health care, there have been some critiques drawing attention to the lack of funds, trained personnel, and insufficient emphasis on community care. The ground reality, however, suggests that these objectives are not just overambitious but an overkill.

Poor infrastructure, low funds
The Global Burden of Disease Study shows that in 2013, 50% of all disease burden in India was caused by non-communicable diseases, while mental disorders accounted for about 6% of the total disease burden. A third of this is due to depression, which also significantly contributes to suicide and ischaemic heart disease. Worse, suicide is a leading cause of death in people in India aged 15-29.

Vani S. Kulkarni

Vani S. Kulkarni

There are only 43 government-run mental hospitals across all of India to provide services to more than 70 million people living with mental disorders. There are 0.30 psychiatrists, 0.17 nurses, and 0.05 psychologists per 1,00,000 mentally ill patients in the country. The case of the Bareilly mental hospital — one of three major mental hospitals in Uttar Pradesh — is stunning. In this hospital, 350 patients can be admitted and around 200 patients can attend the out-patient department every day. But all these patients would be at the mercy of only one psychiatrist!

At the macro level, the proposed health expenditure of 1.2% of GDP in the Budget for 2017-18 is among the lowest in the world. In real terms, public health expenditure has consistently declined since 2013-14. Of the total health budget, a mere 1-2% is spent on mental health.

But this is a small part of the explanation of the inadequacy and abysmal quality of mental health services in India. Underlying this deplorable state of affairs is a pervasive perception that those with mental illnesses are pathological or even criminal; hence they do not deserve the type of rehabilitation given to those with physical ailments. Besides, the treatment gap (the difference between those suffering from mental illnesses and those seeking medical/psychiatric care) is widened because of the social stigma attached to such illnesses. In fact, many poor people hide their illnesses and endanger their lives. Others argue that it is not so much stigma but ignorance and lack of knowledge, myths, and supernatural beliefs that impede treatment. Women typically face larger treatment gaps as they are vulnerable to violence, sexual abuse and inhuman treatment.

Raghav Gaiha

Raghav Gaiha

Ethnographic evidence from the Human Rights Watch Report 2014 relating to women inpatients is gruesome. Deepali, a woman with a perceived psychosocial disability, said: “The nurse would sometimes forcefully put the pills in my mouth and stroke my throat to send them down, the way I feed my dogs… I woke up one night and I couldn’t move; my body was in intense physical pain. A nurse came and jabbed an injection into my body, without even taking off my clothes. You are treated worse than animals.”

Often, all women and girls were admitted without their consent and, as the team left, they cried out in despair, “send me home” or “take me home”. Unable to cope with mentally ill relatives, families often abandon them in mental hospitals and elsewhere. In one case, a woman who was declared “fit for discharge” in the 1990s was still in the institution as of August 2013 because of lack of alternative resettlement options for her.

Some women were not even informed that ECT was being administered. Psychiatric nurses admitted that ECT was administered not just on violent and suicidal patients but also on new admissions who tend to be unmanageable.

Women and girls with psychosocial or intellectual disabilities in institutions are often subject to not just physical and verbal abuse but also sexual violence. Some women went to a hospital for three months and returned one month pregnant. Not a single FIR was filed.

Government hospitals refuse to admit “mentally ill” persons in the ICU on the grounds that this facility could be put to better use. A woman suffering from breast cancer for two-three years was denied treatment and subsequently died.

Shift to community-based care
An emphatic case could be made for shifting from institutional care to community-based care for people suffering from mental disorders. A study published in The Lancet Psychiatry, 2017 offers corroborative evidence from VISHRAM (the Vidharbha Stress and Health Programme), which is a community-based mental health initiative. The reduction in the treatment gap was due to increased supply of mental health services through front-line workers and their collaborative linkage with the physicians and psychiatrists in the facilities, as well as increased demand for mental health services due to improved mental health literacy. The substantial reduction in the median cost of care resulted from availability of general as well as specialist services in the village itself.

Whether legislation such as the Mental Healthcare Bill help overcome supply and demand barriers seems highly unlikely, as the root causes lie in pervasive negative attitudes, massive neglect of mental health care, rampant abuse and unchecked inhuman practices, and weak redressal and enforcement mechanisms. The Bill seeks to address major lacunae in mental health care and is thus an important step forward. However, its implementation will require substantially larger public resources and, more importantly, restructuring of mental healthcare services with a key role for the community in their provision, rapid expansion of mental health literacy, effective monitoring and enforcement of the objectives envisioned in it. With limited awareness of these challenges, and with a slight risk of exaggeration, the Bill is an overkill.

This opinion editorial was first published in The Hindu

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Excerpt:

Vani S. Kulkarni teaches Sociology at the University of Pennsylvania, and Raghav Gaiha is (Hon.) Professorial Fellow, Global Development Institute, University of Manchester.

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Is Demise of Small Farmers Imminent?http://www.ipsnews.net/2016/05/is-demise-of-small-farmers-imminent/?utm_source=rss&utm_medium=rss&utm_campaign=is-demise-of-small-farmers-imminent http://www.ipsnews.net/2016/05/is-demise-of-small-farmers-imminent/#comments Tue, 17 May 2016 10:05:37 +0000 Raghav Gaiha and Vani Kulkarni http://www.ipsnews.net/?p=145148 Raghav Gaiha, Former Professor of Public Policy, University of Delhi, India; and Vani S. Kulkarni, Lecturer in Sociology, University of Pennsylvania, USA.

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Raghav Gaiha, Former Professor of Public Policy, University of Delhi, India; and Vani S. Kulkarni, Lecturer in Sociology, University of Pennsylvania, USA.

By Raghav Gaiha and Vani S. Kulkarni
NEW DELHI AND PHILADELPHIA, May 17 2016 (IPS)

Imminent demise of small farmers is predicted as they are not competitive in a context of transforming agrifood markets. Most important is the transformation of the “post–farm gate” segments of the supply chains.

Raghav Gaiha

Raghav Gaiha

Agrifood markets have been transforming because of growing affluence, urbanisation and large inflows of FDI induced by liberalised investment policies. A few salient features include replacement of local and fragmented food value chains by geographically much longer chains. Traditional village traders/brokers/processors have declined while small and medium firms have proliferated with eventual domination of large domestic firms and multinationals (Reardon and Timmer, 2014). For example, rice mills have declined rapidly. Instead small but especially medium and large scale mills have emerged located in towns. A comprehensive Asian Development Bank report on Food Security in Asia (2013) draws attention to some contrasts between Bangladesh and India in rice supply chains. The role of the village trader, for example, has shrunk, controlling only 7% of farms and sales in Bangladesh, and 38% of farms and 18% of sales in India.

Vani S. Kulkarni

Vani S. Kulkarni

A large share of food undergoes processing. Grain milled rice is made into bread or polished rice, for example. The rapid growth of food processing is driven by women’s participation in the labour force and dietary shifts, promoted in part by modern retail. The retail segment has transformed rapidly in the last decade. Many governments had public sector cum cooperative retail ventures (e.g. India, Vietnam, and China). These were dismantled with structural adjustment and liberalisation. The supermarket “revolution” has been a catalyst. Supermarket chains seldom buy fresh produce directly from farmers. Instead, they tend to buy from wholesale markets or from specialised wholesalers who in turn buy from preferred suppliers.

In the downstream, dietary changes have been significant. Domestic consumption of high-value crops such as fruits and vegetables rose by 200 % during 1980-2005, while consumption of cereals stagnated. High value food exports –including fruits and vegetables, meat and milk products, and fish and seafood products-from developing countries increased by more than 300% during 1980-2005, and now constitute more than 40 % of total developing country agrifood exports (World Bank, 2008). The growth in high value agricultural exports has been much faster than the growth in traditional exports such as coffee, cocoa and tea, which decreased in overall importance.

The shift towards high value agriculture and concomitant “restructuring” or modernisation of supply chains are associated with (i) increasing number and stringency of food standards for quality and safety; (ii) consolidation of supply chains; and (iii) a shift from spot market transactions in traditional wholesale markets to increasing levels of vertical coordination of supply chains.

Overall, the supply chain is lengthening geographically and “shortening” inter-mediationally (or, “simply fewer hands in the chain”). The former implies that food markets are integrating across zones/states in a country; it also implies “de-seasonalisation” of the market. A case in point is the potato market in India, China and Bangladesh.

Although there is considerable pessimism about small farmers’ ability to participate in high value food chains because of their small scale of production, failure to comply with stringent quality standards and unreliability of supply, recent evidence is mixed. The main arguments that transaction costs and investment constraints are a serious consideration in these chains and that processing and retailing companies express a strong preference for working with relatively fewer, larger and modern suppliers are not rejected. But the evidence also shows that many more small farmers participate in such chains than predicted by these arguments.

In India, small farmers play an important role as suppliers in growing modern supply chains. In China, production in the rapidly growing vegetable chains (and in several other commodities) is exclusively based on small farmer production. Poland, Romania and CIS do not show any evidence of “exclusion” of small farmers. Studies of high value export vegetable chains in Africa find in some cases that production is fully organised in small farms or fully in large farms or mixed in small and large farms (Swinnen et al. 2010).

Small farmers are indeed excluded in some supply chains and in some countries, but this is far from a general pattern, and, in fact, small and poor farms are included in supply chains to a much greater extent than expected on arguments based on transaction costs and capacity constraints.

Several reasons underlie this view. (i) Buyers often have no choice where small farmers supply a large share of supply and occupy a large fraction of land. In parts of East Asia and China, with a high population pressure on land, sourcing is often from small farms. (ii) It is often not the case that companies contract with large farms simply because of lower transaction costs. In fact, many companies prefer not to depend on large farms because contract enforcement is harder. (iii) In some cases, small farms have substantive cost advantages. This is particularly the case in labour-intensive, high maintenance, production activities with relatively small economies of scale, such as dairy or vegetable production.

Empirical evidence reveals that small farmers engage in high value contract production because of guaranteed sales and prices, and access to inputs, and not so much for direct profit and income benefits.

Vertical coordination is widespread in high value chains, often as an institutional response to problems of local market imperfection. But vertical coordination varies from integrated (large) farms managed by food companies to extensive contracting arrangements with small farmers. Contract farming improves access to credit, technology and quality inputs for poor, small farmers hitherto faced with binding liquidity and information constraints. But reneging of buy back arrangements on specious poor quality standards is frequent due to weak enforcement mechanisms (a case in point is India).

Evidence on impact of these value chains on small farmers is patchy and inconclusive.

Available evidence suggests that where the smallholders are only partially participating as suppliers, the poorest rural households may benefit from inclusion through the labour market than small farmer participation. In other words, whether small farmers are included in these chains or not, is unlikely to be a good indicator of the welfare effects. On the other hand, the shift of suppliers from traditional to modern markets causes price effects. These price effects and their welfare implications depend on scale economies in modern versus traditional production systems, trade, relative demand and production elasticities (or how responsive is production to price changes), and on the factor intensity of high value commodities. In poor countries, where modern supply chains increase demand for labour- intensive commodities, the spill over effects are likely to be positive.

The transaction costs faced by private actors when transacting with a large number of farmers could be reduced by investing in intermediary institutions (e.g. producer groups). Intermediary institutions reduce the number of transactions and the cost of exchange between farmers and processors or input suppliers. Whether small coverage of producer groups undermines this argument is beside the point as what is emphasised is that the potential of such groups is considerable. Besides, as argued by a World Bank report, Enabling the Business of Agriculture 2016, clear and accessible laws foster a business environment that benefits all market players-especially farmers including vulnerable female farmers and smallholders, consumers and large investors.

In conclusion, the imminent demise of small farmers is exaggerated, if not mistaken altogether.

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Excerpt:

Raghav Gaiha, Former Professor of Public Policy, University of Delhi, India; and Vani S. Kulkarni, Lecturer in Sociology, University of Pennsylvania, USA.

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