Implementing FCTC Article 17 through Participatory Research with Bidi Workers in Tamil Nadu, India

Introduction: The exploitation, poor conditions and precarity in the bidi (hand-rolled leaf cigarette) industry in India makes it ripe for the application of the FCTC’s Article 17, ‘Provision of support for economically viable alternative activities’. ‘Bottom up’, participatory approaches give scope to explore bidi rollers’ own circumstances, experiences and aspirations. Methods: A team of six community health volunteers using a participatory research orientation developed a questionnaire-based semi-structured interview tool. Forty-six bidi rolling women were interviewed by pairs of volunteers in two northern Tamil Nadu cities. Two follow-up focus groups were also held. A panel of 11 bidi rollers attended a workshop at which the findings from the interviews and focus groups were presented, further significant points were made and possible alternatives to bidi rolling were discussed. Results: Bidi workers are aware of the adverse impact of their occupation on them and their families, as well as the major risks posed by the product itself for the health of consumers. However, they need alternative livelihoods that offer equivalent remuneration, convenience and (in some cases) dignity. Alternative livelihoods, and campaigns for better rights for bidi workers while they remain in the industry, serve to undercut industry arguments against tobacco control. Responses need to be diverse and specific to local situations, i.e. ‘bottom up’ as much as ‘top down’, which can make the issue of scaling up problematic. Conclusion: Participatory approaches involving bidi workers themselves in discussions about their circumstances and aspirations have opened up new possibilities for alternative livelihoods to tobacco

What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda.

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed