Manifest 2009-003

Cross-Border Synergies and the Quality of LifeA Conceptual Framework

Sati ShankarGlobal Synergetic FoundationNew Delhi,Feb,11th, 2009

www.satishankar.com

Abstract: Socio-cultural similarities on either side of the international border, a universal phenomenon, are more pronounced in the case of Nepal-India border, because such ties have been enhanced by open border with no restrictions on the movement of people on either side. Social and cultural similarities do exist along the Nepal China boundary as well but more so in the case of Nepal India border where people have easier access and interaction. Ethnic and linguistic similarities exist along the Nepal-India border both in the south plains and hills in the east and west. The open border has naturally promoted social and cultural interaction among the nationals of both sides through matrimonial relationship as well. Keywords: Open borders, synergies, quality of life, development, welfare, economic,

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Manifest 2009-003

Cross-Border Synergies and the Quality of LifeA Conceptual Framework Dr.S.S.D.Pandey www.satishankar.com20090211

1. Statement of the Problem: The Indo-Nepal Border: Open and Closed We are taking case of Indo-Nepal Border Region. Bound by the 1950 Treaty of Peace and Friendship, neither India nor Nepal is in a position to unilaterally introduce such travel provision restricting the free movement of their people across the border, however, the 1751 km long Nepal-India border was fixed by the Sugauli Treaty of 1916, return of Naya Muluk to Nepal by British India in 1858. Both the countries are socially and culturally linked and have been deeply imbibed into the socio-cultural history of both the countries. The Terai region of Nepal bordering India is an extension of the Indo-Gangetic plain. The "geographical factors have been reinforced by religious, cultural and ethnic affinities between the inhabitants of Terai region and their counterparts across the border. The overwhelming presence of people of Indian origin in and the presence of Nepalese population in the Terai region contiguous to the Indo-Nepal border has made socio-cultural intercourse indispensable. The 1700 km long Indo-Nepal open border has not only facilitated socio-cultural exchanges that date back to centuries but have been strengthened by age old historical ties. The geographical proximity and socio-cultural affinity have determined the contour of the relationship between both the countries. The geographically contiguous and open border in this context has serious implications. In this context, "it is virtually impossible to stop the streams of ideas, information, weapons and money moving through the trans-state networks...and these networks have become more sophisticated as a result of recent development in communication and transportation. The open border has the potential to facilitate such transactions very smoothly. This is possible because Diasporas often create transstate networks that permit and encourage exchanges of significant resources such as money, manpower, political support and cultural influence, with their homelands as well as their ethnic community living in other parts of the world. Socio-cultural similarities on either side of the international border, a universal phenomenon, are more pronounced in the case of Nepal-India border, because such ties have been enhanced by open border with no restrictions on the movement of people on either side. Social and cultural similarities do exist along the Nepal China boundary as well but more so in the case of 2

Manifest 2009-003Nepal India border where people have easier access and interaction. Ethnic and linguistic similarities exist along the Nepal-India border both in the south plains and hills in the east and west. The open border has naturally promoted social and cultural interaction among the nationals of both sides through matrimonial relationship as well. When health infrastructures in Nepal were not developed, a large number of people from the Terai of Nepal as well as from the hills used to go to hospitals in India across the border. During the last few decades, Nepal has been able to develop health facilities in the country, particularly in itsTarai region, with the establishment of regional, zonal and district hospitals with modern medical facilities. This has resulted in the large-scale flow of patients from India into these hospitals. One noteworthy development of medical facilities in the Terai has been the opening of the modern eye hospitals and ophthalmology units in zonal and regional hospitals. These facilities have resulted in the large scale inflow of eye patients from the bordering states of India because of quality and cheap services. A medical institution that has attracted a large number of cancer patients from India is the cancer hospital in Bharatpur with ultra modern cancer treatment facilities. The flow of Nepalese cancer patients to Mumbai is still continuing. There are 10 medical colleges in Nepal, most of them in the private sector. Three medical colleges are located in Kathmandu, one in Pokhara and 6 in the Terai: Dharan, Birgunj, Bharatpur, Bhairahawa, Nepalganj and Chisapani. These medical colleges have attracted a large number of Indians including non-resident Indians seeking medical education and also patients seeking medical services in these hospitals. The flow of Nepalese students seeking medical education in India is also continuing. While communicable diseases may pose the most immediate concern, the significant impact of globalization on noncommunicable diseases is also beginning to be recognized. Much of this impact arises from the global production and trade of health-related goods.Notable are pharmaceuticals, food and drink (including alcohol), biologicals such as blood products (Kimbrell 1993; 1998), and increasingly health information. Most immediately, this creates the potential for spreading health risks far wider than previously. Infected blood products traded globally in the 1970s, for example, resulted in the worldwide spread of Hepatitis Band HIV/AIDS. More subtle are influences over lifestyle through the global marketing of fast-food diets, tobacco products and alcoholic drinks. The temporal dimension of health impacts is also varied. Foremost is the speed in which health risks arise and are spread within and across countries. The seventh cholera pandemic, beginning in Indonesia 1961, has been both the longest pandemic in history (i.e. 38 years), as well as the most rapidly spread. Within two years of being introduced to Peru in 1991, it had spread to nineteen other countries in Latin America (Lee and Dodgson 1998). Relatedly, it is expected that global climate change will affect the seasonal range of many vector-borne diseases (e.g. malaria, Lyme disease, dengue fever). As Kaferstein (1997) writes, over the last 3

Manifest 2009-003two hundred years, the average distance travelled and speed of travel has increased one thousand times, while incubation periods of disease have not. Similarly, the Harvard Working Group on New and Resurgent Diseases (1997:165) observe, that the more specific impacts of the cognitive dimension on health include influences, led by the mass media, on healthy or unhealthy lifestyles. Beginning with the spatial dimension, one of the most prominent features of is an increased mobility of people, animals, plants and objects across national boundaries. The most direct consequence for health is the increased potential for the spread of communicable diseases. Greater movements of people through business activities, immigration, rural-urban migration, displacement and tourism create more opportunities for the transmission of disease because of more widespread, frequent and close physical contact. Recent pressures to make cross border movements stringent is not totally unjustified keeping the above facts in view but we must not forget the ties between the people of both the countries the contribution of cross border accesses of health and other variety of facilities which have been contributing to the quality of lives of the people of both the sides. From this new perspective, it is hoped that the present study would be a significant contribution to the understanding of the Indo Nepal border problems, helpful in policymaking and surveillance activities and in restoring and retaining the Quality of life of the people of both countries. 2. Overview of literature: Cross-border co-operation Although, India and Nepal have been having a long history of collaborative association, and many studies on Indo-Nepal Relations on various dimensions can be found, formal studies on sustainable development, from collaborative regional planning point of view, are relatively few and far between. Even in the world literature, until recently, cross-border co-operation on a sub national level has not gained much attention in major social science discourses. However, around the beginning of the 1990s scholars of federalism and of regional science started to trace the growing international activities of sub-national political units in Europe and North America (Michelmann & Soldatos 1990; Brown & Fry 1993; Hocking 1993a; Groen 1994 and 1995). Whereas much attention was given to para-diplomatic (Soldatos 1990, 1993) or interregional (Raich 1995) activities of provinces, states and cities, the longest tradition and the most enhanced features of international activities of these units are micro-diplomatic or cross-border activities (Cohn & Smith 1996; Martinez 1986; Swanson 1976). Developments in some border regions have advanced to the point that the older notion of micro-diplomacy needed to be replaced by one of cross-border institution building, even though most of these 4

Manifest 2009-003cross-border institutions are rather soft, not very formalized and mostly network-like institutions. Global economic, technological, ecological and social developments contribute to a rapid increase of interdependence across territorial boundaries and to a political process. Brian Hocking (1993b) called localizing foreign policy. In addition, factors within the political system, including trends toward decentralization in most western countries and, most importantly, the political processes of continental integration have created opportunities for increasingly professionalized sub national units to pursue. In Europe, the Single European Act (1987) initiated the European Internal Market. The Maastricht Treaty (1992) then set the framework for the Monetary Union. In North America, these processes were fostered by the Free Trade Agreement between Canada and the U.S. (FTA 1988) and by the North American Free Trade Agreement (NAFTA 1994) between the USA, Canada and Mexico. These highly visible signs of cross border cooperation can be seen as catalysts for facilitated new cross-border activities on a sub-national level. Studies on sustainable development of Indo-Nepal border region and specifically the location we are concentrating upon, from collaborative regional planning point of view, was initiated by Pandey (2000). His subsequent studies (2000a, 2001, 2001a, 2001b, 2002, 2002a, have layer a sound foundation. At this point of time, help from UGC in the form of a Major Research Project is gratefully acknowledged. Health Policy Measures of Quality of life Both health policy analysts and social scientists have done considerable works constructing and employing measures of health and quality of life for use with large and diverse populations. There is a voluminous medical and health policy literature focused on the peoples quality of life as it is affected by various diseases and /or treatments to ameliorate or cure those diseases. (40.p116) but a point to note is that the quality of life measure in medical and health care literature tends to focus on individuals dysfunction and its relation to some such norms. At the deeper level, medicine views bodily parts and organs and human body and the people from functional point of view. In recent years health policy researchers have developed a variety of measures that go substantially beyond crude morbidity and mortality measures. It should be noted that the importance of life plans for a good life suggests at least two other ways in which different mortality rates within society affect the opportunities of their members to attain good lifeexpectancy. A few examples may be put in order. The Sickness Impact profile (SIP), was developed by Marilyn Bergner and his collogues to measure the impact of a wide variety of forms of ill 5

Manifest 2009-003health. A study that measures the quality of life but without focusing on health care and disease can be found in the Swedish Level of Living Surveys (Erickson, 1993). A second example of an evaluative framework is the Quality of Life Index (QLI) developed by Walter Spitzer and colleagues to measure the quality of life of cancer patients. A third prominent measure developed by Milton Cohen, S Franshel and others is the health status index (HSI) which measures the level of functions along certain dimensions. (Cohen, Bush, and Patrick, (1975)) The point to note is that both the practical and theoretical difficulties in constructing valid measures that are feasible for large and varied populations require compromises. Nevertheless, several features of these measures are significant in showing the complexity of the quality of life measures employed in health care and should be acceptable for not very specific purposes. Studies on quality of life under the influence of cross-border synergies and specifically the location we are concentrating upon are again few and far between. An attempt has been made by Pandey (2002c) to analyse health and quality of life under the influence of cross-border synergies using the capability approach, Sen. (1985, 1992, and 1993) and Capability Sets, Pandey (1999). 3. The Conceptual Framework: Towards an effective response to health issues, one of the most immediate needs is for a better understanding of the cross border access (which may, if one wishes so, be seen as globalization) through sound empirical research. Two key questions may begin to guide such research: (a) To what extent is the cross border access of health occurring within different spheres and along different dimensions? And (b) What positive and negative effects are the cross border access of health facilities having (or expected to have) on the health of residents of the region and groups? Health, broadly defined, concerns many spheres of human societies. It accounts for significant economic activity through, for instance, substantial public and private expenditure, large workforces and manufacturing of medical supplies and pharmaceuticals. It is highly political, for example, because of allocative decisions concerning treatment, research and salary levels. There are clear cultural aspects in the form of lifestyles, and cultural beliefs about health and illness. And there are clear environmental implications such as urbanization, climate change and resource depletion. Beginning with the spatial dimension, one of the most prominent features of is an increased mobility of people, animals, plants and objects across national boundaries. The most direct 6

Manifest 2009-003consequence for health is the increased potential for the spread of communicable diseases. Greater movements of people through business activities, immigration, rural-urban migration, displacement and tourism create more opportunities for the transmission of disease because of more widespread, frequent and close physical contact. In general, political, non-technical activities of sub-national cross-border units are much more recent .The following analytical description will focus first on the opportunities opened up by cross-border institutions. Four important functions of cross-border co-operation can be distinguished: Establishing a regulatory regime, Functioning as a transfer hinge, creating an innovation pole, facilitating cross-border coalition building In reality these functions often overlap; the differentiation is merely analytical but useful in highlighting various elements. These functions have different disciplinary origins. Whereas the first function represents the dominant legalistic and normative approach, the next two results from economic considerations and the last represents a typical political science approach. While cross-boundary co-operation has been found to serve important functions in furthering policy goals, this does not necessarily mean that cross-border cooperation helps to promote sustainable development based solutions. The preconditions that promote sustainable development may be summarized as the existence of institutions that help to overcome intersectoral cleavages. It is also true, however, that some categories of cross-border linkages make it harder to create such preconditions. Sustainable development is the development that meets the needs of the present without compromising with the ability of future generations to meet their own needs (World Commission on Environment and Development (1987). In attempts to operationalise this goal, one procedural principle gained central importance: the need for cross-sectoral integration. As Thierstein and Walser (1997) put it: The strengths lie in its cross sectional character which integrates economics, ecology and social aspect. The Rio Declaration states that peace, development and environmental protection are interdependent and indivisible (Principle 25). Sustainable development is comprised of three problem dimensions that should be analyzed in parallel (Daly 1992 according to Thierstein/Walser 1997): (i) (ii) (iii) Economic Dimension: where the focus is on allocation; (ii) Ecological Dimension: where the focus is on scale;

Social Dimension: where the focus is on distribution.

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Manifest 2009-003A striking characteristic of cross-border regions is that the linkages across the border are almost always centered on pectoral focal points. We can see this pectoral differentiation in the process of cross-border region building on the basis of, (a) (b) The formation of various selective policy networks (Marin & Mayntz 1991), The existence and relevance of antagonistic epistemic communities(Haas 1987), and region

(c) The appearance of antagonistic visionsin respect to what the cross-border is intended to accomplish.

The essential feature of cross border accesses is that it is a process changing the nature of human interaction. Foremost are changes to spatial (e.g. state) boundaries, but temporal and cognitive boundaries are also being crossed. As a result, many health issues are also being changed by these global dimensions. Towards an effective response to quality of life and these health issues, the most immediate need is for a better understanding of globalization through sound empirical research. It is expected that a research of this type would help and facilitate policy initiatives at local, national, regional and global levels. This might begin with encouraging greater awareness of the global dimensions of health among policy makers and health practitioners, but could then be followed by specific policy decisions to optimize the benefits, and mitigate the costs of health and raise the quality of life of the human being. 4. Research Questions or Hypotheses: Objects: (a) To explore the ground realities on Indo-Nepal Border region in relation to cross border socio economic interactions with a view to quality of life. (b), To explore the ground realities on Indo-Nepal Border in relation to cross border accesses of health care facilities and utilization (c) To analyse Indo-Nepal Policy compatibilities from the point of view of enhancing Quality of life, (d) To devise a policy framework for effective border management with optimal access to health facilities. Hypotheses to be tested are:

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Manifest 2009-0032000 2001 Cross border synergies and Quality of life of the people of Indo-Nepal order region are positively related. Any attempt to restrict open nature of Indo-Nepal border will have negative impact on the quality of life of the people of Indo-Nepal order region are positively related.

5. Coverage Focus is to be given on three levels: (1) At the global level a birds eye view of the cross border impacts on quality of life, (2) At the country level policy frames of reference, (3) At the micro level ground realities, cross-border socio-economic dynamics and its policy implications. (I) Universe of study The present study is concerned with the quality of life, especially the health dimension of the people residing along the border of India and Nepal, of course, with a focus on certain Districts, It becomes therefore, necessary to get hold of the first hand information on both sides of the Indo-Nepal border. The present study will cover the residents of India and Nepal residing nearby Indo-Nepal border, in the Districts Mahrajganj and Siddharth Nagar of Eastern Uttar Pradesh from India side and Naval Parasi and Roopandehi and Kapilvastu on the Nepal side. (ii) Sampling Frame: Selection of samples from the both sides of the border of India and Nepal in the specified region will be done with the following schemes: With an assumption that the cross-border Socio-economic interaction between India and Nepal diminishes as the distance from the border increases, a gravitating approach will be followed for sampling and data collection. Thus, density of samples will be decreasing accordingly. This approach can be understood with the help of the following conceptual scheme: ______________________________________________________________________

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Manifest 2009-003INDIA>> [NO MANS LAND] [NO MANS LAND] > [NO MANSLAND] ________________________________________________________________________ Beyond ten kilometers on both the sides are tertiary layers. The primary, secondary and the tertiary layers represent the regions which are farther and farther from the no mans land respectively. Criteria for Selection of Region/Districts: The comparative backwardness of the Maharaj Ganj and Siddharth Nagar districts, from the point of view of the Quality of life, in Uttar Pradesh has formed the basis for selection. Interaction and cooperation among the people residing in the neighborhood is highest, therefore, the two districts Naval Parasi and Roopandehi are selected as they lie in the extreme vicinity lest a no mans land dividing the neighborhood but without affecting the socio-cultural interaction attributed to the open border. (3) Sampling procedure

Given the nature of the study, it is obvious that we need to obtain primary data for analyzing the issues at hand. Information the project will draw from its field work and primary evidences that would allow us to devise a comprehensive platform for policy analysis & formulation. A random and purposive clustered sampling procedure will be adopted in the study. Methodologies to be employed include: Institutional analysis, ethnomethodology, ethnography, participant-observation method, unobtrusive measures, content analysis, secondary analysis and comparative analysis of the experience of countries with different policies, institutions, etc; The survey instrument will be designed to take into account country specific factors. Some standard rules for taking field notes have to be followed in collecting such data, i.e., taking notes as soon as possible, and not to talk to anyone before note taking, counting the number of times key words or phrases are used by members of the folk group, carefully recording the order or sequence of events, and the sequence, not to take anything as too insignificant; recording even the smallest things, drawing maps or diagrams of the location, including the movements and any reaction by others, writing quickly and devising ones own system of punctuation, avoiding evaluative judgments or summarizing; always make backup copies of your notes and keep them in a separate location and so on.. The key point behind all of these is that the researcher must operate on two levels: becoming an insider while remaining an outsider. These notes would 10

Manifest 2009-003contain rich, detailed descriptions of everything that went on. There would be no attempt at summarizing, generalizing, or hypothesizing. The notes would capture as factual a description of the drama as possible to permit multiple interpretations, and most of all, to later infer cultural meaning. Almost all case studies involve unstructured interview and ethnographic methodology (meaning the subject was allowed to express themselves in their own words). It's difficult to describe the variety of techniques used to arrive at useful generalizations in a case study. Homothetic (group) designs simply add up the totals and look at averages. Idiographic (single subject) designs have the advantage of rescuing individual data from the pile of averages. This argument works best if the individual in question falls into some extreme category (successful at crime or a complete failure at it). Scientists refer to these cases as "outliers". Secondary analysis is the reanalysis of data that was originally compiled by another researcher for other purposes than the one the present researcher intends to use it for. Secondary data analysis is only limited by the researcher's imagination. While the technique is mostly quantitative, limitations exist that often force such researchers to have some qualitative means of garnering information also. In such cases (as with much Historical-Comparative research), the qualitative part of the study is used as a validity check on the quantitative part. (4) Units of observation and sampling size: Selection of Respondents With this conceptual scheme, a selection will be made out of a total of two tehsils and twenty five blocks, including tehsils as sadar blocks of the two districts from India side. A total of sixty observation sites will be selected on random basis, out of which thirty will be taken from India side and thirty from Nepal side. From each observation site, a total of twenty individuals will be interviewed on pre structured questionnaire, thus, we will be having nearly1200 respondents to provide necessary information. The selection of respondents will be made on the bases of following parameters: (I) Distance of unit from no mans land (ii) Population (iii)Composition of urban, semi urban and rural settlement. On Nepal side the criteria of sampling will be the same. 7. Data Collection

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Manifest 2009-003Given the nature of the study, it is obvious that we need to obtain primary data for analyzing the above issues. Data are not inherently quantitative, and can be bits and pieces of almost anything. They do not necessarily have to be expressed in numbers. Data can come in the form of words, images, impressions, gestures, or tones which represent real events or reality as it is seen symbolically or sociologically (If people believe things to be real, they are real in their consequences - the Thomas Dictum). Qualitative research uses unreconstructed logic to get at what is really real -- the quality, meaning, context, or image of reality in what people actually do, not what they say they do (as on questionnaires). Unreconstructed logic means that there are no step-by-step rules. Qualitative research most often is grounded theory, built from the ground up. Criteria for Data Collection Villages, hospitals, offices and various other departments will be surveyed in a random way without informing beneficiaries, Panchayat officials, developmental officials and others. Different approaches like social and village mapping, group discussions, involvement of beneficiaries in the discussions will be adopted. All the individuals will be interviewed separately without interference, at their convenient time in an open, informal, conducive, non-threatening and non-promising. Officers and Sarpanch will be interviewed separately for collecting various data. As already mentioned above, study will be heavily based on the primary information, needless to say that secondary data will also be used. It may come from published (Publicly available) or arranged from official records. Primary data will be collected by means of questionnaire, interviews, and observations and by various methods detailed in the preceding section. For secondary data, we will have to rely on government publications as well as on the information from the revenue, police and surveillance authorities of both the countries. It will, therefore, be time consuming and expensive. For Questionnaire/Schedule to be used (1)Identification of data: Since Quality of life is directly related to level of earning: On the basis of occupation: Self employed, Service, Agriculture, Labour. Out of which, a selection will be made on proportional ground for a maximum of 20 schedules per observation point to be administered by the investigator by visiting personally. (2)Approximate number of questions to be asked: Approximately 35 to 40 questions. (3)Scaling Techniques (If used) (4)Projective Tests incorporated (If any) (5)Time per interview One to one and half hour per schedule, as each schedule will have 35 to 40 items. (6)Index construction (If any) (7)Coding Plan (whether questions and responses will be prerecorded or not; whether the coding is done for computer or for hand tabulation) 12

Manifest 2009-003Questions and responses will be prerecorded and coding will be done for computer. It will be done keeping the following facts in view: Coding scheme will be devised, usually in basic terms like frequency (amount of content), direction (who the content is directed to), intensity (power of content), and space (size of content). Manifest coding is found to be quite reliable because one can train assistants to do it, ensuring inter-coder reliability, and all one is doing is using an objective method to count the number of times a theme occurs in your coding scheme. Latent coding requires some knowledge, usually gained from fieldwork or observation, about the language rules, or semiotics, of the subjects. It is less reliable than manifest coding, but involves the researcher using some rubric or template to make judgment calls on implicit, ironic, or doubtful content. Since not everything always fits in categories, there's always some leftover content to be accounted for, and it must be interpreted in context by a knowledgeable researcher who knows something about the culture of his/her subjects. A key point to remember is that the more quantitative aspects of content analysis come first; the qualitative part of the analysis comes last, although some advocates say the technique involves moving back and forth between quantitative and qualitative methods. For Interviews (1) (2) How (Free associational,nondirective,focused,direct or on telephone) Direct associational & in-depth interview to fill the questionnaire;

Particular characteristics Quality of life comprises many characteristics; a few ones may only be stated here. For, the broadercategoriesareoutlook,support,health,daily living,activities,socialinteractions,socialadaptivity,alertness,,communicat ion, emotional behavior, education, earning capacity ,since Quality of life is directly related to level of earning. . Observation Techniques Type of observation; participant/quasiparticipant or nonparticipant Participant/quasiparticipant (ii) Units of observation Individuals and households (iii) Whether there will be the only technique or other will also be employed Techniques are most efficiently and cleverly used when researcher keeps is eyes open and adapt to the delicate nature of the data and information he/she has gathered. Therefore, it is not fixed and proper adjustments are possible and other techniques may be used as the data structure and data bases of India and Nepal may not be homogeneous. (i)

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Manifest 2009-0037. Data Processing This study intends policy formulation; data will be coded and analyzed in such a manner that simulation studies are possible. Most of the general softwares are available with the host institution only specialized analysis will require customized software which will have to be developed by some professional developer or will be hired. 8. Time Budgeting The proposed research work will be broken up in to several sages and time required for each stage (tentative) is given below: Preparatory work, including 1 selection and appointment of staff and their training 2 Pilot study, if any 3 Drawing of Sample 4 Tool Construction their pretesting and printing) 5 Data collection 6 Data processing(including coding editing, sorting, computer analysis) 7 Data analysis & interpretation 8 Report writing TOTAL (iii) Organizational Framework 1 month

3 months 3 months 5 months 4 months 4 months 4 months 24 MONTH S

Details of the project staff, other than the Project Director, to be appointed: 9. Cost Estimation

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