Author: cprindia

EMPLOYMENT JOURNEYS IN SEMARANG REGENCY, INDONESIA
URBAN ECONOMY MIGRATION

The Centre for Policy Research in collaboration with Just Jobs Network is investigating youth employment and migration patterns in small cities in India and Indonesia, two Asian countries that seek to leverage urbanisation to reap the demographic dividend. This piece explores trends from surveys and qualitative enquiries conducted in Semarang Regency in Central Java, Indonesia, where factory work has been the default employment for men, and large numbers of women, for decades but is no longer the long-term aspiration for young workers.

Advocates, workers’ organizations and scholars have long pointed to the contingent and short-term nature of work in labor-intensive manufacturing sectors like garments and food processing, where large firms often rely on young workers – especially women – to power their factories. However, less attention has been given to a set of related concerns: To what extent do young people aspire to life-long industrial jobs, independent of pay or working conditions? And what work do they do once they’ve left the factory?

Qualitative interviews with young migrants in the industrial areas south of Semarang – a port city in Central Java – speak to these questions and offer important insights about the factors that shape the employment journeys of young people in 21st century emerging economies. The data was collected as part of an ongoing project of JustJobs Network, in collaboration with the Centre for Policy Research in New Delhi, which seeks to understand the employment and migration experiences of young people in non-metropolitan urban geographies in India and Indonesia.

We find that youth in the industrial cluster of Semarang Regency have complex working lives that reflect the dynamic interplay of the formal and informal economy. Moreover, young industrial workers tend to see factory jobs as only one stage in the course of an entire employment journey.

Consistent with earlier scholarship, we find that youth working in the area’s garment factories tend to see factory work as offering limited opportunities for wage growth, skill development and economic mobility. Beyond this, however, many factory workers express an interest in starting their own businesses, placing high value on the independence they would gain through self-employment – even if it means earning less. In fact, a common phenomenon among older migrants who were interviewed is the “usaha sampingan” – or side business – which many imagine will eventually be their primary form of employment, after they leave their factory jobs.

This observation gives rise to two different insights. First, it suggests that young people use the capital they accumulate in factory work to invest in their own enterprises later in their working lives. And second, it illustrates that young workers’ early exit from factory jobs is driven by both push factors – such as the contingent nature of contracts and constrained wage growth – and pull factors – young people’s aspirations for something more than an assembly line job. Women in particular value the independence of entrepreneurship, which gives them the flexibility they need to take on care work.

Another interesting finding of our work in Semarang Regency regards the dynamic relationships between the formal and informal economy, and the way former factory workers’ enterprises promote these linkages. Some of the businesses that workers start after leaving factory work are directly tied to the skills they learned on the job. For example, we met an entrepreneur who buys scraps of fabric from local factories and weaves rugs, dishcloths and other textile products from them.

In other cases, former factory workers establish businesses that cater to current factory workers, relying on tacit knowledge of their social and economic needs. For example, we met a man running a boarding house and motorbike parking lot next to a major garment factory. He migrated for a job at the same factory and left it after a period of years to set up his enterprise across the road. Many other types of service providers similarly co-locate with large factories – like laundry services, repair shops, mobile phone recharge kiosks, and food stalls. The purchasing power of factory workers is significant: in our survey, respondents estimated their monthly budget for leisure and entertainment at IDR 300,000 (US$ 22), around 20 percent of their wages.

What are the policy implications of these insights? The first relates to the target populations for entrepreneurship programs. As a 2014 JustJobs Network study indicated, entrepreneurship policies in countries like Indonesia tend to target unemployed and underemployed young people who may have no option beyond starting a micro-business. These sorts of interventions miss the possibility of giving factory workers like those in Semarang Regency the tools they need to build businesses once they enter a new stage of their working lives. Moreover, while current policies tend to promote “survival” entrepreneurship, a different strategy – focused on harnessing the education, skills, work experience, capital as well as tacit knowledge and social networks of entrepreneur ex-factory workers – may be more successful in generating growth-oriented small and medium-sized enterprises. Such businesses will do more to address the major job creation challenge facing emerging economies like Indonesia than sole proprietorships.

Second, the trend our research reveals in Indonesia suggests that policymakers may need to adopt a different approach to informality. While a job’s formality is often used as a proxy for its quality – with labor market reforms reflexively oriented toward formalization – the active choice of some workers to move from the formal to the informal economy implies that formal and informal jobs may suit different needs at different stages in a worker’s employment journey. Smaller, self- and family-owned enterprises, which today largely operate in the informal economy, have certain qualities that appeal to workers.

This means two things: (1) Governments ought to consider long-term, fiscally sustainable approaches to creating strong safety nets for informal economy workers and entrepreneurs; along these lines. Indonesia’s recently rolled out universal health and employment insurance – BPJS – is a step in the right direction. And (2) The effort to formalize must be seen as a flexible, incremental process, one that enables small, everyday enterprises to thrive rather than squeezing them out of the economy in favor of large industrial outfits like those employing garment workers in Semarang. The relationship between these two types of firms is complementary – not only for the economy but for the individual worker over the course of her employment journey.

Authored by Gregory Randolph

Reproduced with permission from the JustJobs Network blog.

DISCUSSING NON-DETENTION AND CONTINUOUS COMPREHENSIVE EVALUATION (CCE)
EDUCATION

As Union MHRD minister Smriti Irani and the Delhi state government signalled their intention to reverse the no-detention clause of the Right to Education Act (RTE), CPR along with partners organized a seminar on the issue.

The first of a series, the seminar on 30th April debated the provisions of non-detention and Continuous Comprehensive Evaluation (CCE) in the RTE Act of 2009. A range of stakeholders, including educationists, teachers, researchers, government officials, and parents discussed whether failing students could solve the problem of low learning levels. They agreed that to raise learning levels, systemic issues such as shortage of trained teachers and good resource materials had to be addressed instead.

Watch the full recording of this important and interesting discussion above—a first step towards a much-needed informed public discussion on the issue.

AS PART OF ‘POLICY CHALLENGES – 2019-2024: THE BIG POLICY QUESTIONS FOR THE NEW GOVERNMENT AND POSSIBLE PATHWAYS’
CPR ECONOMY IDENTITY DISCRIMINATION

By Neelanjan Sircar

According to the International Labour Organization, female labour force participation in India dropped from 35% in 1990 to 27% in 2014.1 The gender gap in labour force participation in 2014 was 53 percentage points,2 and urban female labour force participation in India has all but stagnated for the last two decades.3

This has occurred in a context of rising per capita income – which accelerated in India from the 1990s onward – and a significant reduction in fertility rates. Indeed, standard economic theory predicts that as countries move from lower income to middle income (as India is doing), women leave the workforce as there is less need to engage in the most arduous forms of labour – such as agriculture and brick kilns – for a bit of extra money. As incomes rise sufficiently, it is argued that women are offered white-collar jobs and re-enter the labour force – as in the West.

But India’s numbers are far worse than what standard theories predict. A recent World Bank report found that the country is ranked 121st out of 131 countries in the female labour force participation rate, and much worse than many of its neighbours.4 In fact, Sri Lanka’s female labour force participation stabilized at around 35% decades ago, and Bangladesh consistently demonstrates well over 50% female labour force participation.

Most worryingly, India is losing its most educated and productive women.5 National Sample Survey (NSS) data shows that women who have passed higher secondary have the lowest female labour force participation in India.6 This is to say nothing of the ‘marriage penalty’ or ‘child penalty’ for women who drop out of the labour force due to marriage and childbirth. It is increasingly obvious that standard economic theory has it exactly backwards. We can’t wait for incomes to rise: incomes in India will stagnate unless we find ways to get women, especially the most economically productive, back into the labour force.

What can policymakers do to draw women back into the labour force?

Answering this question necessitates a closer look at the data. Recent research shows that the decline in female labour force participation in India is largely due to a drop in women entering the labour force in rural India.7 In plain language, this means that as rural incomes rise, women prefer not to do the backbreaking work of agricultural labour – which is understandable. But even then, there is still significantly greater female labour force participation in rural areas compared to urban areas. In other words, even with rising incomes, women in urban areas are not entering the labour market. The important question is this: why are women refusing or unable to enter the labour force in urban areas, where higher wage and higher skill jobs are available in greater numbers?

The challenges of integrating women into the labour force will only be accentuated as India continues to urbanize. From 2001-2011, the urban population growth rate was 2.4 times that of the rural population growth rate in India, significantly higher than any other decadal urban-rural population growth ratio in the country’s history. We only expect this process to accelerate. India is likely to see its urban population rise from 338 million in 2010 to 875 million in 2050; the increase of 497 million between 2010 and 2050 is the largest projected growth in urban population in world history.

Of course, the country will continue to manifest pernicious patriarchal norms that prevent women from entering the labour force. However, as our data shows, women themselves are quite willing to work – and the men in the household are supportive of it, despite these patriarchal norms. But it is Indian cities that are not hospitable to women entering the labour force. The proximate policy challenge for increasing female labour participation, thus, centres around managing rural-urban transitions and making cities hospitable places for women to work.

Why Are Indian Cities So Inhospitable to Women Wanting to Work?

Our understanding of female labour force participation must necessarily encompass a broad swathe of economic activities and opportunities. Labour force participation may be ‘formal’ or ‘informal’, given that most labour in India is in informal sectors. Labour force participation may also include entrepreneurship activities, from operating stores and food stalls to trading. It has been widely recognized that the role of many women in household duties – and its contribution to household economic productivity and expenditure saving8 – is rarely measured properly. Nonetheless, one must acknowledge the importance of female labour force participation outside the home. The opportunity to engage in economic activity outside the home increases the marginal value of employment, and it is also more likely to break discriminatory gender norms that coerce women to stay at home. Thus, no matter how incomplete the definition, standard measures of female labour force participation are important in and of themselves.

From an economic perspective, a woman’s decision to participate in the workforce is broadly viewed as a consequence of evaluating two trade-offs. First, as aggregate household income increases, the marginal benefit of entering the labour force is thought to decrease; that is, if there is sufficient money in the household, there are weaker incentives to get a job. Second, the incentive to join the labour force decreases as the opportunity costs (psychic or financial) of leaving home increase; that is, if it is particularly difficult to carry out necessary tasks at home while working, an individual would be less likely to work a job outside the home.These economic trade-offs, in turn, interact with urbanization in particular ways to negatively impact opportunities for women to enter the labour force.

In rural India, agricultural work is typically near the home, so there is a natural source for female employment. Even in non-farm work, rural India has demonstrated the capacity to employ women. For instance, more women than men availed of the opportunities provided by the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA) – often, small infrastructural work near the village.9

In urban India, on the other hand, such a natural source of women’s employment rarely exists near the home. Industries like construction tend to be less preferred by women and also tend to discriminate against women in hiring. This obliges women in urban India to look far from home for suitable employment. Unfortunately, the lack of safe transport for women to travel significant distances creates obstacles to working outside the immediate locality. If women are unable to procure safe and stable transport to and from a place of work in urban spaces, they are unlikely to enter the labour market, which likely negatively impacts female labour force participation.

These challenges help explain why urban women, among the most skilled in the population, are often missing from the labour market. In principle, more well-off and educated women should be able to command higher wages and better jobs, which would facilitate their entry into the labour force. But availing of these jobs often implies that women have to travel far for a suitable job. Thus, while a section of economists continue to argue that urban Indian women simply choose to stay at home as income rises, the real reason for low urban female labour force participation may well be the increased ‘costs’ of entering the labour market.

A Data-Driven Perspective

While the aggregate data shows a worrying trend of declining female labour force participation, we still lack systematic large-scale data on the labour market behaviour of working-age women. I have been conducting a wide-ranging study of female labour force participation jointly with Apurva Bamezai, Devesh Kapur and Milan Vaishnav. The research is taking place in four cities – Dhanbad, Indore, Patna and Varanasi – and the surrounding peri-urban and rural areas of each city. In each of the four urban areas (and surrounding areas), 3500 households are to be surveyed. In each household, a working-age female and the (usually male) primary wage earner is to be interviewed. This allows us to understand not only women’s own perceptions about the labour market but also possible constraints from men in the household.

Preliminary data from completed surveys in Dhanbad, Patna and Varanasi reveal important trends. In each of these three cities, only 20-30% of working-age women are (or have ever been) in the labour force. This is consistent with the overall national employment numbers described above. If a woman is in the labour force, she is 20 to 30 percentage points more likely to be engaged in agriculture compared to her working male counterpart. This suggests that even when they are able to enter labour force, a disproportionate number of women are engaged in labour near the home.

There is little evidence that women are willingly opting out of the labour force, as posited by the theory of income effects. Among working-age women who have never been employed, we find that 60-70% of women are willing to work if offered a suitable job.10 Somewhat surprisingly, a very similar percentage of male respondents believe that the woman should be allowed to work if offered a suitable job.

In each of these three cities, less than 30% of women feel ‘very safe’ travelling alone at night, compared to more than 40% of men. Our preliminary analyses also indicate that perceptions of easy, safe travel are major determinants of whether a woman is willing to enter the labour force. Taken together, this provides suggestive evidence that the city can be inhospitable to women who are willing to enter the labour force, even if there is support at home.

The Way Forward

Declining female labour force participation is a deeply worrying trend that must be reversed if India is to accelerate its economic development. Strong patriarchal norms still exist in India, but, as discussed here, low female labour force participation is about much more than social conservatism: a prime cause is how Indian cities discourage women from entering the labour force.

Fundamentally, women are not joining the workforce in urban India because urban infrastructure is failing them. The data suggest that there exist both a desire for women to work and support at home for it, provided there is stable and safe transport to and from work. Indeed, recent work by Girija Borker has shown how the safety of the Delhi Metro provided many college-going women the opportunity to attend high-quality colleges far from home.11 A similar principle is likely to encourage greater female labour force participation as well.

But the challenges of each Indian city are unique and context-specific. There are a number of complicated social factors that impact female labour force participation, and it would be foolhardy to generalize too much from the data we have collected. Ultimately, more systematic large-scale data collection on women’s labour choices is required, as this is the only way to identify actionable policies to address India’s low female labour force participation.

Other pieces as part of CPR’s policy document, ‘Policy Challenges – 2019-2024’ can be accessed below:

The Future is Federal: Why Indian Foreign Policy Needs to Leverage its Border States by Nimmi Kurian
Rethinking India’s Approach to International and Domestic Climate Policy by Navroz K Dubash and Lavanya Rajamani
India’s Foreign Policy in an Uncertain World by Shyam Saran
Need for a Comprehensive National Security Strategy by Shyam Saran
A Clarion Call for Just Jobs: Addressing the Nation’s Employment Crisis by Sabina Dewan
Time for Disruptive Foreign and National Security Policies by Bharat Karnad
Multiply Urban ‘Growth Engines’, Encourage Migration to Reboot Economy by Mukta Naik
Schooling is not Learning by Yamini Aiyar
Clearing Our Air of Pollution: A Road Map for the Next Five Years by Santosh Harish, Shibani Ghosh and Navroz K Dubash
Protecting Water while Providing Water to All: Need for Enabling Legislations by Philippe Cullet
Interstate River Water Governance: Shift focus from conflict resolution to enabling cooperation by Srinivas Chokkakula
Managing India-China Relations in a Changing Neighbourhood by Zorawar Daulet Singh
Beyond Poles and Wires: How to Keep the Electrons Flowing? by Ashwini K Swain and Navroz K Dubash
Regulatory Reforms to Address Environmental Non-Compliance by Manju Menon and Kanchi Kohli
The Numbers Game: Suggestions for Improving School Education Data by Kiran Bhatty
Safe and Dignified Sanitation Work: India’s Foremost Sanitation Challenge by Arkaja Singh and Shubhagato Dasgupta
Safeguarding the Fragile Ecology of the Himalayas by Shyam Saran
Towards ‘Cooperative’ Social Policy Financing in India by Avani Kapur
1 International Labour Organization, ‘Key Indicators of the Labour Market Database’, 2016, http://data.worldbank.org/indicator/SL.TLF.CACT.FE.ZS.
2 World Bank, ‘World Development Indicators’, Database, 2015.
3 Stephan Klasen and Janneke Pieters, ‘What Explains the Stagnation of Female Labor Force
Participation in Urban India?’, The World Bank Economic Review 29(3) (2015):449-478.
4 Louis A. Andres, Basab Dasgupta, George Joseph, Vinoj Abraham and Maria Correia, ‘Precarious Drop Reassessing Patterns of Female Labor Force Participation in India’, World Bank Policy Research Paper No. 8024 (World Bank, 2017).
5 It is worth noting that women who are college graduates do show somewhat higher levels of labour force participation. But this is likely explained by the fact that households with the most liberal attitudes towards female work allow their daughters to complete college and not get married as early, and display a host of other factors likely to encourage female labour force participation.
6 Farzana Afridi, Tara Dinkelman and Kanika Mahajan. ‘Why Are Fewer Married Women Joining the Work Force in India? A Decomposition Analysis over Two Decades’, IZA Working Paper No. 9722 (2016).
7 Ibid.
8 Ashwini Deshpande and Naila Kabeer, ‘(In)Visibility, Care and Cultural Barriers: The Size and Shape of Women’s Work in India’, Ashoka University Economics Discussion Paper 04/19. (2019).
9 Economic Survey 2018.
10 This is consistent with recent evidence from the NSS. Erin Fletcher, Rohini Pande and Charity Maria Troyer Moore, ‘Women and Work in India: Descriptive Evidence and a Review of Potential Policies’, HKS Working Paper No. RWP18-004 (2017).
11 Girija Borker, ‘Safety First: Perceived Risk of Street Harassment and Education Choices of Women’, Working Paper, 2018.

CPR RESEARCHERS ANALYSE THE ASSAM ELECTIONS
ELECTION STUDIES POLITICS

Based on days of field work, CPR researchers Neelanjan Sircar, Bhanu Joshi and Ashish Ranjan share field notes from the regions of Upper Assam and Barak valley, as the state awaits election results, to be announced after a month.

The battle lines are drawn between the BJP and the Congress. And the key question is: ‘Do voters take a chance on a party (BJP) that is promising greener pastures but has the potential to set fire to a social tinderbox, or do voters stick with the safety of a party (Congress) they know inside and out after 15 years of rule?’

There are no easy answers. Particularly so, because Assam is an immensely complicated state comprising regions with vastly different histories and cultures, juxtaposed with what appears to be a unifying desire for growth and development among a number of voters.

This in-depth field analysis unpacks the multiple narratives. Read the full paper here.

Sircar, Joshi and Ranjan will be sharing their next piece on the Lower Assam region.

KEY OUTPUTS
SOUTH ASIA

The Centre for Policy Research organised the 5th South Asia Regional Meeting of think tanks supported by the Think Tank Initiative in November, 2015.

A range of topics spanning agriculture, trade and food security in the region; the role think tanks play in influencing policy; climate and environment; addressing issues of poverty and development; and working toward greater South Asian cooperation were deliberated at the meeting. In addition to sharing learning and understanding challenges, think tankers and donors focused on charting the future trajectory, with the aim of continuing to be effective within the South Asian milieu.

Over twenty think tanks; the Canadian High Commission; political representatives from India and Sri Lanka; select media representatives; and donors participated in the meeting.

Provided below are key outputs that emerged from the meeting:

A summary report highlighting the key themes addressed and the recommendations that emerged.
Videos of the following sessions:
Session on Agriculture, Trade and Food Security
Panel on Collaborative Adaptation Research Initiative in Africa and Asia (CARIAA)
Session on Climate and Environment
Session on Poverty, Development, Inclusion and Public Service Delivery
Session on Governance, Urbanisation and Accountability
Special Session on Safe and Inclusive Cities
Key Note Address by Harsha de Silva, Hon. Deputy Foreign Minister, Sri Lanka, on Think Tankers as Policy Makers
Photographs from all days: Day 1 Day 2 Day 3
Presentations by: CSTEP, Harish Damodaran, IPS, CPD
Storified live tweets from the meeting.
The dedicated event page can be visited here.

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.

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 ANNOUNCEMENT
WATER RESEARCH

Centre for Policy Research (CPR) and the Ministry of Water Resources, River Development & Ganga Rejuvenation (MoWR) have signed an agreement establishing a ‘MoWR Research Chair – Water Conflicts and Governance’ at CPR, with a mandate to pursue independent and evidence-based research to inform policy making, and enabling institutional transformation towards addressing the evolving challenges in India’s water sector.

Dr Srinivas Chokkakula has been appointed as the MoWR Research Chair – Water Conflicts and Governance. Dr Chokkakula is a Fellow at CPR, and has an interdisciplinary training in political geography, planning and engineering.

The Research Chair will pursue a broader research agenda in transboundary water conflicts/cooperation, initially focusing on interstate river water cooperation and disputes resolution targeting policy-relevant research outputs. The Research Chair will also help foster an enduring CPR-CWC (Central Water Commission) collaborative research relationship, beginning with a forum for dialogue on contemporary water sector issues and challenges. The forum will make particular efforts to bring in key stakeholders’ perspectives – of the States and civic society actors – towards better Centre-States and state-society engagement in policy making. The Research Chair is also expected to extend advisory inputs as required by the MoWR and its agencies such as the CWC.

Dr Srinivas Chokkakula’s research and policy interests are primarily in water policy and institutions, focusing on transboundary water conflict/cooperation and governance. His research interests also extend to the broader area of politics of infrastructure development, including inland waterways, smart cities, and rural roads. He currently leads multiple research projects clustered under a TREADs (Transboundary Rivers, Ecologies, and Development studies) programme engaging primarily with interstate (federal) river water governance in India. Chokkakula has written and published widely on the topics, both in academic journals and mainstream outlets, including a recent monograph, ‘Why do interstate water disputes emerge and recur? An anatomy of ambiguities, antagonisms and asymmetries’. His complete bio can be accessed, here.

WORKSHOP BY CPR
RIGHTS IDENTITY DISCRIMINATION

Listen to audio (above) of the workshop analysing the draft Equality Bill, drafted and presented by Tarunabh Khaitan, which has been designed for NCT-Delhi, but is also adaptable to states or the centre. The draft was updated incorporating suggestions shared during the workshop.
A summary report of the workshop is available here.

For the full draft bills, both for Delhi and other states, and media coverage, please visit the dedicated page here.

FULL VIDEO OF THE DISCUSSION AND CURATED ANALYSIS BY CPR SCHOLARS
POLITICS ELECTION STUDIES

Watch the full video (above) of the CPR Election Adda discussion on ‘Analysing the 2019 Haryana and Maharashtra Assembly Election Results’ featuring Rahul Verma (Fellow, CPR); Supriya Sharma (Executive Editor, Scroll.in); Neelanjan Sircar (Senior Visiting Fellow, CPR and Assistant Professor, Ashoka University); Gilles Verniers (Co-Director of Trivedi Centre for Political Data, Ashoka University); Sheela Bhatt (Senior Editor).

Haryana and Maharashtra went to the polls within six months of a resounding victory for the Bharatiya Janata Party (BJP) in the 2019 Lok Sabha elections. While India is amidst economic slowdown, the popularity of Prime Minister Narendra Modi remains high and has contributed to the BJP’s strong showing in both these states. To understand this phenomenon, the CPR team presented a detailed analysis of the result, which was followed by a wider panel discussion. This panel discussion was supported by Rosa Luxemburg Stiftung – South Asia.

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

Scholars at CPR have closely followed the electoral developments of the Assembly Elections. Read their curated analysis below:

Analysis of the Result:

There is no doubt that the vote was against the ruling establishment by Rahul Verma
Rahul Verma writes in Hindustan Times about factors that have changed the electoral fortunes of the BJP just months after its resounding win in the national elections. He explains that the BJP has a reason to worry, given it lost more in rural areas, failed to sustain a coalition of extremes, and saw a dip in reserved seats. Verma highlights that these election results have given another lease of life to the Opposition parties and the next round of elections in Delhi and Jharkhand will provide an answer to whether these parties are going to build on this opportunity.

Haryana verdict likely to boost regional satraps by Neelanjan Sircar
Neelanjan Sircar writes in Hindustan Times about how the results of the Haryana Assembly elections will embolden regional actors. He points that the BJP has increased its state-wise vote share compared to the last state election, but it has underperformed goals that it set for itself after its triumphant national election performance. More importantly, Sircar highlights that the Jannayak Janta Party seems to be on an ascendant in Haryana politics and its geographic configuration of support, which complements the Congress, and means the BJP requires higher vote shares to win seats in Haryana.

Haryana shows BJP isn’t invincible in assembly polls. But here’s what saves it in the end by Rahul Verma and Pranav Gupta
Rahul Verma and Pranav Gupta write in ThePrint about how the Haryana verdict serves a good reminder that under a slowing economy, parties with formidable state leaders can challenge Modi-Amit Shah’s ambition. They analyse that the results show that while the BJP succeeded in building a meta-narrative around national issues, it remains on the back foot on local issues. Further, caste is no longer an evergreen in Indian election, but springs up more prominently in some elections, depending on many other factors. Lastly, they point that concerns of economic well-being cannot always be trumped by emotive issues of religious nationalism.

Pre-Election Analysis:

BJP frontrunner in Haryana, Maharashtra. But real benefit is in states with strong opposition by Rahul Verma
Rahul Verma and Pranav Gupta write in ThePrint about how the BJP became a dominant party from a marginal player in Haryana and Maharashtra. They point to the role of pre-election coalitions and how the party has successfully mobilised a coalition of non-dominant castes in the states, thus making it a force to be reckoned with. Verma and Gupta also highlight that a weak and divided opposition has played a crucial role in improving the BJP’s fortunes. In conclusion, they write that a victory in Haryana and Maharashtra will not only put the party firmly into the politics of these states, but will also create favourable conditions for it in the upcoming Jharkhand and Delhi elections.

BJP has risen in Maharashtra by dismantling Sharad Pawar’s old empire piece by piece by Rahul Verma
Rahul Verma writes in ThePrint about BJP’s two-pronged strategy to dismantle Sharad Pawar’s empire in order to rise in Maharashtra. He explains that the amendment of the Maharashtra Cooperative Societies Act enabled the BJP to gain control of sugar and milk cooperatives, local bodies, and cooperative banks in rural Maharashtra. Further, the investigation into the financial mismanagement in Maharashtra State Cooperative (MSC) Bank during the previous regime and cases against members of Pawar family and 71 bank directors, created unease among many Congress-NCP politicians who feared a similar hunt-down. The declining value of contesting on the Congress-NCP ticket further added to the anxieties among these politicians and brought many of these local satraps in the BJP-Shiv Sena fold.

Has lack of strong opposition in Maharashtra and Haryana made the elections a no-contest?
Rahul Verma writes in TalkPoint by ThePrint about the reasons for the weakening of the opposition. He highlights that the opposition has not done enough to raise issues, mobilise voters, and enthuse workers on the ground. Further, the projection of the BJP’s national dominance is making the opposition look further disarrayed. Voters also do not perceive the opposition as credible enough. The fragmentation of the opposition has brought down the value of the tickets of these parties. Finally, Verma also points that the BJP has an added advantage of its national leadership.

Neelanjan Sircar writes in TalkPoint by ThePrint highlighting that even though the Haryana and Maharashtra assembly elections might be a no-contest battle for the BJP, we should not extrapolate this electoral environment to future state elections. He points to the results of the 2018 assembly elections in Chhattisgarh, Madhya Pradesh, and Rajasthan that show that Congress’ state units can win elections independently of the party’s fortunes at the national level.

[WATCH]: What do the Maharashtra and Haryana elections have in store?
Rahul Verma appeared on an episode of The Big Picture by Hindustan Times to discuss significance of these assembly elections. He also explained how the BJP has maintained its dominance and what the crisis in the Congress is.