Author: cprindia

FULL VIDEO OF THE DISCUSSION
URBAN ECONOMY URBAN GOVERNANCE

Watch the full video (above) of the discussion on ‘Fractal Urbanism: Residential-segregation in Modernising India‘ featuring Andaleeb Rahman.

The presentation showed how residential caste-segregation is independent of city size, using the first-ever large-scale evidence of neighbourhood-resolution data from 147 of the largest cities in contemporary India (the sample includes all cities in India with at least 0.3 million residents in 2011). This analysis sheds new light on one of the central conundrums in Indian urbanism — the persistence of caste segregation across the country, and across cities of varying sizes. It documents how patterns of residential caste segregation in the largest metropolitan centres with over 10 million residents closely track patterns in much smaller cities that are nearly two orders-of-magnitude smaller. This finding punctures a hole in one of the central normative promises of India’s urbanisation — the gradual withering of traditional caste-based segregation. These national findings are complemented by a unique census-scale micro-data containing detailed elementary caste (jati) information for nearly five million urban households in Karnataka. The analysis provides further fine-grained evidence of how segregation within the wards at census-block scales accounts for a significant part of the city scale patterns of segregation and is a central driver of ghettoisation of the most spatially marginalised groups in urban India — Muslims and Dalits. The authors offered several hypotheses and explanations and discussed implications for urban planning, policy, as well as broader modernisation theories.

Andaleeb Rahman is currently a Postdoctoral Associate at Cornell University. His research interest lies in the area of food policy and ethnic politics.

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

As Kashmir continues to be on the boil for over 60 days now, a factual trajectory of the history of the state and its conflict (from 1947 till 2006) is captured in this primer by the late B G Verghese of CPR.

The primer was written with the objective of educating people, given the lack of easily accessible literature on the subject, and presents the central story of the Jammu and Kashmir (J&K) conflict post 1947–in a series of snapshots.

From the history of its invasions, coups, and accession, to the account of the UN resolutions, to the resulting Indian, Pakistani and Chinese territorial control of the erstwhile princely state of J&K in 1949, the following wars, the many attempts at the peace process–including the origins of the plural, multi-ethnic and multi-lingual tradition of Kashmiriyat–the primer is an important reference point for understanding and contextualising the current situation of the state.

A visual timeline of the highlights from the primer can be accessed above.

VIDEO RECORDING OF CPR-CSH URBAN WORKSHOP
URBAN GOVERNANCE

Watch the full video (above) of the preliminary findings presented by Sanjeev Vidhyarthi from his research on the actors shaping the fast growing Indian cities and their metropolitan regions.

The findings focus both on the changing perception of spatial plans, as well as the range of urban actors and how their plans are beginning to shape Indian urban regions in unprecedented ways.

Sanjeev Vidyarthi is an Associate Professor of Urban Planning and Policy at the University of Illinois, Chicago.

EXCHANGE OF VIEWS BETWEEN EXPERTS FROM INDIA AND AUSTRALIA
POLITICS INTERNATIONAL POLITICS

Watch the full video (above) of a public forum organised by the Centre for Policy Research, which brought together experts from Niti Aayog (government of India’s think tank) and Australia, to discuss policy reforms, and how these can be enacted.

There was an exchange of views between the two coutnries on how to manage the policy environment, assess and analyse government and non-government stakeholders, and effect good policy. Particularly, since designing and implementing effective policy reform in multi-tiered complex democracies is difficult and challenging, especially where there are vocal and entrenched interests and stakeholders involved.

WATCH THE FULL VIDEO
WATER RESEARCH

Watch the full video of the talk (above) by Anthony Acciavatti focusing on a decade-long-project to create a dynamic atlas of the Ganges Machine–a method of mapping that exposes the juxtaposing layers of infrastructure and adjoining built forms. The goal of this dynamic atlas is to not only map space, but also map how spaces change over time.

Acciavatti also discusses the importance of mapping the choreography of water and human settlement at a time when the Government of India is beginning to invest a $1.5 billion loan from the World Bank to clean up the Ganges river.

A LITERATURE REVIEW AND ANNOTATED BIBLIOGRAPHY BY SUSAN E CHAPLIN
SANITATION URBAN SERVICES RIGHTS

Susan E Chaplin finds that existing literature provides little evidence of how sanitation inequalities impact the daily lives of poor women and girls.

What is the research about?

In this working paper, Susan Chaplin examines existing literature to find out what is known about how inequalities in urban sanitation access impacts the lives of poor women and girls, who have to queue up each morning to use public toilets, or have to decide which open defecation sites are the least dangerous to use.

How was the research conducted?’

The 68 articles and reports discussed in this literature review were largely collected using Google Scholar searches and the website Sanitation Updates, which provides regular email alerts on recently published journal articles and reports. Most of the evidence-based research and grey literature focused on India, Bangladesh, Kenya, Uganda, Malawi and South Africa

What are the key findings?

Despite the focus on gender inequalities and sanitation in low income countries, within development goals, programmes, and projects, only 16 articles and reports either addressed gender inequalities or used gender analysis in examining results from their research projects.
The urban sanitation inequalities faced by working women, along with those who were ageing, disabled or living on pavements, has been largely ignored in the literature.
The linkages between gender-based violence and the lack of urban sanitation are poorly researched, documented or addressed in practice.
There is a lack of understanding in urban sanitation policies of how gender inequalities create toilet insecurity for millions of women and girls.

Conclusion

To understand how gender inequality operates at multiple levels across societies in the cities of the Global South, in relation to sanitation access, there is a critical need for better data collection which is gender aggregated. Most national statistics, at best, often just provide a very broad overview of sanitation facilities at the household level. These statistics don’t provide an adequate overview of the everyday lives of poor women and girls who are compelled to develop strategies to cope with lack of access to safe sanitation facilities. For many poor women and girls, this specifically means finding ways to cope with gender-based violence that occurs around community/public toilets and open defecation sites.
There is an urgent need to develop gender-sensitive understanding of the heterogeneous nature of slums and informal settlements, the diversity of the people who live in them, and the relationships between them, if urban sanitation inequalities are to be addressed to meet Sustainable Development Goals.
Data and research is also needed on how this lack of access impacts poor women and girls, women working in informal sectors, women with disabilities, ageing women, and homeless women. The understanding created by this new research could then be used to develop more appropriate and effective strategies to reduce gender inequalities in urban sanitation provision.

FULL VIDEO OF PANEL DISCUSSION AS PART OF CPR DIALOGUES
SOUTH ASIA INTERNATIONAL POLITICS

Watch the full video of the panel discussion on ‘Geopolitics and Geo-Economics in a Changing South Asia’, organised as part of CPR Dialogues, featuring Nimmi Kurian, Zorawar Daulet Singh, Ambassador Shivshankar Menon, chaired by Srinath Raghavan.

The contemporary phase of international politics is full of uncertainty and fluidity. The US is unable to enforce its writ over the system, nor is it able to supply the public goods necessary to produce a stable and flourishing world economy. Rising powers are contending for new roles and seeking to reshape the rules that govern world order. If we step back, however, what we notice is actually a recurring cycle in world history. A pattern of struggle and competition where each epoch has ultimately produced a larger and more dynamic process of capital accumulation and international division of labour. After a struggle for leadership, the baton passes towards a new contender who resuscitates world order and assumes the onus of managing the process of economic globalisation. Does the present phase portend such a scenario? What aspects of the ongoing power transition are similar to the past and what is distinct? Can the dominant power and its rivals arrive at a modus vivendi that avoids a zero-sum confrontation?

Coming to India and its region, the changing international environment has profound consequences. Both the geoeconomic order – an open world economy where capital and goods could move relatively freely between states – and a peaceful geopolitical setting underwritten by a great power peace has enabled India since the end of the last Cold War to focus on economic growth and development. Profound changes to this status quo imply that policymakers and strategic thinkers are being called upon to supply fresh ideas and frameworks for India’s foreign policy.

If unrelenting pressures on globalisation do continue to increase, it would imperil South Asia’s economic story. Short of finance capital, non-renewable energy resources, and industrial technologies, South Asia’s transformation for the past two decades has been intrinsically linked to reliable access to economic resources from other high-income and emerging economies. Any disruption to trans-national and trans-continental interdependence, will naturally push the region to look within it own socio-economic base to sustain its economic transformation. This would place greater responsibilities on India to safeguard not only its own economic prospects but supply public goods and assist its neighbours too. And, there is no sensible reason why India must seek to do this alone with its scarce resources and growing domestic claims. Cultivating diverse partnerships are, therefore, not a luxury but a strategic necessity. Setting the terms and shaping how other major powers with greater economic heft engage with the South Asia is one of the central challenges for India’s foreign policy. What have been missing from Indian debates are more sophisticated approaches to the multitude of regional visions and connectivity ideas that are being espoused by several great powers. Can India leverage its unique location at the crossroads of many of these geoeconomic visions provides to mediate and steer Asia’s political economy evolution in directions that advance its interests?

Furthermore, a fundamental assumption – indeed a sacrosanct premise – for India’s strategic thinking in the post-Cold War period has been internalising the reality of one preponderant power centre that shaped political and economic life across the globe. This structural setting – unipolarity as it was described by many – led to a basic Indian foreign policy framework of a sustained, albeit gradual and tentative at each step, integration into the US-led order as well as of course a transformation in bilateral relations with the US and its key allies. This has been a bipartisan strategy and for the most part it could be claimed that Indian policymakers accomplished this process within the broad confines of strategic autonomy with some success. But given the geopolitical changes now underway, without a careful strategic readjustment and a sensible assessment on Asian geopolitics, India’s foreign policy risks losing the advantages that might accrue from a multipolar Asia. How should India reimagine its place in this diffusion of global power and disintegration of the unipolar consensus?

The panel explored these and related themes to understand what possible roles can India realistically adopt to shape the ongoing power transition in a way that advances its domestic transformation and security along with a stable Asian and world order.

Srinath Raghavan is a Senior Fellow at CPR.

Nimmi Kurian is a Professor at CPR.

Zorawar Daulet Singh is a Fellow at CPR.

Ambassador Shivshankar Menon is the former National Security Advisor and Indian Foreign Secretary.

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

Coverage of the panel by ThePrint (digital partner for CPR Dialogues) can be accessed here.

ANALYSING THE PM’S RESPONSE
POLITICS KASHMIR INDIA-PAKISTAN

SOUTH ASIA
CPR faculty G Parthasarathy comments on the Prime Minister taking stock of the situation in Kashmir following the death of Burhan Wani on DD News.

BY CENTRE FOR POLICY RESEARCH AND JUST JOBS NETWORK
URBANISATION URBAN ECONOMY URBAN SERVICES

The high-pitched debate about data on employment and job creation in India has only served to highlight that the paucity of quality employment is a serious barrier to economic mobility, especially for young people who are moving off the farm. In order to leverage the oft-discussed demographic dividend, however, policymakers need a clear picture of ‘where’ structural transformation is actually happening.

Through this research project titled ‘The role of small cities in shaping employment outcomes for migrant youth’, the Centre for Policy Research and JustJobs Network draw policy attention to the potential of range of non-metropolitan urban locations, including secondary cities, small towns, densifying and urbanising villages and peri-urban spaces – collectively referred to as small cities – to improve employment opportunities for a vast proportion of young people in emerging economies. Using the cases of two cities each in India and Indonesia, the research project has studied the types of mobilities and migration small cities experience, the labour market experiences of youth in these cities, as well as the governance and planning frameworks that address key issues in economic development, employment and migration. Central to the project are the young men and women that have been the subjects of enquiry: their dreams and aspirations and their strategies for navigating pathways towards economic mobility.

Small City Dreaming is a short documentary film that offers a glimpse into the working lives of young people in small cities in India and Indonesia. It explores the connections between villages and small cities through the work journeys of three characters: Oscar in Kupang, in eastern Indonesia; Bhagchand in Kishangarh, Rajasthan, India; and Latifah in Semarang Regency, Central Java, Indonesia. Seeing the small city through their eyes, we learn that even as many young people in small cities remain stuck in dead-end jobs, others use networks and skills learned in the city to become entrepreneurs. The depictions of the daily lives of Oscar, Bhagchand and Latifah and their articulations of their struggles and dreams are intended to urge audiences to move beyond the dominant uni-dimensional imaginations of village-to-metropolis migrations to explore multiple kinds of migrations and mobilities, often across territorial entities that do not neatly fit into our understanding of the ‘village’ and the ‘city’.

READ THE FULL BLOG BY JISHNU DAS, BENJAMIN DANIELS, ADA KWAN AND MADHUKAR PAI
HEALTH

After an autopsy lasting 200 years scientists concluded that the mummy Irtyersenu, first revealed to London’s Royal Society in 1825, died of tuberculosis (TB) around 600 BCE. Today, TB still causes much suffering and lost productivity around the world, despite the perception of ‘no longer being an issue’ in higher income countries. In 2017, TB affected 10 million people, and killed more people than HIV/AIDS – a total of 1.3 million fatalities worldwide.

India may well be the `epicentre’ of the disease: The country accounted for a quarter of the global TB cases and TB deaths in 2017. Nearly a third of the world’s 3.6 million undiagnosed or unreported cases are thought to live there, and in Mumbai, the first strain of the TB bacteria resistant to all known treatments was reported in 2012.

The good news is that we know how to control the epidemic and bring it close to eradication. Well-executed public health programs that screen potential patients, bring them to treatment quickly, and ensure treatment completion can halt the spread of this ancient scourge. In China, the World Health Organisation estimates that vigorous efforts to bring treatment to those already diagnosed halved the TB prevalence rate of TB from 215 per 100,000 people in 1990 to 108 in 2010.

But India is different. It was long conjectured that, like in China, the majority of TB patients were receiving care in the public sector. But then, in 2016, Nimalan Arinaminpathy and colleagues used an ingenious method to come up with realistic estimate. Based on the sales of anti-TB drugs in the private market, they showed that, in fact, it was the private sector that was treating two-thirds of India’s TB patients.

‘There were 17.793 million patient-months (…) of anti-tuberculosis treatment in the private sector in 2014, twice as many as the public sector. If 40–60% of private-sector tuberculosis diagnoses are correct, and if private-sector tuberculosis treatment lasts on average 2–6 months, this implies that 1.19–5.34 million tuberculosis cases were treated in the private sector in 2014 alone. The midpoint of these ranges yields an estimate of 2.2 million cases, two to three times higher than currently assumed.’

Given that most prior anti-TB programs had been conceived of and delivered in the context of a top-down public healthcare system, how would India manage in this completely differently context?

A new approach to combating TB – with the private sector

In 2014, the Indian RNTCP, Mumbai Corporation and Bihar State government, in partnership with NGOs PATH and World Health Partners, with support from the Bill and Melinda Gates Foundation India, started to work on this difficult challenge. As part of a new program, World Health Partners in Patna and PATH in Mumbai, serving the role of intermediary agencies, implemented Private Provider Interface Agencies that sought to expand the capacity and improve the quality of TB diagnosis, treatment, and care in the private sector. This was not easy.

While prior studies hinted at low knowledge about TB standards in the private sector and long diagnostic delays, there was lack of data on how exactly private practitioners managed TB. What systematic mistakes were providers making? Were there pockets of excellence in these cities? How could outstanding doctors be identified? How do informal and AYUSH providers manage TB?

To help implement this program, our team, we put in place the world’s largest surveillance of TB care quality in those two cities. Instead of focusing on administrative data that has severe limitations in these contexts, we decided to use a gold-standard method of quality measurement for primary care: standardised patients, or SPs. Our methodology was first validated in a pilot study in Delhi, and has been subsequently used for our larger study in India, as well as similar studies in Kenya, China and South Africa.

{A brief interlude. In an SP interaction, a trained professional pretends to be a patient and visits a doctor. The SP presents with a pre-determined set of symptoms, a scripted personal history, and pre-planned responses to common questions. The same SP may present that scenario to hundreds of different doctors during one study. Since those presentations are all identical and researchers know what the SP was presenting with, the quality of care the SP received can be benchmarked to standards of care and accurately compared across providers and across time. Furthermore, since the provider does not know their actions are being recorded, the SP approximates the quality of care delivered to real patients.}

Together with the Institute for Socioeconomic Research on Development and Democracy, we recruited and trained 24 people from the local community, who then took on the tough task of presenting as SPs to multiple providers. After a month-long training process, our brave SPs went on to complete 2,652 interactions at 1,203 health facilities. Because the two organisations in these cities had painstakingly completed street-level listings of healthcare providers, we were able—for the first time—to create representative estimates of quality in 2014-15, just before the programs scaled up for implementation.

Quality in the private sector

Our recently published paper reports the results from our pre-program study in 2014-15, summarising the quality of care delivered by private health care providers in these cities at that time. There were three key features of the ‘market’ for TB care in these cities.

First, patients choosing a health care facility at random would have been treated in a manner consistent with national and international guidelines just 35% of the time. We believe that even this is an overestimate because we did not penalise providers when they also gave patients unnecessary (or even harmful) tests and medications. In fact, most patients also received unnecessary medications, including broad-spectrum antibiotics that may contribute to drug-resistance, or fluoroquinolone antibiotics and steroids which may mask symptoms while the TB infection worsens. The fraction of providers who correctly managed the case without giving unnecessary medicines is a frightening 9%.

But here is the thing. These low numbers are not because `all providers are low quality’ but instead reflect the tremendous quality variation in these cities. Part of this variation is because medical care in these cities is delivered by providers ranging from highly specialised chest specialists and MBBS doctors to those with degrees in Ayurveda, Yoga, Unani, Siddhi and Homeopathy (collectively called AYUSH), as well as providers without any formal qualifications at all. In Mumbai, 50% of providers in program areas were AYUSH; in Patna, 40% had no formal medical training at all. And MBBS providers consistently provided higher quality care, correctly managing 46% of cases compared to 23.5% for AYUSH and informal providers.

But part of this variation is also because, within both groups, there was always some providers who correctly managed every SP and some who got every case wrong. Providers were remarkably consistent — those who managed TB right once got it right again. Those who wrongly gave steroids and antibiotics to TB patients did so repeatedly.

The second feature of the market was therefore the recognition that there were excellent doctors in both cities, but qualifications were only a crude marker of quality.

Third, we are all accustomed to hearing about over-medication among healthcare providers. This is evident in our data, but there are also more nuanced patterns. The good news is that only 3% of our SPs received anti-TB medications without a microbiological test result, and that anti-TB medications were almost exclusively given by providers with the appropriate qualifications. Overuse of anti-TB medication had been a major concern for TB control programs, and we have now been able to show that neither pharmacists nor informal and AYUSH providers abuse anti-TB medications. The bad news is that all types of providers continue to use antibiotics indiscriminately, and more worryingly, some providers prescribe fluoroquinolones and steroids, both of which can mask the symptoms of TB and render diagnosis more difficult.

Scaling up anti-TB programs: A four-fold path to success?

Equipped with this granular description of the health market, the programs in these cities started to scale up in 2014. After 2015, both Mumbai and Patna started to see significant improvements in TB notification rates among private sector providers with greater use of microbiological tests and improved treatment completion rates. We have now begun to analyse new data from the quality of care surveillance conducted after the program was in place (not included in our recent publication). Our preliminary results suggest the program accomplished substantial improvements in how patients were being managed. Although these are early days, the signs are encouraging.

Now, the government, with support from The Global Fund, is expanding this model of private sector engagement to several cities through its Joint Effort for Elimination of Tuberculosis. And it is likely that they will face a comparable situation, with high quality dedicated doctors practicing amidst many indifferent and mediocre providers.

Based on our experience, we propose a strategy called IFMeT that may be key to successful private-public partnerships to fight TB. The four components that comprise IFMeT are Identification, Focusing, MEssaging and Testing.

Identification: Our data show that there are great providers in every city, but there are many providers with doubtful quality. Identifying `champion’ high quality providers early in the program is critical to the success of the program. The SP method is one tool in the arsenal, but care is required to balance anonymity and program success.

Focusing: Quality improvement efforts often work with a large set of providers through trainings and continuing medical education. An alternative to improving average quality is to connect patients with pre-identified top providers and focus investments and training on this small provider group, while leaving lower-volume or lower-quality providers untouched. In both Mumbai and Patna, 20% of providers were responsible for 80% of patient volume initially, suggesting high returns to focused effort. This `provider focusing’ approach massively decreases the scale of the program while retaining virtually all its benefits.

Messaging: The widespread use of unnecessary medicines may be tied to financial incentives. But financial linkages in the private sector are complex, closely guarded and difficult to uncover or build a program around. A better approach is to concentrate in one or two key behaviors. At this point, the indiscriminate use of anti-TB drugs is no longer of paramount concern. Fighting the use of broad-spectrum antibiotics may have to wait. But the use of fluoroquinolones and/or steroids can make TB diagnosis even harder and messaging only on the overuse of fluoroquinolones and steroids can have substantial impact.

Testing: We often assume that the main problem in the private sector is over-testing driven by profit motives. In fact, most providers are getting diagnoses wrong because they don’t test enough. Doctors need to do more X-rays, sputum tests and GeneXpert tests for patients presenting with symptoms consistent with TB, even when the odds of a positive result seem low. We found that when doctors were given better diagnostic information like test results, their decisions were more appropriate, and they gave fewer unnecessary medicines. Encouraging more testing, whether through price reductions for the patient and private laboratories, or communication with the provider is key to success when it comes to TB.

IFMeT, these strategies will take a very large problem without clear boundaries and bring it down to a series of actionable and manageable steps. Granville’s Egyptian mummy suffered many ignominies throughout her history, not the least of which was 200 years of being assigned a wrong cause of death until DNA testing revealed TB to be the culprit. With the resurgence of TB, the rise of drug resistant strains and the fact that this disease, more than any other, lays bare a society’s claims to fairness and equity, we cannot afford such mistakes in diagnosis any longer.

For additional resources: Quality of TB Care (QuTUB) Project https://www.qutubproject.org/

Jishnu Das is a Lead Economist at the World Bank, Washington DC and a visiting Senior Fellow at CPR.

Benjamin Daniels is a researcher at the World Bank, Washington DC.

Ada Kwan is a doctoral candidate at the University of California, Berkeley.

Madhukar Pai is Director of the McGill International TB Centre, Montreal.