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NRMC India conducts a variety of sectoral research which helps in taking the projects/ programmes forward by providing critical knowledge for design, capacity building, implementation and policy advocacy through a robust knowledge base.

1) Insuring Health for the Base of Pyramid: Perspectives on Service Delivery from the Field

NRMC has undertaken studies to measure the impact of Rashtriya Swasthya Bima Yojana (RSBY)** and state health insurance schemes across ten states in India. The studies’ assessment entailed interactions with multiple stakeholders of the scheme – community, insurers and the healthcare service providers (public and private). The studies have led to a number of insights where the schemes/programs have fulfilled the intent to percolate benefits of cashless medical services through the structure of private health insurance for the Below Poverty Line (BPL)1 population of the country.

Our experience with the community suggests a number of operational and awareness related issues could be attributed to the lack of access to the benefits of the scheme, one of them being reluctance of private hospitals to operate under the scheme. This feedback from the community led our team to engage with the private healthcare facilities and doctors to explore the reasons behind this putative reluctance. This brief note shares the perspective of the private hospitals to the implementation issues under health programs.

NRMC team interactions with doctors and staff in hospital administration were dotted with a lack of willingness to remain empanelled under the scheme, with some reported to have already opted out. Hospitals, that are the last mile service providers under the scheme, have been left at the behest of the insurer to deal with their issues, grievances and concerns.insuring health 1 Their perspective has a bearing on the implementation of health insurance schemes/programs; their inputs being of those who are entrusted with service delivery under the scheme/program and are yet powerless to effectively drive the process. It is a valid argument that they are capable of identifying operational bottlenecks and hence the importance of their say in planning and policy formulation stages itself.

1.In context of RSBY, any Below Poverty Line (BPL) family holding yellow ration card, whose information is included in the district BPL list prepared by the State government is a beneficiary.

A large number of the doctors and medical facilities that were interviewed reported to have faced rejection of claims by the insurance company at least once over the past two years. More importantly, majority of these were unaware of the reasons for claim rejection. Absolute power with the insurance company to take decisions regarding the conduct of empanelled hospitals coupled with perceived lack of medical expertise on part of the insurer also added to the doctors’ hostile perception regarding this discretion. A gynaecologist recalled hassles in explaining to insurer’s staff of the reasons for not conducting a sonography for a patient with prolapsed uterus. Hasty decisions to penalise the healthcare facilities, however, prove to be much more than mere monetary loss for these hospitals.

The implementation of the scheme, though paperless, is challenged by technical glitches and administrative delays. What choice does a doctor have in an emergency case when the beneficiary details do not match with the scheme’s database? The scheme mandates verification of the beneficiary prior to beginning of treatment for being eligible to claim. Should the doctor, in such a case, delay the treatment putting the patient’s life in danger, or continue the treatment according to the hospital’s norms? The alleged refusal of RSBY in such cases clearly stems from inefficient management of data rather than hospital’s unwillingness. “The government and the insurance company have taken a stance that it is always the doctor’s intent to misuse the scheme,” voiced a paediatrician who de-empanelled from the scheme two years back. Instances of non compliance from patients also create a barrier of effective delivery of service by health service providers. For instance, in case the beneficiary forgets to bring the registration card to the hospital or brings a wrong year’s card, the doctor is unable to treat the patient under the scheme pending verification. This raises a question on the effectiveness of IEC activities undertaken to spread awareness among beneficiaries about the provisions of the scheme. Instances in the past where patients have then gone ahead to complain to the authority of the doctor’s refusal to treat under the scheme have led to hassles, and in some cases penalisation. Perhaps in order to safeguard the interests of the beneficiary, and the assumed malevolence on part of the hospitals, have led to stringent checks on hospitals that overlook the need of flexibility to provide for some benefit of doubt to the doctors. In such a scenario, the need for an unbiased investigative approach to understand the reasons behind a doctor’s decisions becomes important.

The appreciation of the intent of the scheme to make quality private healthcare available to the ‘poor’ is somewhat dampened by the ‘unrealistic’ rates of treatment for hospitals. They assert that low package rates for hospitals take a toll on pockets of private healthcare service providers acting as a disincentive to continue with the scheme. How relevant are the package rates as a factor for retaining empanelled hospitals, however, remains unanswered. Many of the doctors prefer to help the patients who need monetary support on a personal level by providing discounts or free medicines. They are aware of the issues in implementation, and they have suggestions for improvements. Can flexible system of pre-approval of treatment expenses in certain emergencies be explored? Can the IEC activities be strengthened for better awareness among the users of the scheme? Could solutions be found to make the system more responsive to complaints of healthcare providers to promptly resolve technical issues? Can the grievance redressal mechanism under the scheme be made more conducive to the hospitals from the beginning? Could ways be found to better leverage smaller private hospitals with lower than 30 beds at district/block level to fulfil the intent of reaching to the remotest areas of the country?

It is perhaps time now for the policy makers and the private healthcare facilities to open communication channels among them. Feedback from the service providers/doctors is critical to iron out implementation gaps, making it more conducive for the healthcare facilities to execute the much needed scheme for financial risk protection against health shocks.

*This article is written by Shivalika Gupta, Assistant Manager, NRMC based on her interactions with doctors and staff of healthcare facilities under various studies undertaken by NRMC.

**RSBY was launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families in 2008. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. Beneficiaries under RSBY are entitled to hospitalization coverage up to Rs. 30,000/- for most of the diseases that require hospitalization. Coverage extends to five members of the family which includes the head of household, spouse and up to three dependents. Beneficiaries need to pay only Rs. 30/- as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding. Government has fixed the package rates for the hospitals for a large number of interventions.

2) Smallholder Women Farmers in India: A Research Study

Agriculture in India is usually associated with images of male farmers on tractors or working on their fields with bullock drawn ploughs. But there are startling facts that belie these popular images for instance, women constitute 40 percent of the agricultural workforce, and this proportion is rising, according to the 2007 Report of the Sub-Group on Gender and Agriculture for the 11th Five Year Plan. The State of Food and Agriculture Report 2010-11 of the Food & Agriculture Organisation (FAO) shows that this is part of a global trend. Women make up on average 43 percent of the agricultural labour force in developing countries, ranging from 20 percent in Latin America to almost 50 percent in East and Southeast Asia and sub-Saharan Africa.

What ownership and control do smallholder women farmers in India have over key agricultural assets and resources like land, water, credit, and agricultural inputs? What constraints do they face in access to markets and marketing opportunities? What is their food and nutrition security? What is the impact of global and national market-related processes on them? What policies, programmes and investments do the Union and State Governments have for their development? These are some of the interesting questions that we explored in a desk study undertaken for Oxfam India on Smallholder Women Farmers in India.

A glimpse of some of the main findings of the study is provided below:

Feminisation of agriculture

About 85 percent of all rural women workers in India are in agriculture, according to the 2007 Report of the Sub-Group mentioned earlier. The 2001 Census showed that almost a third of all cultivators are women, and women also constitute over 46 percent of agricultural labourers. In states like Uttaranchal with high migration of men to the plains, over 56 percent of cultivators are women. With such a significant presence in agriculture, why do women and their work tend to be invisible? Feminist scholars say that women in agriculture in India operate in a transitional economy, where pre-capitalist modes of production co-exist with the modern market economy. Labour relations on the farm and within households are in the form of family conjugal obligation. The length of time spent on agriculture and household activities and volume of work done are very high, but these are under-valued as they are not market-based and are seen as part of women’s obligations. Women actively involved in agriculture may be under-counted as they may be misreported as `housewives’ or as `not working’.

But this situation is changing. A process of feminisation of agriculture is increasingly under way. As population increases and land holdings get fragmented, dependence on subsistence production becomes unviable. Women seek local wage labour opportunities and men migrate for wage labour or even desert women. Women of households that own some land cultivate and manage it along with other livelihood and domestic tasks. The process of feminisation is double-edged, particularly for smallholder women farmers. On the one hand, with low access to land, labour, and other means of production, they have low potential for market gains. This increases their work burden, leaving less time for domestic tasks and child care. On the other hand, it also increases their access to social resources and decision-making opportunities. In agriculture, they acquire increased understanding and voice in the choice of crops, application of fertiliser, time to irrigate, hiring of labour, and investment in capital goods and inputs.

Land rights

While almost a third of cultivators are women, less than 2 percent of women own land in India as a whole. The situation is much more variable when we look at smallholder women in different States. For example, the Agricultural Census of 2005 shows that in Odisha, under 3 percent of marginal holdings (1 hectare or less) are owned by women, whereas in Chhattisgarh, a little over 13 percentof marginal holdings are owned by women. Women’s access to land is largely through inheritance, and inheritance is governed largely by customs which are highly biased against women. States also have inheritance laws that vary according to region and religion. While these are better than customs, they are still biased against women. There is a large gap between women’s rights in law and disinheritance in practice, for example women `voluntarily’ surrendering their inherited share of land to their brothers in return for the security that the latter ostensibly provide them. And finally, even where women legally own land, there is a yawning gap between ownership and actual managerial control over the land.

A breakthrough Amendment in 2005 to the Hindu Succession Act brought Hindu women’s inheritance laws on agricultural land on par with men, overriding State laws that discriminated against women. The Amendment conferred daughters including married daughters, birthright over joint family property. A 1985 policy directive recommended that States give joint titles to husband and wife in transfer of assets like land and house sites through Government programmes. This has been implemented only in 9 States. In general, Government officials lack awareness of laws and policies pertaining to women’s land rights and seldom implement them.

The absence of land titles impacts access to agricultural credit for women farmers. Between 2004 and 2006, Reserve Bank of India statistics show that women received only 6 percent of direct agricultural credit. The absence of land titles as collateral is the main reason for poor access to credit.

Food security

Women’s role in agriculture and their own food security within the household is gendered. The process of feminisation of agriculture that is under way is leading to women working harder without getting higher returns. This effectively means that women have less time for child care and inadequate income for quality diets. The excessive demands made on the time and energies of women, combined with poverty and discriminatory practices associated with rigid social norms result in their poor nutritional status. Based on the third National Family Health Survey (NFHS 3) data of 2005-06 and comparing it with the second survey (NFHS 2) of 1998-99, researchers Jose and Navaneetham found that almost 22 percent of women in India suffered from both anaemia and Chronic Energy Deficiency (CED) - a condition where the Body Mass Index (ratio of weight to squared height) is below 18.5, showing significant undernutrition. Almost 48 percent of women have either anaemia or CED. The situation is worse in some States, for example in Jharkhand and Bihar, almost 32 percent women have both CED and anaemia.

Government policies and programmes

Over the last decade, a number of Government-appointed Committees have studied the problems of women in agriculture. For the formulation of the Eleventh Plan, the Sub-Group on Gender and Agriculture and the Working Group on Agricultural Extension went into issues in depth. So did the National Commission on Farmers, the Programme for Small and Marginal Farmers suggested by the National Commission on Enterprises in the Unorganised Sector (NCEUS), the Draft Policy on Women in Agriculture by the National Commission for Women, and the Committee on State Agrarian Relations and the Unfinished Task in Land Reforms. All these Committees have repeatedly recommended a number of measures to support women farmers, for example, joint titles on land, incentives for group farming, enhanced access to credit, access to water and role in water management, access to common pool resources, women-focussed extension and capacity building, support services for health and child care, and gender audit of programmes and schemes in agriculture and rural development. Most of these recommendations are also to be found in the National Policy for Farmers, 2007. However, very little is known about the status of implementation of these recommendations and it can be safely surmised that little is happening by way of implementation.

There has been an evolution in policy approaches towards gender in agriculture since the Sixth Plan. The present approach of the Ministry of Agriculture is one of `gender mainstreaming’, which means that women have to be part of all the schemes/programmes of the agriculture sector. The components of gender mainstreaming in agriculture are women’s empowerment, capacity building, and access to inputs as well as technology and resources. However, the measures for gender mainstreaming tend to be compartmentalized across different Departments under the Ministry. The National Gender Resource Centre in Agriculture has the mandate of gender mainstreaming. It has however been criticised for its narrow focus and lack of engagement with the larger framework of agrarian change, like the decline of common pool resources leading to increased women’s labour, and cropping pattern changes impacting women adversely.

An example of its narrow focus is the Ministry of Agriculture’s approach to technology as a means to increase productivity. This translates into an instrumental approach to women- how women can contribute to agricultural productivity and production. The effort is entirely on `women-friendly’ tools and equipment, and technology for production activities considered being in women’s domain- for example, mushroom cultivation, aquaculture, and post-harvest processing. Initiatives on appropriate technologies and production programmes for women in isolation perpetuate the gender division of labour. At the same time, technology development without reference to its gender impact (as in the case of Green Revolution technologies) leads to displacement of women’s labour. There are many technology-based development departments like agriculture, horticulture, sericulture, fisheries, animal husbandry, agricultural engineering, and forestry. There is very little co-ordinated effort in technology development and extension between these departments. At the same time, there is also a lack of convergence between these technology-based development departments and rural development programmes.

The Outcome Budget 2009-10 of the Ministry of Agriculture reported that the Women Component Plan (WCP) has been introduced to ensure 30 percent allocation of resources/benefits to women under all Beneficiary Oriented Schemes. However data on compliance with targeted assistance to women by different Departments of the Ministry of Agriculture and on the quality of outcomes is non-existent or very scanty. Where compliance is reported, the numbers of beneficiaries reached are very small. There are substantial gaps in women’s access to markets, credit and technology under the Schemes reported. The Mahila Kisan Sashaktikaran Pariyojana has been announced as a sub-component of the recently launched National Rural Livelihoods Mission. The Pariyojana guidelines suggest a strong focus on production by women farmers and a much weaker focus on empowerment aspects.

Potential areas for intervention

Our study suggested a number of broad areas for intervention :

Technical and extension inputs tailored to women for improving viability of farming
Gender-sensitisation and awareness-raising for both men and women to support women's bargaining power in households and society
Promoting collectives of women- broadening the focus from production to empowerment
Synergies between women in agriculture and allied activities, self help groups and Panchayats
Engendering climate change adaptation policies
Enhancing women's food security through interventions in production, grain/ seed banks, campaigns for PDS reform and increased public investment in agriculture
Advocating in parallel tracks, legal reform for women's land rights and creating other entitlements for women farmers
Engaging Central & State Governments for (i) following up recommendations on women in agriculture of various Government Committees (ii) monitoring compliance and outcomes of gender-based budgeting in agriculture and rural development schemes
Supporting existing civil society initiatives through networking, research, legal work and workshops

Blog Article

From Monitoring Aid Effectiveness to Effectively Using Aid for Monitoring

The media-fuelled debate a year ago on British aid to India in the wake of India’s defence establishment choosing the French Dassault Rafale over the British Typhoon generated more heat than light. That was not very surprising because it is in the nature of media sensationalism for slugfests to masquerade as debates, and the British tabloid press was only being true to type. The British political establishment leapt into the fray, with a ruckus in UK Parliament and talk of a high-level delegation coming to Delhi to press the Typhoon’s case. This was a reflection of British politicians wanting to be seen as concerned about the pain that recession and welfare cuts are inflicting on the British public, even as the overseas aid budget remains intact. The 'debate’ proceeded on expected lines: The tabloids attacked the ingratitude of the Indian Government for not awarding the £6.3 billion contract for Typhoons in return for £1 billion of British aid over the last 5 years. Talking heads on Indian television bristled at British arrogance for even contemplating such a quid pro quo. Quotes and sound-bites from different times and contexts were pressed into service, including a jaw-dropping one from Secretary of State for International Development Andrew Mitchell, apparently about British aid during a visit to India in December 2011- “The focus is also about seeking to sell the Typhoon.” A leaked memo from former Indian External Affairs Secretary Nirupama Rao advising the Government to decline British aid from April 2011 because of the “negative publicity of Indian poverty promoted by DFID” did the rounds of TV studios and op-ed pages, so did Pranab Mukherji’s remarks in a Rajya Sabha debate last August “We do not want the is peanuts in our development exercise”. Then there was an attempt to control damage and restore political correctness all round with a statement on DFID’s website that the remarks attributed to Mukherji misrepresented the Indian Government’s position and was outdated because DFID has since focussed on the three poorest States and on pro-poor private sector investments, and that Secretary of State Mitchell was merely saying that aid was one part of India’s wider relationship with Britain, which includes trade.

Lest we in India should be carried away with smugness and schadenfreude, here are a few sobering thoughts. Although systematic efforts have been made to alleviate poverty over the past six decades, and poverty incidence declined from about 55 percent in 1973-74 to 27.5 percent in 2004-05, the number of the poor has remained more or less the same. The Eleventh Plan noted “...because the population has also grown, the absolute number of poor people has declined only marginally, from 320 million in 1993-94 to 302 million in 2004-05...” Poverty is concentrated both spatially and among social and economic groups, and those most vulnerable to poverty include landless labourers, marginal farmers, socially backward classes and people living in remote areas. The National Commission for Enterprises in the Unorganised Sector (NCEUS) estimates that 76.7 percent of the Indian population in 2004-05 lived on an average per capita daily expenditure of just Rs. 16, with a maximum expenditure of just Rs. 24. Levels of malnutrition, child malnutrition and chronic energy deficiency are high, and the Global Hunger Index 2011 ranked India 67th out of 81 countries, even below Rwanda.

The scale and depth of poverty has been a matter of concern for the Government of India for decades and the challenge has been to work at scale to address it through anti-poverty and other development programmes. Over the period of the Eleventh Plan, the Government’s flagship development programmes have expanded in scope and coverage. The MGNREGA has spent over Rs. 156,000 crore, the ICDS about Rs. 39,000 crore, the NRHM over Rs. 69,000 crore, and the SSA almost Rs. 78,000 crore. The NRLM has a budget of Rs. 3915 crore. If these programmes are adequate and effective, we should expect to see a significant dent in poverty. But this massive increase in social sector expenditure by itself will not transform into better outcomes.

Indeed, the overall environment in delivery of programmes and schemes is focused on inputs, with few incentives to measure quality and deliver on outcomes. Some of the main weaknesses in Centrally Sponsored Schemes are unrealistic objectives, a top-heavy, centralized delivery structure and strict guidelines that hinder implementation. Apart from these design failures, there are significant weaknesses in the current framework for monitoring & evaluation. There are no clearly defined criteria for evaluation, and the responsibility for evaluation as well as implementation are assigned to the same Ministry or Department. This compromises the objectivity of evaluations. What is needed is realistic and clearly defined objectives for schemes along with clarity about the objectives that the schemes are to be evaluated on. Evaluations should be carried out accordingly by independent evaluators.

To its credit, the Government has already taken steps towards independent evaluation. In late 2010, an Independent Evaluation Office was established under the Planning Commission to assess the outcomes and impact of the major flagship programmes. However the IEO has been extremely slow to take off. It comes on the heels of the very mixed performance of Outcome Budgets. The change required to move from measuring government performance by money spent to outcomes delivered is a big one, and the entire OB exercise under-estimated this. A sea change in knowledge, skills and attitudes is needed, along with appropriate incentives in order to move towards meaningful OBs. Underpinning this is a change required in the culture of accountability in Government. The all-important questions- What works? Under what conditions does it work? How much does it cost? Can we get better value for money? – need to become foundational, in place of minimum compliance with accountability norms that are seen as externally imposed.

A promising step has been taken by the Performance Management Division under the Cabinet Secretariat. The Performance Monitoring & Evaluation System (PMES) is designed to help government departments define, measure and monitor their progress against defined targets and indicators. At the beginning of each year (1 April), government departments have to develop a Results Framework Document (RFD). The RFD addresses three basic questions: i) What are the main objectives of the department for the year? ii) What actions are necessary to achieve these objectives and iii) What are the success indicators necessary to evaluate these actions? The RFD feeds into an online MIS system which is then tracked through the year. The department’s progress against set targets is reviewed after 6 months and finally evaluated at the end of the year. It has been reported that the Planning Commission is contemplating linking financial allocations to Ministries with performance under the RFDs. How good are the RFDs and what difference are they making to performance? It is as yet too early to answer this question.

What the entire `debate’ on bilateral aid has missed is the learning opportunity for innovative project design, performance management, and monitoring & evaluation that many bilateral aid projects have provided. Though the actual outlays may be peanuts compared to India’s flagship development programmes, there is much to be learnt from bilateral projects and assistance to flagship programmes. For example, DFID, IDA and the EU provide small supplementary funding for the Sarva Shiksha Abhiyan. The Government of India and the development partners undertake Joint Review Missions twice a year. The main objective of the JRM is to review progress in the implementation of the programme with respect to SSA’s goals and to discuss follow-up actions in light of the Terms of Reference (TOR) agreed upon for each JRM. Now contrast this with the monitoring of the Right To Education (RTE). While RTE comes under the Ministry of HRD, its monitoring is carried out by an RTE Division in the National Committee for Protection of Child Rights (NCPCR), which works under the Ministry of Women and Child Development. The RTE Division has a handful of consultants on contract, reportedly with unclear definitions of roles and responsibilities, inadequate authority and meagre resources of around Rs. 50 per school annually.

Rather than get stuck in a non-productive debate or moral grandstanding on the need for aid and the ulterior motives of aid, big topics that have more to do with deep-seated beliefs about international politics and global justice than aid per se, it is better to focus on what aid achieves and what changes in accountability systems in recipient countries, notably monitoring and evaluation, it can trigger. The buzzword for British aid is now `value-for-money’, which is nothing but accountability to the British taxpayer. Results-based management of aid is meant to make aid effective, but equally it is also about communicating to taxpayers what their contribution is achieving. True, there can be window-dressing and obfuscation involved in this, but in the end it is about accountability to the taxpayer. It is high time we moved towards similar accountability to our citizens and taxpayers, and a little humility in learning from others will not harm us. The quantum of aid may be very low in comparison with the budget a flagship programme has, but the careful deployment of external aid and expertise/experience in strengthening monitoring & evaluation of our flagship programmes will help plug leakages, improve accountability and make the programmes much more effective. Considering the magnitude of problems, we need these programmes to work well and good M&E systems hold the key to effectiveness. The focused use of external aid to M&E of flagship programmes is a win-win proposition for both donor and Indian Governments and for the programme beneficiaries. Poverty and human development will be addressed at scale, and taxpayers of both donor and recipient countries will see evidence of effectiveness of their money.