By Vani S. Kulkarni and Raghav Gaiha
PHILADELPHIA and NEW DELHI, Sep 28 2017 (IPS)

Care for the elderly needs to be better targeted by the health system and social networks.
The National Health Policy (NHP), 2017 is unable to see the wood for the trees. Life and death questions are dealt with perfunctorily or simply overlooked. For example, it overlooks the rapid rise in the share of the old (60 years or more), and associated morbidities, especially sharply rising non-communicable diseases (NCDs) and disabilities. With rising age, numerous physiological changes occur and the risk of chronic diseases rises. The co-occurrence of chronic diseases and disability elevates the risk of mortality.

Another, more recent report, “Caring for Our Elders: Early Responses, India Ageing Report – 2017 (UNFPA)”, complements the NHP by focussing on the vulnerability of the aged to NCDs, recent policy initiatives and the role of non-governmental organisations in building self-help groups and other community networks. While all this is valuable, it fails to make a distinction between the aged in general and those suffering from chronic conditions. It matters as many suffering from chronic conditions and disabilities may find it harder to participate in such networks. Nor are the important questions of the impact of these networks and their replicability discussed except in a piece-meal manner.

The health system is ill-equipped to deal with surging NCDs; nor is the staff well trained to treat/advise the aged suffering from dementia or frailty, and for early diagnosis and management of conditions such as hypertension. The quality of medical care is abysmal, and hospitalisation costs are exorbitant and impoverishing. Health insurance covers a fraction of medical expenses incurred. However, many of these chronic conditions such as hypertension can be prevented or delayed by engaging in healthy behaviours. Physical activity and healthy diets can mitigate these conditions. Others could be managed effectively if detected early such as diabetes. Some of course can’t be treated but rendered less painful and debilitating through assistive devices such as stroke). Supportive families and community networks often make a significant difference.

Based on the India Human Development Survey (IHDS) 2015, among aged males and females (over 60 years)¸ the proportions of those suffering from NCDs nearly doubled during 2005-12, accounting for about a third of the respective populations in 2012. More females than males suffered from these diseases. The proportions were higher among those over 70, and these doubled in the age groups 60-70 years and over 70.

A vast majority of those with NCDs had access to medical advice and treatment and the proportion remained unchanged during 2005-12. As there is considerable heterogeneity in providers of medical help — from qualified doctors to faith healers and quacks — and a sharp deterioration in the quality of medical services, it is not surprising that the proportions suffering from NCDs have shot up despite high access. Access to government health insurance nearly doubled but remained low as barriers for the aged remain pervasive such as fulfilling eligibility criteria, slow reimbursement and a lack of awareness of procedures. In any case, the proportion of medical expenses covered was measly.

Loneliness and immunity
Loneliness is a perceived isolation that manifests in the distressing feeling that accompanies discrepancies between one’s desired and actual social relationships. The link between loneliness and mortality is mediated by unhealthy behaviours and morbidity. The fact that loneliness predicts health outcomes even if health behaviours are unchanged suggests that loneliness alters physiology at a more fundamental level. Research shows that loneliness increases vascular resistance and diminishes immunity.

We have used two proxies for loneliness: one is single-member households and the other is whether one is married or widowed. Snapping of the spousal bond in old age poses serious health risks. In 2005, old females with NCDs were twice as likely to live in single member households than the corresponding males. In 2012, while the females were two and a half times more likely to be living in single member households, the share of males rose more than moderately. In effect, old females with NCDs became much lonelier.

Whether related to or unrelated to loneliness, a high risk factor for NCDs is daily consumption of alcohol, especially local brews. Daily consumption of alcohol among the aged with NCDs rose more than twice over the period 2005-2012. Banning of liquor sales in a few States hasn’t helped because of strong resistance from vested interests including politicians and expansion of illicit sales.

Networking as support
Another measure is the proportion of those married and widowed. More females were married than males while the widowed were much higher among the females in 2005. Both male and female proportions of those married doubled in 2012 but the latter remained larger. While widowed males tripled, widowed females rose just under twice. However, children often play an important role in elderly support with the caveat that filial piety shows signs of diminishing. So if we look at households with 2-4 members, we find that the proportion of aged females with NCDs living in them was much higher than that of males in 2005, and both rose rapidly, especially the latter. So it is arguable that family support more than compensated for the sharp rise in loneliness. An important point is that today, ‘women are increasingly filling other roles, which provides them with greater security in older age. But these shifts also limit the capacity of women and families to provide care for older people who need it’.

That social networks are effective in providing support to the aged is far from axiomatic as there are questions of size of a network, whether it is proximal or non-proximal and whether there is social harmony. If social networks are instrumental in bonding together in periods of personal crises, this could compensate for a lack of family support, e.g. widows living alone, and help alleviate morbidity. We find that bonding rose sharply among both aged males and females suffering from NCDs during 2005-12.

The IHDS also provides data on inter-caste and village conflicts, with the proportion of those suffering from NCDs living in villages that experienced inter-caste or other conflicts more than doubling during 2005-2012. Lack of social harmony induces helplessness, disruption of medical supplies and network support.

The World Report on Ageing and Health 2015 (WHO) is emphatic about what is known as ageing in place, that is the ability of older people to live in their own home and community safely, independently, and comfortably, regardless of age, income or level of intrinsic capacity. Ageing in place can be further enhanced by creating age-friendly environments that enable mobility and allow them to engage in basic activities. This reinforces the case that solutions to those with chronic diseases lie within but also outside health systems.

From a policy perspective, health systems have to be configured to deal with not one NCD but multiple NCDs to manage them better. The impact of multi-morbidity on an old person’s capacity, health-care utilisation and the costs of care are significantly larger than the summed effects of each. Besides, the reconfigured medical system must be complemented by stronger family ties and social networks. This is not as Utopian as it may seem as examples of such complementarities abound.

This story was originally published by The Hindu, India

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By Vani S. Kulkarni and Raghav Gaiha
PHILADELPHIA AND BOSTON, Nov 10 2015 (IPS)

Few dispute that women’s autonomy and betterment of their lives are moral imperatives. But whether these are also key to economic development is contested.

In an admirably cogent article, Esther Duflo (2013) evaluates a bi-directional relationship between women’s empowerment and development. Although somewhat overemphatic about the role that development alone can play in driving down gender inequality, she highlights that affirmative action has an important role, too. Amartya Sen, in several influential writings, however, has forcefully argued that continuing discrimination against women can hinder development. We are inclined to this view as “masculinity” is unrelated to development.

Dominance and control over women are set in male attributes and behaviour (“masculinity”), regarded as a shared social ideal. Masculinity is characterised by two factors — namely, “relationship control” as a behavioural attribute and “attitudes towards gender equality” as an underlying value. Behavioural changes are, however, slower than changes in male attitudes (UNFPA, 2014).

Women’s empowerment is defined “as improving the ability of women to access the constituents of development—in particular health, education, earning opportunities, rights, and political participation” (Duflo, 2012).

Gender equality and empowerment of all women and girls are enshrined in SDG 5. This is an ambitious goal. The litany of sub-goals is impressive but daunting. These include ending of all forms of discrimination against all women and girls; elimination of all forms of violence against them in the public and private spheres, including trafficking and sexual exploitation; ensuring their full participation in opportunities for leadership in political, economic and social spheres; universal access to sexual and reproductive health and reproductive rights; and equal rights to all economic resources including land.

Duflo argues that gender inequality is often greater among the poor, both within and across countries. Moreover, within countries, gaps between boys and girls persist in poorer and more isolated communities. But economic growth, by reducing poverty and expanding livelihood opportunities, has the potential for reducing gender inequality.

Are girls treated differently than boys? Yes, but only during crises. In India, for example, the excessive mortality rate of girls, relative to boys, spikes during droughts. So, in extreme circumstances, improved access to health services would disproportionately help girls, even if parents do not change their behaviour toward them. This flies in the face of mounting evidence of female foeticide, infanticide and pervasive neglect of girls in education, and wage disparities in some of the more affluent northern states in India. In fact, the selective abortion of female foetuses, usually after a first born girl, has increased over the past few decades, and has contributed to a widening imbalance in the child sex ratio. Cultural taboos prevent women from reporting, for example, gynaecological disorders unless they become acute. So we are far less sanguine about improved access to health services as a by-product of growth –a somewhat dubious proposition in itself – benefiting girls and women disproportionately.

At all level of incomes, women do the majority of housework and care and, correspondingly, spend less time in market work. Constrained in these ways, they are more likely to be engaged in informal but hardly remunerative home-based enterprises. So if economic development frees their time, they are more likely to switch to more productive activities. But this overlooks the imperfections of credit markets that deny them credit for being not creditworthy. Besides, social norms restrict their mobility.

Are labour market outcomes likely to be more favourable? A recent World Bank study (2015) is far from reassuring. It reports that in the workplace, females earn between 20 per cent and 80 per cent lower average wages than do males, depending on the country. Evidence from India’s Labour Bureau is more definitive. The data show that there has been little progress in terms of parity of salaries for men and women for equivalent work. Even more alarming is the fact that, in some spheres of activity in rural areas, the divide has widened. As of 2013, the discrimination in wages paid to women tends to be higher in physically intensive activities (such as ploughing and well-digging), but lower in the case of work such as sowing and harvesting.

So development alone will not accomplish much –indeed, much less than conjectured by Duflo – in empowering women. She doesn’t of course overlook the case for affirmative action to ensure greater participation of women in the political, economic and social spheres. But she remains sceptical of women’s empowerment contributing substantially to development as women are not always the best decision-makers.

Let us consider two examples from her research in which women made a positive contribution to development.

In an earlier but highly influential study (with Chattopadhyay) of Panchayats (village councils) in two Indian states, headed by women elected through quotas, it is demonstrated that these Panchayats invest more in infrastructure that is directly relevant to the expressed development priorities of women. In West Bengal, for example, where women complained more often than men about water and roads, the Panchayats invested more in water and roads. In Rajasthan, where women complained more often about drinking water but less about roads, the councils invested more in water and less in roads. Whether such choices would have been made in the absence of quotas for women heads of Panchayats is highly unlikely. Besides, there may be dynamic gains through changes in male attitudes towards women as decision-makers. Questions, however, remain about complaints by women as a preference revelation mechanism in a rural setting, as also about women Panchayat heads’ autonomy or ability to ignore or circumvent investment allocation priorities handed down from “above”.

In a test of whether income in the hands of women of a household has a different impact on intra-household allocation than income in the hands of the men, she found that pensions received by women in South Africa translated into better nutrition for girls. In contrast, no such effect was found when the pension was received by a man and no corresponding effects were obtained for boys.

Duflo is, however, far from convinced that women generally make the best decisions for development and thus there is a real risk of exaggerating their contribution. The fact that returns on loans given to women to run small enterprises are lower (or even zero) relative to those run by men is not conclusive evidence of women entrepreneurs’ inefficiency. This is a muddled inference for two reasons: as noted by her, women are often compelled to engage in home-based but hardly remunerative enterprises by their family responsibilities and binding time constraint. Relaxation of not just this but other constraints enhances their returns substantially.

A recent World Bank study (2015), as a synthesis of empirical evidence, is illuminating.

Women running subsistence-level firms are prone to external pressures to divest some of the cash from loans or grants to relatives or household expenses.

Evidence shows that women’s demand for saving accounts is high. A review of nine randomized field experiments in countries covering different regions (including Kenya, Philippines, Nepal and Guatemala) shows that savings are a promising way to improve rural women’s productivity. In Western Kenya, for example, women with access to savings accounts invested 45 percent more in their businesses and were less prone to sell business assets during health emergencies.

Capital in-kind (e.g. a physical asset such as livestock) works better than in cash to nudge women to keep the money in the business rather than to divert it for household use or pass it on to relatives.

Many of women’s additional constraints can be overcome by simple, inexpensive adjustments in programme/intervention design.

A two-month grace period versus immediate repayment requirements for poor urban women borrowers in Kolkata, India, significantly raised long-run (three-year) business profits by encouraging risk taking.

Women enjoy greater autonomy if they are able to use mobile money services to conduct financial transactions in private, receive reminders to save and obtain information on prices in real time without having to travel long distances.

Panel household survey data for Bangladesh, covering a twenty-year period, show a beneficial effect, greater for females than for males, of 20-year cumulative microcredit borrowing on household per capita income and the reduction of extreme poverty.

Business skills matter. A vocational training programme in slums in New Delhi imparting skills in tailoring enhanced employment, self- employment and earnings of women but attrition rate was high due to lack of child care support and distance.

In conclusion, the evidence supports the view that economic development and women’s empowerment reinforce each other. If women’s empowerment is a by-product of development, it is just that. That women’s empowerment is a major driver of development is contested but highly plausible.

(End)

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By Vani S. Kulkarni and Raghav Gaiha
PHILADELPHIA AND BOSTON, Oct 7 2015 (IPS)

Mohammad Yunus, the founder of Grameen Bank in Bangladesh, transformed the lives of millions of poor women through unsecured micro loans or micro credit to self-help groups. Microcredit evolved into microfinance that also includes savings and basic forms of insurance and transfer mechanisms. Within a few years, microfinance became a global phenomenon. Although microfinance continues to grow, the enthusiasm for it shows signs of waning.

In recent years, there has been a great deal of scepticism regarding the “miracle” of microfinance. Critics have questioned whether the rhetoric has moved far ahead of the evidence, with some even suggesting that microfinance can spell the death of local economies. Meanwhile, its defenders present robust evidence to substantiate their claims that microfinance delivers enormous benefits. We argue that the miracle is largely intact but needs strengthening.

According to data from MIX, which tracks microfinance institutions (MFIs), there is a solid and growing base of microfinance providers, with a global loan portfolio amounting to US$ 81.5 billion in 2012 with an outreach of 91.4 million low income clients. Women make up 80 per cent of the clients of the world’s largest 34 microlenders. Yet half of the world’s adults still do not have accounts in financial institutions and 76 per cent of the poor are unbanked. When you add all this up, the case for vigorous expansion of financial inclusion in the SDGs is patently obvious.

Recent shift of the focus to financial sustainability raises serious concerns about dilution of the outreach of microfinance [for example, the number (breadth) and socioeconomic level (depth) of the clients served by MFIs.] That the trade-off exists is undeniable but little is known about its extent. It is often emphasised that large-scale outreach to the poor on a long term basis cannot be guaranteed if MFIs are not financially sustainable. Consequently, donors, policy makers, and other financiers of microfinance have shifted from subsidising MFIs towards financial sustainability and efficiency of these institutions.

Analysis of a large cross-section of countries reveals that MFIs providing mainly individual loans are more profitable, but the fraction of poor borrowers and of women in the loan portfolio is lower than in institutions that concentrate on group lending. Moreover, MFIs that provide individual loans increasingly focus on wealthier clients, a phenomenon that is often referred to as “mission drift,” while this is less so for the group-based MFIs. So the importance of institutional design in reducing the trade-off cannot be overlooked. Besides, sustainability is feasible without mission drift by reducing costs and gaining efficiency through innovative use of information and communication technology.

Research has documented that social networks help the diffusion of microfinance. A survey in Guatemala demonstrated that individuals imitate the choices made by other members of the same network – in this case a household’s access to credit was closely related to membership in a church network. In another example, a majority of representatives of financial institutions in India concurred that self-help groups (SHGs) were more likely to be successful in villages with a high density of social networks and associations.

Not only do SHGs benefit from the presence of networks, they themselves also contribute to trust, reciprocity and associational capital (such as through strengthening of local institutions). Moreover, presence of successful SHGs induces quicker formation of other SHGs at a much cheaper cost and the self-reinforcing process gathers momentum over time.

Group lending not only reduces transaction costs of small loans but also ensures high repayment rates. However, group liability may also impose a “cost.”

The incentive for group participants is to reduce the risk taken by their fellow members, since participants do not benefit from the upside of any risky investment, but are liable for the downside. As a result, members of a group may impose excessive risk aversion. Our analysis of selected Asian countries – especially India – offers insights.

Drawing upon Indian evidence, assortative matching into poor and rich groups was reported by about 71 per cent of members of SHGs.

Few believed that the poor were excluded because of high interest rates and/or stringency of financial discipline. However, remoteness of villages, absence of functioning local institutions and lack of awareness of benefits of group lending were identified as major impediments in covering larger segments of the poor – especially by representatives of financial institutions.

A cross-country analysis establishes robustly that gross loan portfolio (GLP) of MFIs benefits not just the poor but also the poorest. In other words, GLP of MFIs is negatively associated with the incidence, depth, and severity of poverty. Hence sustained flows to MFIs may help avert accentuation of poverty as a consequence of the slow and faltering recovery of the global economy.

Much of micro evidence (such as that which is gathered at the household level) on poverty reduction is mixed. A striking case is that of Bangladesh, where the impact in some studies is positive and large, while in others the impact has been insignificant or weak. In Peru, it is the “better-off” rather than the core poor who benefit most from microfinance. By contrast, there is a substantial positive effect on a multi-dimensional welfare indicator in India. In China, while microfinance is welfare enhancing, the main beneficiaries are the non-poor. Experimental evidence for Thailand, the Philippines and India (Hyderabad slums) suggests that the (relatively) affluent benefit more.

An important insight for Bangladesh and elsewhere is that the exit from poverty requires longer-term participation. Household entrepreneurs require time to achieve productive efficiency or to earn higher returns from self-employment activities. Since existing members of microcredit generally obtain larger amounts, MFIs should be encouraged to offer larger loans sooner rather than later.

Before the 2004 Tsunami in Sri Lanka, access to microfinance helped income convergence among the borrowers – a process that was disrupted by this natural disaster. However, microfinance loans after the Tsunami helped in reducing the income gap between those who were hit by it and others who were not. This process of recovery was fast. There is thus strong evidence for the effectiveness of microfinance as a recovery tool.

Women in higher loan cycles of Kashf’s microfinance programme in Pakistan experienced a significant increase in empowerment compared to their counterparts in the first loan cycle. Being in a higher loan cycle affects the ability of a female borrower to decide how to use the loan. Microlending thus leads to higher financial empowerment. Besides, there was social empowerment as mobility restrictions were much fewer among them.

A detailed analysis for India has a much broader focus on women’s empowerment and offers a positive role of microfinance. A large majority of SHG participants themselves reported that they had gained self-confidence, greater respect within the family, a more assertive role in family decision-making, a more important role in children’s health and education and that there was a reduction in domestic violence. In the broader community sphere, however, a considerably lower share of respondents gave a positive response.

But these indices of empowerment do not reveal the “costs.” Higher incomes and a broadening of spheres of activities entailed greater responsibilities for women and extra hours of work. In the absence of reallocation of domestic responsibilities, some of the welfare gains from extra incomes earned were partly offset by longer hours of work.

In conclusion, while the miracle of microfinance has eroded somewhat with financial sustainability overriding social goals, there are ample grounds for optimism about recreating it.

(End)

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By Vani S. Kulkarni and Raghav Gaiha
Philadelphia and Boston, Sep 30 2015 (IPS)

The 17 sustainable development goals (SDGs) and the whopping 169 targets were adopted in the largest ever United Nations Summit, attended by Prime Ministers, Presidents and the Pope, among other luminaries, in New York. These goals encompass world peace, the environment, gender equality, elimination of poverty and hunger and much, much more.

So far, they have evoked mixed reactions ranging from complete dismissal to grudging acceptance and overwhelming euphoria. Much of the scepticism is rooted in the ambitiousness of the SDGs relative to highly varying and, in most cases, limited capacities of developing countries to accomplish them. A comment in The Economist (19 September, 2015) derides them as “higgledy-piggledy, “bloated” and “unwieldy” but acknowledges a shift in development thinking.

While we commend the vision of SDGs for their comprehensiveness, emphasis on their inter-relatedness and inclusiveness, we have drawn upon recent evidence to develop the following key strategic elements in the spirit of enriching the policy debates.

A profound and lasting contribution of the Millennium Development Goals (MDGs) was that they enhanced awareness of the multiple deprivations that afflicted large majorities of the people in many developing countries and policy challenges that confronted the governments, multilaterals and donors.

The SDGs have not just expanded their vision but also enriched it by focusing on sustainability. As Amartya Sen emphasised in the context of universal health care, it is not so much lack of affordability but a failure to recognise the capacity of poor countries (such as Rwanda), and states (such as Kerala in India) to mobilise and utilise resources effectively.

As global poverty fell, so did the gap between rural and urban poverty. Still, more than three-fourths of the extremely poor live in rural areas. It is clear, then, that global poverty remains a rural problem.

Overemphatic endorsement in recent studies of urbanisation as the main strategy for sustainable development neglects agriculture and the rural non-farm economy (RNFE) as key drivers of growth and reduction of inequality and poverty, as a vast majority of rural people still depend on them for their livelihoods.

Structural changes have occurred in both agriculture and the RNFE. Some features of changes in agriculture include its commercialisation, the emergence of high value food chains associated with demographic changes, urbanisation and growing affluence, and growth of agricultural exports.

Some have questioned the importance assigned to smallholder agriculture as a pathway out of poverty. Specifically, they contest the argument of the World Development Report 2008 that stimulating agricultural growth is “vital for stimulating growth in other parts of the economy,” and that smallholders are at the core of this strategy.

Pervasiveness of smallholder participation in high value food chains in different regions – especially in vegetables and fruits, milk and dairy products, and meat – is much higher than generally expected.

But there are barriers, too: lack of access to technology, credit markets, economies of scale in marketing, and ways of meeting stringent food quality standards. Contract farming is an option. Producers’ associations also contribute to overcoming some of these constraints. Central to this is inculcation of entrepreneurial skills among smallholders – especially young men and women – making sure that land, labour, credit and output markets function more efficiently.

While a majority of recent studies are emphatic about low labour productivity in agriculture impeding sustainable agricultural development, it is seldom acknowledged that these are manifestations of “underinvestment” in agriculture and market imperfections (e.g. dominance of local money lenders charging exorbitant interest rates, limited land rental markets, the sharp wedge between farm gate and wholesale prices for smallholders). Size neutrality of new agricultural technology implies an important role for extension services.

As part of the diversification of the rural economy, the RNFE has assumed greater importance in that it comprises a diverse set of activities ranging from pottery to trading and manufacturing with varied returns. Available evidence points to a large “overlap” between smallholders and those engaged in the RNFE using time disposition data. There is also some evidence that more than a small share of those classified as engaged in the RNFE live in rural areas but work in urban areas, raising questions about a sharp rural-urban dichotomy.

Other issues that deserve greater attention include labour tightening and higher wage rates, reduction of vulnerability of agriculture to weather shocks, volatility of prices, and forging of closer linkages with small and secondary towns. Central to expansion of the RNFE is how to make it more attractive for not just those who are engaged in both agriculture and the RNFE but also others who may move out of agriculture in pursuit of more rewarding opportunities elsewhere. Inculcation of managerial skills, more efficient credit and output markets, and improvements in rural infrastructure to enable easier access to output markets could stem the rural-urban migration tide and thereby the rapid growth of slums.

For poverty reduction, some forms of inequality matter more than others. Important ones include inequality in the distribution of assets, especially land, human capital, financial capital and access to public assets such as rural infrastructure. Broadly, a pro-poor agenda should include measures to moderate current income inequality while facilitating access to income-generating assets and the promotion of employment opportunities for the poor.

Much of the cross-country evidence relates to the benefits of financial depth rather than to broad financial inclusion. The Global Financial Development Report 2014 (World Bank, 2014) makes an emphatic case for the latter on the grounds it reflects a growing realization of its potentially transformative power to accelerate development gains through greater access to resources for investing in education, capitalizing on business opportunities, and confronting shocks. Indeed, greater diversification of clientele through financial inclusion is likely to lead to a more resilient and more stable economy.

As more and more economies upgrade to middle-income and institutional quality improves, private capital inflows will become increasingly important. A stable macro-economic environment and incentives for public-private partnerships would promote growth and poverty reduction. Greater transparency of contracts and better enforcement are imperative. Not just national but local institutions matter a great deal in a sustainable rural transformation and poverty reduction.

Institutional responses to risks need to be strengthened by promoting community level institutions; widening and deepening of the reach of financial institutions; and providing social protection to the most vulnerable. When designed well and targeted effectively, these institutions and programmes help poor households build resilience against risks and severe hardships.

Local organizations (e.g water users’ associations, producers’ groups, women’s groups) not only help in equitable use of scarce natural resources in a community but also in facilitating access to credit and other markets.

Indeed, contrary to the deep pessimism, the SDGs reflect a renewed commitment to and optimism about bettering the “nasty, short and brutish lives” of the poor, disadvantaged and vulnerable in the near future.

The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, IPS – Inter Press Service.

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