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8. Other important programmes to combat malnutrition in India

8. Other important programmes to combat malnutrition in India

Two major programmes designed to improve food security viz. the PDS (making available foodgrains at affordable prices) and employment generation schemes (improving purchasing power through self and wage employment) have already been discussed in detail. However, it will be in the fitness of things to briefly mention other programme which attack malnutrition directly or indirectly, since ultimate test of food security lies in nutritional well being of all. Direct attack on malnutrition has become necessary because it was felt that hopes of aggregate growth percolating down to most disadvantaged and vulnerable groups did not come true. "In the face of continuing poverty and malnutrition, an alternative strategy of development, comprising a frontal attack on poverty, unemployment and malnutrition became a national priority from the beginning of the Fifth Five Year Plan. This shift in strategy has given rise to number of interventions to increase the purchasing power of the poor, to improve the provisions of basic services to the poor and to devise a security system through which the most vulnerable sections of the poor (viz. women and children) can be protected" (NNP, 1993).

A. WOMEN AND CHILD DEVELOPMENT SECTOR

1. Integrated Child Development Service Programme (ICDS)

This is a unique programme under which a package of integrated services consisting of supplementary nutrition, immunization, health check up, referal and education service are provided to the most vulnerable groups even within children and women, i.e. children up 6 years of age and expectant/nursing mother, through a common focal point called Anganwadi (the courtyard centres) in each of the village/urban slums.

The objectives of ICDS (Annual Report, Department of Women and Child Development, 199394) are:

One ICDS project covers either a tribal or a rural Block, the territorial unit at sub-district level or a cluster of urban slums in an urban project. Preference in selection of Blocks is given to those which have comparatively larger proportion of the population of tribal people and other disadvantaged categories. The ICDS programme was launched experimentally and rather modestly, by covering 33 Blocks/slums in 1975-76. The author happened to be the Director incharge of the programme in the then Ministry of Education and Social Welfare immediately thereafter, when programme was internally evaluated and expanded to 66 Blocks. Since then, the programme has been expanded gradually in a phased manner and by the end of March 1993, it consisted of 3066 projects with 19.5 million children and mothers receiving supplementary nutrition under the programme. In addition, 9.34 million children were receiving pre-school stimulation. The entire expenditure of the 2871 centrally sponsored ICDS projects (of the total 3066 projects in place by the end of March 1993) is borne by the Central Government, barring expenditure on supplementary nutrition which concerned State Governments incur. Expenditure on rest of the projects is borne of the state governments. How massive is the programme can be gauged by the fact that "21.4 million women and children are likely to have been covered by one or other aspects of this programme in 1993-94 and an amount of Rs. 4618 millions is likely to have been spent by the Central Government itself. UNICEF and some other international agencies are also assisting the programme. (Annual Report, Min. of Women & Child Dev., 1993-94)

An evaluation of the ICDS programme carried out in 1990-92 has revealed that some of the positive impacts of programme are (i) IMR in ICDS covered areas was significantly lower (66.6/1000) compared to IMR in the non-ICDS areas (86/1000); (ii) immunization coverage in ICDS areas has been much better (iii) there has been better coverage of prophylaxsis programme of Vit. A and iron; (iv) the nutritional status of covered children was going up and (v) the percentage of low birth weight babies was also found to be lower. On the negative side, the report has brought out inadequate community participation and perhaps too much dependence on Government. Another status appraisal of ICDS, carried out in four States by the National Institute of Nutrition, Hyderabad revealed that "Nutritional status of ICDS beneficiaries in Bihar was better than their non-ICDS counterparts and only marginal differences were observed in the remaining three States of Andhra Pradesh, Madhya Pradesh and Orissa". This report, therefore, suggests better training and motivation of ICDS workers to monitor growth properly and continuously identify the children and mothers at risk, arrange for clinical intervention in their cases, increase the quantum of their supplementary nutrition and so on. In fact, NIN is now starting the "nutrition surveillance" in ICDS blocks in Andhra pradesh on pilot basis for achieving the abovementioned purposes.

It is now well recognised that proper and continuous training of ICDS functionaries at all levels and functional monitoring is vital to the success of a programme like ICDS which seeks of deliver a package of services. At the same time, motivation of the village people to support the programme is also a much needed element. In fact, the worker incharge of the focal point of delivery in the village i.e. Anganwadi worker is supposed to be a girl from the village itself so that she does not have too many overheads and does not take it as a job being performed like by a Government employee. She must be able to feel that she is enabling the children and women, many of whom are her relatives in her own community, to derive the benefits from the programme.

2. Special Nutrition Programme (SNP)

This programme was launched way back in 1970-71 for the same target group as in ICDS i.e. children below 6 years age and expectant and nursing mothers. The programme is confined to tribal areas and slums. Main activity under this programme is to provide supplementary feeding to the beneficiaries for 300 days in a year, although some individual initiatives were made in some States to link some other services with supplementary feeding. For example, in early seventies in the small State of Tripura in North Eastern India, a school drop out tribal girl was selected for running the feeding centre, provided with some motivational training and then encouraged to impart pre- school education to the children, teach them simple personal hygiene etc. Tribal communities were exhorted, and they invariably did so, to construct a small hall where the pre-school activities could take place. Under this programme, every child is to receive 300 calories and 8 to 15 gms of protein and every expectant and nursing mother 500 calories and 20 to 25 gms of protein per day. As and when ICDS projects coyer 'tine areas having the SNP, the programme is merged with ICDS.

Balwadi Nutrition Programme

Bal (children) wadi (home or centre) Nutrition Programme is a contemporary of SNP and is being implemented since 1970-71 by the Central Social Welfare Board and national level nongovernmental voluntary organisations, namely, Indian Council for Child Welfare, Harijan (Scheduled Castes) Sevak (Service) Sangh (Board), Bhartiya (Indian) Adimjati (Scheduled Tribe) Sevak Sangh and Kasturba (wife of Mahatma Gandhi) National Memorial Trust. This segment of nutrition programme is thus implemented essentially by non-governmental organisations. The Central Social Welfare Board, which is a semi-government umbrella organisation in the field of social work, gives in turn, grants-in-aid to voluntary organisations to actually run the programme and so do the other four national level voluntary organisations, which also extend assistance to various voluntary organisations beside running some centres directly.

The beneficiaries of SNP are basically from the disadvantaged section of the society like tribal/scheduled caste people, urban slum dwellers and also migrant labourers. The in-charge of the Balwadi Centre is an honorary worker, like Anganwadi worker of ICDS, and is paid an honorarium which is Rs. 200 per month for trained and Rs. 150 for untrained. She is assisted by a helper who is also an honorary worker. The Balwadis not only provide supplemental nutrition but also look after the social and emotional development of children attending these Balwadis.

A total number of 5641 Balwadi centres are presently being run by the five organisations. About 229 thousand children in the age group 3-5 years are covered under the programme. The budget for the SNP during 1993-94 stood at Rs. 100 million.

3. Creches for Children of Working and Ailing Women

The scheme, implemented since 1975, has been designed to free the working, and in some cases ailing mothers, from the task of looking after their children while they are on work or are sick. The coverage under the scheme is available only to those children whose parent's total monthly income does not exceed Rs. 1800. Children generally belong to casual migrant vendors, construction labourers groups etc. The services available to the children include sleeping and daycare facilities, supplementary nutrition, immunization, medicines, entertainment and checkups at weekly intervals.

The scheme is implemented by the Central Social Welfare Board which gives grants-in-aid to various non-governmental organisations to manage the creches. Two other national level voluntary organisations namely, Indian Council for Child Welfare and Bhartiya Admijati Sewak Sangh also implement this scheme.

A total of 12470 creches are being run under this scheme; during 1993-94, covering three hundred thousand children. Assistance to the tune of Rs. 230 million is being provided to the CSWB and voluntary organisations to implement the scheme.

4. Wheat Based Supplementary Nutrition Programme

The scheme was started with the twin objective of providing supplementary nutrition to children and popularising wheat intake. Min of Food places at the disposal of the Department of Women and child Development about 100 thousand tonnes of wheat from the central reserves annually and that Department, in turn, sub-allocates this wheat among States which utilise the wheat mostly to produce wheat based ready-to-eat nutrition supplements. With the spread of ICDS, this wheat or its products are increasingly being utilised for distribution of supplementary nutrition in ICDS and mid-day-meal programmes The wheat is supplied to the State Governments by the Food Corporation of India at the same subsidised rates as for the public distribution system.

5. World Food Programme Project

World Food Programme-UN provides food-stuffs so that supplementary nutrition could be provided through the projects supported by them. WFP-India project has been extended from time to time and the present extension would last till the end of March 1995. WFP currently supports 12 projects in India, with a total commitment of 292 million dollars worth of food aid. "The major part of WFP's assistance to India supports projects in forestry, irrigation and supplementary nutrition. WFP's food assistance to India is focused on poverty alleviation, directly targeting the most vulnerable section of the society" (WFP News letter April 94). The WFP provides Soya Fortified Bulger Wheat, Corn Soya Blend and edible oil to benefit about 2.1 million pre-school children, expectant and nursing mothers. For the last three years or so, the WFP obtains wheat or rice locally from the Food Corporation of India in exchange for the butter oil it gets as donation from some European countries.

6. CARE Assisted Nutrition Programmes

Under the Indo-CARE Agreement of 1950, CARE-India extends food aid so that supplementary nutrition can be provided to pre-school children of age less than six years and expectant/nursing mothers. The CARE assistance is now dovetailed with ICDS projects and some of the ICDS projects utilise this assistance for the nutrition component of the programme. The programme covers ICDS projects in 10 States of the Indian Union. CARE has also monetized oil received by it as donation for generating funds worth Rs. 100 million for implementing activities supportive of ICDS programme.

During 1993-94, CARE would provide slightly above 200 thousand tonnes of food commodities to cover around 9 million beneficiaries.

7. Tamilnadu Integrated Nutrition Project

This project located in the Southern State of Tamilnadu, was started sometime in 1980-81 with the World Bank first time extending assistance for nutrition programmes in India. Second phase of the project with a life of six years has started in 1990-91.

The project would ultimately cover 316 of the 385 development Blocks in Tamilnadu. This will enable all the rural areas of the State to come under the coverage of either this project or ICDS, as in most of nutrition programmes discussed earlier. The target groups in this project are also children up to 6 years of age and pregnant/nursing mothers. Like ICDS, pre-school education is provided to children in 3 to 6 years group. The project seeks to provide enhanced inputs in the areas of health, communications, training, project management, operations, research, monitoring and evaluation. The NNMB repeat surveys for rural areas in Tamilnadu showed that "the prevalence of severely underweight 1-5 (i.e below 60% NCHS median weight for age) dropped from 12.6% in 1975-79 to 4.2% in 1980-90, at a faster rate than all India improvement of 15% to 8.7% in the same period The rural IMR decreased from 121 in 1976 to 85 in 1988, as compared to all-India IMR decrease from 139 to 102. A comparison of deaths among children 0-4 yrs. to total deaths shows that Tamil Nadu at 22.2% (in 1987) is second only to Kerala (13.3%) (with all India average was 42.0%)". (Ready, Mrs. Vinodini, 1992) It, therefore, appears that this project, implemented in just one state with strong political and administrative back up, has been able to secure better coordination between nutrition, health and educational services and certain strong points observed in this project need to be replicated in other nutrition programmes

8. UNICEF Assistance for Women and Children

India has been associated with UNICEF since 1949 and is one of the major countries as far as activities of UNICEF are concerned. The activities are guided by the provisions of the Master Plan of Action, the latest of which was signed between India and UNICEF on 30 May 1991 and extends up to 1995. During the Five year period, UNICEF is likely to spend around U.S. $ 175 million in India from its general resources. UNICEF's assistance covers a wide spectrum and is available in the sectors of health, education, nutrition, water and sanitation, rural development urban basic services etc. Of course, the focus of all its programmes is essentially on children and also on women, with the ultimate objective of better child health survival & development.

B. INTERVENTIONS IN THE HEALTH SECTOR

Inspite of a drop in the growth rate of population (from 2.22% during 1971-81 to 2.14% during 1981-91), "every year around 17 million people are added to the population, which creates a demand for additional resources for clothing, housing, food, education, health, schooling etc. With 2.4% of the world land area, India supports 16% of the world's population." (Annual Report Min. Health, 1994). Population control, therefore, remains a key to the resolution of not only food and nutrition security in India, but almost all the problems that the country faces. The ultimate objective of all socio-economic development is to bring about a meaningful and sustained improvement in the well being and welfare of the people and there is no better index of the well being of people than the state of their health. The importance of the status of the health of people can, therefore, scarcely be over emphasised. Whether directly or indirectly, all health programmes are as important in combating malnutrition as programme that make available purchasing power, foodgrains at the subsidised prices and supplementary nutrition to children and mothers.

In fact, now a days the sensitive index of a community's health status is the chance of survival and growth of its children below five years of age. It is another matter that the author himself, in the early stages of his service (1969-71), had an occasion to observe a community of tribal people whose philosophy to life was, and I hear still is, entirely different from ours. This community, the Nishi Tribe (earlier known as Daflas), inhabited the high hills in one of the districts of the North East Frontier Agency, now the State of Arunachal Pradesh in North East India. Author's own headquarters, as the administrative head of that area, was full 13 days foot march from the nearest motor head. The area was thus, completely cut off from rest of the world, the only contact being the wireless net used by the government and once in a while helicopter sortie. The people were completely self sufficient and the only thing they needed from the outside world was salt which earlier used to come from Tibet and was later on air dropped. It was observed to be a simple and happy community, producing enough to feed themselves for the whole year by slash and burn (Jhum) cultivation on hill slopes and supplementing their diets with mutton obtained from hunting & smoked inside their huts for use throughout the year. I never saw them grieving for the death of a child, they would simply accept it matter of factly, explained away by the jungle law of the survival of the fittest. Of course, when a child passed the age of 13-14 years, he would develop into a beautiful specimen of human being, well built, tough and happy go lucky. The author, bred in a different environment, could neither understand not appreciate their philosophy. However, it appeared that high child mortality was perhaps necessary in order to maintain the balance between humans and nature, especially the need to maintain a long cycle in the shifting cultivation. Child births were many but women were tough and did not appear to have any adverse effects of frequent deliveries, probably because of being used to hard labour all the year round. My wife was amazed one day when she saw the wife of my Political Interpreter returning home from her Jhum Khet (slope of shifting cultivation), about 4 kms away, with a new born baby in her arms. The area was free from various infections and I have myself seen a man's intestines having come out through wound inflicted by a spear, but the local medicant put it back, covered the wound with some paste made of local leaves and sewed it with pig's hair ! Of course, the area could not remain isolated forever and even without completion of the motor road under construction those days, the market economy and modern civilization slowly entered the area. We, the change-agents, introduced wet rice permanent cultivation in valley lands to replace jhum cultivation. Valley lands being limited, land disputes erupted for the first time. With money and markets, entered terylene shirts, radio transistors, cosmetics and so on. Gradually their uncomplicated simple life started giving way to a life like ours, one not infrequented by greed, disputes and selfishness. This digression, though not necessary, was spontaneous, and only serves to establish the fact that the earth has now shrunk and global standards of life styles have to be adopted by every community sooner or later. In India as a whole, Mahatma Gandhi's philosophy of reducing wants has been given up. Substantial improvement in various health indicators have to be therefore, achieved by 2000 AD and some of these as given in the country paper for International Conference of Nutrition (Min of Food, 1992) are listed below:

1. Infant Mortality

- To be brought down from estimated 80 per 1000 live birth in 1990 to 60.

2. Child Mortality Rate

- From 20 in 1990 to Below 10 per thousand live births.

3. Crude birth rate

- From 29.9 to 21 per thousand.

4. Crude Death Rate

- From 9.6 in 1990 to below 9 per thousand.

5. Low Birth Weight Infants

- From 18 percent in 1990 to 10%.

6. Protein Energy Malnutrition (Kwashiorkar)

- Negligible presently, to be eliminated.

7. Severe Protein-Energy Malnutrition (Marasmus)

- From 8.7 percent in 1990 to below 1 percent.

8. Protein Energy Malnutrition (Moderate)

- From 43.8% in 1989-90 to below 15%.

9. Xerophthalmia (Keratomalacia)

- Present incidence resulting in blindness is estimated at 0.04 percent. It may be eliminated.

10. Xerophthalmia (Bitot's spots)

- Presently estimated 0.7% to below 0.1%

11. Iron Deficiency Anaemia

- To be reduced significantly.

12. Iodine Deficiency

- To be brought down drastically

Ministry of Health and F.W. is responsible both for the health as well as family welfare programmes Its basic goal is to ensure Health for All (Alma Ata Declaration) and achieve a Net Reproduction Rate of Unity by 2000 AD. One of the most important programmes is to establish Primary Health Centres (PHC) and sub Centres so that health care service are within easy reach of the people. At present, a PHC covers a population of 30 thousand in plains and 20 thousand in hilly areas, whereas Sub-centre covers 5 thousand in plains and 3 thousand in hilly/tribal and backward areas. Approximately 10 percent of the PHCs work as rural hospitals with provision of 30 beds.

The Health and Family Welfare Ministry also provides maternal and child health services as an important part of the total health care. These services include immunisation of infants, children and expectant mothers; prophylaxis programmes to combat nutritional anaemia and Vitamin A deficiency induced blindness; goiter control programme through production and distribution of iodised salt; popularisation of oral rehydration therapy against diarrhoea; control programme for various diseases ranging from Malaria to AIDS etc. Some of the social initiatives that have a bearing on health are also taken-such initiatives include increase in the minimum age for marriage, social marketing of contraceptives etc.

C. INTERVENTION IN EDUCATION SECTOR

It has now been well demonstrated, including the example of Kerala State in India, that higher educational attainments in a society have a positive influence on health and nutritional status of the people. The education also helps in economic development, which in turn improves food and nutrition security and ultimately improves the quality of life of all people. Female literacy is still more important because "empirical evidence in Indian context has shown a high negative correlation between female illiteracy on the one hand and fertility and infant and maternal mortality on the other. UNESCO studies have also brought out that a stabilised adult literacy level of 70 percent is a positive indication of universal primary education and a critical threshold for economic growth" (ECONOMIC SURVEY 1993-94)

India has made significant progress in this sector. The Gross Enrollment Ratio in the Primary School level has gone up from 42.6 percent in 1950-51 to 105.7% in 1992-93 and at the stage of Class VI to VIII (Upper primary stage), from 12.7 to 67.5 percent. Proportion of children moving up from the primary to Upper Primary stage has also increased from 16.3 percent in 1950-51 to 34 percent in 1991-92. Substantial progress has also been made in literacy levels as can be seen from the table below:

Table 27 LITERACY LEVELS (PERCENT)

YEAR

MALE

FEMALE

TOTAL

1

2

3

4

1951

27.16

8.86

18.33

1971

45.95

- 21.97

34.45

1991

64.13

39.29

52.21

Source: Census of India, 1991.

The programme, though substantial, has not yet reached desirable levels. Lot of work is still to be done in the area of female literacy, which is all the more important in improving the nutritional status of members of the family especially infants and children. Further, "personal hygiene and wholesome dietary practice can be best promoted in the impressionable i.e. formative years of a child. Therefore, an improvement in the level of education has a positive impact on the level of nutrition too." (Country paper for ICN, Min of Food 1992)

Lot of progress has also been made in the growth and spread of educational institutions, right from primary school to the Universities, as will be evident from the table below. Optimum use of these facilities is now required to he ensured.

Table 28 GROWTH OF RECOGNISED EDUCATIONAL INSTITUTIONS

(Number as on 31.3.1993)

Type

1951

1971

1991

1993

1. Primary Schools

209671

408378

558392

572541

2. Upper Primary

13596

90621

146636

153921

3. Secondary Schools Degree Colleges

7416

37051

78619

84086

4. Colleges for Education

370

2285

4862

5334

5. Colleges for Professional education

208

992

886

989'

6. Universities

27

82

146

149

* Includes Engineering, Medical and Teachers Training Institutions, whereas data for previous decades also included Physical Education, Mid wifery. Agri. Vet. & Music etc.

Source: Economic Survey, 1993-94

Implementation of the Directive Principle of the Constitution to universalise elementary education and eradication of illiteracy in the age group 15-35 years is the basic objective for the education sector for the current Five Year Plan. It is a gigantic task, since about 19 to 24 million children in the age group 6-14 and over 121 million adult illiterates in the age group 15-35 (with over 60 percent females in both the groups) are estimated to constitute the target group in this context. (Econ. Survey, 1993-94). Investment in education will have to be stepped up and more and more of higher education will have to be made self-paying. At present, around 75 percent of the financial resources for educational institutions come from central and state governments and share of fee and endowments and other resources have shown a declining trend. This has to be reversed and more and more funds made available for elementary education and adult literacy. This has been put into practice and 1993-94 budget has seen an increase of 37.6 percent in the central plan for education.

D. WATER SUPPLY AND SANITATION

Water is the next most important basic need after air. Even now, in many areas people (really speaking womenfolk) have to spend lot of time and energy in collecting potable water for the family's use. The water used for drinking should be free of all infections, otherwise intake of any amount of nutrition may turn out to be useless. For example, if a person is having worms or suffering from water borne diseases like diarrhoea, what nutrition he consumes will just come out of the body without providing the body with any nutrients, the leaking pot phenomenon ! Provision of safe and potable drinking water to all is, thus, also an important element of nutritional improvement.

Provision of safe drinking water in all the cities, towns and more than hundreds of thousand villages is a major challenge. It is not only the question of physical provisioning of sources but educating people in villages to use these properly and maintain them. The problem is much more difficult in hilly, tribal and decertified areas. Habits of the people also play a part, because it has been observed that many a times, especially in tribal areas, people would prefer to take water from a running stream, even if it has been made dirty by use upstream, rather than from a tube well or a ring well. Considerable progress has, no doubt, been made in arranging for safe drinking water to all but there are still a few interior villages which either do not have a source or are very much undeserved.

Sanitation is also of great importance in upgrading the nutritional status of people, especially those who are more busy with day to day existence. The concept of total environmental sanitation is being propagated in the current plan, making information, education and communication (IEC) an integral part of the programme. The integrated scheme of low cost sanitation and liberation of scavengers is already in operation in 760 towns in various states

The status of water supply and sanitation programme is given in the Table No. 29.

Table 29 POPULATION COVERED WITH DRINKING WATER AND SANITATION FACILITIES

(Percentage coverage as on 31.3.1993)

ITEM/AREAS

1985

1990

1903

Drinking water supply

      

Rural

56.3

73.9

73.5.

Urban

72.9

83.8

84.9

Sanitation Facilities

      

Rural

0.7

2.4

3.15

Urban

28.4

45.9

47.9

Source: Econ. Survey, 1993-94

It must be appreciated that the concept of sanitation in rural India is still tradition bound to a great extent and people tend to keep following them till breaking point is reached. This is one of the reason why the percentage of people covered under sanitation facilities in rural areas is still so low.

The National Drinking Water Mission is the specialised agency which is tackling the problem and it aims to provide safe drinking water in all rural area & maintain hygienic standards of sanitation.

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