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Das J.,The World Bank | Das J.,Center for Policy Research | Kwan A.,The World Bank | Daniels B.,The World Bank | And 7 more authors.
The Lancet Infectious Diseases | Year: 2015

Background: Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients. Methods: We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI). Findings: Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (. r=0·63 [95% CI 0·53-0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5-6·6) with a mean of 6·18 (5·72-6·64) questions or examinations completed, representing 35% (33-38) of essential checklist items. Across all cases, only 52 (21% [16-26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17-4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice-eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02-0·11); p<0·0001. Interpretation: Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India. Funding: Grand Challenges Canada, the Bill & Melinda Gates Foundation, Knowledge for Change Program, and the World Bank Development Research Group. © 2015 Elsevier Ltd.


Urge-Vorsatz D.,Central European University | Herrero S.T.,Central European University | Dubash N.K.,Center for Policy Research | Lecocq F.,Center International de Recherche Sur lEnvironnement et le Developpement
Annual Review of Environment and Resources | Year: 2014

Co-benefits rarely enter quantitative decision-support frameworks, often because themethodologies for their integration are lacking or not known. This review fills in this gap by providing comprehensive methodological guidance on the quantification of co-impacts and their integration into climate-related decision making based on the literature. The article first clarifies the confusion in the literature about related terms and makes a proposal for a more consistent terminological framework, then emphasizes the importance of working in a multiple-objective-multiple-impact framework. It creates a taxonomy of co-impacts and uses this to propose a methodological framework for the identification of the key co-impacts to be assessed for a given climate policy and to avoid double counting. It reviews the different methods available to quantify and monetize different co-impacts and introduces three methodological frameworks that can be used to integrate these results into decision making. On the basis of an initial assessment of selected studies, it also demonstrates that the incorporation of co-impacts can significantly change the outcome of economic assessments. Finally, the review calls for major new research and innovation toward simplified evaluation methods and streamlined tools for more widely applicable appraisals of co-impacts for decision making. Copyright © 2014 by Annual Reviews. All rights reserved.


Das J.,The World Bank | Das J.,Center for Policy Research | Holla A.,The World Bank | Das V.,Johns Hopkins University | And 3 more authors.
Health Affairs | Year: 2012

This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. What's more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes. © 2012 Project HOPE- The People-to-People Health Foundation, Inc.


Winkler H.,University of Cape Town | Rajamani L.,Center for Policy Research
Climate Policy | Year: 2014

The principle of common, but differentiated, responsibilities and respective capabilities (CBDR&RC) is fundamental to the UNFCCC. Some options for a nuanced model of differentiation that addresses both responsibility and capability in a changing world are explored, such as new categories of countries, and some of the political issues that such a model might face are considered. The strengths and limitations of options for graduation based on 'objective' criteria such that countries could move between categories or 'graduate' - an option provided by the UNFCCC - are discussed. Countries could also choose to join another club (e.g. the G20), self-elect into categories or differentiate among themselves implicitly by accepting different commitments and actions. CBDR&RC will form part of the overall legally binding agreement, and must apply symmetry in some respects and differentiation in others to the commitments and actions contained therein. Some possible characteristics of CBDR&RC of relevance in a regime 'applicable to all' are outlined. These include promoting climate action and using mechanisms available in the UNFCCC to instil dynamism. Differentiation on mitigation must consider the distinctions between absolute and relative reductions, as well as commitments to outcomes and implementation. CBDR&RC should be applied to mitigation, adaptation, and the means of implementation.Policy relevanceIn Durban, Parties agreed to negotiate a regime 'applicable to all', which sent a political signal that there should be greater symmetry between nations. The world has changed since the UNFCCC was negotiated in 1992. It is now less helpful to think only in terms of two groups of countries (e.g. Annex I and non-Annex I), and evident that there are significant differences between member states. This requires a more nuanced interpretation of the principles of equity and CBDR&RC, which is an integral part of the UNFCCC. The options for the different approaches outlined in this article might help in the construction of a more nuanced model. All must do more, while some must do more still than others. To achieve this, some defining characteristics of CBDR&RC in a regime applicable to all are suggested. © 2013 Taylor & Francis.


Dubash N.K.,Center for Policy Research
Wiley Interdisciplinary Reviews: Climate Change | Year: 2013

India occupies an intriguing dual position in global climate politics-a poor and developing economy with low levels of historical and per capita emissions, and a large and rapidly growing economy with rising emissions. Indian climate politics has substantially been shaped around the first perspective, and increasingly, under international pressure, is being forced to grapple with the second. This review of Indian climate politics examines the initial crystallization of Indian climate positions and its roots in national climate politics, and then examines the modest ways in which climate politics have been revisited in domestic debates since about 2007. Following elucidation of these themes, the article turns to a discussion of new directions for Indian climate policy and their moorings in domestic climate politics. © 2013 John Wiley & Sons, Ltd.


Rajamani L.,Center for Policy Research
Journal of Environmental Law | Year: 2010

It is axiomatic that the climate impacts documented by the Intergovernmental Panel on Climate Change are likely to undermine the realisation of a range of protected human rights. Yet it is only in the recent past that an explicit human rights approach has been brought to bear on the climate change problem. Scholars and human rights bodies have begun to advocate a human rights-centred approach to climate change-an approach which would place the individual at the centre of inquiry, and draw attention to the impact that climate change could have on human rights protection. This article focuses on the human rights claims raised in the climate negotiations, the implications these claims may have and the interests they may serve. The article argues that human rights approaches, taken in their entirety, have the potential to bring much needed attention to individual welfare as well as to provide ethical moorings in inter-governmental climate negotiations currently characterised by self-interested deal-seeking. Human rights approaches provide benchmarks against which states' actions can be evaluated and they offer the possibility of holding authorities to account. Human rights approaches may also offer additional criteria for the interpretation of applicable principles and obligations that states have to each other, to their own citizens, and to the citizens of other states in relation to climate change. This article seeks to provide initial insights into the ways in which human-rights-based interpretations of applicable principles and obligations may serve to influence some of the current debates in the climate negotiations. © The Author [2010]. Published by Oxford University Press. All rights reserved.


Dubash N.K.,Center for Policy Research
Water Alternatives | Year: 2010

The World Commission on Dams (WCD) has aroused debate as an innovation in global governance. I suggest that the WCD did, indeed, have many innovative features, but argue that processes such as the WCD are better suited to propagating norms than making rules at the global level. The norm setting and propagating role is critical because there are no other plausible mechanisms of debating the larger ideas that inform decision-making, in a way that credibly brings in voices of the poor and powerless. I develop this argument by looking at three aspects of the WCD: its characteristics as a global governance mechanism; how it sought to achieve legitimacy; and its role as an agent of regulative versus normative change.


Dubash N.K.,Center for Policy Research
Global Policy | Year: 2011

This article examines how India's domestic energy challenges have been shaped by global forces and how, in turn, India has engaged and is likely to engage in discussions of global energy governance. A central theme is that exploring India's engagement in global energy governance requires a clear understanding of its domestic energy context and how this has changed over time. The article develops three narratives that have guided Indian energy governance domestically: state control; the grafting on of market institutions; and the embryonic linkage between energy security and climate change. In all these phases, Indian energy has been strongly influenced by global trends, but these have been filtered through India's political economy, creating outcomes that constrain future policy implementation. This path-dependent story also carries implications for India's engagement with global energy governance. With the rise of a new narrative around energy security, increasingly leavened with invocations of clean energy, India is positioned to reformulate its engagement in global debates. However, the perceived need, strategic clarity and resultant eagerness to engage in the task are all limited.© 2011 London School of Economics and Political Science and John Wiley & Sons Ltd.


Saran S.,Center for Policy Research
Climate Policy | Year: 2010

The pervasive mistrust with which the Copenhagen Conference ended does not augur well for post-Copenhagen negotiations. This commentary explores existing fault lines and proposes creative ways of moving forward. The Copenhagen impasse, which is likely to continue, involved attempts by developed countries to overturn the template of historical responsibility and replace it with a reciprocity-based regime that was met with resistance from developing countries. Thus, realistically, Cancún can only serve as an opportunity to rebuild trust and seek areas of convergence, rather than being the occasion for a possible deal. Focusing attention on some limited areas of consensus may create a more congenial environment for future negotiations. Possible ways forward include promoting technological collaboration through a network of innovation centres, supporting the Least Developed Countries (LDCs), Small Island Developing States (SIDS) and Africa, encouraging extensive bilateral cooperation and cooperation under the auspices of the UN on climate change action and renewable energy, forging a commitment not to resort to trade protection, and making a firm commitment to the UN process. © 2010 Earthscan.


Chandra A.,RAND Corporation | London A.S.,Center for Policy Research
Future of Children | Year: 2013

As this issue of the Future of Children makes clear, we have much yet to learn about military children and their families. A big part of the reason, write Anita Chandra and Andrew London, is that we lack sufficiently robust sources of data. Until we collect more and better data about military families, Chandra and London say, we will not be able to study the breadth of their experiences and sources of resilience, distinguish among subgroups within the diverse military community, or compare military children with their civilian counterparts. After surveying the available sources of data and explaining what they are lacking and why, Chandra and London make several recommendations. First, they say, major longitudinal national surveys, as well as administrative data systems (for example, in health care and in schools), should routinely ask about children's connections to the military, so that military families can be flagged in statistical analyses. Second, questions on national surveys and psychological assessments should be formulated and calibrated for military children to be certain that they resonate with military culture. Third, researchers who study military children should consider adopting a life-course perspective, examining children from birth to adulthood as they and their families move through the transitions of military life and into or out of the civilian world. © 2013 by The Trustees of Princeton University, all rights reserved.

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