Sarita Panday’s personal and professional journey from a childhood in a small village in Nepal to an academic career that has taken her across the globe to Australia, Europe, and now Stanford is a story that speaks to the power of education as a life-transforming and world-changing force. Sarita is our 2018-19 postdoctoral fellow in Asia health policy and her research focuses on improving maternal health service provision in Nepal.

The Asia Health Policy Postdoctoral Fellowship is offered annually by APARC’s Asia Health Policy Program (AHPP). On May 1, Sarita will present her research at a seminar cosponsored by AHPP and the Center for South Asia. We caught up with Sarita to learn about her work, the state of maternal health and education in Nepal, and what’s next for her career.

Q: Your research interests include health service delivery and human resources for global health, and your PhD project explored the role of female community health volunteers in maternal health service provision in Nepal. What is the state of maternal health in Nepal? How does it compare to other areas in South Asia?

While substantial progress in maternal health has been achieved over the last two decades, Nepal still has high rates of maternal deaths compared to its neighbouring countries. According to UN estimates, maternal mortality ratio (number of deaths due to pregnancy-related causes per 100,000 live births) is one of the highest in Nepal (258) compared to India (174), Bangladesh (176), Pakistan (176) or Sri Lanka (30).  Maternal deaths in Nepal’s rural areas are three times likely to be higher than in urban areas. Therefore, my research focuses on improving maternal health status in rural area.

Q: Tell us about your current research: What questions/problems you're exploring? What are some of the findings your work has revealed?

As the 2018-19 Asia Health Policy Postdoctoral Fellow at APARC, I am currently working on publications based on my PhD, which focused on improving healthcare for marginalized women in rural Nepal. My next paper, forthcoming in PLOS One, explores the underuse of healthcare services among Nepal’s marginalized communities. In this paper, I analyze the factors that hinder use of healthcare by certain ethnic groups such as Dalits (the lowest group within the Hindu caste system), Madhesi (people living in the southern plains of Nepal, close to the border with India), Muslim, and Chepang and Tamang (indigenous groups in hill villages). These ethnic groups face barriers to health service use that include lack of knowledge, lack of trust in volunteers, traditional beliefs and healthcare practices, low decision-making power among women, and perceived indignities experienced when using health centers. Therefore, community health programs aimed to improve healthcare use among such populations should consider these specific contextual elements along with health system factors.

My next manuscript (in preparation) focuses on the importance of paying community health workers, which is also one of the key findings of my PhD. I found that women volunteers appeared to be highly dissatisfied by the lack of financial incentives for their services and wanted remuneration. This finding contradicts previous claims that reported community health volunteers were happy with their status. I have just finished a first draft of the manuscript and will soon send it for review.

Apart from my fellowship at Stanford, I am volunteering to form a team of interdisciplinary researchers to improve maternal and child health among marginalized communities in Nepal. I am doing this as part of my role as an honorary research fellow in the Department of Politics at the University of Sheffield, where I also earned a PhD in public health. I recently organized a workshop in the UK to leverage partnerships across universities and the local NGO PHASE Nepal. During the workshop, I shared my experience of using participatory approaches (such as participatory video methods and policy workshops) to connect communities with policymakers, and I plan to use similar participatory approaches in my future research. The workshop successfully generated support from colleagues and the local partner.

Q: Your personal and professional journey has taken you from growing up in rural Nepal to pursuing a doctorate in Britain and now a postdoctoral fellowship at Stanford. How would you describe the situation of Nepal’s higher education system, and the demand for foreign education in the country? What are some of the lessons you have learned throughout your own years of international education?

Although Nepal has a long history of education, the current formal education system was formed only in 1951, after the establishment of democracy. In the short period since then, Nepal has made substantial progress in adult literacy rate (from 20.6 % in 1981 to 64.7 % in 2015), but the quality of the public education system remains questionable, with low opportunities for employment. There has been some improvement since the beginning of technical education as a formal sector in 1980: the Ministry of Education, Science and Technology is responsible for education in Nepal and there are currently a total of nine constituent universities with 90 affiliated universities and 1012 campuses. However, the quality of education in Nepalese universities is often controversial due to their being a playground for major political parties. And despite the government’s promises to increase its spending on public education the education budget appears to be cut each year.

As for my own experience, I graduated with a BSc Nursing degree in Nepal without realizing that I wouldn’t get a placement within the public sector. The government hasn’t yet created a position for graduates like me, which forced me to seek a job in the private sector. While I managed to find a well-paying if strenuous job in remote Nepal, I saw many colleagues who struggled to find jobs that matched their qualifications. Some of them worked voluntarily or in low-paying positions. While the Nepalese government continues to produce graduate nurses there’s no system to retain them, despite a severe scarcity of human resources for health.

Q: What's next for your career? What issues are you going to focus on in your upcoming research project?

I have recently been appointed as a Global Challenge Fellow at the University of Sheffield to work on a two-year research project in Nepal. Starting this July, I will work with rural women in two Nepalese districts (Dhading and Sindhupalchok), conducting participatory co-designed research aimed to raise awareness and understanding of the social, cultural, economic, and political factors that hamper women’s access to healthcare services. I plan to use participatory approaches, such as participatory video methods and policy workshops, to connect communities with policymakers, and to partner with PHASE Nepal to improve utilization of healthcare among the country’s marginalized populations.

I’m excited to share my work with the Stanford community in an upcoming seminar on May 1, and hope to see many friends and colleagues there.

Register to attend Sarita's seminar >>

As people around the world look to support earthquake relief efforts in Nepal, scholars from Stanford and the London School of Economics and Political Science offer new research that can help donors make better decisions about where and how to contribute their money.

“NGO reports tend to focus on quantity in delivery, such as numbers of homes and people served—but not on quality,” write Yong Suk Lee (Stanford) and J. Vernon Henderson (LSE).

In a forthcoming paper, the coauthors evaluate reconstruction efforts in Indonesia following the 2004 earthquake and tsunami, and find two trends: aid agencies that directly execute their services—point-to-point—perform the highest quality work. And, when agencies contract their services, higher quality work is performed when a global, not domestic, implementer completes the work.

Knowing this reality, and with improved disclosure of outcomes, the coauthors hope that donors would be able to make more informed choices.

Fishing village survey 

Figure 1. A map details the survival rate of the population and flood damage within northern Indonesia in 2004. Darker shaded areas show a higher survival rate, lighter shaded areas show a lower survival rate. Striped areas denote flooding, largely on the northeastern border. Boundaries marked with thicker lines are ‘kabupaten,’ or county divisions, and lightly colored lines are ‘kecamatan,’ or sub-county units larger than a village alone. (Courtesy of Yong Lee).

Through fieldwork and three rounds of surveys – in 2005, 2007 and 2009 – Henderson and Lee investigated aid work in Aceh, an area of coastal villages in northern Indonesia (Figure 1).

Humanitarian efforts there focused on “hard aid” such as construction of houses and fishing boats. Total aid delivered amounted to $7.7 billion and was implemented by international and domestic aid agencies—some directly and some as contractors—as well as the Indonesian government.

First, Henderson and Lee conducted a pilot survey, and then with a cohort of surveyors from the University of Indonesia, held interviews with village leaders and fishing families. Participants were asked to rate their housing accommodation, and if applicable, how their fishing activity compared to before the disaster.

“Mostly, we sat with villagers to see how willing they were to talk about aspects of aid,” Lee said. “Since it was several years after the tsunami hit, people were pretty open throughout the process.”

Data from those surveys was combined with information from the Recovery Aceh-Nias relief project database maintained by the government and the U.N., as well as demographic information provided by participants.

Delivering aid: Global v. local

Empirical analysis revealed that aid agencies such as the Red Cross and Catholic Relief Services reflected higher quality aid delivery (at a mean quality near 3.00), while agencies such as Save the Children and Concern Worldwide reflected lower quality (at a mean quality between 1.0-1.5).

“What’s surprising is that reputation didn’t really line up with what was expected,” Lee said, citing a few renowned agencies that didn’t receive high marks.

Lee said this could be explained by the fact that aid agencies that specialize in disaster recovery are better equipped, while a learning curve might exist for agencies with wider missions.

Global aid agencies are more likely to have logistical experience given their reach across multiple disaster situations. And while all NGOs face reputational costs for their results, global aid agencies are greater exposed to criticism because, by size, they’re more visible.

Yet, while global aid agencies and implementers may have the raw skills, local implementers have the cultural know-how.

“Local implementers might not have the most experience – like how to construct a house or manufacture a fishing boat – but they will likely know what’s actually desired,” Lee said. “So, there are obvious tradeoffs at play.”

For example, villagers reported bad ventilation in houses. This was because some aid agencies used small windows and concrete instead of wood material more traditionally used in Indonesia. Some boats were impossible to use because of improper design; they sank upon first use or fell apart after a few months.

Image

Collection of photos from fieldwork in Aceh, Indonesia, provided courtesy of Yong Lee. Upper left: A house built in an aid project village shows windows retrofitted after initial construction. Upper right: Boats constructed by aid agencies for fishing activity are refashioned to serve as water taxis for people and cars. Lower: Fishing boats sit unused on the side of the road many of them impossible to use, according to villagers surveyed.

Logistics and oversight

Aid delivery depends in many ways on the location and scale of the disaster. But, a few main aspects can determine if an aid agency doing its own work or operating as an implementer meets or exceeds expectations.

Henderson and Lee suggest that agencies that were highly supervisory had greater positive outcomes from their workers. In the case of Aceh, better monitoring and insistence on quality by leadership is a likely corollary between construction of better quality homes and boats.

“Rather than just give money, NGOs need to really oversee the projects. Organization and management are essential facets,” Lee said. “And that requires a lot of additional effort on their part.”

Oversight is especially relevant in disaster situations because of the often-overwhelming need for reconstruction. A flood of less-skilled workers enters the market to fill this gap, and on average the quality of work degrades.

“It’s much more difficult to impose quality control at this point,” Lee said. “So the implication that comes out of it is how does the implementer effectively utilize less-skilled workers.”

Getting to know the implementers and evaluating their work in-progress would help ensure quality on behalf of the aid agency. And, better dissemination of information about aid outcomes would help assure donors that their monies are being applied in the best possible way.

Future study

Most “hard aid” delivered to Aceh’s villages had finished by 2010, but “soft aid” such as democracy promotion and women’s empowerment stayed longer.

Henderson and Lee conducted one final survey in 2011. The data has been offered as open source material for researchers along with the larger data set.

Noting this, Lee said, “We’re thrilled that people are looking into the data further. It’s exactly what we wanted.”

Research projects applying the data include the impact of the tsunami on Aceh’s local economies and health effects on the population, among other areas.

Over 215 million Muslims live in the Asia-Pacific region, but despite their number and proximity to record growth and opportunity in greater Asia, their experience has been one of persistent, widespread socioeconomic and political decline. 

A new book, Modes of Engagement: Muslim Minorities in Asia, published by the Walter H. Shorenstein Asia-Pacific Research Center (APARC) and distributed through The Brookings Institution, offers leading research on this topic and places it in a geographic perspective. Edited by Rafiq Dossani, a senior researcher at the RAND Corporation and Professor at the Pardee RAND Graduate School of Public Policy, the book paves new paths to understanding the paradox of Muslim minorities in Asia. 

Dossani was at Stanford University for nearly fifteen years as a senior research scholar at Shorenstein APARC and as the executive director of the South Asia Initiative, studying the plight of Muslims and higher education in India, among other topics. The book is a result of a seminar series with the book’s contributors.

“Since the 1970s, especially in China, Asia’s growth rate has been unprecedented within Asia’s own history,” Dossani says. Mainstream Asia has seen a rise in job opportunities and income levels, and as a result, an individual ability to accumulate wealth and commit resources to long-term investments, such as education and innovation activities.

However, not all people have found benefit from this modern, economic transformation. Most notably, Muslims have seen a severe decline in their social and political space, as well as a narrowing of their identity.

Analysts find this surprising because history reflects a narrative that says Muslims should have profited along with the rest. “It wasn’t expected that Muslims would lose out in the countries in which they were minorities,” he says.

The volume investigates this puzzle through three case studies: the Philippines, India, and China. In each country, Muslims are at least 5 percent of the population, the largest number being in India. Dossani weaves together common threads that define the Muslim minority experience. Similarities include the impact of state-led ethnic nationalism and forced assimilation. He also writes that Muslims have been unable to use protest to secure any significant, long-term gains.

Given this dire reality, what prospects lie ahead for Muslim minorities? In conversation, Dossani suggests a few policy priorities gathered from the case studies featured in the volume.

Democracy is not the answer

Democracy, a form of governance that is often championed for its equal civic participation, has not facilitated a level playing field for Muslims when theory dictates it should.

“Democracy is not the answer to handling these problems,” says Dossani, emphasizing, “it is a most inadequate answer.”

This situation is evident in the case of India where Muslims have probably done the worst, compared to the Philippines, which also shares a legacy of colonial rule and transition to democracy.

Muslims in India, who have attempted to elevate their interests on the national stage, are stopped by coalition politics. Larger interests of the group can subsume their own, encroached upon further by caste issues, language barriers and other dividing factors. China’s Hui have found a significantly better experience than the Uyghurs, who were separated from mainland China early on and excluded from opportunities afforded there (the Uyghurs reside in a northwest region, Xinjiang). In the case of India, Muslims make up only ten to fifteen percent of the population in almost every state, thus their voice fails to find leverage in the political sphere, and effectively lose out.

Furthermore, democracy is not a panacea when states are vulnerable.

“When you have very weak and fragile states, where intuitions are subject to capture easily, democracy doesn’t work,” Dossani explains. Muslim minorities are unable to gain clout because the majorities, and elites attempting to fill a power vacuum, crowd them out.

Thus, collective interest and concerted efforts on the part of governmental and non-governmental organizations – a larger nexus of individuals working toward common goals – are essential to create momentum and staying power behind Muslim issues.

“You need civil society where it explicitly deals with the issues of minority populations and tries to convince the national government and state governments that improving the lots of minorities should be a national project with commitment to their improvement,” he says.

Development as a way forward

Some national projects were developed to openly address Muslim issues, but this led other internal ethnic and religious groups to ask, “Why are you appeasing the Muslims?”

Especially since 9/11, governments have increasingly come under pressure. Stigmas that narrow Muslim identity into “extremists” and “terrorists” are more progressively shared, making it near impossible for governments to explicitly offer a helping hand to Muslims without domestic backlash. 

But even with the odds against them, Muslim minorities still have a way forward.

In the three countries studied, Muslims have found traces of success, and in other Asian nations such as Sri Lanka and Nepal, there has been considerable accommodation of Muslims. Across all circumstances, “Muslims have done best in countries where the state has focused on education for all,” Dossani says.

Instead of providing ethnic-based aid, governments should focus on resource availability as a main qualifier for assistance. State-sponsored education and health care initiatives that capture the poorest populations help Muslims who inherently fall into this category. 

“Any wise government would say ‘look we want to connect education to development and focus on the poorest, no matter who they are.’ If they do that, Muslims will automatically get their fair share,” he says. The Philippines has already recognized this reality, and begun to implement development projects that naturally include Muslims.

Regime change can also motivate Muslim accommodation, either directly or indirectly, as is likely in the case of India.

Newly appointed Prime Minister Narendra Modi, although said to have an anti-Islamic stance in the past with the Bharatiya Janata Party, may in fact create policies that favor Muslims because it fits in with a grander vision of national growth. 

Referring to Prime Minister Modi, Dossani says, “It’s not clear that he cares about Muslims, but in some ways, he cares about development.

“At some point, any development-conscious person will realize that no country can progress if 15 percent of the country hangs behind.”

Diaspora matters

The swell of migration in the globalized era has made the formation of diaspora communities, dispersed populations outside of country of origin, a common phenomenon. Muslim minorities are a large part of this movement, seeking opportunity and using their ethnic or religious connections to establish a new life elsewhere.

Muslims of Asian origin are located beyond Asia – in the Middle East, North Africa and Southern Europe, among other areas. But despite being removed from their native soil, an allegiance and interest in the homeland typically remains.

“Diaspora exists in a very big way,” Dossani explains. Their influence should not be underestimated, both financially and politically. The Muslim diaspora provides an important channel of support that helps struggling Muslim populations.

Remittances from relatives overseas can bring in substantial transfers of money and support to populations that may not otherwise have enough resources, or be supported by the government. For several years now, one of the single largest inflows of money into the Philippines has been from these outside sources. India’s Muslim diaspora has a strong diasporan foundation with codified institutions set-up to organize relations. China’s experience is less documented, Dossani says, although he conjectures that some diasporan support exists, whether formally or informally.

Diaspora organizations, often led and supported by expatriates, appear to be growing worldwide, and can play a crucial role in the formation of Muslims’ global identity and network of support. Neighboring countries with Muslim majorities, such as Malaysia and Indonesia, have also offered themselves as diplomatic partners in resolving conflicts over Muslims’ conditions, given their own long histories of addressing them internally.