By Jomo Kwame Sundaram
KUALA LUMPUR, Malaysia, Jun 26 2024 – Comparative research on healthcare financing options shows revenue-financed healthcare to be the most cost-effective, efficient, and equitable, while all health insurance imposes avoidable additional costs.

Jomo Kwame Sundaram

Private health insurance
Rejecting the private health insurance option is easy due to well-known US problems. Risk pooling is limited as private insurance only covers those who can afford it.

The resulting ‘moral hazard’ and ‘cherry-picking’ problems reflect the public’s weak bargaining power vis-à-vis healthcare providers and insurance companies.

US health spending per capita is the highest, partly due to additional private health insurance costs. The share of US national income spent on healthcare has risen to 18%!

Such avoidable insurance management costs are quite high, averaging almost 4% more. Consequently, upward cost pressures remain intense.

Yet, despite spending so much, it only ranks 40th in average life expectancy worldwide. Its other health indicators also leave much to be desired.

Hence, greater spending does not necessarily improve health outcomes, and spending more on insurance does not improve health either.

Revenue financing
Hence, the main healthcare financing choices are social health insurance (SHI) and revenue financing, which enables risk pooling for entire national populations.

After reviewing extensive evidence, the World Bank’s Adam Wagstaff found revenue financing much more cost-effective, efficient, and less expensive than insurance options.

Germany, the only major OECD country heavily reliant on SHI, is second only to the US in health spending per capita, largely due to insurance administration costs.

With insurance premium revenue increasingly inadequate, the government finances the ever-growing funding gap. Rather than being a healthcare financing option for the future, it should be recognised as an atavism, even for highly unionised Germany.

Social health insurance
SHI advocates insist it is needed owing to inadequate fiscal means. But budget shortfalls imply a lack of political will. SHI’s claims to raise more money are grossly exaggerated.

SHI premiums are effectively flat or pro rata taxes, making overall tax incidence more regressive. SHI financing is inadequate everywhere and under growing stress due to ageing societies.

Most governments claim to be committed to inclusion and equitable access, but SHI would undermine declared national commitments to the WHO’s ‘healthcare for all’ and the UN SDGs’ ‘universal healthcare’.

Besides betraying these commitments, SHI cannot ensure the needed funding or financial sustainability. Any realistic government should recognise SHI will be politically unpopular.

SHI’s costs and dangers, including the perverse incentives involved, are rarely acknowledged. Employers have minimised their SHI liabilities by casualising labour contracts. Rather than employ workers directly, they hire indirectly, using various contract labour arrangements.

Priorities?
The typical emphasis on curative health services has also worsened health outcomes by neglecting vital public health programmes. By emphasising curative services, many causes of ill health do not get sufficient attention.

Many preventive and public health problems remain neglected and underfunded. Most governments must spend more on prevention, especially to address largely preventable non-communicable diseases (NCDs).

The world needs far better healthcare financing. Various complementary reforms are also required. Instead, poorly sequenced, ill-considered reforms have been the norm in recent decades.

The resulting ‘non-system’ offers poor, weak and ineffective incentives for public and preventive health provision. Meanwhile, potentially lucrative segments have been privatised or contracted out, often to incompetent political cronies.

The UK NHS capitation system successfully transformed doctors’ incentives. Instead of prioritising patient payments, UK doctors are incentivised to ensure the well-being of those under their care.

Recognise market failure
Former UK Conservative Party adviser and “non-interventionist market economist” Professor Geoffrey Williams rejects “any [government] intervention … in almost every area of economic activity, but not in health, because health is quintessentially the place where markets fail.

“That is why we use health more often than any other example when we teach about market failure, particularly insurance market failure. We know the health market fails and that we cannot find market solutions to those market failures as we might in other forms of market failure.

“We know that government tax funding is the only real way of providing universal healthcare.” Neither universal healthcare nor health for all can be achieved without adequate revenue financing, even if termed insurance.

Improving healthcare
Malaysia has low infant and maternal mortality rates and improved life expectancy thanks to simple, low-cost reforms introduced from the 1960s, especially training village midwives to help mothers and babies.

Lowering such mortality is responsible for over four-fifths of increased Malaysian life expectancy over the decades. Now, much more should be done to improve babies’ and mothers’ nutrition for the ‘first thousand days’ from conception to age two.

A ‘hybrid system’ would not work, as it would only provide some public financing to address egregious ‘market failures’. Targeting would be worse, both costly and involving both inclusion and exclusion errors.

With political will, revenue financing is sustainable despite rising costs. We should renew our commitment to public healthcare, not as it has become, but as it should be.

IPS UN Bureau

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By Manipadma Jena
SHILLONG & BHUBANESWAR, India, Jun 25 2024 – As the school lunch bell goes off, 40 eager little bodies—41 if you count the school dog—burst out onto the veranda. Awaiting them are a stack of steel platters, into which will be ladled a nutritious and delicious lunch, all of it indigenous cuisine.

Earlier in this Lower Primary school in Meghalaya’s East Khasi Hills, in India’s north-east, the government-funded school meals aimed at reducing child malnutrition served only rice, potato and yellow lentils. In a Himalayan foothill region rich in biodiversity, with food systems based on locally grown and foraged edibles, the indigenous communities’ healthy food is again being recognized and entering school meals.

Indigenous food systems, adapted over years to food crises including droughts, extreme cold and snow, persevered even in the face of decades of onslaught from commercialized government-backed monostaples—rice and wheat. These indigenous biodiversity warriors held on to their food systems through their unique and extremely localized culinary skills.

Tribal women sell their completely naturally grown grains, lentils and beans in a weekly town market in Koraput, Odisha’s tribal heartland in the Eastern Ghats. Food grown by indigenous people have the lowest carbon footprint. Credit: Manipadma Jena/IPS

Many of the tribal food and forest products have medicinal values and tribal women were wise in this knowledge. Today, many of these are being packaged into ‘nutraceuticals’ combining nutrients and pharmaceuticals as preventives for general and lifestyle health issues. Just one example of many is Moringa leaves (Moringa oleifera), now packaged and sold in powder and tablet form. It contains minerals, Vitamin A, B⁶ and plenty of iron, which is why pregnant women have been asked for years to include Moringa in their diet.

The biggest recognition of their five decades-long endeavor since India’s Green Revolution comes with the United Nations declaring 2023 as the International Year of Millets following a proposal by India, supported by over 70 countries, to raise awareness about millets’ multiple benefits, from nutrition and health to environmental sustainability.

For perspective, starting in the 1960s, the Green Revolution transformed food systems, greatly expanding monocropping and the overall production of wheat and rice in Asia and elsewhere, replacing millets and other crops in many areas.

Now, the Indian government for its part, has included millets in the public food assistance scheme for the economically weaker sections, which reaches millions of poorer families. Given India’s growing lifestyle diseases and that it’s now known as the diabetes capital of the world, some of the upper classes in India are rapidly transitioning towards millets and other foods with medicinal properties. 

Further, Geographical Indication (GI) tags—an official recognition of a unique product of food, art or craft originating in a specific location—are being awarded in larger numbers by the government. Several food preparations and grains that women of tribal communities have been preserving over generations are being awarded this certification, bringing sustainability and continuity to the GI products by opening up markets and offering trade-related protection under intellectual property rights.

The latest in the list in January 2024 is eastern state Odisha’s chutney made from red weaver ants, a semi-solid paste known in the region for its medicinal and nutritional properties, harvested sustainably and eaten by certain tribal communities.

Preserved by Women Over Centuries, Now Promoted by Government and Non-Profits

“There has been a distinct trend of the government’s attitude becoming more positive towards promoting indigenous foods in the last two to three years,” Bhogtoram Mawroh, a key research official of the Meghalaya-based non-profit North East Society for Agroecology Support (NESFAS), told Inter Press Service.

“Indigenous edibles, local and in-season, are being revived in school meals that had gone out of the children’s platter at home in the last few years. They include nutritious and medicinal cultivated and foraged greens and herbs like Jatira (water celery), Jamyrdoh (fish mint), Jali (wild leafy vegetable), Khliang syiar (herb Centella asiatica), Shriewkai, Jalynniar and Ja Miaw (wild leafy vegetables),” Mawroh elaborates. “The best development is that mothers too are cooking them at home now,” he added.

School students in Meghalaya’s East Khasi Hills enjoy the school meal, which now contains healthier and tastier preparations from a local basket of grown and foraged ethnic ingredients. Credit: Manipadma Jena/NESFAS

NESFAS, which is piloting the indigenous school meal in 11 schools with 414 students from seven villages, aims to increase the coverage to 500 schools. While government school meal funding is utilized, Rome-based The Indigenous Partnership for Agrobiodiversity and Food Sovereignty (TIP) is a major partner.

“Though still being consumed, this vegetable usage has gone down in recent years, especially among the younger generations.  Innovation, in preparation to attract youth back to their ancient foods, is a major component of the revival,” said Mawroh.

Here too, it’s women’s knowledge systems that spearhead innovation. While school cooks are being trained, it’s the Biodiversity Management Committees that play a pivotal role. One of the few matrilineal societies that persists, the women elders in the Khasi community that mainly form these communities are repositories of traditional knowledge on hyper-local biodiversity. They have been gathering food from forests for generations and have knowledge of location, seasonality and properties. They advise what can be included in school lunch menus in each season.

Recognizing this, the biodiversity agency of the state government, along with local and international non-profits, has lately formed 71 Biodiversity Management Committees in rural Meghalaya to formally document in ‘People’s Biodiversity Registers’ all the knowledge of local biodiversity, especially focusing on species that are close to extinction.

Indigenous Food Entrepreneurs: Cafes Run by Women

Yet today, some indigenous women are boldly investing in their food systems at a higher level. They have become indigenous food entrepreneurs, opening exclusively tribal cafés serving centuries-old authentic cuisines, with some experimental recipes aimed at attracting popular taste.

Pioneering ethnic food entrepreneurship in India, Aruna Tirkey has proved indigenous food can be popular and cannot be sidelined as it has been in the last decades. Courtesy: Aruna Tirkey

Aruna Tirkey is one of them. Troubled by ethnic food being sidelined, and with it her community’s identity, customs and culture, she decided eight years ago to revive those, whatever the challenges or financial costs.

From the Oraon tribe in India’s Jharkhand State, Tirkey, a development professional in her 40s, told IPS she started out with just 500 rupees (USD 6), selling millet-based stuffed dumplings on a mobile trolley.

Soon after, Tirkey decided to set up her restaurant in Jharkhand’s capital city, Ranchi, serving exclusively Oraon food preparations. Named ‘Ajam Emba’ translating to ‘great taste’ in Oraon’s spoken dialect, she took the bold step with deep faith and hope that it would resonate with food connoisseurs.

It did. From an income of a few thousand rupees, earnings are currently touching 50 lakh rupees (about USD 59,932) a year.

“Over the last two to three years, Ajam Emba’s sales have shot up because, post-Covid, more people are now conscious about healthy food choices,” Tirkey told IPS. “Our food catering business for marriages, personal and office parties aside from restaurant sales is booming.”

Currently operating from a rented place, Tirkey has poured in all her savings into building her own establishment, supplemented by bank loans. “Once the building is complete with authentic Oraon décor, my earnings will grow four times more. Such is the demand now for the novelty that tribal cuisine offers,” Tirkey said.

“I am the head chef and will keep on experimenting and researching new recipes and best mix of ingredient.”

It is for this reason that her clientele includes a large number of Oraon people themselves who have moved away from home for jobs. In Ajam Emba, they come to rediscover their childhood tastes. Foreign tourists, too, come to get a slice of a unique cuisine known for its minimal carbon footprint.

Tirkey trains and provides employment to her community women as cooks, helpers and waiters. Hundreds of farmers and foragers have benefited from providing ingredient to Ajam Emba’s kitchen.

Dial Muktieh poses proudly beside her Mother Earth Café, which is now a commercial success and preserves Meghalaya’s biodiversity while contributing to her village’s economy. Courtesy: NESFAS

Dial Muktieh, 44, is busy slicing fresh bamboo shoots to be sautéed with smoked beef and served alongside wild edibles’ green salad of jamyrdoh, leaves of garlic chive, perilla, lemon, salt and tomato, with roselle juice to wash it all down. In her Mei-Ramew Café or Mother Earth Café, in Khweng village in the hills of Meghalaya’s Ri-Bhoi district, it’s the youth mostly who come asking for this piping hot dish, which is giving a good run for money to modern junk foods. Also popular are indigenous preparations of dry fish chutney, fried small local fish, fried silk worms and tapioca cake.

Along with Muktieh, who learned traditional cooking and ingredients from her grandmother, Plantina Kharmujai’s and one more Mother Earth Café are centres of hyperlocal ethnic food revival in Meghalaya.

Popular and with more cafés in the pipeline, they are “more entrenched into the local economy, with profitability rising” within four to five years of establishment.

Revitalization and promotion of ethnic cuisines can contribute to healthier, more sustainable and more equitable food systems, well aligned with the objectives of sustainable food systems at the United Nations, say several studies from the International Centre for Integrated Mountain Development (ICIMOD). Ethnic cuisines are also closely linked to sustainable management of agrobiodiversity and agroecosystems. Awareness can help transform the way the world produces, consumes, and thinks about food.

Checkmate: The Vagaries of Climate Change 

Across the Himalayas, as weather patterns become unpredictable, farmers are finding their regenerated traditional crops, food preservation systems and wild edibles to be more resistant to the vagaries of nature.

“Food from forests—many regenerative tuber foods, mushrooms, and greens—are fortunately still available here and have not gone extinct as several species already have in high-altitude regions,” Amba Jamir told IPS from Nagaland, another north-eastern Himalayan foot-hill state. “Now communities plan to take stronger conservation measures and popularize food choices that are sustainable for the planet,” added Jamir, an environment policy and development advisor specializing in upland resource management in the eastern Himalayas.

Food diversity, where it still thrives, means that varied ecosystems—both natural and farmed food sources—are still managed and maintained.

The women elders of Odisha’s Dongria Kondh community embark on a journey to distant hill villages of their clan to collect drought-resistant millet seeds that are on the verge of perishing. Credit: Manipadma Jena/IPS

There is no better instance of this than the practices of the ancient Dongria Kondh tribal community high in India’s Eastern Ghats range of mountains.

In the hill hamlets of Rayagada district in eastern India’s Odisha state, community women elders claim that even ten years ago, their staple crop, millet, had 10 existing varieties, down from 45 varieties that were locally farmed almost 70 to 80 years ago.

In a particularly severe drought year, when they found they were left with just two available varieties, they began their endeavor to revive the lost heirloom strains.

The women, traditionally responsible for keeping the community’s seeds safe, have gotten into urgent mission mode, traveling arduously by foot to remote forest villages after gaining prior information that one or two farmers are still preserving a millet variety the others have abandoned. Millets have very high seed viability, because of which they can be stored for five to six years in case of drought, said agrobiodiversity experts.

Lost for nearly five decades, they rescued the Kodo millet, which is high in fiber and energy content and ideal for diabetics; two varieties of sorghum; and a Foxtail millet. And they are keeping up the search for their lost heirloom seeds.

“In a world where food security is increasingly uncertain in some parts of the world, these foods (millets) could be a game changer,” says Bill Gates in his blog GateNotes. “Could a grain older than the wheel be the future of food?”

Asia is home to 55 percent of the people in the world affected by hunger. More than 400 million people face continuing threats to food security, according to a recent 2024 study by  International Food Policy Research Institute (IFPRI), one of the 15 research centres of the World Bank and the Government-funded Consultative Group on International Agricultural Research (CGIAR).

Millets’ share in cropped area. Credit: FAOSTAT

According to the IFPRI study, Asia has the potential to significantly expand production of millets and thus help to sustainably meet growing food demand in the region and globally. As of 2022 (the latest figure available), Asian millet production was approximately 15.6 million metric tons (MT), compared to 699 million MT for rice and 343 million MT for wheat. In major producers China, India and Nepal, area harvested and production for millet is much lower than that for rice and wheat. Thus, there is clearly room to grow.”

IPS UN Bureau Report

This feature is published with the support of Open Society Foundations.

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