Wednesday, August 14, 2019

Why we need community health providers

They fill the vast gaps of access and quality. There’s a way to reconcile the views of the government and doctors

Are community healthcare providers needed, but unwanted? The controversy over the provision to provide limited licence to practice allopathic medicine, in the National Medical Commission (NMC) bill, unleashed an outcry of “quackery” from the medical professionals. It is essential that we consider who these healthcare providers are, and what role they can play in strengthening our health services. A look at global experience and the chequered history of mid-level health care providers in India will help.

An ideal health workforce is multilayered and multi-skilled, with complementary roles delivering competent, comprehensive, continuous and compassionate care. Doctors and nurses are most identifiable, but a variety of allied health professionals and community health workers are also integral. Among doctors, there are basic and specialist doctors. Among nurses, there are basic nurses, midwives and advanced nurses. A wide array of allied health professionals exist, from radiographers and optometrists, to lab technicians to physiotherapists and so on. Two other categories have been added across different countries, to meet growing but unmet healthcare needs. These are the community health workers (CHWs) and the mid-level healthcare providers.

Several developing countries have deployed CHWs, under different names but with the same intent — providing basic health services at home or close to home. CHWs also act as community mobilisers and trusted links to the organised health services. Ethiopia employed “health extension workers” to provide better antenatal care and reduce maternal mortality. Rwanda has recorded the sharpest fall in maternal mortality in the past 25 years, by deploying CHWs to link communities to nurse-run primary healthcare facilities. Swasthya Sebikas and Swasthya Kormis have strengthened primary healthcare in Bangladesh. Thailand has CHWs designated as village health volunteers and village health communicators. Brazil’s family health teams, too, have CHWs as an important component. India started deploying CHWs initially as mitanins in Chhattisgarh, and later built a nationwide army of accredited social health activists (ASHAs) as part of the National Rural Health Mission.

Mid-level health workers are a category of care providers who are more skilled and qualified than CHWs. This is a concept that emerged when even high income countries recognised that some of the functions that a doctor is traditionally expected to perform can be delivered by skilled persons with a lower level of training. Categories such as nurse practitioners, nurse anaesthetists and physician assistants grew in the United States. These drew on the experience of the Civil War and the Second World War when a shortage of doctors led nurses and paramedics to step in and perform. Formal training programmes, accreditation and role definition followed. Presently, nurse practitioners are a well-defined category in the US, New Zealand and Australia. Apart from shortages of doctors in some regions, the rising costs of healthcare also catalysed the emergence of mid-level healthcare providers.

The Indian experience of creating these categories has been fraught with hesitation and hurdles. Even the National Health Policy (NHP) of 2017 recognises this need, but progress has been slow and contentious. Chhattisgarh initiated a three-year graduate training programme (Diploma in Modern and Holistic Medicine) for creating a cadre of rural medical assistants. They were shown to be as capable as doctors in delivering some of the primary care services. Despite several name changes, the conflict between medical professionals and the aspirations of the new graduates resulted in an identity crisis that finally led to closure of the programme. Assam is the only state where such a course is presently run (Diploma in Medicine and Rural Health Course). On the other hand, the category of Physician Assistants (PAs) has taken root in some southern states and West Bengal, through a 4-year graduate course run by universities. They mostly perform duties under the supervision of doctors in hospitals but have the potential for delivering preventive and promotive services in primary care settings.

Seven years ago, the Union health ministry initiated a proposal to train and employ mid-level healthcare providers through a three-year programme modelled on the Chhattisgarh course, to meet the needs of primary care. The Medical Council of India (MCI) developed a curriculum which was a compressed MBBS programme (“MBBS Bonzai”) more suited to hospitals than to primary care. The MCI, however, balked at regulating this course because it violated its mandate to deal only with medical education.

So, the health secretary of the time, PK Pradhan came up with an unorthodox solution. The course was labelled as B Sc(Public Health), and the National Board of Examinations (NBE) was asked to deliver it through its affiliated hospitals and colleges. The NBE, which was hitherto mandated to deliver only postgraduate medical education, accordingly modified its articles of association to include undergraduate and postgraduate courses in public health. A group of experts, which included VK Paul (presently a member, NITI Aayog) prepared the curriculum for the course. However, the proposal lost steam after Pradhan’s tenure ended.

The proposal resurfaced after NHP 2017 called for a BSc in community health and “bridge courses” for developing mid-level healthcare providers. The proposal to provided bridge courses to AYUSH practitioners of the Indian systems of medicine seems to have retreated in the face of fierce opposition from the Indian Medical Association (IMA). However, the inclusion of community health providers (CHPs) in Section 32 of the recently passed National Medical Commission (NMC) Bill has reignited the debates on the qualifications, competencies and functions of these mid-level providers.

The concerns about this provision in the NMC arise because it was an abrupt insertion into the original bill that went before the Parliamentary Standing Committee on Health in early 2019. The courses prescribed, the institutions which will deliver them, the competencies that will be promoted and the nature of functions they are expected to perform are not clear at this stage. Only the role of the NMC in issuing a limited license is described, with ambiguity on when, where and how much medical supervision is required or autonomy is permitted. The blurred lines between NMC (which regulates undergraduate and postgraduate medical education through medical colleges) and this new cadre are agitating the organised medical profession.

India needs mid-level healthcare providers in several forms — nurse practitioners, physician assistants and community health providers — to fill the vast gaps of access and quality in our health services. They are especially required for primary care. Perhaps it is best to diffuse the controversy over CHPs by bringing them under the purview of the Allied Health Professionals Bill which is due to go before Parliament. The CHPs may not fit well into the NMC but surely they can be accommodated as allied health professionals. That may bring accord between the government and the medical profession.

Srinath Reddy is president, Public Health Foundation of India, and author of Make Health in India: Reaching a Billion Plus

Source; Hindustan Times, 13/08/2019

Mellowing With Age

When Buddha was old and he realised that the time was ripe to leave the world, he called his two favourite disciples and said, “Soon, I won’t be with you. I’ve nothing to offer and nothing to preach; nothing to accept nor expect. All I’ve is the body, which is tattered because of old age. I know nothing of enlightenment.” Youthful arrogance mellows into affable modesty as one grows old and it finally sublimates into selfeffacing humility. The vicissitudes in every individual’s life leave their impressions, but we start feeling their impact and ramifications only with advancing age. Harivansh Rai Bachchan wrote, “Now with age, sitting against the silhouette of a setting sun, I ruminate and introspect. I look at my whole life from a deeper perspective.” Life can only be judged in its totality when it reaches its logical end. During one’s youth, there’s often an irrational and romantic fascination for cutting short one’s life, which is called ‘intellectual hara-kiri’ or ‘James Dean Syndrome’, after the Hollywood heart-throb, who acted in the cult movie, ‘Rebel Without a Cause’, and died very young. Rabindranath Tagore took to painting at the ripe age of 65 and Nirad C Chaudhuri kept writing till he breathed his last at the age of 99. It’s been found in a number of cases that the human body can generate new cells, especially glial brain cells, responsible for higher level of thinking and cognition. This explains why very many greats have been ‘late bloomers’. A new awakening awaits you.

Source: Economic Times, 14/08/2019

Tuesday, August 13, 2019

Economic and Political Weekly: Table of Contents

Vol. 54, Issue No. 32, 10 Aug, 2019

Editorials

The Value of Federalism

Designating Individuals as Terrorists

From the Editor's Desk

The Idea of ‘Second Thought’ and Article 370

Gopal Guru

H T Parekh Finance Column

A Rate Cut That Failed to Please

C P Chandrasekhar

Alternative Standpoint

A Blinkered View of Humanities Education?

Sundar Sarukkai

Commentary

Book Reviews

Unpacking the Motives of Neo-liberal Regimes

D Narasimha Reddy

Sedition Cross-examined - Understanding the Contradictions of India’s Democracy

Ankita Pandey

Perspectives

Food Subsidy in Cash or Kind? - The Wrong Debate

Anirudh Krishna, Tushar Agrawal

In Quest of Inclusive Growth

R B Barman

Special Articles

From Mobile Access to Use - Evidence of Feature-level Digital Divides in India

Jang Bahadur Singh, M Vimalkumar

Restricted and Unrestricted Fiscal Grants and Tax Effort of Panchayats in India

Raghbendra Jha, Hari K Nagarajan, Anirudh Tagat

Groundwater, Gurus, and Governmentality - Seva in the Neo-liberal Development Regime in India

Srirupa Bhattacharya

From 50 Years Ago

From 50 Years Ago: Not without Returns

Letters

‘Where Is My Language?’

Ramanujam Meganathan

Condemning Police Brutality

Sabina Martins

Discussion

Why Caste Matters - Reading Electoral Outcomes through the Optic of Caste

Vishesh Pratap Gurjar

Current Statistics

Appointments/Programmes/Announcements

The perilous state of academic freedom

e types of scrutiny are more scrupulous, thorough and rigorous than others. They uncover indefensible, baseless or unsustainable opinions. They demonstrate that other opinions are less-biased, withstand the test of time, and have a greater openness in accepting their fallibility. In doing so, these inquiries produce a better, clearer understanding of the world, providing a deeper insight into the complexities of the human condition. Therefore, they are of a different qualitative worth than others, more deserving of being called ‘knowledge’. Knowledge-production begins with opinions but does not end with them.

Academic freedom protects such spaces of contestation and scrutiny through which knowledge is produced. It refers to the freedom of scholars to conduct critical enquiry, and the freedom of teachers and students to collectively deliberate on any idea without fear of sanction, censure or illegitimate interference. To sift knowledge from mere opinion requires a sound training in research and an awareness of professional standards of scholarship, norms of peer engagement and time-tested, disciplined ways of knowing (methodologies). This is true of all practices involving standards of excellence. For instance, it is not my subjective opinion that Viv Richards was a great batsman. This fact is established by the collective judgment of the greats of international cricket.

Patiently acquired skills

In short, academic freedom protects the patiently acquired skills and practices of all such knowledge-producing and knowledge-transmitting agents (teachers, researchers and students). Since academic practices are sustained within institutions, academic freedom includes the autonomy of institutions where teaching and scholarly research is conducted.

My intellectual interest in academic freedom was provoked when, in 1999, I was asked to contribute a short essay on the state of academic freedom in India to Academe, a journal of the American Association of University Professors. In that article, I claimed that the freedom of scholars and autonomy of academic institutions is usually threatened by internal as well as external factors.

Internal threats appear when academic institutions are weakened from within, as when academics themselves lose sight of the standards of excellence internal to the practice of research and teaching. External threats develop, on the other hand, when academic institutions are undermined by oppressive communities, the coercive apparatus of the state or unbridled market forces. I had then argued that Indian academia was severely threatened by oppressive communities and self-imposed impediments by academics, but less so by the market or the state.

I took my own community to task for having succumbed to what I called the over-ideologisation of the mind. Many academics, in a hurry to bridge the gap between theory and practice, seemed to me to have replaced patient, open-ended deliberation with dogma and prefabricated, lazy solutions. Other internal threats to academic freedom flowed from wider societal malaise. For instance, merit-based institutions were being converted to little fiefdoms run by academic tin gods doling out petty patronage to loyal supporters and creating suffocating tyrannies for others. In such contexts, ideas were applauded or condemned not for their intrinsic worth but with an eye on who articulated them — one of ‘us’ or one of ‘them’, A person’s caste, creed or political proclivity mattered more than the evidence or argument provided. Such habits of the mind were hardly conducive to the growth of a tradition of scholarly work.

A more serious danger to academic freedom in India came, I believed, from illiberal communities. I illustrated my point by pointing to the fate of the late historian Mushirul Hasan, who was victimised by extremist fellow-Muslims for a rather innocuous remark on the ban on Rushdie’s Satanic Verses.

Interestingly, barring the brief period of Emergency, academic freedom in post-Independence India, I claimed, was not throttled by the state. I did not remember instances of seminars being monitored, academic books being banned, or the imprisonment of academics for their views. However, covert and overt pressures on academic institutions by democratically elected governments were commonplace. As it began to lose its dominance, an edgy and insecure Congress Party had started becoming increasingly unprincipled and randomly interventionist. In West Bengal and Kerela, the Communists could never resist illegitimately interfering in college and university appointments.

The Bharatiya Janata Party-led coalition, in power at the Centre then, had harmed the institutional integrity of the prestigious Institute of Advanced Study, Simla. Its governing body was packed with hand-picked supporters.

What is the state of academic freedom today, twenty years after that article was written? I fear that more and more academics in positions of power appear to be not just over-ideologised but politically indoctrinated. A deepening societal intolerance has only intensified attacks on academic freedom. The exclusion of several important books from university syllabi, entirely on non-academic grounds, exemplifies this. State interference has increased, sacrificing critical pedagogical practices in the name of the government’s idea of national interest. The continuing victimisation of the Jawaharlal Nehru University (JNU), one of the premier academic institutions of the country by the current government’s own reckoning, illustrates this.

Knowledge a ‘commodity’

Alarmingly, new threats to academic freedom have emerged. One comes from the corporatisation of academia, by which I mean the modelling of universities on business corporations. This has naturalised the viewing of administration as management, faculty as paid personnel, and students as consumers who have a right to demand what should be taught, as if knowledge can be purchased as a commodity according to one’s taste! When corporate power exercises control over faculty and curricula, vice chancellors and college principals can hire, fire, and change faculty assignments with as much whim as any corporate CEO.

But the most serious threat to the world of knowledge comes from ‘anti-intellectualism’ that finds the very idea of thought reprehensible. Thinking, reasoning, questioning and critique are deemed dangerous, to be treated with utter disdain. The distinction between knowledge and opinion is entirely blurred; ideas of informed authority, professional academic standards and academic expertise are ridiculed. The very idea that the task of education is to transform students into critical agents, who actively question the common sense of a society, is severely undermined.

If these trends continue, the university as a site of autonomous scholarship, independent thought, and uncorrupted inquiry will be disassembled. Our best young minds will emigrate and the very future of our country imperilled by another ‘brain drain’. India may not easily recover from this blow.

Rajeev Bhargava is a political theorist with the Centre for the Study of Developing Societies, New Delhi

Source: The Hindu, 13/08/2019

Countering the Right’s hegemony

In a fightback, only a deep fostering of intra-subaltern solidarity using culture can help

India has witnessed the rise of the Hindu Right as not just a political but also a cultural force like never before. The has been made possible by a series of tactical moves which has allowed for a consolidation of power with the traditional castes and classes.

The Right has managed to do this by exploiting and magnifying micro-level social conflicts that lie dormant in order to create a meta-level hierarchy and reinforce the hold of traditional power. It has led to a weakening of the resistance of lower end social groups by fragmenting them and allowing intra-caste, intra-religious and intra-regional differences to articulate themselves in order to de-legitimise the resistance and mobility of vulnerable social groups that have so far benefited and accrued some social power. The Right negates the power of such groups in the name of justice and power to those even weaker and further neglected.

In terms of caste, it is now well known that the Right has made significant advances in terms of breaking up Dalit sub-castes and fully exploiting intra-sub caste tensions and mutual prejudices.

Everyday prejudices

Similarly, it is making advances in mobilising lesser mobilised Other Backward Classes (OBC) groups against dominant OBC groups such as Yadavs and Kurmis. It is further sharpening the conflict between OBCs and Dalits. Added to all this is allowing the dominant Rajput caste to vent its angst against the mobility Dalits have accrued so far: by allowing street violence and mob lynching of Dalits. It is reinforcing social power of dominant castes at one end and fragmenting this through a mobilisation of lesser mobilised sub-castes of subaltern castes. It is sharpening dormant prejudices that have existed for a long time between subaltern castes, caste and religion, and religion and region.

Similarly, the relation between Dalits and OBCs has been fraught with mutual suspicion and dislike, in spite of four decades of ‘Bahujan’ identity having been mobilised, mostly in the north. In fact, B.R. Ambedkar himself identified the OBCs as ‘savarnas’ and sometimes equates them with Aryans. This again collates in complex ways with regional dynamics between the north and the south. What the location of the OBCs is in this complex matrix is not very clear historically; politically the kind of mobility they have got after the implementation of the Mandal Commission has only sharpened the differences. Violent attacks against Dalits by the OBCs are a continuous, if less discussed aspect of Indian politics. The Khairlanji incident was the most recent attack against Dalits by the Kunbis who are listed as OBCs in Maharashtra.

Within the minority religion too, which includes Muslims, there are castes, sects and other differentiations. For instance, in Kashmir, there are differences between Sunnis and Shias, between Sunnis of the Valley and those in the border areas of Poonch and Rajouri, and those living in Ladakh. They neither inter-marry nor do they enjoy amicable relations. Class and regional prejudices overlap with that of sect and caste.

The Bharatiya Janata Party (BJP)-Rashtriya Swayamsevak Sangh-led hegemony is not a top-down machination even if there is fear, intimidation, control of media and destabilisation of institutions. The current dispensation is bringing into the open all the cultural contradictions that existed historically. While the Congress’s inclusive nationalism attempted to accommodate social groups politically without overcoming social prejudices, the BJP’s muscular nationalism lies in including them politically but dividing them socially. The divisions existed; the Right is only wi

A new multitude

The fight against the Right is only focusing on critiquing its strategies and exposing it without offering a positive fight to construct an intra-subaltern solidarity. There needs to be a robust cultural programme of fighting prejudices, encouraging inter-dining and inter-marriages. Not mere tolerance but positive celebration of cultural differences is required. Whether or not the Right can be made to retreat depends on this deep cultural programme. We are not clear how one should go about it. This may have to happen as more of a cultural than a political fight. It has to be about humanity, not power; it has to be more about everyday realities than about a programmatic idea of justice.

Every move towards solidarity is also perceived as lowering the status of groups that are higher-up in the ladder-like structure even if they are simultaneously victimised by dominant groups. Sub-division of Dalits is viewed as a pulling down of the relatively well-to-do castes within Dalits; a sub-division of OBCs is seen as a mode of allowing for the domination of traditional caste Hindus. Gandhi attempted ‘change without conflict’; he failed to usher in faster change but offered a semblance of burying conflict. Today, we are witnessing conflict and change itself is suspended between mobility and reinforcing traditional hierarchies. Mere critiquing and electoral defeat of the Right is not going to work.

Castes, religious groups and regional identities should fight it upfront by overcoming the prejudice within. To truly fight the Right, relatively dominant social groups must be prepared to lose a bit of social power they wield, however small it may be. It would also mean being critical of one’s own social location, however oppressed it may be. Is this realistic at the current historical juncture? The Right compulsively requires fear, anxiety and insecurity to block the process. What are the cultural resources on the other side of the political divide?

Ajay Gudavarthy is Associate Professor, Centre for Political Studies, JNUdening them.

Women are good managers in businesses

Not only female founders, but female executives also considered better than male counterparts in ensuring success to their respective startups

Sarah Fink, Head of Research at the Centre of Entrepreneurs, once said, “Women entrepreneurs are more likely to work towards controlled, profitable growth with relatively little interest in merely positioning themselves for lucrative exit. Also, they often prefer to re-invest business profits over equity investment to scale sustainably.” These are not just verbal claims even the world’s top research firms authenticate that women business leaders are ahead of their male counterparts on various fronts. And, this is not something new, The findings of a survey conducted by the Harvard Business Review in 2012, shows that in all key positions women are more effective leaders than men in the corporates.

Womenable, a social organization in the US also found that women are outperforming men in business. The results of the survey that Womenable conducted during 1997-2014 are astounding. According to the survey, women-led organizations in the US registered 72.3 per cent growth while the growth of male-owned firms was only 45.1 per cent during the same period. On the other hand, as per the statistics of First Round, businesses run by with at least one female founder brought 63 per cent more return on investment than companies solely owned by male founders.

Also, female business leaders are ahead of their male counterparts in employment generation. As per the study of Census Bureau on employment generation during 2007-2015, employment generation rate in women-led organisations was 18.39 per cent during that 8-year long period whereas organizations under the leadership of male entrepreneurs could achieve only 0.37 per cent growth. Consequently, the former group created 1.24 million more jobs than the latter one.

Not only female founders, but female executives also considered better than male counterparts in ensuring success to their respective startups. The study carried by Dow Jones VentureSource reveals that startups with more female executives had a better success rate and vice versa.

Attributes that make women better leaders

The above studies clearly reveal that on various leadership positions women perform better in the business world because of some personality traits that give an edge over men. Attributes primarily responsible for better performance are as follows.

Pretty Ambitious

Big dreams, when pursued by big efforts, bring big results. Being ambitious by nature, women strive and work hard to achieve their personal and professional goals. When a woman takes charge as a leader in corporate boardrooms, she aspires to overcome all limitations with her ambitious mindset and positive attitude. A survey by Centre of Entrepreneurship reveals that more than 65 per cent of women at top managerial positions are interested in establishing their own enterprises in the next three years, while less than 33 per cent males at similar positions are interested in entrepreneurship. And 47 per cent established female entrepreneurs are interested to venture into another business, while only 18 per cent men in similar capacity are willing to start one more business in addition to the existing one. The more or less same scenario was observed regarding the expansion of current businesses. The percentage of women entrepreneurs who are keen to expand the business was 32 whereas only 27 per cent of males were keen to expand.

High EQ

People who give respect to others’ emotions and controls their own emotions usually remain strong to their convictions and commitments. Studies suggest that women are emotionally more controlled and they apply their minds over hearts. In comparison, a man can be easily deceived through false emotions. They are short-tempered, aggressive, and overly reactive to things that are least significant in the business world. In contrast, women can easily notice the things manipulated by others, they are better in knowing people’s intentions as well as attention. All these intrinsic qualities of women leaders help them a lot while negotiating with stakeholders, vendors, and competitors.

Good at risk calculation

Various research done in the past about the investment behaviour of men and women helps to conclude that there is a remarkable distinction between the two. Usually, men seek faster growth in their returns and that’s too in a shorter duration whereas women look for long-term steady growth. Men prefer to invest their profits in stocks and commodities, but women want to multiply profits by reinvesting them in their businesses. This behaviour reflects that women have better skills to calculate present risks and future returns and they work on strategies which ensure long-run sustainable growth. This attribute throws light on another leadership aspect, that is, women are more rational in predicting future returns and men are overconfident while making investment decisions.

Source: Hindustan Times, 13/08/2019

Siddhartha’s Suicide

My prayers to V G Siddhartha, the departed soul, founder of Café Coffee Day. Now what we can learn is that life is not worth committing suicide for. Life is worth living. All of us should learn one thing: plan purposefully, prepare prayerfully, proceed positively, pursue persistently, produce productively. First, we need to set our goals, and, second, we need to audit our effort. How we are going towards the goal and realise that more than working hard, we should work smart. When you are working smart, you will audit your life; you will also learn how to be flexible. Agility, mobility and stability are important dimensions in doing business. If we can learn to be flexible, to enjoy what we are doing, then, we teach ourselves that we are bigger than the result. Success should not define us, failure should not define us; one should become bigger than the outcome. When we become bigger than success and failure, there is fulfilment. The Bhagwad Gita says fulfilment is what we need to see. If a person can learn to love what they do and do what they love and if any failure happens in life, just learn from it. If we look at Siddhartha’s life, his assets were more than his liabilities. He could have clearly solved his problem. Somewhere we have to train our mind to healthy options; better options and not bitter options. Let us all pray for Siddhartha, such a good soul and who did good work. Let us all be alert

Source: Economic Times, 13/08/2019

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