Author: cprindia

PAPER CO-AUTHORED BY JISHNU DAS
HEALTH

Health care providers without any formal training provide more than 70% of all primary care in rural India. A new study by Jishnu Das, Abhijit Chowdhury, Reshmaan Hussam and Abhijit Banerjee combines unique data from standardised patients with random assignment to a training programme conducted by The Liver Foundation in West Bengal to assess whether training can improve their quality of care. Findings of this study were published as a paper in the journal Science, titled The impact of training informal health care providers in India: A randomized controlled trial.

Why is the research important?

In many low-income countries, including India, health care providers without formal medical training account for between one-third and three-quarters of primary care visits. What should be done about such informal providers in India is a highly charged debate.

While the Indian Medical Association argues that any kind of training would legitimise an illegal activity, others believe that training can act as a stop-gap solution to rural India’s severe shortage of trained personnel and serve as an effective complement to reform in the public sector. There is currently no evidence on the benefits of training (or the lack thereof) on the quality of care provided by informal providers.

What does the research do?

When people in Indian villages fall sick, they often go to a village provider–who in many cases, has received no formal medical training. As the source of primary care, these providers are asked to provide a broad range of services. They are expected to treat patients with conditions that can be managed in a primary care setting; refer patients with serious conditions to higher level care; and diagnose and manage patients with chronic conditions.

This study was uniquely designed to assess whether a 9-month long training programme, implemented through 72 teaching sessions, would allow informal providers to improve along each of these three types of services. The research assessed:

Does training improve the ability of informal providers to correctly diagnose and manage different conditions?
Does training decrease the use of unnecessary medicines, injections and antibiotics among informal providers? The researchers were concerned that any positive effects may not be sustainable if training adversely affected the providers’ patient loads, and in turn the profitability of their practice. Hence, they also assessed how does training affect the patient load and revenues of informal providers?
How was the research conducted?

The study was completed in three phases. In the first phase, 152 informal providers were randomly selected (out of a total of 304) to participate in a training programme implemented by The Liver Foundation. The training program was implemented over 9 months in 72 classroom training sessions. The remaining 152 providers were offered training after the completion of the study and thereby served as a ‘control’ group.

In the second phase, Das et al. sent standardised patients to all providers in their sample, regardless of whether they had received training or not. The standardised patients were recruited from West Bengal. Each standardised patient was extensively trained to present one of three different conditions and all three conditions were presented to each provider to evaluate their ability to correctly diagnose and manage them.

Since the implementers of the training programme did not know what conditions the standardised patients were going to present, and therefore could not tailor the training to these conditions, the researchers interpret their results in terms of upgrading in overall skill level of the providers.

In addition, the standardised patients did not know whether the providers they visited had been trained by the Liver Foundation. Finally, standardised patients were also sent to every public clinic in the 203 villages that the informal providers came from as an additional benchmark for the effect of training. Reflecting the scarcity of trained medical professionals in the region, the study was able to locate only 11 Primary Health Care Centers in these villages, each of which we evaluated using standardised patients.

Because standardised patients allowed the study to assess care only for these three conditions and not for the multitude of cases that informal providers are asked to provide care for, in the third phase, the researchers sat in the clinics of the informal providers for a full day, recording key details of all clinical interactions.

What were the key findings?

Average attendance in the programme was 56 percent. The main reasons for non-attendance were distance from the training centre and excessive rain. The correlation between attendance and distance to the training centre suggests that if each provider could access training within 5 kilometers from his or her clinic, attendance would increase to 80 percent.
Assignment to training increased the likelihood of correct case management by 7.9 percentage points against a control group mean of 52 percent. If attendance had been 100 percent (instead of the 56 percent observed), training would have increased correct case management by 13.3 percentage points instead. The study found that providers assigned to training were more likely to complete recommended checklists of history questions and examinations, both among standardised patients and in clinical observations.
Public sector doctors were 14.7 percentage points more likely to correctly manage a case than untrained informal providers. Training closed half the gap in correct case management relative to the public sector.
However, there was no decline in the use of unnecessary medicines, antibiotics or injections among providers who were trained. Strikingly, both trained and untrained informal providers were less likely to give unnecessary medicines and antibiotics relative to doctors in the public sector.
The training increased the patient load of the provider. Although the study did not experiment with providers’ willingness to pay for the programme, it computed that the increased revenue would compensate for the cost of training within 66 days if the research used the higher end of its patient load estimates, or 210 days if it used the lower end of its patient load estimate.
Interpreting the findings:

Informal providers are the mainstay of India’s primary care system. The study demonstrates that training informal providers does not worsen care, as has been argued by representatives of the Indian Medical Association. In contrast, it found that training improves their ability to correctly diagnose and manage multiple conditions and although it does not reduce their likelihood of providing unnecessary medicines or antibiotics, it doen’t increase it either. The low costs of training imply that permanently hiring just 11 additional fully trained MBBS providers into the public sector would be as costly as training 360 informal providers every year through this programme.

The full paper can be found here, subject to user access.

SUMMARY OF A BLOG SERIES BY ACCOUNTABILITY INITIATIVE
BUREAUCRACY

Find below a summary of a series of blogs by Accountability Initiative (AI) at CPR on the challenges in navigating the complex government bureaucracy to access basic services and benefits:

In Water Problems in a South Delhi Slum – Challenges of Access, Usage and Awareness, Kriti Seth narrates the problems a common person faces in accessing clean water in the slums of Delhi through the experience of an Anganwadi worker. Lack of awareness of redressal mechanisms and difficulty in approaching relevant authorities compounds the problem. The words of the Anganwadi worker interviewed summarise the crux of the issue, ‘navigating the matrix of zones and departments (like Water, Water sewer, Water maintenance etc.) listed on the Delhi Jal Board website and deciphering the confusing acronyms to finally get the appropriate phone number was a challenge to a comparatively technically sound person like me.’

In Soochna ka Adhikar: Ek Pehlu Ye Bhi.. (Right to Information: Another perspective…)AI’s PAISA Associate (field staff) in Himachal Pradesh, Indresh Sharma describes the roadblocks faced by Arun, a local dairy farmer, who tried to access information through the Right to Information (RTI) Act regarding a road construction on government owned forest land. This led to a bitter dispute with panchayat and land department officials, and as a result, Arun and his family suffered adverse personal consequences, including severe monetary and psychological damage. The piece acknowledges the strengths and power of the RTI Act, but also urges the government to strengthen its provisions, so that such incidents do not recur.

Sachai Ki Jeet (Truth’s Victory), is in essence, a case study on citizen-led actions that demand accountability from the bureaucracy. Dinesh Kumar, AI’s PAISA Associate in Bihar, details the inadequacies of the Public Distribution System (PDS) in Bihar, through which millions of families access daily rations for food at subsidised rates. He shares the story of his relative who mobilised others like him and fought against a nexus of corrupt ration dealers and a hostile bureaucracy to successfully retrieve ration that was rightfully due to him.

In Right to Whose Education, Vincy Davis shares the ongoing story of a man’s mission to get his child admitted to a private school under the quota reserved for students from economically weaker sections under the Right to Education Act (RTE Act 2009). The story traces Sunil’s journey during which he has to face hurdles at every point, and despite having the requisite documents as well as substantial support from his employers, his fight to get his son admitted is still not over.

In Aadhar in Public Service Delivery: An Enabler or a Disruptor , Taanya Kapoor shares a story of the tribal areas of Madhya Pradesh, where the mandatory requirement of Aadhaar enrolment to avail key public services and direct benefit transfers has affected the most marginalised, particularly by restricting their access to cash for daily use. She illustrates this point by sharing the story of a woman from Satna district, one of the most underdeveloped areas in the state, and her struggle to get an Aadhar card made, and consequently being unable to acquire her family’s share of ration from the fair price shop. While, a scheme like Aadhar may be well-intentioned, what needs to be questioned is the sheer incapacity of the state system to tackle implementation issues, which affect many people on a daily basis, writes Kapoor.

In the last two blogs of the series – Bridging Gaps between Citizens and the Bureaucracy – Part 1 and Part 2, Vincy Davis reflects on the journeys of various people whose struggles have featured in the blog series in an attempt to identify common issues within these diverse contexts. One of the main themes that emerges is the struggle to implement a digital India with very low levels of digital literacy, and the implementation process being beset with issues of access; grievance redressal; and bureaucratic complexities. Davis also shares some tried and tested hacks to counter these issues, and lays down a path towards long-term solutions.

BHARAT KARNAD ANALYSES
POLITICS SECURITY

Bharat Karnad, Research Professor at CPR and a national security expert traces the trajectory of the Indian government’s approach to signing the Logistics Exchange Memorandum of Agreement (LEMOA) with the US in a series of select articles over March and April, 2016, listed below:

India in America’s coils?: Questioning the move by the Indian government to sign the LEMOA, Karnad comments that it would effectively reduce India to a client state of the US.
No LEMOA — possible reasons: In this blog, Karnad analyses the reasons for the postponement in the signing of the LEMOA, and calls it interim relief.
Has PM Modi Developed Cold Feet Over The Logistics Agreement with the US?: Welcoming the move that the signing of the LEMOA was likely postponed indefinitely by the Indian government, Karnad writes that New Delhi must have a grander vision for India’s foreign and strategic policies.
The Logistics Exchange Memorandum of Agreement (LEMOA) is one of the three major foundational agreements between India and the US which facilitates the exchange of logistics between military forces of the two nations. The most significant of these will permit the military forces of each country to resupply and replenish, and stage operations out of the other’s military air bases, land facilities, and ports.

FULL VIDEO OF PANEL DISCUSSION AS PART OF CPR DIALOGUES
CLIMATE RESEARCH

Watch the full video of the panel discussion on ‘The International Climate Change Regime: Looking Back to Look Forward’, organised as part of CPR Dialogues, featuring Lavanya Rajamani, Joanna Depledge, Chandra Bhushan, chaired by Ambassador Chandrashekhar Dasgupta.

The international climate change regime is poised at an interesting juncture – after decades of politically charged negotiations to put in place the obligations, rules and institutions to address climate change, the regime is shifting gears towards the day to day business of national implementation. It is a shift that takes the regime into new, less headline-grabbing yet important territory.
Over the course of the three decades that the international climate change regime has been in evolution, Parties have negotiated three legally binding instruments — the 1992 UN Framework Convention on Climate Change, the 1997 Kyoto Protocol and the 2015 Paris Agreement — and numerous decisions under these instruments. These instruments, in particular the Kyoto Protocol and the Paris Agreement, represent fundamentally different approaches to regulating climate change. The 1997 Kyoto Protocol represents a top-down prescriptive approach, and the 2015 Paris Agreement a hybrid approach centred on nationally determined contributions from Parties complemented by an oversight system to incentivize more ambitious contributions over time. Since the Paris Agreement, Parties have been engaged in developing rules to operationalize the Agreement, in particular to discipline national discretion, enhance transparency and strengthen the oversight system. The end of the Rulebook negotiations on 14 December 2018 in Katowice marks the end of an era of intense rule-making under the climate change regime. Although minor technical details may remain to be resolved beyond Katowice, the broad contours of the climate change regime will be firmly in place. Yet this represents only the first step and the implementation now to follow will likely to prove to be much more challenging.

This panel:

looked back on three decades of rule-making, in particular at the major shifts in regulatory approaches embedded in this history
discussed the emerging contours of the Paris Agreement as fleshed out in the Katowice rulebook
explored the challenges and (potential) gaps in implementation, review, and ‘ratcheting’ of ambition over time through the Paris framework
identified the key focus areas for research, advocacy and policy influence as the regime shifts gears.
This panel discussion is the latest in a long line of seminars that CPR has held on the climate regime. In particular it forms part of an unbroken chain of annual seminars CPR holds shortly after the UN Conference of Parties (COP) to deconstruct the outcomes of the COP, explore the underlying politics and identify potential challenges on the road ahead.

CPR has worked on the climate regime, at the international and domestic level, for several years, and in various capacities. In addition to our scholarly work which spans award-winning books and articles in influential international journals, we have also worked with governments, including the Indian government, and played a role in drafting IPCC reports and UN FCCC instruments. More importantly we have, through our work over the last decade, helped to inform public understanding, stimulate a broader public debate and shape public opinion and research on climate policy.

Chandrashekhar Dasgupta is a former Ambassador and an Indian climate negotiator.

Lavanya Rajamani is a Professor at CPR.

Joanna Depledge is Editor of Climate Policy journal and Senior Fellow at Centre for Environment, Energy and Natural Resource Governance at the University of Cambridge.

Chandra Bhushan is the Deputy Director General at Centre for Science and Environment.

The question and answer session that followed can be accessed here.

Lavanya Rajamani’s article in the Hindustan Times (print partner for CPR Dialogues) can be accessed here.

Key takeaways about the Dialogues by Joanna Depledge can be accessed here.

Watch all other sessions of the Dialogues below:

Watch all other sessions of the Dialogues below:

• The Emerging World Order and India’s Role
• Research for Policy Action on Air Pollution, in collaboration with CECFEE
• India’s Technology Transition: The Present and the Possible
• CPR Youth Awards: A Youth-Driven Agenda for Change
• India’s 21st Century Transitions
• Understanding India’s Energy Transition in Global Context
• Is the Urban Future Metropolitan? Big Cities in Urban Systems
• Geopolitics and Geo-Economics in a Changing South Asia

CPR FACULTY ANALYSE
INDIA-PAKISTAN KASHMIR POLITICS

SOUTH ASIA
The death of Hizbul Mujahideen commander Burhan Wani in an encounter with the Indian security forces triggered a series of violent protests across Kashmir. CPR faculty analyse the resultant unrest in Kashmir in a series of commentaries below:

G Parthasarathy in an interview on DD News (above) comments on the Prime Minister’s response to the situation in Kashmir, and the internal political climate of Pakistan.
Writing in the Hindustan Times, Shyam Saran examines the deep and growing divide between the administration and the people of Kashmir.
In the Indian Express, Pratap Bhanu Mehta elaborates on the civil unrest in Kashmir and analyses the rhetoric surrounding the violence.

The Legal Challenge to Aadhaar
A FOUR-PART SERIES CO-AUTHORED BY CPR FELLOW ANANTH PADMANABHAN
TECHNOLOGY RIGHTS BUREAUCRACY

The following series of articles, co-authored by Ananth Padmanabhan, originally published in ThePrint, explore the legal challenge to Aadhaar. As the Supreme Court will soon deliver its verdict on the Aadhaar case, it is important to explore these challenges, which can radically alter the relationship between the citizens and the state.

In the first piece, Legal challenges to Aadhaar: Money bill, early enrolments and exclusions, Padmanabhan explores the challenge of categorising the Aadhaar Bill, 2016, as a money bill. He questions the legality of the enrolments undertaken before 2016 prior to the passing of the Aadhaar Act. He also highlights how several citizens would be excluded from the programme, given the inadequate infrastructure available.

The second article, The Aadhaar challenge: 3 features that put constitutional rights at risk, highlights how by virtue of its characteristics, Aadhaar not only potentially violates the right to privacy, but also the constitutional right to equality.

The third piece highlights Another Aadhaar challenge Supreme Court must address: Excessive delegation. Given that the legislative policy on the management and application of Aadhaar data and current safeguards have been left to the Unique Identification Authority of India (UIDAI), with minimal guidelines, it becomes imperative to engage with the challenge of excessive delegation in terms of management and usage of the scheme.

In the final article, Only a new law that addresses concerns can save Aadhaar, Padmanabhan highlights how the Supreme Court should address all the procedural and substantive issues that currently plague the biometric architecture of Aadhaar.

ACCESS THE FULL VIDEO PRESENTATION
RIGHTS

The Scheduled Tribes (‘STs’) or adivasis consist of a number of heterogeneous tribal groups that have historically self-identified, and been identified by the Indian state, as lying outside the mainstream of society, partly because of their ’distinctive culture and way of life as a group’, and partly because of their ‘geographical isolation’. There are as many as 750 Scheduled Tribes in 26 states and 6 union territories of India. The Indian Constitution enshrines special political representation and affirmative action provisions for STs, and also delineates special protections for land rights of Scheduled Tribes, vis-à-vis the state and other communities, in geographically demarcated tribal majority areas known as ‘Scheduled Areas’. This is because land is not only the most important source of tribal livelihoods, it is also central to tribal identity, history, and culture. However, despite these special protections, the Scheduled Tribes remain one of the most vulnerable, most impoverished, and most displaced of all groups in India. 47.1% of all STs in rural areas are below the poverty line as compared to 33.8% for the national average, whereas 28.8% of all STs in urban areas are below the poverty line as compared to 20.9% for the national average. Inspite of being the only group with constitutional protections for their land rights, 9.4 % of STs are landless compared to 7.4% for the national average. While STs constitute only 8.6% of the total population, it is estimated that they constitute 40% of all people who have been displaced during the period 1951 to 1990, some more than once, due to the construction of dams, mines, industrial development, and the creation of wildlife parks and sanctuaries. Only 24.7% of ST population that was displaced during this period was rehabilitated. Therefore, it is clear that these groups have disproportionately borne the burden of economic development. Why is this so?

The Fourth Annual CPR Land Rights Initiative Conference featured the launch of the Report on ‘The Legal and Political Economy of Land Rights of Scheduled Tribes in the Scheduled Areas of India’, which provides some answers to these questions. Through a review of constitutional provisions, laws, and policies, governing the rights of Scheduled Tribes and the administration of Scheduled Areas, and the financial and administrative structures that effectuate these protections, the Report delineates a conflicting regime of protective and displacing laws, as well as conflicting policy narratives underlying these laws which facilitate the displacement of Scheduled Tribes and their corresponding landlessness. The Report also contains extensive primary data on the current mapping of Scheduled areas, and the current distribution of dams, forests, and mining activity, in the Scheduled areas.

Watch a presentation by Namita Wahi on the key findings of the report (above).

This Report will be the focus of panel discussions and deliberations at the NCST CPR Land Rights Initiative National Seminar on Friday, September 14, 2018.

ACCESS THE FULL VIDEO PRESENTATION
RIGHTS

The Scheduled Tribes (‘STs’) or adivasis consist of a number of heterogeneous tribal groups that have historically self-identified, and been identified by the Indian state, as lying outside the mainstream of society, partly because of their ’distinctive culture and way of life as a group’, and partly because of their ‘geographical isolation’. There are as many as 750 Scheduled Tribes in 26 states and 6 union territories of India. The Indian Constitution enshrines special political representation and affirmative action provisions for STs, and also delineates special protections for land rights of Scheduled Tribes, vis-à-vis the state and other communities, in geographically demarcated tribal majority areas known as ‘Scheduled Areas’. This is because land is not only the most important source of tribal livelihoods, it is also central to tribal identity, history, and culture. However, despite these special protections, the Scheduled Tribes remain one of the most vulnerable, most impoverished, and most displaced of all groups in India. 47.1% of all STs in rural areas are below the poverty line as compared to 33.8% for the national average, whereas 28.8% of all STs in urban areas are below the poverty line as compared to 20.9% for the national average. Inspite of being the only group with constitutional protections for their land rights, 9.4 % of STs are landless compared to 7.4% for the national average. While STs constitute only 8.6% of the total population, it is estimated that they constitute 40% of all people who have been displaced during the period 1951 to 1990, some more than once, due to the construction of dams, mines, industrial development, and the creation of wildlife parks and sanctuaries. Only 24.7% of ST population that was displaced during this period was rehabilitated. Therefore, it is clear that these groups have disproportionately borne the burden of economic development. Why is this so?

The Fourth Annual CPR Land Rights Initiative Conference featured the launch of the Report on ‘The Legal and Political Economy of Land Rights of Scheduled Tribes in the Scheduled Areas of India’, which provides some answers to these questions. Through a review of constitutional provisions, laws, and policies, governing the rights of Scheduled Tribes and the administration of Scheduled Areas, and the financial and administrative structures that effectuate these protections, the Report delineates a conflicting regime of protective and displacing laws, as well as conflicting policy narratives underlying these laws which facilitate the displacement of Scheduled Tribes and their corresponding landlessness. The Report also contains extensive primary data on the current mapping of Scheduled areas, and the current distribution of dams, forests, and mining activity, in the Scheduled areas.

Watch a presentation by Namita Wahi on the key findings of the report (above).

This Report will be the focus of panel discussions and deliberations at the NCST CPR Land Rights Initiative National Seminar on Friday, September 14, 2018.

FULL VIDEO OF LECTURE BY PRATAP BHANU MEHTA
POLITICS

Watch full lecture (above) by Pratap Bhanu Mehta on The Crisis of Liberal Democracy: Some ‘Rudolphian’ Reflections at the UChicago Center, New Delhi.