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Tackling the crisis of child malnutrition

Nirmala Lakshman

Judicial interventions in vital issues of child survival, growth and health clearly imply that if the basic food and health needs of infants and children are not met by the state, it is tantamount to a violation of their fundamental human rights.

THE TRAGEDY of persistent child malnutrition in India, despite steady economic growth, reflects not only the inequitable character of this growth but also the failure of health and nutrition delivery mechanisms to the poor. It also indicates a lack of political will to deal with the crisis on a priority basis. Child malnutrition in India is among the highest in the world, along with Bangladesh, Ethiopia and Nepal. Two recent reports starkly underline the condition of India's children.

The fact sheet of the National Family Health Survey (NFHS 3), which was released by the Government a couple of weeks ago, shows that of children under three, 45.9 per cent are underweight. The last NFHS round in 1998-99 showed the percentage of underweight children under three at 46.7. The improvement in seven years is therefore only negligible. The NFHS 3 also points to a rise in anaemia among children in the 6-35 month age group, from 74.2 per cent since the last round to 79.1 per cent in the latest. These two important indicators of child malnutrition present an alarming picture of child health in the country.

The Focus On Children Under Six (FOCUS) Report, put together by the Citizens' Initiative for the Rights of Children Under Six (CIRCUS), was released at the Bal Adhikar Samvad, a public meeting on the rights of children in December 2006. It surveyed in detail the condition of the Integrated Child Development Services (ICDS) in 2004 in six States, and offers certain critical insights that highlight the unevenness of the ICDS, the only all-India programme aimed at the well-being of all children under six.

The urgent need to tackle the vital issues of child survival, growth and health, which in India are turning into a serious developmental crisis, has also been emphasised by several important judicial interventions in recent years. This highlights the fact that in a democracy with lopsided growth and dire poverty, the judiciary can step in to demand accountability from government and order relief from deprivation. The Supreme Court of India in interim orders in November 2001, April 2004 and October 2004 moved to safeguard the entitlements of children through the ICDS. The order in 2001 was the first significant one, taking forward the notion that the right to food is part of the fundamental right to life as enshrined in Article 21 of the Constitution. By calling for the "universalization" of the ICDS, the Court also underlined the importance of a rights perspective to the issue. This means that the ICDS is not just a welfare scheme but the entitlement of every child under six and every pregnant mother. The implication is that if the basic food and health needs of infants and children are not met by the state, it is tantamount to a violation of their fundamental human rights, including their right to life. By placing poverty issues in a rights perspective, the Court firmly holds governments responsible and accountable for the condition of the most vulnerable sections of the population.

In April and October 2004, the Supreme Court's directions were even more explicit; it emphasised that all pregnant mothers and every child from birth to the age of six should be covered by the ICDS. It also directed the government to specifically increase the number of anganwadi centres (AWC) from 6 lakhs to 14 lakhs and ensure that all Scheduled Caste/Scheduled Tribe hamlets as well as all slums be provided with AWCs. Importantly, the orders increased the minimum expenditure on supplementary nutrition from Re.1 to Rs. 2 per child per day. The Court sought a time frame from the government on the establishment of ICDS centres in every settlement as well. Other crucial judicial interventions include the Bombay High Court's order to the Government of Maharashtra in 2005 to extend the ICDS to all children in the State in a time bound manner, in the context of an alarming rise in malnutrition deaths of children in the State since 2003. These deaths had occurred largely in the tribal dominated districts of Thane, Nashik, Amaravati, Nandurbar and Gadchiroli. In further interim orders in September 2006, the Bombay High Court mandated specific action by the State Government to ensure that there would be no malnutrition deaths in five years' time.

Far-reaching directive

The most far-reaching directive from the recent Supreme Court judgment on ICDS, dated December 13, 2006, specified a time frame (December 2008) for the provision and functioning of the proposed AWCs. It mandated that the Central Government identify SC/ST hamlets for the creation of AWCs "on a priority basis." It further directed that slums and rural habitations are entitled to an "anganwadi on demand", in cases where there is a settlement with at least 40 children under six. The time period for this is three months from the date of demand. In addition, for the first time, the Court took a serious view of the non-implementation of its earlier orders. It asked the Chief Secretaries of nine States to explain the lapse. It issued notices to the Chief Secretaries of 12 States asking them to show cause why contempt proceedings should not be initiated against them in this matter. Further, it called for deed affidavits from all States of the manner in which its orders are being implemented. The Supreme Court's intervention emphasises the serious nature of deprivation that the majority of young children in this country are subject to.

The evidence from the NFHS 3 clearly underscores the urgent need to bolster the effectiveness of the ICDS. The FOCUS survey points out that the ICDS does well in States where it receives more attention such as Tamil Nadu where AWCs are always open, health services are provided and food is available every day. Two other States doing quite well with the ICDS as reflected in the survey are Maharashtra and Himachal Pradesh. On the other hand, in three States out of the six surveyed in the FOCUS report, described as "dormant states", the ICDS is generally functioning at a minimalist level, with Uttar Pradesh being the worst among the States surveyed. Chhattisgarh is another example of poor ICDS functioning; it is a State with high malnutrition indicators (as pointed out in the NFHS 3 survey). Rajasthan is the third poorly performing State among the six States in the survey. There are many variations even within the groups. For instance, the FOCUS survey shows that child immunisation services are as good in Himachal Pradesh as in Tamil Nadu, but Tamil Nadu does better with its pre-school education programme. The sustained functioning of the ICDS with anganwadis always being open and the supplementary nutrition programme (SNP) being in place (with variations in the quality of course) seem to be some of the markers of effective ICDS functioning.

Another important measure of the performance of the ICDS comes from the perceptions of mothers who use the services. In the States surveyed by FOCUS, 72 per cent of the mothers held the view that the ICDS is important to the well-being of their children. Issues like the regular weighing of children, the availability of supplementary nutrition, health and immunisation services, and the attitude of the anganwadi workers towards the children, as well as the availability of pre-school education, all counted towards the view that the ICDS programme was functioning successfully.

The FOCUS survey found a host of other issues that need to be addressed. The issues included wide inter-State variations related to the quality of the SNP, the physical infrastructure of the anganwadis, staff awareness, staff training, the social exclusion of tribal and Dalit children, the exclusion of children with special needs and the inaccessibility of ICDS to the children of migrant farmers and labourers. However, as the survey noted, the ICDS also plays an important role in socialisation and in fighting caste discrimination. Investigators at a village in Mandi District of Himachal Pradesh, for instance, found even though caste discrimination does exist in the village, "it does not affect the working of the anganwadi. Even children from upper caste households come and eat, in spite of the anganwadi worker being a Harijan."

Economist Jean Dreze, who was associated with the FOCUS survey, has repeatedly stressed that the ICDS performs crucial functions that directly affect the well-being and health of children. Writing in The Hindu a few months ago, he pointed out that various hurdles such as a lack of funds, poor staffing and inadequate infrastructure often found in the northern States' ICDS are "shortcomings that are curable, and their persistence essentially reflects a lack of political interest in the well-being and rights of children." Therefore, there is no reason to discredit an all-India programme which can become an effective vehicle to combat the crisis of child malnutrition as demonstrated by the experience of Tamil Nadu.

The Common Minimum Programme (CMP) of the United Progressive Alliance (UPA) Government clearly promises that the ICDS will be "universalized with quality." If this happens, with adequate financial allocations and a reasonable time frame (well within the 11th Plan), it will go a long way in ensuring that young children do not die of malnutrition in India anymore.

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