By Vani S. Kulkarni and Raghav Gaiha
NEW DELHI, India, Apr 20 2022 (IPS)

A trend of declining trust in governments and politicians can turn into a threat beyond some point.

John Adams, an astute political philosopher and second president of the US, was emphatic: “Remember, democracy never lasts long. It soon wastes, exhausts and murders itself.” This has been a subject of intense debate, with recent but mixed evidence. Is this an overly pessimistic view?

The debate, based on big international surveys (such as the World Gallup Poll and Economic Values Surveys) or specific ones, yields conflicting inferences. The key issue is whether loss of political trust (in governments and politicians) is a threat to democracy. A pessimistic view is based on how tax compliance varies with the level of political trust. When citizens believe government is acting for the common good, they see its decisions as legitimate and will be more willing to comply with them. They will pay taxes and obey laws, as this is the ‘right’ thing to do. Conversely, when citizens distrust the government, their willingness to obey its decisions is limited and they are less willing to pay taxes. Given the importance of taxes, a general lack of trust would destabilize the system.

Vani S. Kulkarni

Political trust also impacts the ability of government systems to fulfil their basic tasks for people. Low levels of political trust pose a challenge for the governability of contemporary liberal societies. Indeed, in the worst-case scenario, a vicious cycle emerges for governments and political trust. However, whether this would destabilize democracy is neither stated nor implied.

In India’s context, Vaishnav (2017) develops a model of the electoral market place. He analyses data on politicians, including members of state legislative assemblies (MLAs) and Parliament (MPs), winners and losers in elections, their criminal background, assets, ethnicity, re-election prospects and implications for the sustenance of democracy. In an electoral market, there are buyers (voters) and sellers (parties and politicians). Supply and demand factors are at work. This model is then used to explain the share of politicians with a criminal and wealthy background, their chances of winning an election and re-election and huge financial gains.

Across three recent general elections (2004, 2009 and 2014), a randomly picked candidate had a 6% chance of coming out on top. Compare this with a candidate with at least one criminal case: s/he had a nearly 18% chance of winning. The differences in state elections are slightly smaller but still stark: ‘clean’ candidates (eg, those with no pending criminal cases) have a 9.5% probability of winning, whereas candidates with criminal cases have a roughly 22% chance.

Raghav Gaiha

Our more recent analysis (Kulkarni, et al, 2022) raises a few concerns. Over the period 2004 to 2019, the share of criminal politicians in Lok Sabha elections has sharply risen, especially after 2014; 24% of the winners in the 2004 polls had a criminal background; this share rose to 30% in the 2009 general elections, 34% in 2014 and 43% in 2019. The share of criminal politicians is thus expected to rise further. Another related issue is that India’s two major parties continue to have considerably high shares of criminal politicians. Between the two main national parties, of 303 winners from the Bharatiya Janata Party in 2019, 116 (39%) had a criminal record, as against 29 (56%) of the 52 winners from the Congress party. This contradicts Vaishnav’s view that non-dominant but competitive parties worry more about winning a seat in a closely contested election than dominant parties for which the marginal benefit of winning a seat is relatively small. As both national and state elections have become more competitive, with a rise in the number of political parties in the fray, it is difficult to rule out the possibility that tainted politicians with huge resources will continue to be attractive to dominant parties as well. A more serious concern is that, with rising shares of politicians with criminal records, public trust in politicians first rises and then decreases after a turning point where about 40% of MPs have criminal records and only about a tenth of respondents trust politicians.

In sum, while the erosion of political trust is slow, it is consistent and may turn into distrust at some point, with a real risk of the demise of democracy.

Vani S. Kulkarni & Raghav Gaiha are respectively, lecturer of sociology and research affiliate, Population Aging Centre, University of Pennsylvania, USA.

This opinion editorial was first published in Mint, India.

IPS UN Bureau

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There is broad consensus that realizing the Sustainable Development Goals (SDGs) and the Paris Agreement on climate change require a transformative agenda for agriculture and food systems. In this context, the importance of mobilizing more investments and aligning them to sustainable development and inclusive rural transformation objectives, is widely acknowledged.

The gaps in investment
Estimates of investment required for achieving these goals show that the financing needs are considerable although the appraisals of incremental financing requirements differ significantly.

Raghav Gaiha

In 2019, the United Nations Conference on Trade and Development (UNCTAD) estimated total investment needs for food and agriculture at US$ 480 billion to achieve related SDGs in developing countries, with actual investment at US$220 billion, thus leaving a gap of US$260 billion.

These estimates suggest that transforming food systems to deliver healthy people, a healthy planet, and a healthy economy will require US$300 – US$350 billion extra per year over the next decade.

The swift and massive shock of the coronavirus pandemic has plunged the global economy into a severe contraction. The prospects of economic revival are highly uncertain and downside risks are predominant. Development finance gap is thus likely to worsen.

Towards meeting the financing gaps
To meet these needs, finance will be required from all sources to work in alignment with the 2030 Agenda and the Paris Agreement. The extension of the Debt Service Suspension Initiative (DSSI) through to the end of 2021 led by the World Bank – will help most developing countries to focus on domestic priorities including getting SDG delivery back on track.

A Common Framework for Debt Treatments beyond the DSSI is in the making, while some International Financial Institutions (IFI) are expecting historical highs in their replenishments (IFAD, IDA, AfDB). In addition, there is a call for a new general allocation of USD 650 billion (IMF Special Drawing Rights) to be channelled to benefit vulnerable countries.

Shantanu Mathur

Yet other PDBs have a primary focus on agriculture but their portfolio includes other sectors. This is based on the notion that supporting sustainable small-scale farming through inclusive agri-food value chain development is between two to three times more effective as a means to eradicate poverty than other sectors.

Some PDBs target small-scale enterprises including producers, while others focus their portfolios on larger agribusinesses or larger investments, for instance, in agricultural infrastructure and markets. This diversity is key to understanding the role of different types of PDBs in advancing the 2030 Agenda.

The overarching goal, however, is to address market failures, with counter-cyclical roles, and greater risk tolerance than what other financial institutions have. Given their public mandate and close proximity to public policy and governance institutions, PDBs can play a catalytic role supporting accessible, affordable and usable financial services for rural poor people socially, environmentally and economically sustainable outcomes across food systems.

PDBs (which are already responsible for over two-thirds of formal financing for agriculture), can facilitate a change of course across the financial ecosystem. This includes mobilizing sustainable and green finance, issuing investment products, structuring blended solutions and public-private financing schemes.

At the same time, adopting digital solutions across their business operations, and delivering a suite of financial services and products to different types of clients in food systems – including women, youth, SMEs and smallholders. It is known that private investment in agriculture and/or in other activities within food systems is often constrained by many risks associated with poor infrastructure and economic returns. PDBs are capable of increasing their capacity to crowd in, de-risk, and help align commercial finance to the SDGs and to climate-related goals such as those set in the Paris agreement.

Mobilizing catalytic investments
Stimulating responsible private investment and financial innovations – such as through blended finance – are required to improve food security and nutrition and inclusive rural transformation, and to address the post pandemic gap in ODA. UNCTAD has estimated that around 75 per cent of the gap could be financed, in principle, by the private sector – with the potential to mobilize US$195 billion annually. PDBs are actively engaged in platforms where private investors, businesses, philanthropists and other entities are investing to fund SDG aligned projects.

In their Communiqué (Matera, June 2021) the G20 Development Ministers have welcomed the establishment of a “Finance in Commons” Working Group on Financing Sustainable Food Systems, led by IFAD, that is meant to bring together PDBs, recognizing the critical role of the private sector to build upon public efforts to improve agri-food systems.

As a concrete action – emerging out of the United Nations Food Systems Summit (UNFSS) is the advent of a Coalition for Action to launch a PDB global Platform, with focus on increasing investments in inclusive and sustainable food systems chains, for accelerated learning, innovation, mobilization and deployment of capital and services.

Going forward, closing the financing gap will require strong international cooperation and political will to enhance the fiscal space to ensure sustainable domestic financing. Multilateral Development Banks can work with PDBs and test/validate sustainability-related financial instruments, encompassing (sustainability/green) bonds, funds and other investment vehicles aimed at advancing sustainable development objectives. This will play an important role in mobilizing much-needed finance to reduce the SDG financing gaps in developing countries and become possible long-term financing instruments of international and national public financial institutions.

Raghav Gaiha is Research Affiliate, Population Aging Research Centre, University of Pennsylvania, USA, & (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, UK; Shantanu Mathur is Lead Adviser & Senior Partnership Officer, Global & Multilateral Engagement International Fund for Agricultural Development (IFAD).
(The views are personal)

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Off the main streets in Gonder, Ethiopia, poverty becomes starker. Credit: James Jeffrey/IPS

By Vani S. Kulkarni and Raghav Gaiha
PHILADELPHIA and NEW DELHI, Mar 13 2020 (IPS)

With about 109 million people, Ethiopia is the second most populous nation in Africa after Nigeria, and the fastest growing economy in the region. However, it is also one of the poorest, with a per capita income of $790.

About 80% of the Ethiopian population lives in rural areas, but these are increasingly migrating to urban areas due to a lack of job opportunities. However, with unemployment levels at 16.5%, the situation in urban areas offers even fewer possibilities of finding employment.

Poverty is predominantly a rural phenomenon in Ethiopia. While urban headcount poverty declined from 36.9 percent in 2000 to 14.8 percent in 2016, rural poverty only declined from 45.4 percent to 25.6 percent in the same period.

Unfortunately, the evidence on the role of health in reducing poverty is sparse. We, therefore, focus on rural disability as an impediment to promoting rural employment and reduction of rural poverty. Our analysis is based on the Ethiopia Socio-Economic Survey (ESS) covering 2011/12, 2013/14 and 2015/16. It is a nationally representative panel survey.

We sketch below (i) factors associated with rural disability in Ethiopia; (ii) factors associated with rural employment-especially the association between employment and disability; and (iii) association between rural poverty and disability and the underlying links.

Vani S. Kulkarni

About 13.77 % of the rural Ethiopian population suffered from disabilities in 2015-16. About 63% suffered from a single disability while the rest from multiple disabilities (>1). The largest share was of the age-group, 31-50 years, followed by the older age-group,51-70 years. These two age-groups together accounted for over 70 % of those suffering from a single disability. The largest share of multiple disabilities was of 51-70 years, followed by the oldest (>70 years) and 31-50 years. The combined share of 31-50 years and 51-70 years was about 67 %. If we go by prevalence of disability by age-group, it was highest among the oldest, followed by 51-70 years. A similar pattern was observed for multiple disabilities except that the prevalence among the oldest was just under 50 %.

Disability by gender shows a frequently observed contrast. The shares of females in both single and multiple disabilities-over 52 %- was higher in 2015-16. However, differences between prevalences by gender were low, with slighly higher prevalences among females.

The highest share of those suffering from one disability was of those belonging to largest households(>6 members), followed by those in lower-sized households (between 3-5 members). The latter, however, accounted for the largest share of multiple disabilities, followed by largest households. Prevalences within single and multiple disabilities offered yet another contrast. The highest prevalence of single disability was observed among those living alone, followed by those living in households with just two members. This is replicated for multiple disabilities, with the higher prevalence than of single disability.

Rural employment by duration in 7 days was classified into ranges of hours worked: 0 hour, 1-25 hours, > 25 hours in 7 days, and disabilities into none, 1 and > 1. The former refer to 2015/16 while the latter refer to 2011/12.

The largest share of those working 1-25 hours was associated with those without any disability, followed by those suffering from a single disability and then a sharp drop in the share of those with multiple disabilities.A similar distribution was observed among those working longer hours, >25 hours, with the largest share of those without any disability and lowest of those with multiple disabilities. There was a low reduction in proportions of each disability group working 1-25 hours, with the highest among those without disability, followed by those with a single disability and then among those with multiple disabilities. A similar pattern was observed among disability groups in longer duration of employment, >25 hours. Thus it follows that single and multiple disabilities-especially the latter-were associated with restricted hours of employment, compared with those without any disability.

Raghav Gaiha

There are two issues in rural poverty analysis: one is its persistence, and second is movement into and out of it over time. Just under one-half of extremely poor in 2011/12 remained so during this period, a lower proportion of middle class remained in it, and more than half remained affluent. About 30 % of extremely poor in 2011/12 moved up into middle-class and a little under a quarter into affluent in 2015/16. From middle-class under 30 % descended into extreme poverty and about 33 % became affluent. From affluent, about 29 % decended into middle-class and a much smaller proportion became extremely poor. Hence high persistence of poverty coexisted with considerable upward economic mobility.

As a vast majority of the Ethiopian rural population did not suffer from any disability, it is not surprising that they constituted largest shares of extremely poor, middle class and affluent in 2015/16. Their proportion of extremely poor was lowest and of affluent highest. The proportion of disabled who were extremely poor was lowest but higher than among disabled, and higher in middle class and affluent but again lower than among non-disabled. Thus disability wass associated with greater vulnerability to extreme poverty and restricted prospects of being in middle class.

In conclusion, the challenge of reduction in poverty remains enormous while not paying due attention to preventing and eliminating disability is likely to make it much harder.

(Vani S. Kulkarni is Lecturer in Sociology, University of Pennsylvania, USA; and Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England, and Research Affiliate, Population Studies Centre, University of Pennsylvania, USA). The views are personal.

About 15% of the world’s population lives with some form of disability, of whom 2-4% experience significant difficulties in functioning. Disability is part of the human condition, and almost everyone will be temporarily or permanently impaired at some point in life, and those who survive into old age will experience increasing difficulties in functioning. Here the focus is on empirical validation of whether disabilities are associated with economic hardships through loss of employment and consequently impoverishment in rural India. The motivation stems from continuing neglect of health in the budgetary allocations –including the allocations for 2020-21.

Vani S. Kulkarni

The prevaence of dsability is 9.70 % in the rural population in 2012. Of the disabled, more than half (51.3 %) suffer from 2-4 disabilities. Persistence is also largest in this range of disabilities (about 31 % remain in it between 2005-2012).

Shares of those suffering from 1 disability are largest in the age-group 31-50 years, followed by 51-60 years. In the case of 2-4 disabilities, the largest share is found among those 31-50 years old, 51-60 years old and then among the older group,61-70 years. Shares of those suffering from >4 disabilities rise from those 31-50 years old to 61-70 years and then decline. Within the youngest (15-30 years), about 98 % do not suffer from any disability which declines among older age-groups (just under 50 % among the oldest >70 years). In the older age-group (31-50 years), a vast majority do not suffer from any disability, and small proportions suffer from a single and multiple disabilities. A similar pattern is observed among those in the age-group, 51-60 years, with substantially lower proportions without any disability and larger proportions suffering from single and multiple disabilities. Among the older, 61-70 years, the proportion without disability is considerably lower, but those with single and multiple disabilities rise,with about 30 % suffering from >4 disabilities. As aging grows rapidly, the burden of disabilities is likely to surge. But at the same time, high prevalence of disability among a large segment of the working age group is likely to have deleterious employment effects.

Employment in rural areas is disaggregated into four categories: no employment, <240 hours in the previous year (ie, previous to 2012), part time employment >240 hours, and full time employment (at least 250 days and at least 2000 hours).

Raghav Gaiha

Instead of using a poverty cut-off (the World Bank uses several), we have used terciles of per capita expenditure (at constant prices). The bottom tercile denotes extremely poor, the next middle class and the third affluent.

As non-disabled households are a huge fraction, it is not surprising that their shares are highest in each tercile. In the non-disabled households, the proportions are almost equally distributed among the terciles. In the lowest disability group (<0.31) at the household level, the proportion in the first tercile is lowest, and highest in the second and third terciles. The highest disability group (>0. 60), however, offers a contrast. Their proportion in the lowest tercile is highest compared with other disability groups but slightly lower than the proportion in the second tercile. Their proportion in the third tercile not just within this disability group but also across all other disability groups is lowest. Thus highly disabled are largely confined to extreme poverty with most restricted prospects of becoming affluent through barriers to long duration employment (including but not limited to discriminatory practices in hiring the disabled).

Ironically, while the SDGs assign high priority to preventing and overcoming disability, officially adopted by 193 countries including India, the FM’s budget for 2020-21 is not just a missed opportunity for growth stimulus but almost cruel to those experiencing persistent health deprivation by cutting the health outlay.

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

Adapted from: Disabled and Extremely Poor, The Hindu, 6 March, 2020.

By Raghav Gaiha
MANCHESTER, Oct 21 2019 (IPS-Partners)

I met late professor T.N. Srinivasan (popularly known as TN) a couple of months before he passed away in November 2018. Despite his original contributions to trade theory, ¬development economics, inequality and poverty, he never won the Nobel in economics. His colleague at Yale had once ¬remarked that TN would get not one but two Nobels. I was too much in awe of TN to ask this question but my friend asked him directly if he could think of an Indian economist who might win the Nobel for economics in the near future. He said, “Abhijit but not so soon”. He was right but not entirely.

After studying at University of Calcutta, Abhijit Banerjee went to Jawaharlal Nehru University and Harvard, where he completed his doctoral research. He then took up faculty positions at Princeton and in quick succession at Harvard and later at MIT, where he is the Ford Foundation inter¬national professor of economics.

He is that rare economist who moves effortlessly from abstruse aspects of information theory to applied microeconomics in different regions of the developing world. Although highly regarded in all fields that he has worked in, he (along with Esther Duflo and Michael Kremer) is best known for pioneering research in formulating, refining and extending randomised control trials (RCTs) to understand and shed light on alleviation of global poverty. He and Duflo set up the Poverty Action Lab at MIT in 2003, which later became the Abdul Latif Jameel Poverty Action Lab. This network has engaged in impact evaluation, policy outreach and capacity building in 81 countries.

They planned, refined and ¬extended ¬randomised control trials to alleviate global poverty.

What is an RCT? Borrowing an example from Abhijit’s research, take an experiment to examine the impact of textbooks on students’ test scores. The textbook is distributed to half the class randomly on a certain day. Say, six months later, a test is held and students are graded. If the score of the treatment group—the students who got the textbook—is higher than that of those who did not, it is valid to infer that the higher score is due to the textbook. Neither textbook distribution nor adding teachers improved the performance of the students. The failure of these two variables to influence the results is neither interesting nor surprising. However, scant attention is given to teacher absenteeism, which is rampant in rural schools.

Another widely cited example is the randomised evaluation of a group-lending microcredit programme in Hyderabad. A lender worked in 52 randomly selected neighbourhoods, leading to an 8.4 percentage point increase in take-up of microcredit. Small business investments and profits of pre-existing businesses increased, but consumption did not significantly grow. Two years later, after control areas had gained access to microcredit, but households in the treatment area had borrowed for longer and in larger amounts, very few significant differences persisted. But whether these findings are generalisable to other contexts is doubtful. So the verdict that microcredit is not the miracle it is claimed to be seems doubtful.

Is RCT the magic wand it is widely believed to be? Multi¬lateral agencies, governments and donors were quick to embrace it as it offered a simple tool to ¬assess policy impact. It is not uncommon to get ¬seduced by the charms of RCTs if you are not aware of their limitations.

Angus Deaton, another Nobel laureate, made a succinct appraisal of RCTs. Consider hypertension. There are two different drugs that ¬improve the condition. In clinical trials, one performs better than the other on average. However, management of hypertension may be more difficult in some cases and thus, a drug that is more effective on average may not be in those instances. So, while it is useful to know which drug is better on average, it is not so helpful where specific treatment is required.

Failure of the two educational experiments is attributed to limited learning of the students. Instead of relying on this ex-post observation, it would have been more helpful to embed these experiments in a theory of learning. There are also serious concerns about the spillover effects of an experiment in one village. By word of mouth, good practices may spread to the control group and neighbouring villages, compounding the difficulty of attribution to an intervention. Scaling up may depend on how an intervention is implemented and the context. Macro interventions (such as interest rate ¬reductions to revive the Indian economy), however, are not amenable to RCT as there is no control group.

These comments are not meant to denigrate Abhijit’s highly original and pathbreaking research. He is a worthy recipient of the Nobel. The claim, however,that RCTs have saved millions from abject poverty is exaggerated, if not misleading.

(The author is [Hon.] Professorial Research Fellow, Global Development Institute, Manchester. Views are personal.)

This story was originally published by Outlook

Excerpt:

By Veena S. Kulkarni and Raghav Gaiha
NEW DELHI, India and JONESBORO, US, Oct 7 2019 (IPS)

China’s almost meteoric transition from a being a low income to a middle income country within a span of four decades is often perceived as a miracle analogous to the post Second World War Japanese economic development experience.

China’s GDP rose from $200 current United States dollars (US$ henceforth) in 1978 to $9,470 current US$ in 2018 (World Development Indicators, The World Bank). Unsurprisingly, China’s rapid and near sustainable growth has attracted widespread interest among academics and policy makers alike.

Veena S. Kulkarni

China embarked on a set of systematic reforms of its centrally planned economy in the year 1978, which ignited this spark of economic growth.

In nearly three decades after the reforms, China increased its Gross Domestic Product (GDP) eightfold with an average growth in GDP and GDP per capita of 9.5% and 8.1% percent (measured in constant US$), respectively (Hofman and Wu 2009).

These figures appear more exceptional when seen relative to China’s performance: a) in the pre-reform period and b) by its contemporaries at that time. While China with an average GDP per capita rate of 2.1% was out ranked by several countries during a two-decade period before the reforms, its GDP per capita was the highest across a list of 105 countries for the years 1978-2005 (Hofman and Wu 2009).

The extraordinary growth in income levels seem to have been replicated with respect to other economic indicators such as poverty rates and wealth per adult. The poverty head count ratio declined by more than four fifths in less than a decade from 17.2% in 2010 to 3.1% in 2017 (World Development Indicators, The World Bank). Additionally, there is a notable increase in the wealth per adult from US$4,292 in 2008 to US$47,810 in 2018 (Global Wealth Data Book 2018, Credit Suisse Research Institute).

Further, convergence between the timings of the economic reforms with that of the demographic transition led to low dependency ratios (low share of non-working relative to working age population) creating a ‘perfect storm’ for bolstering economic growth.

The more recent trends of the economy growing between 6-7% do admittedly indicate a downward trajectory but the prospects in absolute terms remain high.

However, this more seldom than not favorable scenario is projected to have an expected and significant impact on the age composition and epidemiological profile of China. All the standard health indicators show that China has completed what demographers would call mortality/epidemiological transition.

Mortality/epidemiological transition is characterized by two interrelated components: a) a greater concentration of deaths at older ages, and b) a dominance of deaths by degenerative illnesses as compared to communicable diseases.

Life expectancy at birth in China between 1990 and 2017 rose by nearly a decade for women (from 70.7 years to 79.9 years) and over third quarter of a decade for men (from 66.9 years to 74.5 years) (Global Burden of Disease). Such dramatic rises in life expectancy obviously translates into increasing share of the elderly total population.

The percentage of population 65 years or older has more than doubled from 4.43% in 1950 to 9.33% in 2015 and is projected to increase to 11.97% in 2020. An examination of the trend indicates the rate of growth of the elderly unlike the period between 1950 and 1970 has not only been consistently on the rise, it has done so noticeably after 1990.

The projected percentage of elderly population at 11.97% in 2020 is more than twice that in 1990 (5.63%) (World Population Prospects 2019, United Nations Population Division). The projection for year 2040 considering the age of 60 as the benchmark predict more than one in four persons to be elderly (World Health Organization).

On the second component of the epidemiological transition, Non-Communicable Diseases (NCDs) affect for more than 80% of the 10.3 million premature deaths and 77% of Disability Adjusted Life Years (DALYs), the statistic that is not that distant from other OECD countries.

A review of the ranking of the top ten most causes of major deaths for the years 2007 and 2017 reflects the realization of the second part of the mortality/epidemiological transition. Except for the road injuries, the ten major causes of deaths fall in the category of degenerative illnesses.

Further, both in 2007 and in 2017, the first four causes, stroke, ischemic heart disease, COPD and lung cancer are nearly unequivocally related to lifestyle factors. Stroke and ischemic heart diseases that are highly correlated with hypertension rose by 27% and 54% between 2007 and 2017.

Additionally, there was 95.7% spike in percentage of most deaths caused by hypertensive heart disease between 2007 and 2017. Hypertensive heart disease moved from a rank of 11 to a rank of eight. In a similar vein, the ranking of the impact of diseases with respect to the number of years of life lost (YLLs) or causing premature deaths shows stroke and ischemic heart disease as topping the list both in 2007 and in 2017.

Further, between 2007 and 2017 the increase in that ‘deadly’ impacts were 21.8% (stroke) and 43.9% (ischemic heart diseases). The corresponding rise for hypertensive heart disease was 79.8%. Yet another disconcerting evidence on the growing detrimental effect of hypertension can be gleaned from the climbing in the ranking of diseases causing disability.

Stroke moved from being the thirteenth highest in 2007 to being fifth highest in 2017. The combined effects of causing most deaths and disability owing to stroke and ischemic heart disease is respectively more than 25% and 40%.

Also, relative to ten countries in the comparison group delineated by the Global Burden of Disease (GBD) Project, based on GBD’s regional classification, trade partnerships and sociodemographic indicators, YLLs and DALYs due to stroke and ischemic heart diseases is the highest in China.

Raghav Gaiha

The above patterns and trends clearly evince a transition to a lifestyle that is more prone to incidence of cardiovascular diseases, a change that has been empirically observed to accompany usually interrelated reasons such as rising levels of income, urbanization, globalization and consumption of processed food as substitute to home made and fresh food.

The latter appears to be a prominent contributor to China’s epidemiological profile tilting toward cardiovascular illnesses such as stroke, ischemic heart disease and hypertensive heart disease.

Dietary risk has been found to be the most significant factor in explaining most of the deaths and disability in 2007 and in 2017. Additionally, there was a 29.6% increase in the risk caused by dietary patterns between 2007 and 2017 (Global Burden of Disease).

One of the integral ingredients for making food edible and/or enhance taste is salt. However, salt is the primary source of sodium and increased intake causes hypertension and consequently heightens the probabilities of stroke, heart attack and other related cardiovascular ailments.

The average salt consumption for a healthy Chinese is 10.5 grams as opposed to the recommended 6 grams as per the Chinese Dietary Guidelines (World Health Organization). This higher than optimal quantity of salt utilization has been attributed in addition to putting salt in home cooked food and at the table (such as soy sauce, fish sauce and table salt), increasing eating of packaged food combined with lower consumption of fresh fruits, vegetables, dietary fiber like whole grains.

The diet part is in particular significant given the high dietary risk. The Food Sustainability Index, a weighted average of indicators in the health and nutrition category, has been created by the Economist Intelligence Unit and the Barilla Centre for Food and Nutrition (BCFN). China ranks 21 among the 38 countries for which the Nutritional Challenge Index has been created also by The Economist.

The enormity of role of salt in determining people’s healthy diet and consequently healthy years of life acquire prominence when coupled with the facts that China’s population is aging quite rapidly and elderly are more susceptible to hypertension and other cardiovascular diseases.

Moreover, reduction of salt is considered as one of the most cost effective strategies to improve health outcomes and reduce number of deaths. World Health Organization estimates 2.5 million deaths globally could be prevented if salt consumption is reduced to the recommended level.

Expectedly, World Health Organization in collaboration with the local organizations and with the Chinese government has initiated public service campaigns to increase knowledge, awareness and support to homes, schools, work places and the food industry to reduce amount of salt.

The State Council as part of the Healthy China 2030 Initiative has set a goal of reducing the salt intake by 20%. Also, at the forefront of recognizing the urgency of reforming the food industry to align with ensuring a sustainable production of healthy food is the Barilla Foundation as evidenced by its unveiling of the report, ‘Fixing the Business of Food, the Food Industry and the SDG Challenges’ on September 24, 2019.

In addition to the advocacy and the activism aspects, an area that demands a careful assessment is governmental expenditure on health care. The slowing of economic growth coupled with the shifting demographics toward the elderly enhances the urgency of planning for the future.

It is estimated that government expenditures on health would increase three times to about 10% of the GDP by 2060 (The World Bank and World Health Organization 2019). This is all the more critical considering illnesses such as hypertension that are usually a consequence of high salt consumption. As hypertension does not cause symptoms at the early stages, it can easily go undiagnosed.

In China it is estimated that only 13.8% of the 270 million people who have hypertension have the disease managed (World Health Organization). Thus, it is pivotal to focus on both preventative and curative measures with respect to the occurrence of illnesses caused by unhealthy dietary lifestyle that include high salt consumption.

Not doing so implies high cost to the society with respect to loss of productive years through death and/or disability. Based on China’s compliance with the mission of World Health Organization and Sustainable Development Goals (SDGs) that are founded on the ambition of ‘leaving no one behind’, it appears that China is committed to the goal of reducing the salt intake within the next decade as part of the larger initiative of providing a healthy productive life to all of its citizens.

Excerpt:

In an inaugural lecture at the Radcliffe Institute at Harvard University, Amartya Sen began with a swipe at Queen Victoria who complained to Sir Theodore Martin in 1870 about & quote: this mad, wicked folly of ‘Woman’s Rights’ “, as in her rarefied world nobody could trample upon her rights. The world has of course changed dramatically and women’s rights are widely acknowledged but injustices persist. Our concern here is with health injustices that are widely prevalent in India. These take multiple forms: female foeticide, widespread morbidity and denial of access to good quality healthcare until a critical condition develops. Our focus here is on vulnerability of women to non-communicable diseases (NCDs) and their limited access to good quality healthcare in India.

Farhana Haque Rahman

NCDs kill 40 million annually, accounting for about 70 % of all deaths globally. NCDs are chronic in nature and take a long time to develop. They are linked to aging 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 major NCDs include cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. These account for 42 % of deaths in India. Some of the risk factors associated with NCDs are aging, unhealthy diet, physical inactivity, smoking, excessive use of alcohol and excess weight.

The burden of NCDs shifted to the older segments of population ( 60 years), highest prevalence being amongst to the oldest men and women ( 80 years+), with higher prevalence among women.

In sharp contrast to women who recorded a significant rise, overall prevalence of NCDs among men fell significantly during 2004-14, based on the National Sample Survey data for India. Men accounted for the majority in 2004, but women did so in 2014. The majority of NCD cases were in the rural areas for both men and women. However, the prevalence among urban women was higher than among urban men in 2014.

There was a significant affluence gradient to prevalence of NCDs among men, with a sharp increase in the prevalence from the lowest expenditure quintile to the highest in 2004. This is similar to what women experienced. A similar pattern is reproduced among both men and women in 2014, but with one reversal. While the prevalence among the most affluent men was higher than among the most affluent women in 2004, the latter recorded a higher prevalence ten years later, in 2014.

Raghav Gaiha

An important issue is whether higher vulnerability of women to NCDs manifests in greater access to good quality healthcare. To assess this, we rely on the India Human Development Survey 2015. To assess the quality of health care, we distinguish between two healthcare providers: public hospitals/doctors and private hospitals/doctors. More respondents rank private healthcare providers higher in quality than public providers. Another proximate indicator of quality is location of healthcare facilities. Quality of treatment received at home and in the same village is often inferior to treatment received in another village/town/district. The point to note is that a village may or may not have a primary healthcare centre but towns and districts are much better equipped with healthcare facilities for specialized treatment of NCDs. So location is another predictor of quality of healthcare.

Public providers were chosen by just under one-third of old women suffering from at least one NCD. In a striking contrast, large majorities –about two-thirds- depended on private providers (excluding traditional faith healers) in 2012. Similar proportions are reproduced for old men. So on this quality criterion, there was little difference between old men and women.

But the distance travelled by women and men reveals a contrast.

Large shares of old women, about 45 %, suffering from at least 1 NCD had their first treatment at home and in the same village. The majority, about 55 %, travelled to another village/town/district. Large shares of men suffering from 1 NCD, about 40 %- were treated at home and in the same village while the majority, about 58 %-travelled to another village/town/district.

From this perspective, the fact that larger shares of women received treatment at home and in the same village than men with a chronic NCD suggests that women had lower access to costlier and more specialized treatment despite their greater vulnerability to NCDs; however, the difference between men and women in their reliance on private providers is not significant.

In brief, while women are more prone to NCDs, their access to costlier and more specialized healthcare is lower than that of men. So the evidence favoring discrimination against women in good quality healthcare is limited but suggestive of a bias.

Social and family norms that restrict women’s access to health care are not as rigid as generally believed. Greater awareness of equity and better recognition of women’s contribution to household and social welfare could enhance their access to health care. Besides, outside employment options for women with some bargaining power (eg, high school education) could reinforce their autonomy.

(Farhana Haque-Rahman, a journalist and communications expert, is a former senior United Nations official and Raghav Gaiha is Visiting Scholar, Population Studies Centre, University of Pennsylvania and (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England).

By Farhana Haque Rahman and Raghav Gaiha
ROME and NEW DELHI, Aug 6 2019 (IPS)

On a cold night in December 2012, a ghastly crime was committed in New Delhi which stunned the world. Six men dragged helpless Nirbhaya-a 23-year-old female physiotherapy intern- to the back of the bus and raped her one by one. As she kept fighting off her assailants by biting them, one of the attackers inserted a rusted rod in her private part, ripping her genital organs and insides apart. She died a few days later. One of the accused died in police custody in the Tihar Jail. The juvenile was convicted of rape and murder and given the maximum sentence of three years’ imprisonment in a reform facility, and subsequently released. The Supreme Court awarded the death penalty but legal complications have prevented its execution.

Farhana Haque Rahman

In January, 2019, a 16-year-old girl had simply decided to go to her boyfriend’s birthday party. A week later, her body was found along a highway, her head and one of her arms chopped off. Her face may have been burned with acid. In her small town in eastern India, it is forbidden for a teenage girl to date, and the police believe the girl’s father arranged for her to be killed — supposedly to protect the family’s honour.

Just as gruesome is the story of the 30-year-old Fatima who reported to UNFPA in Cox’s Bazar in southeast coast of Bangladesh in 2017, “My sister was killed after gang rape in front of me, and they threw hot water on my body. I can’t sleep, my life is a nightmare, I can’t bear the pain of losing my sister.”

Worse, minor girls remain highly vulnerable to brutal rapes and murder. In May, the same year, a ten-month-old baby girl was allegedly raped by a family member in Jamnagar district of the western state of Gujarat. Cases of brutal rapes of minor girls abound in Bangladesh too. The rape and murder of 13-year-old Ayesha Siddiqua Sumaiya, living in Rangpur, is a case in point. A student of Class VII, she was alone in her home – her parents were at a religious function – when a gang swooped on the minor, raping and then strangling her to death.

Raghav Gaiha

Report on Violence Against Women (VAW) Survey 2015, Bangladesh, paints in vivid detail high incidence of different forms of violence against women. During 2014, the most common form of partner violence was controlling behaviour, experienced by more than one third (38.8%) of ever-married women, followed by emotional violence (24.2%), physical violence (20.8%), sexual violence (13.3%) and economic violence (6.7%). Rates of lifetime partner violence (any form) were highest in rural areas (74.8% of ever-married women) and lowest in city corporation areas (54.4%). Rates in urban areas outside of city corporation areas were 71.1%, slightly lower than in rural areas.

More than one quarter (27.8%) of women reported lifetime physical violence by someone other than the husband (non-partner) and 6.2% reported experiencing such violence during the last 12 months. Rates were highest among adolescents for both lifetime (30.9%) and last 12 months (11.2%) non-partner physical violence.

Most sexual violence in India occurs in marriage; 10 percent of married women report sexual violence from husbands. The reporting percentage is low in part because marital rape is not a crime in India. Adolescent wives (13–19 years) are most vulnerable, reporting the highest rates of marital sexual violence of any age group. Adolescent girls also account for 24 percent of rape cases in the country, although they represent only 9 percent of the total female population.

Barely 1 percent of victims of sexual violence report the crime to the police in India. Similar evidence is found for Bangladesh. Notions of honour are central to the discourse on rape. The rape of a daughter, sister or wife is a source of dishonour to males within the family structure. This deters the reporting of rape to the police, reinforced by a belief in the impunity of perpetrators, the fear of retaliation, and humiliation by the police through physical and verbal abuse.

The consequences of domestic violence are grave and intergenerational: physical trauma, repeated physical assaults result in chronic disease (e.g. chronic pain); acute neurological (e.g. fainting) and cardiopulmonary (hypertension) symptoms; life-style risk behaviours (substance misuse); psychiatric disorders (depression); and children and adolescents adversely affected by witnessing domestic violence (post-traumatic stress disorder). Besides, domestic violence also results in malnutrition among women and children.

One major problem with anti-rape laws is that their enforcement is feeble and painfully slow, and thus largely inconsequential as a deterrent to sexual violence.

Dominance and control over women are set in male attributes and behaviour (“masculinity”), regarded as a shared social ideal. Violence is not necessarily a part of masculinity, but the two are often closely linked, mediated by class, caste and region.

Interventions that address masculinity seem to be more effective than those that ignore the powerful influence of gender norms and systems of inequality. Effective women-focused initiatives strengthen resilience against violence by combining economic empowerment with greater awareness of rights and women’s relationship skills. Behavioural changes are, however, slower than changes in male attitudes.

In conclusion, although rise in sexual violence against women and girls is scary and abhorrent, there are grounds for optimism.

(Farhana Haque Rahman is Director General of IPS Inter Press Service; she is a communications expert and former senior United Nations official. Raghav Gaiha is (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England, and Visiting Scholar, Population Studies Centre, University of Pennsylvania, USA).

Excerpt:

By Manoj K. Pandey, Vani S. Kulkarni and Raghav Gaiha
Canberra, Philadelphia and Manchester, Mar 20 2019 (IPS)

Depression is often distinguished from other non-communicable diseases or NCDs (e.g., cancer, diabetes, cardio-vascular diseases, hypertension) because of the stigma attached to it. Among other consequences, those suffering from depression are often denied access to medical care. Indeed, the latter is an outcome of interaction between supply of and demand for medical care. On the provider side, stigmatizing attitudes by service providers are identified as a barrier to access. On the demand side, stigma and low mental health literacy by community members are just as emphatically reported as barriers to accessing care.

Manoj K. Pandey

Many NCDs share common risk factors such as tobacco use, physical inactivity, and unhealthy diets that are associated with cardio-vascular diseases (CVDs), diabetes, and cancer. The South African adult population has high levels of these risk factors, and large proportions of the disease burden can be attributed to these modifiable risk factors. Mental disorders increase the risk of all these diseases, which in turn increase the risk of mental disorders (Patel et al.2018 a).

Our recent study focuses on the association from depression to other NCDs, based on a state-of-art analysis of the five waves of the National Income Dynamics Study (NIDS) panel survey data for South African adults (30 years and above) for 2008, 2010, 2012, 2014, and 2016/17 (Pandey et al. 2019). NCD outcomes are the dependent variable with depression in the initial year and other explanatory variables that vary with time or do not. Examples of the former include age, wealth, whether living alone and affiliation to social networks, and of the latter gender and ethnicity. Although much has been written on the association from NCDs to depression, the research on the reverse association from depression to NCDs remains patchy. Hence the focus here is on the latter.

There are robust associations from depression to other NCDs in South Africa. With controls for socio-economic factors, the initial condition of moderate and severe depression is robustly associated with NCDs such as high blood pressure, stroke, heart diseases, cancer, and at least one NCD in subsequent years. This result is also consistent for mental health conditions where poor baseline mental health condition increases the risk of NCDs later. Moreover, the risk of NCDs is higher when severe depression or poor mental health conditions are present (with or without NCDs)—with a slightly larger risk when severe mental health conditions co-occur with an NCD in the initial year.

Vani S. Kulkarni

Relative to the Africans, the Whites are less likely to suffer from diabetes but more vulnerable to heart diseases, cancer and at least one NCD. The Coloureds have higher risks of NCDs while the Asians/ Indians are more vulnerable to diabetes and heart related problems. At older ages, the proportion of black Africans is higher than it was previously which accounts for the decrease in lung cancer because black Africans have a lower rate of smoking than White and Coloured people. The South African Indian community is more insulin resistant than other ethnic groups and therefore at greater risk of diabetes type 2 and ischaemic heart disease.

The Lancet Commission on global mental health and sustainable development (2018) and WHO (2015) report adverse impacts on the health of the caregivers. Caring for a person with a chronic, disabling NCD or mental disorder, such as cancer or dementia, is stressful and associated with an increased risk of chronic health problems, including depression, hypertension, sleeping problems, and fatigue; increased use of psychotropic drugs; and premature mortality. Indeed, such indirect impacts on caregivers, who are often members of the patient’s household, result in sick households.

The Mental Health Care Act 17 of 2002 in South Africa requires that service users undergo a 72-h emergency management and observation period for involuntary admissions to designated general district and regional hospitals across the country, before they are referred to specialist psychiatric hospitals. However, implementation remains daunting, with inadequate infrastructure and specialist staff. Indeed, several studies are emphatic that this requirement has negatively affected the quality of care provided (Petersen et al. 2017).

Raghav Gaiha

A case could be made for substantially higher investment in primary health-care systems (Patel et al. 2018 b). On the supply side, these investments include greater accountability of services to local communities, enhanced sensitivity of providers to local conditions and beliefs, and provision of care to the needy. On the demand side, effective local services can address complex problems of patient access, offset the financial burden of adult chronic illness, and restrict unnecessary use of expensive private care. Although additional resources are needed, the magnitude is likely to be less than projected if the efficiency of investment in primary medical care is factored in.

Excerpt:

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

Excerpt:

A disquieting finding of The State of Food Security and Nutrition in the World 2017, Building resilience for peace and food security, or (SFSN2017), Rome, is that, in 2016, the number of chronically undernourished people in the world increased to 815 million, up from777 million in 2015 although still lower than about 900 million in 2000. Similarly, while the prevalence of undernourishment rose to 11 percent in 2016, this is still well below thelevel attaineda decade ago. Whether this recent rise inhunger and food-insecurity levels signals thebeginning of an upward trend, or whether itreflects an acute transient situation calls for a close scrutiny.

Undernourishment is associated with lower productivity. More importantly, in an agrarian economy with surplus labour and efficiency wages, a weather or market shock could result in rationing out of those lacking adequate physical stamina and dexterity from the labour market. This could perpetuate the poverty of the undernourished, often referred to as nutrition –poverty trap.

By contrast, other indicators of food security have registered improvement. Stunting refers to children who are too shortfor their age. It is a reflection of achronic state of undernutrition.When children are stunted before the age of two, they are athigher risk of illness and more likely thanadequately nourished children to lackcognitive skills and learning abilities in later childhood and adolescence.Globally, the prevalence of stunting of children under five years fell from29.5 percent to 22.9 percent between 2005and 2016. The global average of the prevalence of anaemiain women of reproductive age increased slightlybetween 2005 and 2016. When anaemia occurs duringpregnancy, it causes fatigue, loweredproductivity, increased risk of maternal andperinatal mortality, and low birth weight babies.

Has Asia’s experience been different? It is argued below on the basis of Table 1 that it has been more mixed.

Although proportion of undernourished in different sub-regions of Asia varied within a narrow range in 2004-06, it became narrower in 2014-16. In all sub-regions, the proportion of undernourished fell during this period but slowly, as in Asia as a whole. Under-five stunting is a key indicator of child malnutrition. The range was large in 2005, with a high of 44.6 % in Southern Asia and a low of 9.4 % in Central Asia. The range became narrower in 2016 but Southern Asia continued to have the highest prevalence of over 34 % (but lower than in 2005) and Eastern Asia the lowest of 5.5 % (substantially lower than in 2005). So except for Central Asia which witnessed a slight rise, all other sub-regions recorded reductions in stunting. Prevalence of anaemia among women of reproductive age was widespread with a high of 50 % in Southern Asia and a low of about 19 % in Eastern Asia in 2005. While the prevalence of anaemic women fell in Southern Asia from 50 % to 43.7 % in 2016, this sub-region still had the highest prevalence.

Geetika Dang

SFSN (2017) attributes much of the worsening in food security-especially in Sub-Saharan Africa- to frequency of conflicts, droughts, and fragility of governance, but the analysis is largely conjectural.

As Asia was not so prone to conflicts, we sought to unravel the relationship between these indicators of food security and income growth, allowing for unobservable country –level heterogeneity and residual time effect. Whether the political regime of a country is more inclined to protect the poor and vulnerable -especially children and women in the reproductive age-group- against the risks of undernourishment from weather and market shocks is unobservable but crucial for isolating the effect of income.

Our analysis shows that there are robust relationships between these indicators and per capita income (PPP2011) and the residual time effect. Assessing the effect of income in terms of elasticities, proportionate change in say prevalence of undernourishment/proportionate change in income, we find that the elasticity of undernourishment to income is –0.28, implying that a 1 % higher income will lower prevalence of undernourishment by 0.28 %. A related finding is that the elasticity (in absolute value) rose substantially during 2005-16, implying that a 1% higher income will be far more effective in curbing undernourishment. Moreover, there was a substantial negative residual time effect, implying that controlling for income, other time related factors led to reduction in prevalence of undernourishment.

Raghav Gaiha

Although limited in scope, our analysis confirms that income growth is key to food security in Asia. This is not to suggest that other factors (e.g. social safety nets, greater nutritional awareness-especially among women-and education) do not matter. They matter too but call for a broader investigation.

Geetika Dang is an independent researcher; and Raghav Gaiha is currently (Hon.) Professorial Research Fellow, Global Development Institute, University of Manchester, England, and Visiting Scientist, Department of Global Health, Harvard School of Public Health (2015 and 2016).

The views expressed are personal.

By Raghav Gaiha and Shantanu Mathur
NEW DELHI, Dec 19 2017 (IPS)

Lack of diet diversity is viewed as the major cause of micronutrient malnutrition in Sub-Saharan Africa. Imbalanced diets resulting from consumption of mainly high carbohydrate based-diets also contribute to productivity losses and reduced educational attainment and income. Consequently, micronutrient malnutrition is currently the most critical for food and nutritional security problem as most diets are often deficient in essential vitamins and minerals. In Tanzania, for example, most rural and urban households consume mainly staples as their main food, which are high in carbohydrates, but low in micronutrients and vitamins. Staple food items increase energy availability but do not improve nutritional outcomes if not consumed together with micro-nutrient rich foods.

Raghav Gaiha

A recent study analyzed the relationship between production and consumption diversity in smallholder farm households in four developing countries: Indonesia, Kenya, Ethiopia, and Malawi (Sibhatu et al. 2014). These four countries were selected mainly because of availability of recent household data. The results are classified under (i) association between production and diet diversity, (ii) role of market access, and (iii) role of selling and buying food. Farm production diversity is positively associated with diet diversity, but the effect is relatively small. In the pooled sample (of all four countries), producing one additional crop or livestock species leads to a 0.9% increase in the number of food groups consumed This effect, however, varies across the countries in question. In Kenya and Ethiopia, the estimates are very small and not (statistically) significant. In these two countries, average production diversity is quite high; further increasing farm diversity would hardly contribute to higher diet diversity. One indicator of market access is the geographic distance from the farm household to the closest market where food can be sold or bought. The estimated effects are negative, implying that households in remoter regions have lower dietary diversity. Better market access through reduced distances could therefore contribute to higher diet diversity. Reducing market distance by 10 km has the same effect on diet diversity as increasing farm production diversity by one additional crop or livestock species.

Shantanu Mathur

Another approach is to take into account what households sell and buy. This information is only available for Ethiopia and Malawi. If a household sells at least parts of its farm produce, it has a positive and significant effect on diet diversity. It is also much larger than the effect of production diversity. This comparison suggests that facilitating the commercialization of smallholder farms may be a better strategy to improve nutrition than promoting more diversified subsistence production. Furthermore, the negative and significant interaction effect confirms that market participation reduces the role of production diversity in dietary quality.

Better market access in terms of shorter distance and more off-farm income opportunities increase the level of purchased food diversity. If off-farm income opportunities are greater in rural areas with short distances to market, the market access effect can’t be disentangled from the income effect. The interaction between level of farm income and participation in off-farm activities is often complex as small farmers tend to work as labourers in the latter while relatively affluent dominate as owners in more remunerative enterprises. The two important inferences are: (i) increasing on-farm diversity among smallholders is not always the most effective way to improve diet diversity and should not be considered a goal in itself; and (ii) in many situations, facilitating market access through improved infrastructure and other policies to reduce transaction costs and price distortions seems to be more promising than promoting further production diversification. One major caveat, however, remains. Even the alternative measure of diet diversity/quality is merely a crude approximation to nutrition (Gaiha et al. 2014).

In brief, market access through buying/selling food is more closely associated with diet diversity than production diversity. Diet diversity, however, is a weak proxy for nutrition. Indeed, there is no shortcut to empirical validation of the link between diet diversity and nutritional outcomes-especially consumption of micronutrients.

Excerpt:

By Raghav Gaiha and Shantanu Mathur
NEW DELHI, Dec 11 2017 (IPS)

Although difficult to ascertain whether it is a trend reversal, two recent FAO reports (2017a, b) show a rise in hunger globally as well as in Africa. The number of undernourished (NoU) in the world suffering from chronic food deprivation began to rise in 2014 –from 775 million people to 777 million in 2015 – and is now estimated to have increased further, to 815 million in 2016. The stagnation of the global average of the proportion of undernourished (PoU) from 2013 to 2015 is the result of two offsetting changes at the regional level: in Sub-Saharan Africa, the share of undernourished people increased, while there was a continued decline in Asia in the same period. However, in 2016, the PoU increased in most regions except Northern Africa, Southern Asia, Eastern Asia, Central America and the Caribbean. The deterioration was most severe in Sub-Saharan Africa and South-Eastern Asia (FAO 2017a,b).

Raghav Gaiha

Food systems are changing rapidly. Globalization, trade liberalization, and rapid urbanization have led to major shifts in the availability, affordability, and acceptability of different types of food, which has driven a nutrition transition in many countries in the developing world. Food production has become more capital-intensive and supply chains have grown longer as basic ingredients undergo multiple transformations. Expansion of fast food outlets and supermarkets has resulted in dietary shifts. The consumption of low nutritional quality, energy-dense, ultra-processed food and drinks, and fried snacks and sweets has risen dramatically in the past decade.

The concomitant shift to the more market-oriented nature of agricultural policies means that agricultural technology and markets play a more important role in determining food prices and rural incomes, and more food is consumed from the marketplace rather than from own production. The greater market orientation of food production and consumption has increased the bidirectional links between agriculture and nutrition: agriculture still affects nutrition, but food and nutritional demands increasingly affect agriculture. Increasing demands for energy-intensive products exacerbate environmental impacts of food value chains: for example, excessive use of agricultural chemicals to extract more dietary energy from every hectare while contaminating the very food it produces, along with groundwater and the soil; and the greenhouse gas emissions from livestock industries to feed the ever-increasing demand for meat and dairy products (Carletto, 2015).

Shantanu Mathur

A food value chain involves a series of processes and actors that take a food from its production to consumption and disposal as waste. In a value chain, the emphasis is on the value (usually economic) accrued (and lost) for chain actors at different steps in the chain, and the value produced through the functioning of the whole chain as an interactive unit. A value chain is commodity specific, and thus involves only one particular food that is relevant within a diet.

As value chains are crucial in determining food availability, affordability, quality, and acceptability, they have potential to improve nutrition. What is required is to identify opportunities where value chain actors benefit from supplying the market with agricultural products of higher nutritional value. Value chain development, however, has rarely focused attention on consumers—consumers are simply considered as purchasers driving the ultimate source of demand. In this light, the value chain strategy is likely to be enriched by a stronger consumer focus, and, in particular, a focus on consumer nutrition and health. The empirical evidence on the role of value chains in improving nutrition is, however, scanty and mixed.

Basically, nutrition results from the quality of the overall diet, not just from the nutrient content of an individual food. In value chains, the focus is generally commodity specific, rather than on how to integrate multiple chains to contribute to an enhanced quality of diet. There may be offsetting impacts such that, if one value chain works better and consumption of the associated food increases, consumption of other foods may decline.

On the demand side, the central issue is how to promote consumption of nutritious foods by target populations that may not be able to afford a healthy diet. Similarly, on the supply side, an important concern is the feasibility of targeting the poorest smallholders and informal enterprises along the value chain, particularly, involving women.

An example from Nigeria elucidates the potential of value chains for enhancement of nutritional value and the constraints that must be addressed. Chronic undernutrition is pervasive in Nigeria, with rates of stunting and underweight alarmingly high and little progress over the last decade. There are major disparities in nutrition outcomes between the wealthy and poor, between the north and south, and between urban and rural areas. Micronutrient deficiencies are widespread across social groups. Vitamin A deficiency, for example, is associated with 25% of child and maternal deaths. Together with direct nutrition interventions, it is necessary to improve the functioning of food value chains and provide access to nutrient-dense foods to the urban and rural poor.

Cowpeas make a substantial contribution to the nutrition of poor populations in Nigeria. Cowpea grains contain an average of 24% protein and 62% soluble carbohydrates. They are rich in thiamine, folates and iron, and also contain zinc, potassium, magnesium, riboflavin, vitamin B6 and calcium, as well as the amino acids lysine and tryptophan. Markets for cowpea products are mainly informal, and the majority of products are produced by small-scale businesses and sold locally. Few formal sector businesses have invested in cowpea products, and there is limited innovation in value-added products. A merit of cowpea foods is that they are readily acceptable to diverse populations, widely available across the country and can be distinguished from less nutritious alternatives. However, affordability and availability of cowpeas is constrained by major supply-side problems. Cowpea prices fluctuate between seasons, due to the susceptibility of grains to degradation and low use of improved storage technologies. Although simple, safe and low-cost technologies are available in the form of improved storage bags, these are not prominent in wholesale and transport stages of the value chain. Besides, existing preservation techniques make use of pesticides that create risks of toxic contamination. Improving use of storage technologies along the value chain, including on-farm facilities, transportation and storage facilities in markets would help alleviate this constraint-especially for smallholders.

So the challenges are creating incentives for businesses to focus better on nutritional foods and conditions enabling smallholders to integrate better into these chains.

Excerpt:

By Varsha S. Kulkarni and Raghav Gaiha
New Delhi, Nov 20 2017 (IPS)

Have demonetisation and the GST aggravated income inequality?

With the Gujarat State elections barely a few weeks away, the debate on the Indian economy has become increasingly polarised. While the official view of demonetisation unleashed in November 2016 elevates it to a moral and ethical imperative, the chaos caused by the goods and services tax (GST) launched on July 1, 2017, is dismissed as a short-run transitional hiccup. Both policies, it is asserted, are guaranteed to yield long-term benefits, unmindful of large-scale hardships, loss of livelihoods, closure of small and medium enterprises and slowdown of agriculture. Critics of course reject these claims lock, stock and barrel. Lack of robust evidence is as much a problem for the official proponents of these policies as it is for the critics. Hence the debate continues unabated with frequent hostile overtones.

Varsha S. Kulkarni

Beneath the debate are deep questions of inequality and its association with poverty. Thomas Piketty produced a monumental treatise, Capital in the Twenty-First Century, demonstrating that rising income inequality is a by-product of growth in the developed world. More recently, Lucas Chancel and Piketty (2017), in ‘Indian income inequality, 1922-2014: From British Raj to Billionaire Raj?’, offer a rich and unique description of evolution of income inequality in terms of income shares and incomes in the bottom 50%, the middle 40% and top 10% (as well as top 1%, 0.1%, and 0.001%), combining household survey data, tax returns and other specialised surveys.

Some of the principal findings are: one, the share of national income accruing to the top 1% income earners is now at its highest level since the launch of the Indian Income Tax Act in 1922. The top 1% of earners captured less than 21% of total income in the late 1930s, before dropping to 6% in the early 1980s and rising to 22% today. Two, over the 1951-1980 period, the bottom 50% captured 28% of total growth and incomes of this group grew faster than the average, while the top 0.1% incomes decreased. Three, over the 1980-2014 period, the situation was reversed; the top 0.1% of earners captured a higher share of total growth than the bottom 50% (12% v. 11%), while the top 1% received a higher share of total growth than the middle 40% (29% v. 23%).

Raghav Gaiha

Sharp reduction in the top marginal tax rate, and transition to a more pro-business environment had a positive impact on top incomes, in line with rent-seeking behaviour.

India’s wealth gain

According to Credit Suisse Global Wealth Report 2017, the number of millionaires in India is expected to reach 3,72,000 while the total household income is likely to grow by 7.5% annually to touch $7.1 trillion by 2022. Since 2000, wealth in India has grown at 9.2% per annum, faster than the global average of 6% even after taking into account population growth of 2.2% annually. However, not everyone has shared the rapid growth of wealth.

Our research, based on the India Human Development Survey 2005-12, focusses on a detailed disaggregation of income inequality, along the lines of Chancel and Piketty, recognising that incomes in the upper tail are under-reported; and examines the links between poverty and income inequality, especially in the upper tail, state affluence, and prices of cereals.

Our analysis points to a rise in income inequality. A high Gini coefficient of per capita income distribution, a widely used measure of income inequality, in 2005 became higher in 2012. The share of the bottom 50% fell while those of the top 5% and top 1% rose. The gap between the share of the top 1% and the bottom 50% narrowed considerably.

More glaring is the disparity in ratios of per capita income of the top 1% and bottom 50%. The ratio shot up from 27 in 2005 to 39 in 2012. Far more glaring is the disparity in the highest incomes in these percentiles. The ratio of highest income in the top 1% to that of the bottom 50% nearly doubled, from a high of 175 to 346.

All poverty indices including the head-count ratio fell but slightly.

Poverty and inequality

Higher incomes reduced poverty substantially. Inequality measured in terms of share of income of the top 10% increased poverty sharply but only in the more affluent States. Somewhat surprisingly, higher cereal prices did not have a significant positive effect on poverty. Similar results are obtained if the share of the top 10% is replaced with the Gini coefficient as a measure of inequality.

It is plausible that poverty reduction slowed in 2016-17 because of deceleration of income growth; and huge shocks of demonetisation and the GST to the informal sector have aggravated income inequality. Indeed, depending on the magnitudes of these shocks, poverty could have risen during this period.

In sum, regardless of the longer-term outlook and presumed but dubious benefits of the policy shocks, the immiseration of large segments of the Indian population was avoidable.

This opinion editorial was first published in The Hindu

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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

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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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

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

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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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

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

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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The proportion of persons 60 years and older is projected to almost double during 2000–2030 in South Africa. Credit: Jeffrey Moyo / IPS

By Manoj K. Pandey, Vani S. Kulkarni and Raghav Gaiha
Canberra, Philadelphia and Manchester, Feb 20 2017 (IPS)

Old age is often characterised by poor health due to isolation, morbidities and disabilities in carrying out activities of daily living (DADLs) leading to depression.

Mental disorders—in different forms and intensities— affect most of the population in their lifetime. In most cases, people experiencing mild episodes of depression or anxiety deal with them without disrupting their productive activities. A substantial minority of the population, however, experiences more disabling conditions such as schizophrenia, bipolar disorder type I, severe recurrent depression, and severe personality disorders. While common mild disorders are amenable to self-management and relatively simple educational or support measures, severe mental illness demands complex, multi-level care that involves a longer-term engagement with the individual, and with the family. Yet, despite the considerable burden and its associated adverse human, economic, and social effects, governments and donors have failed to prioritise treatment and care of people with mental illness. Indeed, pervasive stigma and discrimination contributes to the imbalance between the burden of disease due to mental disorders, and the attention these conditions receive.

The percentage of the population aged 60 years and above in South Africa rose from 7.1% in 1996 to 8 % in 2011, an increase from 2.8 million to 4.1 million individuals. The proportion of persons 60 years and older is projected to almost double during 2000–2030 because of (i) a marked decline in fertility in the past few decades; (ii) the HIV and AIDS pandemic contributing to this change in the population structure, with a higher mortality of young adults, especially women of reproductive age; and (iii) a rise in life expectancy to 62 years in 2013-– a staggering increase of 8.5 years since the low in 2005.

Four in ten elderly persons in South Africa are poor. More than a third make an average living, and the rich constitute about 27%. Provincial variations show that rural provinces have higher proportions of poor elderly persons compared to those residing in the urban provinces. Racial differences show that elderly Whites and Indians/Asians occupied a higher socio-economic status than black Africans and Coloureds.

Ours is the first study that offers a comprehensive analysis of depression among the old (60+ years) in South Africa, using the four waves of the National Income Dynamics Study (SA-NIDS) (2008, 2010, 2012 and 2014).

A self-reported measure of depression is used. SA-NIDS gives data on not depressed in a week, depressed for 1-2 days, 3-4 days and 5-7 days. We focus on those depressed for ≥ 3 days in a week. Referring to this as a measure of severe depression, its prevalence reduced from 15.3 % among the old in 2008 to 14.5 % in 2014, with a dip to 12.6 % in 2012.

Aging is a major factor in depression. Those in early 60s are generally more depressed than older persons in their 70s and 80s.

Old women were consistently more depressed than old men, as they are subject to violence. It is associated with conflicts over the man’s drinking, the woman having more than one partner, and her not having post-school education. Another factor is that women are typically much more likely to be overweight and obese, leading to non-communicable diseases (NCDs) and subsequently higher depression . A challenging aspect of obesity prevention among black South Africans is the positive perception that both women and men attach to a large body size.

Married men and women are less depressed than others. Marriage thus serves as a barrier to loneliness and a source of support during periods of stress for old persons. However, old persons in larger households without any other old person are more prone to depression. It is not clear whether larger households result in neglect of old persons or their abuse.

Ethnicity matters. The Africans are more prone to depression than the reference group of the Whites and Coloureds. There is limited evidence suggesting that Asians/Indians/Others are less likely to be depressed.

Pensioners are less likely to be depressed despite some evidence in the literature on pooling of pensions with other household resources and denying the pensioner any financial autonomy. Although this can’t be ruled out, it is evident that the favourable effect of pensions in preventing depression is robust.

Of particular significance are the results on multimorbidity (more than one disease at a time). Two combinations of NCDs (diabetes and high BP, and cancer and heart disease) are positively associated with depression. Equally important are the associations between disabilities in activities of daily living or DADLs (e.g. difficulties in dressing,bathing, eating, walking, climbing stairs) and depression. In many cases, both sets of DADLs are positively associated with depression. The relationship between depression and body mass index or BMI categories (underweight, normal, overweight and obese) is not so robust except that in some cases overweight were less likely to be depressed than the reference category of obese.

Shock of a family member’s death (in the last 24 months) was robustly linked to higher incidence of depression. There is some evidence suggesting that this shock had stronger effects on women relative to men.

As loneliness and lack of support during a difficult situation can precipitate stress leading to depression, we experimented with measures of social capital and trust as barriers to depression, and the mediating role of preference for the same neighbourhood.

Although social capital doesn’t have a significant negative effect on depression, social trust does. Besides, the mediating role of preference for the current neighbourhood is confirmed in most cases. An exceptional case is that of the Africans for whom neither social capital nor social trust is of any consequence except the mediating role of preference for the current neighbourhood.

The burden of depression in terms of shares of depressed in total depressed has risen in the more affluent wealth quartiles-especially that of the most affluent. However, likelihood of depression remained lower among the third and fourth quartiles, implying that the likelihood of depression was higher in the poorest (or the least wealthy). It is somewhat surprising that despite marked inequalities even among the Africans, there is no wealth effect on depression.

Although older people are in worse health than those younger, older people use health services much less frequently. These patterns of utilization arise from barriers to access, a lack of appropriate services and the prioritization of services towards the acute needs of younger people.

A larger ethical issue is rationing of health care to older people on the notion that health services are scarce and must be allocated to achieve the greatest good for the greatest number of people. WHO 2015 rejects this view on two counter-arguments: older people have made the greatest contribution to socioeconomic development that created these services; and they are entitled to live a dignified and healthy life.

Mental health care continues to be under-funded and under-resourced compared to other health priorities in the country; despite the fact that neuropsychiatric disorders are ranked third in their contribution to the burden of disease in South Africa, after HIV/AIDS and other infectious diseases. In fact, mental health care is usually confined to management of medication for those with severe mental disorders, and does not include detection and treatment of other mental disorders, such as depression and anxiety disorders.

From this perspective, the proposed National Mental Health Policy Framework and Strategic Plan 2013-2020 is a bold and comprehensive initiative.

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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

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

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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By Raghav Gaiha
NEW DELHI, Oct 19 2015 (IPS)

After Adam Smith and Amartya Sen, Angus Deaton, this year’s Nobel laureate in economics, has contributed most to broaden and enrich our understanding of human well-being. His brilliant and path-breaking contributions to the theory and measurement of consumption, poverty, inequality, nutrition – and, more recently, aging, morbidity and suicides – have inspired a generation of economists to carry out reformulations, refinements and extensions.

Raghav Gaiha

Multilaterals, donors and national policy makers have not been far behind in rethinking development priorities and policies. Blending micro and macro- economics in remarkably creative ways and expanding frontiers of our knowledge through meticulous and innovative empirical validation, Deaton remains peerless. This endorsement, however, does not imply that he hasn’t had his share of controversies.

Much much has been written about his contributions to demand theory, demonstrating how interdependent demands are for different commodities through relative prices, why consumption is more volatile than income if aggregated from individual choices, the pitfalls in measuring poverty and inequality globally and nationally and his emphasis on carefully designed household surveys.

More, however, needs to be said on some of these propositions and on his more recent contributions to understanding human well-being through self-assessed measures of well-being and health status, aging, morbidity and mortality.

His distrust of causal inferences drawn from standard econometric techniques and the current fad of randomised controlled trials (RCTs), and why foreign aid may do more harm than good under certain circumstances cannot be dismissed lightly but remain controversial.

Let me begin with his deep scepticism of global poverty estimates that the World Bank produces periodically. The estimation requires (i) purchasing power parity ratios or PPPs (i.e. how many dollars are needed to buy a dollar’s worth of goods in the country, say India, as compared to the United States); and (ii) determination of a poverty cut-off point. The latter is taken to be the average of the national poverty lines of the poorest 15 countries in the world in PPP. In admirably lucid comments, Deaton draws attention to some flaws in the construction of PPS and their comparability over time, and determination of the poverty line. The revision of the 1993 PPS in 2005, and a higher poverty line of $1.25 (instead of $1.08) resulted in a jump of the global count of the poor for 1993 by half a billion. Likening it to an “earthquake”, Deaton pointed out that this had little to do with the revision of the PPPs and largely a result of a “faulty” poverty line. As India became richer, and its poverty line was much lower, it graduated out of the 15 poorest countries, and the average poverty line of the new 15 poorest countries rose. As a result, India’s prosperity left India and the rest of the world poorer. His eminently sensible suggestion is to estimate global poverty using India’s original poverty line or the average of the same 15 poorest countries. As he elaborates, “ …the world count would simply be the number of people living below the poverty line set in India when a large fraction of its population was destitute”.

Inspired by Sen’s focus on human functionings and capabilities, Deaton is emphatic that income-based measures of poverty risk missing important features of it. As an illustration, a government that raises taxes to pay for better public services, or better public health, may increase income poverty, while poverty or deprivations more broadly decrease. In a similar vein but in striking contrast to Picketty’s blockbuster, Capital in the 21st Century, Deaton takes a much broader view of inequality transcending its narrow economic boundaries. Much of his recent work accordingly focuses on health inequity by country/region, age, gender and over time. Many of the insights are rich and fascinating and some are surprising.

Not a narrow economist, Deaton argues compassionately that health inequalities are a moral concern. But whether these are seen as injustices depends greatly on how these come about. He argues that childhood inequalities arising from parental circumstances are key to understanding many of these injustices. So public interventions designed to mitigate harshness of such circumstances are necessary.

In a succinct and definitive observation, he points out that “The stories about income inequality affecting health are stronger than the evidence.” A case in point is that infant and child mortality in developing countries is “primarily a consequence of poverty so that, conditional on average income, income inequality is important only because it is effectively a measure of poverty. ” But this is only a small part of the explanation as mother’s health and literacy, hygiene and sanitation, low birthweight and discrimination between boys and girls matter immensely. Some of these concerns receive critical attention in other studies.

Taller populations are richer, and taller individuals live longer and earn more. In order to understand the relationship between health and wealth, he investigated the childhood determinants of population adult height, focusing on the roles of income and disease. In a sample of European countries and USA, there is a strong inverse relationship between post-neonatal (one month to one year) mortality, as a proxy for disease and nutritional burden, and the mean height of those children as adults.

In a further scrutiny of the “wealthier is healthier” hypothesis, Deaton and Case report direct comparisons of a number of objective and subjective measures of economic and health status in two sites, one in the district of Udaipur in rural Rajasthan, and one in the shack township of Khayelitsha near Cape Town. This hypothesis is rejected in both cases. To illustrate, the economically better-off South Africans are healthier in some respects, but not in others. They are taller and heavier, but their self-assessed health is no better; they suffer from depression and anxiety to the same degree. The explanation lies in the multidimensionality of health, weak correlations between some components, and with income.

A distillation of his recent research is contained in his book, The Great Escape: Health, Wealth and the Origins of Inequality, 2013. His major conclusion is that not only people are becoming more prosperous but also they are living longer and are taller and stronger. The gap between life expectancy in advanced countries and the developing world has shrunk. However, a stark reality is that a billion poor are stuck in abject poverty and low life expectancy. His assertion that aid is likely to do more harm than good because governments are weak, fragile and corrupt is not without merit but contestable.

In an analysis based on the Gallup World Poll, Deaton investigates the relationship between subjective well-being and age. One of his major findings is that there is a U-shaped relationship between evaluative well-being (or life satisfaction) and age in high income, English speaking countries, with the lowest level of wellbeing in the age-group 45-54 years. But this pattern is not universal. The relation between physical health and well-being is bidirectional. Older people with coronary heart disease and arthritis, for example, exhibit higher levels of depression and impaired hedonic wellbeing (feelings of happiness, sadness and pain). But wellbeing could also have a protective role in health maintenance.

Deaton’s enthusiasm for using subjective wellbeing and self rated health status measures, based on Gallup Poll and other similar surveys, rests on the premise that instead of relying on revealed preference through markets we might as well use actual preferences. But the important point is that revealed preferences are subject to some restrictions consistent with rationality while actual preferences are not. Also, some of the simplistic statistical methods and averages used are far from persuasive and intriguing. My admiration for Deaton’s scholarship, however, remains undiminished by these disagreements.

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