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A bad return on investment

Why the world's largest child-welfare scheme cannot stop children dying from malnutrition in India's city of gold. Pramit Bhattacharya reports. Listen to podcastpodcast

india Updated: Mar 21, 2013 16:41 IST
Pramit Bhattacharya
Pramit Bhattacharya
Hindustan Times

As UPA Chairperson Sonia Gandhi prepares to intervene next week in the great national debate about who is poor, she might want to visit northeastern Mumbai to see how the poorest are not even classified as such and how a giant government scheme to save their children from malnutrition is failing.

The nauseating stench from a mountain of garbage, greets a visitor to Rafi Nagar at the base of the Govandi dumping ground in northeastern Mumbai, heralding a neighbourhood that houses about 2,000 of the city's poorest people.

Barely half an hour away from the financial nerve centre of Bandra, Rafi Nagar lies in Mumbai's infamous malnutrition belt of Mankhurd-Govandi, a 4-km, grimy swathe of land, which has Mumbai's lowest scores in the human development index.

Najibulnisa Ahmed's entire family in Rafi Nagar is malnourished. Both her children are admitted to the nutrition rehabilitation centre. Photo by Pramit Bhattacharya

Malnutrition deaths in the area came to light when Hindustan Times reported the death of 16 children in 2010 in Rafi Nagar. While the death toll has moved up to 18, little else has changed in the lives of this community of ragpickers and other sorters and processers of the assorted detritus of the city.

Almost no one is officially regarded as poor, though many qualify, and so there are few ration cards that entitle them to subsidised food and other welfare measures.

Severe malnutrition is endemic and many families have more than one malnourished child. A key reason is that most mothers are underweight. Few however consult doctors and those who do are unable to afford the medications that their doctors prescribe.

A malnourished mother is likely to give birth to a malnourished child, doctors say. In Mumbai, the proportion of babies with low birth weight is 40%, nearly double the national average, according to the Mumbai human development report 2009, prepared by the ministry of urban housing and poverty alleviation.

Aasma Sheikh, the mother of Gulnaz, a severely malnourished child who attracted media attention last year and died in March, is underweight. Not surprisingly, two of her kids, one four years old, the other five, are malnourished. Aasma was prescribed medicines, which she cannot afford. There are more pressing concerns for her. Water is one.

"The doctor had advised me to purchase medicines but if I have to spend Rs 30-40 each day on water, how will I save money for medicines?," asks Aasma.

Children at a nutrition rehabilitation centre in Rafi Nagar, where there are fed nutrient-rich foods 4-5 times a day. It is run by an NGO, Apnalaya. Photo by Pramit Bhattacharya

Families here earn roughly Rs 100-150 a day, but have to spend a substantial amount on water and kerosene. There is no water supply and they have to spend up to Rs 30 for a can of water containing 25 litres.

While Mumbai gets an average water supply of 200 litres per capita per day, the city's slums get less than 90 litres. Slums such as Rafi Nagar get nothing.

Given the lack of access to water and sanitation, morbidity is high --- most children have diarrhea or other infections. Diarrhea and acute respiratory infections are the leading child killers worldwide. Malnourished children are more susceptible to such illnesses because they lack enough nutrients to fight infections.

Deadlier Than Terror
Under-nutrition in Mumbai is a silent crisis, one that claims more lives each year than the toll from all of city's terrorist bombings.

Most of the malnourished children in the nation's financial capital are from its world-famous slums. A recent study by non-governmental organization (NGO) Dasra puts the number of malnutrition related deaths in Mumbai's slums at 26,000 per year, a figure the government disputes.

As the Mumbai human development report pointed out, there has been no change in the condition of slum-dwellers even though non-slum areas have seen an improvement in their lifestyles. "If anything has changed, it is the deterioration in health and sanitation conditions and the increasing social trauma of visible inequity", the report said.

While the government offers knee-jerk reactions to malnutrition, especially when deaths occur, there is no sustained effort. The state is loath to give "legal status" to slums such as Rafi Nagar and provide basic amenities such as piped water and sewerage to slum-dwellers. After the Hindustan Times report was published, women and child development minister, Varsha Gaikwad paid a visit to Rafi Nagar and on the same day, a third ICDS centre started working.

India's main nutrition programme, ICDS is the world's oldest and largest child services program, started in 1975 to tackle malnutrition and provide pre-school education to children younger than six.

Seven months after Gaikwad visited Rafi Nagar, Aasma's two malnourished children bear testimony to the fact that the visit made little difference to their lives.

In urban areas, it is difficult to combat malnutrition without the involvement of municipal authorities, responsible for health, sanitation and drinking water. Urban malnutrition is poised to become a growing issue: for the first time in India's history absolute growth in urban population has exceeded growth in rural areas, according to provisional census figures for 2011.

The only time municipal workers showed up in Rafi Nagar was just before the monsoons' to demolish 50 homes.

Many urban planners try to prevent urban growth by discouraging rural-urban migration, with tactics such as evicting squatters and denying them services that ultimately prove futile.

Such efforts ignore the fact that most of the growth does not come from migration but from more locals --- they make up 65% of India's urban population rise --- and from reclassification of many rural areas to urban.

While the poor nutritional status in slums underlines the divide in living conditions in cities and state apathy in providing basic public health, it also highlights the ineffectiveness of ICDS in tackling under-nutrition.

One Size Does Not Fit All
ICDS was conceived to cater to the needs of the rural population but the scheme has been extended to urban areas in the past decade, where it is active mostly in slums.

Little attention to children below three years --- a time when intervention is most effective, an over-ambitious design that tries to attempt too many things with too few resources, lack of community participation, and grossly inadequate training and compensation to Anganwadi workers, have maimed the ability of ICDS to fight under-nutrition.

ICDS works through Anganwadi centres. Nearly 1.2 million Anganwadi workers or sevikas form India's frontline nutritional workforce. ICDS offers a package of services: supplementary nutrition, nutrition and health education, health monitoring and referrals for children below 6 years of age, adolescent girls and women. Pre-school non-formal education, growth monitoring and immunisation against major diseases are services provided exclusively to children.

Given the range of roles an Anganwadi worker is supposed to perform for Rs 4000 per month, she usually focuses mainly on the role where there is a semblance of monitoring, the distribution of food supplements. The scheme functions in typical bureaucratic style with a centre-based approach and very little outreach. As long as survey forms and registers are filled, supplementary rations get delivered and distributed, no questions are asked.

"The ICDS scheme has been reduced to a mere survey and there is very little service delivery," says Sarath Chandran, convenor of a Bandra-based non-governmental organisation, Centre for Right to Housing, which voiced demands for new ICDS centres.

Even as a survey organization, it does a half-hearted job. In many Anganwadi centres, there are no scales to weigh children. In others, only children who are able to come to the centre are weighed.

Local communities are not involved in ICDS and the Anganwadi worker is usually from a different locality and often from a different community.

While ICDS norms encourage selection of Anganwadi workers within the community, such norms are rarely followed in Mumbai. In some cases, the divide between the Anganwadi worker and the community she is supposed to serve, is widened by her prejudices. "If these people produce so many children, what can we do?," asks Sheila Godbole, an Anganwadi worker in Indira Nagar. She argues that people in that slum do not care for their children and are not receptive to her suggestions, an argument repeated in other slums.

Faulty selection and inadequate training to Anganwadi workers render them ineffective in educating parents, and there is very little change in food habits and feeding practices. Infrequent home visits and the lack of involvement of the community have ensured that nutrition and health education hardly receive any attention.

Mahendra Gaikwad, nodal officer in charge of ICDS in Mumbai, argued that nutrition education is not completely absent and they do organise a nutrition awareness week every year. Even that rarely involves outreach and mothers are expected to visit the Anganwadi centre to learn about nutrition.

Several families with small children in Indira Nagar as well as Rafi Nagar said that Anganwadi workers visited their homes only when they had to do a survey, which happens once in three months and sometimes not even then.

Although there is a norm that each Anganwadi worker should visit five families a day, the norm is widely flouted. "Sometimes one, sometimes none," is how it works, Anganwadi supervisors say.

"The sevikas come to the centre, sit there between 11:00am and 1:00pm and leave," says Nilofer Khan, another underweight woman with malnourished children in Rafi Nagar.

Little wonder then that children below three, pregnant and lactating mothers, who need attention most but are unable to come to the centre, miss out on ICDS services. 88% of pregnant women and 92% of lactating mothers do not receive health check-ups from ICDS centres in India, according to National Family Health Survey data.

There is indeed a provision for take home rations (THR) for children below three and for pregnant and lactating mothers. However, take home rations find little favor among the supposed beneficiaries and is government money (over Rs 300 crore annually in Maharashtra) going down the drain literally.

In Indira Nagar, THR packets, sheera or upma powder packed with micro-nutrients, blocked gutters on the day they were distributed, a local social worker says. Only one in ten families use it, an Anganwadi worker says.

Unless the ICDS is reworked to address the needs of slum-dwellers and local authorities and urban planners change their attitude to slum-dwellers, the children of Rafi Nagar will continue to fall through the cracks of schemes meant to create an inclusive India.

The investment...

Rs 10,330 cr - 2011-12 budget for the Integrated Child Development Services scheme, India's main weapon against child malnutrition

Rs 300 cr - Money spent in Maharashtra on mostly discarded take home rations

...And the returns

40% of children in Mumbai with low birth-weight

22% of Indian children with low birth-weight

*Some names in the story have been changed to protect privacy.

(The Tracking Hunger" series is a nationwide effort to track, investigate and report India's struggle against hunger and malnutrition. This special report on malnutrition is the result of a fellowship jointly awarded by Save The Children and Hindustan Times. To know more about Save the Children:

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First Published: Oct 14, 2011 01:22 IST