Hanging In, Stepping up and Stepping Out: Livelihood Aspirations and Strategies of the Poor Development in Practice

In recent years understanding of poverty and of ways in which people escape from or fall into poverty has become more holistic. This should improve the capabilities of policy analysts and others working to reduce poverty, but it also makes analysis more complex. This paper describes a simple schema which integrates multidimensional, multilevel and dynamic understandings of poverty, of poor people’s livelihoods, and of changing roles of agricultural systems. The paper suggests three broad types of strategy pursued by poor people: ‘hanging in’; ‘stepping up’; and ‘stepping out’. This simple schema explicitly recognises the dynamic aspirations of poor people; diversity among them; and livelihood diversification. It also brings together aspirations of poor people with wider sectoral, inter-sectoral and macro-economic questions about policies necessary for realisation of those aspirations

Improvement in Crop Production in Ghana: Is it due to Area Expansion or Increased Productivity?

Agriculture continues to be the mainstay of the economy of Ghana contributing more than a third of the country’s Gross Domestic Product. As such, successive governments in Ghana and their development partners continue to formulate and implement policies, programmes and projects in the sector in order to spur productivity. As a result, some improvements in agricultural production in the country have been recorded in recent years. This paper examines whether or not these improvements are due to expansion in cultivated land area or increased productivity. Time series data covering the period between 1999 and 2009 from Ghana’s Ministry of Food and Agriculture were used for the study. Two main estimations were carried out. The first was a set of estimations of the growth rates of output, area cultivated, and productivity of selected staple crops produced and consumed across the country. The second was an estimation of the relationship between area under cultivation and output of the selected staple crops. The results revealed that improvements in the production of most staple crops in Ghana in recent years are largely due to area expansion rather than improvements in productivity. The results further showed that though output is generally increasing, productivity is decreasing. The conclusion is that improvements in agricultural production, particularly staple crops recorded in Ghana in recent times are due to area expansion rather than productivity increases. This has negative implications for the country’s drive towards self-sufficiency in food production and the attainment of the Millennium Development Goals. It is recommended that policy interventions that aim at improving agricultural production in the country should focus on enhancing productivity rather than area expansion. Key Words: Agriculture, Ghana, Growth Rates, Staple Crops, Productivit

Evaluation of the 2012/13 Farm Input Subsidy Programme, Malawi: Final Report

This report evaluates the 2012/13 Malawi Government Farm Input Subsidy Programme (FISP). The main objective of the evaluation is to assess the impact and implementation of the FISP in order to provide information regarding • the overall value for money of investments in the FISP as regards its contributions to agricultural production, food security, farmers’ and consumers’ welfare • means by which future implementation of the FISP might be changed in order to improve its effectiveness and efficiency We consider in turn the two main questions that the report addresses, beginning with the overall contributions and value for money from the FISP. The FISP medium term plans sets out the objectives of the FISP as being to ‘increase food security at household level through agricultural output growth’ by increasing agricultural productivity and input market development. However economic theory and experience from other countries suggests that if implemented consistently, effectively and efficiently at a manageable cost the programme has the potential to drive broad based national economic growth and diversification by raising the productivity of the agricultural land and labour held by the large rural population, lowering food prices, raising real wages, and stimulating non-agricultural demand and supply. This depends upon the ability of the programme to cost effectively increase seed and fertiliser input use in maize production, drive up maize productivity and improve input supply services (the direct impacts of the programme) with the support of complementary policies that support low maize prices, rising real wages and rural diversification (the indirect impacts of the programme). Increases in production and maize productivity as a result of the programme are difficult to assess. Bringing together evidence from a wide range of sources, section 7 of the report suggests that the programme led to increased production of around 723,000MT of maize and 32,000MT of legumes. Malawi’s rapidly growing population means that the programme’s incremental production benefits are increasingly important for Malawi’s national food security. These benefits are however undermined by likely informal exports (despite an export ban) encouraged by pressures from the relatively low dollar denominated maize prices in Malawi following the major devaluation of the Kwacha. The programme also led to increased profitability of maize production by beneficiary households and increased rural incomes by between MK50,000 and MK70,000per household receiving and using a full pack of fertiliser and maize seed (ignoring spillover effects and benefits from receipt of fertiliser that does not contribute to incremental production).For many poorer beneficiaries, who receive only one coupon for 50 kg of fertiliser, it seems that benefits are only sufficient to reduce their food insecurity, and are not enough to enable them to advance their livelihoods – to ‘step out’ or ‘step up’ rather than just ‘hang in’. Addressing this in the context of both limited fiscal resources and rapidly growing population pressure is a major challenge facing the programme and the Government and country as a whole. There is, however, evidence that the FISP is encouraging some diversification out of maize into increased legume production. Assessment of the potential wider indirect impacts of the programme (addressed in section 8) requires comparison of situations with and without the subsidy. A Local Economy Wide Impact Evaluation (LEWIE) model, a novel form of CGE modelling, investigating this suggests that there are significant spillover local growth effects from the subsidy as a result of both its injection of cash into the economy and of the increase in real incomes caused by its raising land and labour productivity. However real wage rates fell during 2012/13 as a result of rising maize prices, which, as mentioned above, have been affected by the devaluation of the Malawi Kwacha and consequent export and inflationary pressures. It is not possible to estimate possible effects of FISP in reducing the extent of the fall in wages. These wider influences on maize prices pose a major challenge to the welfare of poor Malawians and to the Malawian economy, with or without the FISP. Policies that address this and promote low and stable domestic maize prices are essential for FISP to deliver improved food security and the wider growth benefits outlined above – and some specific options are suggested. The overall benefit cost ratio (BCR) for the FISP is estimated at 1.7taking account of only direct impacts, and at1.8if wider indirect impacts are also included. Fiscal efficiency (the ratio of net economic benefits to government expenditure) is estimated at 0.75for direct impacts and 1.04 including indirect impacts. Analysis of national food security scenarios with and without the FISP suggests that in the last 6 years it may have led to average annual savings of maize imports of some 385,000MT, directly offsetting up to between 85 and 110% of programme costs. Benefit cost ratio estimates are however sensitive to some of the parameters used in their calculation, notably maize prices, incremental maize productivity, and fertiliser costs. The Fiscal Efficiency of the programme and its overall cost are also affected by likely high rates of input leakage and of displacement of unsubsidised farmer purchases by subsidised inputs, and by the subsidy rate and low farmer contributions. The importance of low and stable maize prices for programme benefits has been discussed above. More attention to these issues in the implementation of the programme could lead to substantial increases in the effectiveness and efficiency of the programme with increased benefits and/or reduced costs. Analysis of determinants of maize productivity shows that yields are generally increased by early planting, early and good weeding, use of hybrid seed, use of inorganic nitrogenous fertiliser and of phosphate where soils are phosphate deficient, and use of organic fertilisers. Returns to use of inorganic fertiliser are also increased by use of hybrid seed, use of organic fertiliser, and higher plant density. Gains from using subsidised inorganic fertiliser and hybrid seed may also be substantially reduced if use of subsidised inputs leads to delays in planting. These observations, which are widely known, underpin many aspects of the design and implementation of the FISP, for example the increasing provision of hybrid and legume seeds in the subsidy package, the intention to provide coupons and inputs early in the season (with priority given to the south, then centre then north), and the inclusion of both nitrogenous and compound fertilisers. Analysis of the implementation of the programme in section 4 and of the timing of receipt of coupons by households in section 6 shows that a number of reasons (some of them beyond the immediate control of programme management) have led to late access to coupons and inputs – and this tends to raise costs and increase displacement as well as reduce yields. Incremental production is also affected by displacement rates and by leakages of inputs through theft and corruption. Programme costs have been held in check from 2009/10 with much better physical control of quantities of subsidised fertilisers. As noted in section 4, there are opportunities for reducing fertiliser procurement costs (and improving timeliness of delivery) through modified tender and payment procedures. Programme costs could also be reduced by increasing farmer contributions as a proportion of input costs, and there is a difficult balance here between on the one hand supporting those who can least afford inputs and benefit most from a high rate of subsidy, and on the other hand reducing overall programme costs. A third way of reducing programme costs and/or increasing benefits is to reduce displacement and leakage, with improved security of coupons (where there has been substantial improvements in 2011/12 and 2012/13); better transport tendering and monitoring procedures (the latter building on approaches trialled with ESOKO in 2012/13); more timely input delivery, market opening and coupon distribution; and better targeting of inputs to poorer farmers unable to afford unsubsidised inputs. Increased farmer contributions may also decrease the incentives for theft, corruption and leakage. Determination of more precise numbers of farm families and (building on useful innovations in 2012/13) greater farmer access to and understanding of publicly available beneficiary lists could also improve targeting outcomes and accountability and control of coupons. Greater use of use of such systems will, however, have to take account of the support for and benefits from the widespread ‘sharing’ of coupons in the Central and Southern Regions. Increasing attention to matters of accountability, access to coupons, and conditions at markets are to be welcomed and will no doubt be built on as more information becomes available on their strengths and weaknesses. Despite its high cost, the FISP is making a positive set of contributions to the welfare of Malawians, and this represents a considerable achievement by all those involved in its resourcing, design and implementation in challenging conditions. These contributions are however threatened by macroeconomic pressures; by high and increasing population pressure in rural areas; by the high visibility of instances of late implementation, corruption and theft; by evidence of poor targeting; and by political and economic pressures. These contributions and these pressures call for renewed efforts to both work for and demonstrate improved efficiency and effectiveness and increased benefits and probity of the programme. In order to facilitate wider and better informed debate around the FISP, this report will be supplemented by two short policy briefing papers summarising key issues raised regarding FISP implementation and impacts. The value of this report is, however, that it brings together in one place a comprehensive review of the programme. Readers are advised to refer to those sections that are of direct interest and not be put off by the size of the report as a whole. The ‘summary and conclusions’ section at the end of the report contains a longer and more detailed summary of the report

Specialists or Specialising Generalists A Grounded Theory of the Role of the Clinical Pharmacist in Neuroscience

Neuroscience is a relatively small and emerging clinical pharmacy specialism focusing on drug therapy for neurological disease. Against a professional momentum for specialist practice within pharmacy, there is paucity both of relevant research, and a clearly defined role for specialist pharmacy practice in neuroscience. A qualitative research study was undertaken, using constructivist grounded theory method, to explore how hospital based pharmacists practicing in neuroscience define and develop their role and specialism. Data were concurrently generated and analysed, through verbatim transcription of telephone interviews with fourteen pharmacists. Data analysis resulted in the identification of three processes: (1) Acquiring and utilising knowledge in practice; (2) Gatekeeping access to drug therapies; (3) Integrating into the neuroscience service. The key findings within each process are: (1) Pharmacists utilise different forms of knowledge and there can be barriers to gaining knowledge. Pharmacists identify strengths in their breadth of clinical knowledge and holistic consideration of patients’ drug therapy. (2) Pharmacists act as barriers to drug therapy but also act to expedite and secure access to drug therapy. (3) Pharmacists act as an organisational nexus between pharmacy and neuroscience services and identify the importance in practice of forming working relationships within neuroscience services, underpinned by trust. The study identified a basic social process: Maintaining an overview of drug therapy for patients with neurological disease. This process conceptualises the tensions experienced by the pharmacists between their role as near-patient facing clinical specialists, but also as pharmacist generalists. The study findings have implications for supporting pharmacy practice in neuroscience

Reasons for Failure of Prevention of Mother-To-Child HIV Transmission in a Rural South African District Hospital

Further reduction of mother-to-child transmission (MTCT) of HIV requires improved understanding of the reasons for MTCT. We reviewed maternal and infant case notes for HIV positive infants diagnosed by polymerase chain reaction at Bethesda Hospital. Nineteen cases were analysed. Median gestation at first antenatal consultation (ANC) was 22.5 (interquartile range [IQR] 19.25–24). Eleven (57.9%) mothers were HIV positive at first ANC, whilst eight tested negative and later positive (2 antepartum, 6 postpartum). Median maternal CD4 was 408 cells/μL (IQR 318–531). Six (31.6%) received no antenatal antiretroviral therapy (ART) because they were diagnosed as HIV positive postpartum; 9 (47.3%) received antenatal ART and 3 (15.8%) were never initiated on ART. At 6 weeks postpartum, 5 infants (26.3%) were not on prophylactic nevirapine (NVP) because their mothers had not yet been diagnosed. Maternal seroconversion in pregnancy and breastfeeding, and possibly false-negative HIV tests, were important reasons for prevention of mother-to-child transmission (PMTCT) failure

Intraoperative monitoring of visual evoked potentials in patients undergoing transsphenoidal surgery for pituitary adenoma: a systematic review

BACKGROUND: Transsphenoidal surgery is the gold standard for pituitary adenoma resection. Although rare, a serious complication of surgery is worsened vision post-operatively. OBJECTIVE: To determine whether, in patients undergoing transsphenoidal surgery for pituitary adenoma, intraoperative monitoring of visual evoked potentials (VEP) is a safe, reproducible, and effective technological adjunct in predicting postoperative visual function. METHODS: The PubMed and OVID platforms were searched between January 1993 and December 2020 to identify publications that (1) featured patients undergoing transsphenoidal surgery for pituitary adenoma, (2) used intraoperative optic nerve monitoring with VEP and (3) reported on safety or effectiveness. Reference lists were cross-checked and expert opinion sought to identify further publications. RESULTS: Eleven studies were included comprising ten case series and one prospective cohort study. All employed techniques to improve reliability. No safety issues were reported. The only comparative study included described a statistically significant improvement in post-operative visual field testing when VEP monitoring was used. The remaining case-series varied in conclusion. In nine studies, surgical manipulation was halted in the event of a VEP amplitude decrease suggesting a widespread consensus that this is a warning sign of injury to the anterior optic apparatus. CONCLUSIONS: Despite limited and low-quality published evidence regarding intra-operative VEP monitoring, our review suggests that it is a safe, reproducible, and increasingly effective technique of predicting postoperative visual deficits. Further studies specific to transsphenoidal surgery are required to determine its utility in protecting visual function in the resection of complex pituitary tumours

The management and outcome of hyponatraemia following transsphenoidal surgery: a retrospective observational study

PURPOSE: Hyponatraemia is a common complication following transsphenoidal surgery. However, there is sparse data on its optimal management and impact on clinical outcomes. The aim of this study was to evaluate the management and outcome of hyponatraemia following transsphenoidal surgery. METHODS: A prospectively maintained database was searched over a 4-year period between January 2016 and December 2019, to identify all patients undergoing transsphenoidal surgery. A retrospective case-note review was performed to extract data on hyponatraemia management and outcome. RESULTS: Hyponatraemia occurred in 162 patients (162/670; 24.2%) with a median age of 56 years. Female gender and younger age were associated with hyponatraemia, with mean nadir sodium being 128.6 mmol/L on postoperative day 7. Hyponatraemic patients had longer hospital stay than normonatraemic group with nadir sodium being inversely associated with length of stay (p < 0.001). In patients with serum sodium ≤ 132 mmol/L, syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the commonest cause (80/111; 72%). Among 76 patients treated with fluid restriction as a monotherapy, 25 patients (25/76; 32.9%) did not achieve a rise in sodium after 3 days of treatment. Readmission with hyponatraemia occurred in 11 cases (11/162; 6.8%) at a median interval of 9 days after operation. CONCLUSIONS: Hyponatraemia is a relatively common occurrence following transsphenoidal surgery, is associated with longer hospital stay and risk of readmission and the effectiveness of fluid restriction is limited. These findings highlight the need for further studies to better identify and treat high-risk patients, including the use of arginine vasopressin receptor antagonists