Malnutrition Not Due to Cash Poverty Alone

By Jomo Kwame Sundaram

KUALA LUMPUR, Malaysia, Mar 26 2025 (IPS) - The World Bank set its US ‘dollar-a-day’ poverty line using its 1990 data. Despite many doubts and criticisms, its poverty numbers fell until the COVID-19 pandemic began in 2020.

Cash measures

The Bank claimed credit for reducing poverty in the three decades before 2020, mainly due to rapid growth in China. But official poverty estimates elsewhere have generally declined more slowly, if at all.

Poverty has long been seen in terms of inequality, as people generally feel poorer compared to others. Meanwhile, explanations of poverty differ considerably, with many calling for better policy measures.

For decades, the Bank refused to address inequality, focusing instead on poverty. Efforts to improve poverty measurement have long been driven by the belief that policy cannot be improved without better estimating it.

Measuring or estimating cash incomes has inevitably been prioritised. But the focus on money incomes poses problems. Money measures of poverty can be helpful but also deceptive. For instance, many children from urban households with incomes above the poverty line remain undernourished.

However, incomes above any arbitrarily set poverty line do not necessarily ensure well-being. This has generated interest in poverty indicators other than money incomes.

Such criticisms reflect a money fetish and the widespread practice of measuring welfare, well-being and poverty in cash terms. Recognising the value of other poverty indicators is now uncontroversial.

Dimensions of poverty

Yet many still want a single composite multidimensional poverty index despite its well-known problems. A dashboard of several key dimensions of poverty, rather than a single composite index, offers much more relevant information to improve policymaking.

Aware of such problems and limitations, OECD and UN Member States have not approved of composite indices. Neither adopted the pioneering work on composite indices by the most influential statistician of both bodies.

Composite indices, such as the human development index, have only been adopted and used by UN funds and programmes, which do not require Member State approval or review.

Meanwhile, lower infant and maternal mortality have accounted for over 80% of improved life expectancy in many developing countries. Low-cost reforms for safer pregnancies and births have significantly extended average life spans at low cost.

Food security

The UN Food and Agriculture Organization (FAO) has long defined food-secure households as those with enough income to afford enough carbohydrates or dietary energy (typically measured in calories or joules) for a sedentary lifestyle.

Despite this low bar and its methodological problems and limitations, undernourished or ‘food-insecure’ households have increased worldwide since 2014, growing for years while the World Bank’s estimate of poor households continued to decline!

According to the Bank, the number of poor worldwide only increased for the first time since the 1990s during the pandemic, both absolutely and relatively. This discrepancy between multilateral poverty and undernourishment trends has triggered debates over the significance of different well-being and deprivation measures.

Various controversies and doubts about Bank poverty numbers have prompted many to regard undernourishment as a better indicator of deprivation and lack of well-being than the poverty measure.

Although income inequality trends are moot and the subject of much dispute and controversy, disparities worldwide have risen again in recent years.

Meanwhile, dollar billionaires have proliferated worldwide as inequality has worsened. As income and wealth inequalities worsen, some convergences have also occurred, causing both trends to be mixed and uneven.

With rural impoverishment spreading worldwide, urbanisation has grown while reducing rural food production for household subsistence consumption. Rural households typically produced food for own consumption by breeding animals, harvesting fruits and vegetables, or even gathering food available nearby.

However, urban areas offer far fewer subsistence production and consumption opportunities. Cash incomes and spending increasingly determine food consumption, including personal nourishment.

Nutrition matters

As man does not live by bread (‘carbs’, i.e., dietary energy from carbohydrates) alone, a more holistic approach requires a more comprehensive approach to human nutrition.

Comparisons of the physical development of children of food producers and cash croppers suggest that household money incomes have not always determined the nutritional status of many.

Food producers’ children are generally better off than those of cash croppers. Why? Probably, food producers are far more likely to provide adequate nourishment to their families regardless of cash incomes.

Thus, children of food producers meet many of their food needs without buying them on the market. Hence, the common presumption that higher cash incomes ensure well-being, including nutrition, is doubtful.

Malnutrition challenges our understanding of well-being and its complex determinants. Many now suffer malnutrition, not only due to both macro and micro-nutrient deprivation but also due to the growing significance of diet-related non-communicable diseases.

As with obesity and overweight, diabetes incidence has risen with new consumer preferences. Incomes, the media, and other influences increasingly shape lifestyles with significant consequences for nutrition and health, many of which are perverse.

Related IPS Articles

• Food Systems Worsen Diets, Health

• Address Malnutrition with Food Insecurity

• Rethink Food Security and Nutrition Following Covid-19 Pandemic

• Address Malnutrition, Not Just Food Security

• Build Healthy, Sustainable Food Systems to Fight Malnutrition

• Tackle ‘Hidden Hunger’ by Improving Food Systems

• Opinion: Better Nutrition for Better Lives

• Progress Against Undernutrition, But Uneven

• The World Sees Progress Against Undernutrition, but it’s Uneven

• Tackle Malnutrition Now

Available online here: Malnutrition Not Due to Cash Poverty Alone

How to Sustainably Finance Universal Health Care

By Mary Suma Cardosa, Chan Chee Khoon, Chee Heng Leng, Jomo Kwame Sundaram

KUALA LUMPUR: To achieve universal health coverage, a country needs a healthcare system that provides equitable access to high quality health care requiring sustainable financing over the long term. Publicly provided healthcare should be on the basis of need, a citizen’s entitlement for all regardless of means.

Health inequalities growing

But recent decades have seen health care trending towards a two-tier system – a perceived higher quality private sector, and lower quality public services. One typical consequence is medical doctors, especially specialists, leaving public service for much more lucrative private practice.

This ‘brain drain’ has led to longer waiting times and complaints of deteriorating public service quality, as more people with means turn to private facilities. As costs in private hospitals are high and increasing, this causes those who can afford private health insurance to turn to it to hedge their bets.

If these trends are not checked, the gap between private and public health sectors in terms of charges and quality will grow, increasing polarisation in access to quality health care between haves and have-nots.

Health care financing

Financing arrangements are key to developing an equitable healthcare system that is financially sustainable in the long run. For universal coverage and equitable access, health financing should be based on social solidarity through cross-subsidisation, with the healthy financing the ill, and the rich subsidising the poor.

Experience the world over shows health markets functioning poorly, both in financing and providing healthcare. Furthermore, heavy reliance on market solutions has contributed to spiralling costs and constrained healthcare access.

Private health insurance

A voluntary private health insurance (PHI) scheme cannot be financially viable in the long term as individuals with lower health risks are less likely to buy insurance from a scheme which they see as primarily benefiting others less healthy.

Since voluntary schemes are usually based on PHI, government support for such schemes would strengthen these companies. There are good reasons to be wary of the growing influence of PHI interests in healthcare financing discussions.

Premiums for PHI are risk-rated, meaning that individuals with pre-existing conditions and higher risks – such as the elderly, or those with family histories of illness – will face un-affordably high premiums or be denied coverage.

‘Moral hazard’ and ‘supplier-induced demand’ in a ‘fee-for-service’ reimbursement system encourage unnecessary investigations and over-treatment, or costly monitoring to limit such abuse. Hence, PHI companies use ‘managed healthcare’ services to contain costs by limiting investigations and treatments.

Voluntary PHI schemes charge high premiums while fee-for-service payments escalate costs which inevitably raise premiums. Thus, the US spends the most on health in the world, but with surprisingly modest health outcomes to show for it.

Much public expenditure is needed to insure the poor, especially those with prior health conditions. Achieving UHC would require costly public subsidisation of such profitable arrangements. This would not be cost-effective, let alone equitable.

Government support for PHI companies would strengthen their growing presence and influence, typically involving transnational insurance conglomerates. PHI companies are likely to try to undermine others threatening their interests.

Social health insurance

Unlike VHI, social health insurance (SHI) is usually mandatory to cover the entire population. Although often proposed and promoted with the best of intentions, the limitations and problems of SHI are also important to consider.

SHI would effectively require collecting an additional ‘payroll tax’ from the public. This could be designed with various distributional consequences, e.g., if flat, it would be regressive. As an additional tax would reduce take-home incomes, SHI schemes have been difficult to introduce.

Like PHI, SHI also has inherent tendencies for over-treatment and cost escalation due to ‘moral hazard’ and ‘supply-induced demand’. These require costly, strong and typically bureaucratic administrative controls.

Surviving SHI schemes owe their ‘success’ to specific reasons, e.g., Germany’s evolved from its long history of union-provided health insurance. But most working people in developing countries are not in formal employment, let alone unionised. Hence, SHI would have difficulty gaining broad acceptance.

In any case, Germany and other countries with successful SHI in the past have been moving to greater revenue funding of healthcare as formal employment and unionisation decline with changing labour arrangements.

With SHI, government revenue would still have to cover the indigent and poor. It is difficult to collect premiums from the self-employed, or the casual and informal workers not on regular payrolls. But universal coverage would not be achieved without including them.

Revenue financed healthcare

Inherited revenue-based healthcare financing is basically sound and should not be replaced due to other healthcare system problems. In most societies, revenue-sourced healthcare financing can be retained, reinforced and improved by:

o increasing government health care allocations.

o reducing ‘leakages’ by eliminating waste, corruption, ‘cronyism’, etc.

o promoting ‘developmental governance’, competitive bidding, etc.

o raising government revenue, especially from more progressive taxation, e.g., wealth, ‘windfall’ and ‘sin’ taxes, especially on activities worsening health risks such as tobacco and sugar consumption.

Revenue financing better

Revenue-financing avoids many administrative costs incurred by PHI and SHI. It has no need for an elaborate parallel system, costly mechanisms and more staff to register, track and pay SHI contributors and beneficiaries, and to deter selfish opportunistic behaviour.

Compared to PHI, SHI seems like a step forward for countries with weak or non-existent public healthcare systems. But moving from revenue-financing to SHI would be a step backwards in terms of both equity and cost-effectiveness.

SHI requires additional layers of health care system administration – to enrol, collect, ascertain coverage, determine benefits and make payments – which incurs unnecessary costs compared to revenue-financing.

Hence, such insurance systems involve much more per capita health spending, raising it by 3-4%. Despite being much more costly than revenue financed systems, they do not have better health outcomes.

As SHI effectively imposes a payroll tax, it discourages employers from hiring employees with ‘proper’ labour contracts. Hence, SHI was estimated to reduce formal contracts by 8-10% and total employment by 5-6% in rich countries.

International evidence clearly shows progressive tax-funded public health systems are more equitable, cost-effective and beneficial than SHI. Public health programmes needing popular participation, e.g., breast or cervical cancer screening, have worse outcomes with SHI compared to revenue-financing.

This can be best achieved by improving or developing a revenue-funded healthcare system, with additional resources deployed to expand and enhance primary health care, and better service conditions for medical personnel.

Strengthening public healthcare services can do much, not only to improve staff work conditions, but also morale and pride in their work.

Mary Suma CARDOSA is a medical doctor specializing in pain management and past President of the Malaysian Medical Association. CHAN Chee Khoon, ScD, is a health systems and health policy analyst with postgraduate training in epidemiology. CHEE Heng Leng, PhD, is an academic researcher working in the area of health and health care policy. All are members of the Citizens Health Initiative.

Covid-19 Cannot Be Defeated by a Divided World

Jomo Kwame Sundaram, Anis Chowdhury SYDNEY and KUALA LUMPUR, Jul 16 (IPS)  - Announcing an independent evaluation of the global Covid-19 response on 9th July, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus asked why it has been "difficult for humans to unite and fight a common enemy that is killing people indiscriminately?". He warned: "The greatest threat we face now is not the virus itself. Rather, it is the lack of leadership and solidarity at the global and national levels… we cannot defeat this pandemic as a divided world", highlighting inter-governmental conflicts over the pandemic and its containment. 

Solidarity desperately needed With more than 600,000 acknowledged deaths, almost 13 million are believed to have been infected by Covid-19 in mid-July. In less than half a year, every country had been affected by the pandemic, designated by the WHO as a "public health emergency of international concern" (PHEIC) on 30th January. Richard Horton, editor of the prestigious Lancet medical journal, has urged the United Nations to convene an emergency special session of the UN General Assembly (UNGA) to make "appropriate recommendations to Members for collective measures".  A "meeting under the auspices of the UN is the only means available to construct a global response to this pandemic". Wondering "why such a global gathering has not yet taken place", he pleaded, "It must take place. And soon".  Covid-19 has been devastating, not only because of its heavy toll on human life, but also because of its adverse impacts on livelihoods, especially for much of the ‘precariat', particularly in the most vulnerable developing countries.  The pandemic's indirect impacts are not well understood as national health systems, already undermined by years of under-investment and creeping privatization, struggle to cope.  Other preventable deaths are rising as less people get medical attention due to loss of livelihoods and health coverage. The Global Fund to Fight AIDS, Tuberculosis and Malaria has estimated an additional 1·44 million deaths from the three killer diseases.  Horton warns, "Global health has entered a period of rapid reversal...Yet no plan is in place, or even being proposed, to address this global regression in human health". For him, "this pandemic deserves historically unrivalled global political leadership. And yet all we have is silence". He asks, "How have we fallen so low?".  WHO "left out to dry" Helen Clark, former New Zealand Prime Minister and co-chair of the independent review, lamented that the WHO has been undermined by lack of support from the United Nations Security Council (UNSC) and the G20, observing, "toxic geopolitics have stopped it doing anything useful at all". On 7th July, the United States gave the required one year's notice to the UN that it would withdraw from the WHO. With the world's largest economy, US withdrawal will greatly weaken WHO finances when it is needed more than ever. The US has not provided meaningful world leadership in recent years, but has instead increasingly undermined the multilateral order it was the primary architect of. Yet, the current campaign against the WHO is unprecedented, and is widely believed to be connected to political, economic and diplomatic mobilization to check China's rise.  In the current context, US withdrawal is expected to greatly undermine multilateral cooperation more broadly. sides endangering the lives and health of billions worldwide, it will undermine multilateralism more generally, not only in the UN system, but even at the World Trade Organization (WTO). WHO could have done better Undoubtedly, the WHO's role in the pandemic could have been better, although how so depends on one's perspective. Despite resource constraints and member-imposed regulations and protocols, it has done well, designating the outbreak a ‘public health emergency of international concern' (PHEIC) on 30th January.  Then, there were only 7,818 confirmed cases of human-to-human transmission, mostly in China, and 82 cases in 18 countries outside China. The WHO advised all countries to "be ready to contain any introduction of the virus and its spread through active surveillance, early detection, isolation and case management, contact tracing, and prevention".  Yet, mistakes were undoubtedly made, e.g., discouraging the use of face masks, ostensibly to ensure adequate protective personal equipment for medical personnel and other ‘frontline workers'.  But there is no conclusive evidence, except for uncorroborated claims by the anti-China Japanese and Taiwanese authorities, greatly amplified by the media in India, Australia and the US, of the WHO being controlled by and biased towards China. Refusing to prepare The first WHO fact-finding mission to China emphasized the success of prompt, early precautionary measures, including testing, tracing, isolation and treatment. Contagion could still have been contained by adopting WHO recommended measures. Yet, except for a handful of East Asian countries and Kerala state, in southwest India, much of the rest of the world, including most who could afford more adequate precautionary measures, did little to contain the contagion until they had little choice but to impose ‘stay in shelter' lockdown measures.  When the WHO declared Covid-19 a "pandemic" on 11th March, there were over 118,000 confirmed cases and 4,291 deaths in 114 countries, with more than 90% of cases in four countries: China, Iran, Italy and South Korea.  By then, new infections were already declining rapidly in China and South Korea, while 81 countries reported no cases, and 57 had ten cases or less. Yet, inaction persisted, even justified in terms of developing ‘herd immunity'. To be sure, many rich countries had been weakening the WHO for decades before the Covid-19 pandemic. Reliable long-term mandatory funding had fallen from 62% of its budget in 1970-71 to 18% in 2017.  As Stewart Patrick noted, "much of the blame can be laid at the feet of member states, which have saddled the WHO with an ever-expanding mission set reflecting their individual priorities, while providing it with a modest operating budget… smaller than that of some big city U.S. hospitals.  "Compounding these difficulties, national governments have repeatedly proved resistant to accepting WHO guidance or fulfilling their international legal obligations during declared public health emergencies".  Security Council must act  In 2014, the UNSC responded promptly to the Ebola crisis, declaring the virus a threat to peace and security, thus ‘legally obliging' Member States to do whatever they can to check the threat.  Despite its much greater morbidity and mortality impacts worldwide, the UNSC took half a year to back the UN Secretary-General's global ceasefire appeal following the Covid-19 outbreak.  Covid-19 is arguably the greatest threat to peace and security since the Second World War. Now that the UNSC is finally acting, only seven of the 15-member Council can convene UN Member States for an emergency UNGA special session to do the right thing.

Also available online here: http://www.ipsnews.net/2020/07/covid-19-cannot-defeated-divided-world/