The Young Child in Karnataka
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- The Young Child in Karnataka
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The Young Child in Karnataka
A STATUS REPORT
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Karnataka FORCES
SUTRADHAR, Bangalore, 2004
08768
r
Community Health Cell
Library and Information Centre
If 367, "Srinivasa Nilaya”
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Phone : 553 15 18 / 552 53 72
e-mail : chc@sochara.org
Acknowledgements
Fhe status repoil on the young child was taken up as a project of Karnataka FORCES. As
the state convenor of the network. Sutradhar conceived and managed the project;
including commissioning, reviewing and editing the papers. However, we are grateful to
many others who helped us through this process.
We would like to acknowledge the financial support of PLAN India for this project. We
thank Sir Dorabji fata Trust for its support to Sutradhar during this period; and Sir Ratan
Tata Trust for seed money to develop the preliminary concept.
We are grateful to all the members of the research-writing team; including Dr Archana
Mehendale. Kavitha Krishnamoorthy, Vinalini Mathrani. Dr Maya Mascarenhas, and
Padma Sastry. They undertook the difficult task of collating government data and making
sense of it; and patiently accommodated our feedback through several drafts. In
particular; we would like to thank Dr Archana Mehendale, who readily agreed to begin
work on the project well before any financial support was in sight. We are also grateful to
Michael Sanjivi of Mobility India for his insightful additions to the disability paper.
Lastly, we would like to thank Karnataka FORCES members for their feedback and
support: Dr Veda Zachariah. of Sanjivini Trust. Lakshmi Krishnamurthy, CHC and
Belaku Trust. We would also like to thank the Sutradhar team, including Preeti and Indra
for their support.
Mandira Kumar.
Sutradhar,
Convenor, Karnataka FORCES. 2004
Sutradhar. 599. 7 Main, 17A Cross,
Indiranagar Stage 2, Bangalore 560038.
www.sutradhar.com
Supported by:
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Plan
Be a part of it.
Abbreviations and Acronyms
ANM
ANC/PNC
ARI
AWC
AWW
BCG
BPL
CDPO
CSSM
CSWB
DIET
DOE
DPEP
DPT
DSERT
DWCD
ECCE
ECD
ECE
ESI
FORCES
GDP
GNP
GOI
GOK
IAPE
ICDS
IEC
UPS
ILO
IMR
KSSCW
KSSWAB
LBW
MBA
MCH
MHRD
MMR
NCAER
NCERT
NCF
NFHS
NGO
NIPCCD
Auxiliary Nurse Midwife
Antenatal eare/Prenatal care
Acute Respiratory Infection
Anganwadi Centre
Anganwadi Worker
Bacillus Calmette-Guerin
Below Poverty Line
Child Development Project Officer
Child Survival and Safe Motherhood
Central Social Welfare Board
District Institutes of Education and Training
Department of Education
District Primary Education Program
Diphtheria. Pertussis and Tetanus
Department of State Education, Research and Training
Department of Women and Child Development
Early Childhood Care and Education
Early Childhood Education
Early Childhood Education
Employee State Insurance
Forum for Creche and Childcare Services
Gross Domestic Product
Gross National Income
Government of India
Government of Karnataka
Indian Association for Preschool Education
Integrated Child Development Services
Information, Education, Communication
International Institute for Population Studies
International Labour Organisation
Infant Mortality Rate
Karnataka State Council for Child Welfare
Karnataka State Social Welfare Advisory Board
Low Birth Weight
Maternity Benefit Act
Maternal and Child Health
Ministry of Human Resource Development
Maternal Mortality Rate
National Council for Applied Economic Research
National Council for Educational Research and Training
National Creche Fund
National Family Health Survey
Non-Governmental Organisation
National Institute of Public Cooperation and Child Development
NMR
NPE
NSSO
ORT
PEM
PHC
PIE
PMGY
PNDT
PSE
RCH
SC
SNP
SSA
ST
TBA
U5MR
UN
UNICEF
VEC
WHO
Neonatal Mortality Rate
National Policy of Education
National Sample Survey Organisation
Oral Rehydration Therapy
Protein Energy Malnutrition
Primary Health Center
Public Interest Litigation
Pradhan Mantri Gramodaya Yojana
Prenatal Diagnostic Techniques
Preschool Education
Reproductive and Child Health
Scheduled Caste
Supplementary Nutrition Provision
Sarva Shiksha Abhiyan
Scheduled Tribe
Traditional Birth Attendant
Under Five Mortality Rate
United Nations
United Nations Children’s Fund
Village Education Committee
World Health Organisation
CONTENTS
1. Introduction
MANDIRA KUMAR
2. Facts and figures: the young child in Karnataka
ARCHANA MEHENDALE
3. Sex selection and sex determination: law and reality
ARCHANA MEHENDALE
4. Maternity provisions: entitlements, benefits and healthcare
VINALINl MA LI IRANI
5. Creches and day care centres
ARCHANA MEHENDALE
6. The Integrated Child Development Services
KAV1THA KRISHNAMOORTHY
7. Early childhood education
KAVITHA KRISHNAMOORTHY
8. Health and nutritional status of the young child
DR. MAYA MASCARENHAS
9. Disability and the young child
PADMA SASTRY
1. Introduction
The “Status Report on the Young Child" was commissioned by Karnataka FORCES in
2003-2004. Karnataka FORCES is one of nine state chapters of a national advocacy
network, FORCES - Forum for Creche and Childcare Services. This network is unique in
its work of advocating for early childhood care and development services, for
underprivileged children below six years.
These children typically belong to families mired in poverty, for whom government
services are the only option. As service providers, the government is unparalleled in its
outreach and potential of impact. It is a challenge for the government to ensure the
delivery of quality services at such a large scale; and a responsibility to wisely spend the
financial sums that are involved.
In this context; as an institution of civil society, a national level NGO network can bring
to bear its collective wisdom and diversity in strengthening the effectiveness of
government programmes and policies. FORCES members, including NGOs such as
Mobile Creches and SEW A, have drawn on their field practice and research, and played a
key role in influencing policy formulation in early childhood care and development.
Through this status report. Karnataka FORCES has attempted to understand the structures
and possibilities offered by different policies and programmes, and their actual impact at
ground level. We anticipated that this exercise would illuminate areas for change and
spawn ideas for action.
The document attempts to synthesise and analyse available secondary information. This
has been a challenge, as government data lies scattered and is not always available in the
public domain. We hope that this report will provide the larger backdrop and reference
point against which our future advocacy initiatives, research studies, and community
programmes can be positioned.
We welcome your feedback in refining our perspective, and your support towards our
endeavour.
2
2. The importance of early childhood care and development
There are many arguments in favour of improved childcare services for young children.
1.
2.
3.
4.
5.
The most compelling argument is from the perspective of human development and
cognition, which recognises that 75 per cent of brain development occurs by the age
of six years. There are critical “windows of opportunity” in the early years, when the
child is most receptive to care and stimulation. Children who do not receive adequate
healthcare and food at this stage fall into a cycle of malnutrition and illness. When
this is coupled by a lack of adequate stimulation, the young child is liable to have
cognitive disadvantages that are not easily compensated for in adulthood.
From a rights perspective; maternal and childcare services are a step towards
ensuring the rights of both women and children. They are of particular benefit to the
vast numbers of women working in the unorganised labour sector.
Early childhood care also makes sound financial sense in economic terms. Young
children who receive good nutrition, healthcare and preschool education are more
likely to go to primary school: and to complete schooling. They are more likely to be
healthy and productive adults.
One of the most common forms of child labour is sibling care, which becomes the
burden of the young girl child. Childcare services ensure gender justice; by making it
possible for girls to be free to attend school. Educated women, in turn, are better able
to meet the family's needs of health care, nutrition, and infant stimulation.
In terms of scale, children under six years constitute 12 per cent of the population.
This is no small size, and is particularly significant, as young, vulnerable children are
a group least able to stand up for their needs or rights.
3. The status report: key issues
We looked at key issues and programmes that relate to the young child in Karnataka. A
set of eight themes were chosen for their significance:
1.
2.
3.
Facts and figures on the young child: This introductory paper provides an
overview on the status of children with respect to key indices, with inter
district variations.
Sex selective foeticide: The falling child sex ratio in the state reveals that
this needs to be an area of urgent attention. Foeticide is one of the most
casually administered, violent forms of discrimination against one half of
our children - our girls.
Maternity provisions embrace issues of maternal health and entitlements,
and relate directly to the start that a child gets. They are of particular
significance for the large number of women who work in the harsh, fragile,
and unrecognised labour economy. Almost a third of families are headed by
women, for whom maternal and childcare services are a crucial social
support.
3
4.
5.
6.
7.
8.
Creches support working women and young children at their most
vulnerable stage. They are of particular significance in the context of
migration and urbanisation; where traditional extended family support may
not exist. They also free girls from sibling care; allowing greater access to
girls’ schooling.
Anganwadis as part of the Integrated Child Development Scheme (ICDS)
are the main, the largest, and the most holistic service for the young child.
They serve both mother and child; meeting the triple needs of food, health
care and preschool education.
Preschool education: This paper explores services in early childhood
education; and comments on the growing, unregulated private sector that
steps in when government services are inadequate.
Health: Too many of our young children are malnourished and anaemic.
This paper comments on the larger public health delivery system that must
work in tandem with the ICDS to provide essential healthcare - to our
young children as well as their mothers; who are often still in their teens
themselves.
Disability: A poorly functioning health care system puts all children at risk
for disability. 'Phis paper highlights the many preventable disabilities and the
need for early detection and treatment.
4. The framework and methodology
In each of these papers, we first trace international and national perspectives, and see how
the child has been viewed through time. Government policies and programmes are
formulated in keeping with these perspectives, sometimes with targets of coverage and
time, and fiscal commitments and responsibilities of centre and state. In this document,
government provisions and schemes are outlined in detail, to understand problems that
may exist in the way schemes are formulated. We also attempt to understand problems in
accessing or providing services, the quality of services provided, and the impact on
indicators of children’s well-being.
Data on the provision of services is inadequately recorded. It is therefore not possible to
infer a causal link between policy, programme, delivery and outcome. At best; shifts and
trends in key indices provide a sense of the shifting status of children. An attempt has
been made to correlate data where possible, so that coverage and impact can be inferred
and assessed. Wherever possible, disaggregated data by district, gender and social
stratum has been obtained.
Each paper concludes with a summary of issues of concern, and priority areas of action.
4
Scope and limitations
This status report is based on secondary data, largely compiled from Bangalore. It does
not include data from the centre or the districts. The data is mostly from government
sources, as these remain the only large scale source of information. The insights and work
of NGOs has been included to understand how they perceive gaps in the system, and how
they have tried to respond to these lacunae.
There are undoubtedly omissions and repetitions in the papers. Some overlap is
deliberate; so that each paper provides an adequate overview of the issue and can be read
independently of the other.
5. The young child and the state
Laws
1961
1992
1994
1996
Maternity Benefit Act
The Infant Milk Substitutes, Feeding Bottles and Infant
Foods (Regulation, Prevention and Misuse) Act
• The Prenatal Diagnostic Techniques (Regulation, Prevention
and Misuse) Act
• The Persons with Disabilities (Equal Opportunities,
Protection of Rights and Full Participation) Act___________
Policies
•
•
1974
1983/rev. 2002
1986/rev. 1992
1993
2000
2002
• National Policy for Children
• National Health Policy
• National Policy on Education
• National Nutrition Policy
• National Population Policy
• National Policy and Charter for Children
Schemes/programmes
1975
1992
1994
1997
2000
•
•
•
•
•
Integrated Child Development Services
National Plan of Action for Children
National Creche Funds Scheme
Reproductive and Child Health Programme
Sarva Shiksha Abhiyan
Over the years, the state’s approach has changed from a welfare to a development model,
and concomitantly children’s issues have moved from a needs-based approach to a rights
approach. This was first seen in the National Policy for Children, 1974, and stated more
explicitly in the National Policy and Charter for Children, 2002. These shifts have
manifested themselves in development discourse: maternity “benefits” are now seen as
maternity “entitlements”. The Persons with Disability Act, 1995, and the Prenatal
Diagnostics Techniques (PNDT) Act. 1996, were based on a rights approach.
5
This paradigm shift can be attributed to a concern for child rights at the global level
during the last decade. The Convention on the Rights of the Child (CRC) came into force
from 1990. and was ratified by India in 1992. The convention broadly covers areas of
survival, protection, development and participation, which every signatory nation is
obligated to ensure for its children. Along with its commitment to the CRC, the state has
enacted various laws, policies, schemes and programmes to address the needs of children.
The table above lists the main laws and programmes relevant to children under six years.
The world over, the young child has been seen as the primary responsibility of the family,
not the state. This still holds true for children under three years; whose needs are distinct
from those of the 3-6 years age group. The fact that existing childcare services address
the needs of only a fifth of young children speaks for itself.
When we review recent policies in different sectors; there still seems to be a long way to
go. both at the centre and the state, in explicitly accounting for the needs and rights of
young children. In key sectors such as health, education and labour; all of which have a
direct bearing on the young child, this is quite apparent:
•
•
•
The revised National Health Policy, 2002, does not make any direct references to
child health indicators or programmes.
The 86Ih amendment to the constitution recognises the fundamental right to
education for children between 6-14 years. For children under six years, the state
will continue to “endeavour to provide” early childhood care and development.
The sum of Rs 500 currently provided under the Maternity Benefits Act at
childbirth is appallingly small, and has not been raised despite a petition by
FORCES to the Second Labour Commission.
The following indicators make it clear how ineffective our provisions for addressing
children’s needs are. At first glance, indices for Karnataka appear to be better than the
national indices. However, the national indices are a blurred composite that reflect the
poor performance of many northern states. Compared to the neighbouring southern states,
as well as in absolute terms, Karnataka has a long way to go.
Indicators______________________________ India______
Total child population (under six years)_______ 15,78,63,145
Infant Mortality Rate (1999)________________ 70________
Sex ratio (2001)__________________________ 933_______
Children under 3 years with anaemia (1999)
74.3%
Coverage of immunisation (1999)____________ 42%_______
47%
Underweight children under 3 years age
(NFHS-2)_______________________________
4, 27.862
Anganwadi centres providing services
(March 2002)____________________________
1,66,55,533
ICDS beneficiaries of preschool education
(under six years)__________________________
Source: The Indian Child: A Profile, MHRD, 2002
Karnataka
68,26,168
57.7
964
70.6%
60%
43.9%
39.878
12,85,812
6
The Karnataka State Programme of Action for the Child. 1994, laid out a five-year plan
of action for 1995-2000. It spelt out many targets, strategies and indicators for early
childhood education, daycare, health and nutrition. However, the current indices of child
development reflect that these objectives have not been met. In many areas, such as
immunisation or peri-natal mortality, the trends show a decline.
The State Plan of Action needs to be reviewed and debated more widely in the public
domain. The next Programme of Action was formulated in late 2003, but issues related to
Early Childhood Care and Development have not received a special focus in this.
The section below presents some thoughts and concerns raised in the course of compiling
the status report.
5. Data on the young child
For the government to effectively plan, implement and revise programmes in a logical
way, collating data on the number of children requiring services as well as data on the
actual delivery of services is of paramount importance. However, researchers across all
the themes found it extremely difficult to obtain and analyse data related to children. This
suggests the disturbing fact that data is evidently not feeding the government’s
planning process.
Firstly; data on children under six years is not recorded as such, a reflection on (he
overall importance accorded to them. Census data on young children is computed by
deducting them from the whole population, as a “residual category of non-1 iterate
persons”. Government surveys such as the census are carried out every ten years and may
not enumerate the under six years age group accurately, as children may have transited
out of that age bracket during that period. Demographics between the decades use smaller
samples and do not sufficiently capture the large inter-district variations that exist.
A review of secondary literature often yielded conflicting data. Much of the available
information is dated. The latest publication on the “Indian Child”, 2002, released by the
Ministry of Human Resource Development; lacks data on essential services such as
creches for the young child.
On visiting government offices, it was found that data was unrecorded or partially
recorded. This again reflects the secondary status of women and children. For example,
no records were available on the number of statutory creches run in compliance of the
Plantations Act and the Mines Act. Under the Maternity Benefits Act (MBA), the Labour
Department keeps track of the number of “Shops and Establishments” it inspects, but not
the number of beneficiaries! As it has no targets for inspecting these establishments, and
22 different services to inspect, recording the number of women who have availed of
maternity benefits is not their priority.
7
There is often no parity' in the indicators being used to record schemes for a similar
service. For example, the Employee State Insurance (ESI) Act records the number of
payments and amount of disbursals vis-a vis maternity entitlements, but not the number
of beneficiaries. Flow then can one compare the MBA and ESI Acts, or assess their
coverage as a percentage of pregnant women availing of their entitlements?
In a system where record-keeping is over-emphasised, such as the ICDS, we know that
the records maintained are not always accurate. For example, the anganwadi worker or
helper simply does not understand the complicated growth chart and its significance; and
pencils in figures because she is expected to do so. Perhaps a simpler measure or tool can
be devised for this purpose. Similarly, an immunisation schedule may require three doses,
but this is not always taken into account when recording immunisation coverage. What
this suggests is a need to look into both the validity and reliability of data, as well as
the need for greater training of childcare functionaries in recording data.
6. Coverage: access and quality issues
The terms used by the government in relation to coverage, particularly the ICDS, can be
easily misunderstood. For instance, the government claims that there is “universal
coverage” of ICDS in Karnataka. In government terms, this means that there is one
project (comprising about 125-150 anganwadis) in every block. This does not at all imply
that every child under six years has access to an ICDS centre. Access needs to be spelt
out by every possible indicator for a functional and effective anganwadi centre.
This includes infrastructure, services, personnel, quality, inclusion of vulnerable children,
proximity to residence, etc. The criteria for starting an ICDS centre also need to be
relaxed; so that the most marginalised children - of small tribal and rural hamlets as well
as unrecognised urban slums - have a basic start to life. Ensuring universalisation also
requires that an anganwadi be made accessible to children with disabilities - if this is an
objective in elementary schools under the government scheme of Sarva Shiksha Abhiyan
(SSA); the same needs to apply to anganwadis too. If an anganwadi is to be accessible to
girl children and young children; it needs to expand its services to become an
anganwadi-cum creche. This has been planned but not implemented.
ICDS was universalised in 1993 in Karnataka. However the intended target is that only
40 per cent of the centres in rural/urban areas should provide supplementary nutrition;
and only 50 per cent should provide preschool education. Such poor targets reflect poor
concerns and imply even poorer implementation; and are particularly disturbing given the
young child's needs for both nutrition and stimulation. In services such as immunisation
where the ICDS intends to provide 100 per cent coverage, the NFHS-2 survey shows that
only 60 per cent children are immunised in Karnataka.
An assessment of coverage vis-a-vis the targets set by the government also points to
large gaps. For instance, the centre was able to set up only 659 anganwadi-cum-creches
versus its own target of 1,00,000 creches aimed to be set up by year 2000. The total
number of creches as per the last available data of’96-’97 was only about 20,000.
8
This implies a service to less than 1 per cent of children under six years. In Karnataka
there are no anganwadi-cum-creche at all.
This gross failure on the part of the government to meet its planned targets - manifested
in the poor nutritional and health status of the young child in Karnataka - needs to be
highlighted through various kinds of advocacy measures.
7. Service delivery'
The government sector
In a country as vast as ours; and riddled with an ever-shifting political climate, there is an
inevitable and large time lag between the promulgation of a central act and the actual
enactment of structures and schemes for implementation at the state level. Changes at
ground level lie beyond that, and require the coming together of a multitude of factors:
political will, social acceptance, community awareness, advocacy by pressure groups, etc.
This process of social change takes decades. Though the Persons with Disability Act,
1995, mandates that anganwadis should be accessible to children with disability, in 2004
the FORCES study revealed that they were rarely seen at anganwadis. The PNDT Act
was passed in 1996, but in Karnataka, as of 2004. we are yet to see “appropriate
authorities at the sub-district level” to monitor the implementation of the PNDT Act.
Faulty schemes, with inadequate funds, staff and training, result in poor quality of
maternal and childcare services. In the case of creches, it appears that there are too many
schemes for the same purpose. Each scheme offers different wages to the creche worker,
resulting in problems at the ground level. The comparative benefits of a single, wellfunded, easy to administer scheme versus “diverse and flexible” schemes needs to be
carried out.
The childcare functionary in the key scheme for young children, the ICDS, is treated as
little more than an ayah. She is expected to take on far too many tasks at far too little
compensation. This is self-defeating and causes the entire scheme to fail in its objectives,
and is a gross waste of large public expenditure with dubious outcomes.
In actual practice; grant-in-aid schemes have often remained static, eg in the case of the
central creche scheme it has not been revised in 20 years, and remains at Rs 1.05 per child
per day. Does the underutilisation of this scheme imply that it should remain static or
even be reduced, or does it suggest that the amount should be reviewed and realistically
enhanced in keeping with rising costs? It is therefore no surprise to learn that for the last
10 years no new creches have been sanctioned under this scheme, despite an increasing
and evident need.
Undoubtedly, lengthy bureaucratic procedures limit the ability or desire of poor,
working family to avail of any scheme, particularly when the benefits are too paltry
compared to the efforts made to avail of them. It is difficult for poor women to easily
prove their eligibility for maternity assistance, that too for meagre Rs 500.
9
Similarly, disabled children need to traverse long distances to acquire a disability
certificate. Thus social benefits are not availed of by the people they are designed for.
It is evident that many schemes are not gender-just. While international treaties speak of
parenthood and equal responsibilities, why are statutory creches determined only by the
number of women employees?
it is evident that check-and balance mechanisms need to be instituted for government
services to improve. The most powerful lobby for the improvement of services would be
from the people benefiting from the sendees. In the case of the young child, the
anganwadi centre remains the key service provider. For the ICDS system, the government
has instituted the Balavikasa Samithi, a body with representation of parents, anganwadi
workers, panchayat members, etc. This body has the potential to serve as a mechanism
for dialogue and accountability, but in actual practice, neither are parents aware of the
Samithi. nor are anganwadis taking a lead in activating it.
The private sector
The private sector includes the for-profit sector; as well as the small, not-for profit sector
of voluntary agencies. In the current scenario, there are also examples of newer forms of
partnerships between the government and private sector, and the institution of subsidised,
rather than free social services.
In the case of health, preschool education, and day care; there is an increasing expansion
of private services due to the failure of the government system. A large, private pre
school sector caters to the needs and aspirations of working families, but is unregulated
and comes under no scrutiny regarding the quality of services offered. There are also
newer partnerships instituted by the government; such as the health insurance scheme in
Karnataka, where the poor are required to contribute an amount for availing of the
services of private health care providers.
In the case of welfare measures such as maternity benefits and creches, the government
has placed the onus on the private employer. However, given the large and surplus pool
of labour, employers governed by a for-profit ideology do not feel compelled to institute
welfare practices. Under such circumstances, they avail of inherent loopholes in the
systems set up by the government. The ESI benefit for maternal health is often not
dispensed - either by employing fewer women, or by paying them a wage that will not
necessitate that dispensation. Similarly, there is no recorded data of statutory creches set
up in plantations or mines of Karnataka.
Should any of these benefits not be provided, there are few grievance mechanisms
available to the poor for redressal. More often than not, employees would be nervous of
jeopardising their job security. Since employers are not held accountable due to a lack of
punitive measures, they are unlikely to provide the dispensation or service.
10
There also appears to be devolution of responsibility to voluntary agencies. While
there are many grant-in-aid schemes available for NGOs to run creches, it is ironic that
the government of Karnataka has not converted even a single anganwadi to an
anganwadi-cum-creche even though a 25 per cent conversion was called for.
8. Budgets for children
As we know, children constitute a third of our population, and children under six years
make up 12 per cent of the population. The HAQ report on union budgets for children
reveals that out of every 100 rupees, only 1.20 rupees was spent on children (in the years
1990-1999). One can extrapolate that only a sliver of the total union budget is spent on
the child under six years. Budgetary analysis is significant as it is one of the most direct
manifestations of the state’s intent and concern for children. The decrease in budgetary
allocations for critical social sectors such as health also has a direct impact on children.
In Karnataka, it has been difficult to get a clear sense of spending on the young child as a
fraction of the overall budgetary outlay. There are innumerable schemes; and a lack of
clear trends in planned, revised and actual expenditure makes it difficult for us to draw
any conclusions. Yearly variations in these figures are due to many extrinsic factors; from
political shifts to elections and drought. It is also difficult to disaggregate spending in
schemes that often address both women and children's needs (eg the Reproductive and
Child Health programme).
Analysis and advocacy in budgets needs to be at three levels: demand for greater
allocations where required, such as for health; optimal usage of a scheme such as ICDS;
and an understanding of the causes for under-utilisation, eg creches.
If we were to prioritise for greater allocations and better usage; we would request that
money be primarily spent to strengthen the ICDS in its universalisation and functioning
in all senses. Basic infrastructure with safe drinking water must be available. A wellbalanced. hot cooked meal must be in place in all projects, including Bangalore (urban).
Immunisation as per the required schedules must be delivered. Large numbers of children
in the state are malnourished and anaemic, and this must be our first concern.
9. Suggestions and strategies for change
9.1 Advocacy
Public Interest Litigations and public hearings
There is no doubt that campaigns for change need to be grounded in good field surveys.
One example is the Right to Food Campaign, which carried out surveys of the nutritional
status of children across several states of India. This was followed by a PIL filed in the
Supreme Court. Jan snmvais or public hearings on health are now being organised across
the country. These provide a forum for collective representation and systemic change.
11
The scale of such single-issue surveys, combined with strategies of legal recourse, media
coverage, as well as community mobilization, appear to be effective in seeking enduring
and systemic, large-scale change.
Media advocacy at the regional level
The issues that concern the child often involve change in mindsets and perspectives.
Mass media can play a useful role in creating a climate of social change. Issues of sex
selective abortion, gender discrimination, breastfeeding, and negative attitudes towards
disability can be countered by the consistent use of regional media that create spaces for
alternate discourse. Tamil Nadu FORCES has used media in various ways: from spots on
television on different aspects related to the young child; to the imaginative “cradle
campaign” where cradles were hung in the hard-nosed Labour Department to draw
attention to the needs of the young child.
Community mobilisation and education
In the context of the young child, working with the community in their role as caregivers
is particularly significant. For children under three years, parents are the primary'
caregivers for breastfeeding, bathing, feeding, infant stimulation; and various forms of
psycho-social stimulation that pave the way for health, language and cognition.
An informed community is also one that can play a role in demanding that government
services work. They can participate in local structures of self-governance; ensuring that
the ICDS centre is given the support. Financial and otherwise, that it may need. NGOs
such as Samuha have begun to redefine their role: from childcare service providers to
facilitators in the creation of informed communities.
9.2 Need for research, documentation and alternate data
The status report reveals that government data on young children is evidently lacking.
This underscores the imperative for NGOs to collate alternate data as a tool for advocacy.
As NGOs often work at a small scale and research skills are not always available, such
studies need to be thought through well in terms of the ease of undertaking them and the
possible impact they could have.
•
•
There are benefits to participating in nationwide surveys, so that the advantages
of tool design, analysis and advocacy efforts can be widely shared. As FORCES
we need to partner with other alliances and identify a few core areas where such
data can be well utilised and its impact multiplied. One such nationwide study
could be the functioning of the ICDS system.
Easy-to-administer surveys that provide local, quantitative data for advocacy
can also be taken up; for eg, the enumeration of the number of creches or private
preschools; the number of disabled children and younger children at anganwadis;
the number of women who have availed of maternity benefits in a given area.
12
•
Smaller qualitative studies are also required. These may throw light on
disturbing trends, eg the casual use of oxytocin to hasten childbirth: childhood
illness patterns; or the quality of preschool education in anganwadis. An intent
may be to use these findings to design context-specific tools for community
advocacy eg documenting caregiving practices, both good and bad, for designing
a parent education programme.
9.3 Registration and accreditation of the private preschool sector
There is evidently a need for a check-and-balance mechanism to be instituted for the
growing, unregulated private pre-school sector. Just as the state requires elementary
schools to be registered, preschools that serve vulnerable children also need to be brought
into the ambit of concern. The state and other concerned organisations should play a role
in spelling out norms for a safe and functioning early learning centre.
As an NGO network, Maharashtra FORCES has played in role in joining hands with the
government in lobbying for the setting up of an accreditation system. Karnataka
FORCES too could take this up.
9.4 Convergence
The young child cannot continue to only be the responsibility of the Department of
Women and Child Development. The recent Common Minimum Programme (CMP) of
the government. May 2004, commits to the universalisation of ICDS in every
settlement. For children of primary and secondary schools, the CMP speaks of the
National Commission for Education and the mid-day meal scheme. Yet education and
nutrition are most vital to the young child, and the ICDS as it stands needs to improve in
both these areas.
The continuity and convergence between different sectors and departments that is
required at all levels - both policy and field - can be addressed only by a National
Commission for Children. Such a Commission was proposed in 1999; but the bill is yet
to be submitted to Parliament by the Department of Women and Child Development.
FORCES must partner with organisations such as CRY-Child Relief and You, to hasten
this process.
The two most important partnerships that would allow for systemic coherence are:
•
•
Between the Department of Women and Child Development and Department of
Education; to ensure improved preschool education and nutrition. Under the Sarva
Shiksha Abhiyan (SSA) scheme of the Department of Education, fiscal provisions
for universalising anganwadis have been made, but there is no other provision for
preschool education.
Between the ICDS and the PHC, to ensure improved healthcare.
13
10. Concluding thoughts
This report has helped us in putting together a snapshot of key concerns in relation to the
young child. It has suggested areas for further enquiry and action. It has ratified our belief
in focusing on the ICDS as the most important area of concern. Looking at the young
child holistically, we realise that piecemeal sops and schemes do not help: a more
systemic approach is required. It is time to review entire schemes and acts that have
failed to impact the young child, particularly for creches and maternity entitlements.
A summary of the themes and priority areas for future advocacy is presented below.
Issue______
Sex Selective
Abortion
Problem/manifestation
Decreasing child sex
ratio shows gender
discrimination
Maternity
Entitlements
No social security for
poor working women at
crucial time of childbirth
Creches
Not enough creches for
working mothers
ICDS
Key service provider for
young children has
inadequate service
delivery
AWW and helper spend
very little time on
preschool education
Preschool
Education
Health
• 75% children are
anaemic
• 48% rural children are
malnourished
• Perinatal deaths on the
rise; 42% deaths due to
prematurity
• Immunisation coverage
decreasing
Disability
• With inadequate health
care, all children are at
risk of being disabled
• Children with disability
are not visible at AWCs
Action points_____________________________
• Set up a Karnataka CASA (Campaign against
sex selective abortion)
• Sensitisation of doctors, and raids against errant
practitioners
• Set up 'Appropriate authorities’ at sub-district
level___________________________________
• Raise amount of benefit
• Institute penalty procedures for non-compliance
(in the organised sector)
• Institute welfare funds for workers in the main
unorganised sector vocations
• Make benefits available to underage mothers
and adoptive mothers______________________
• Convert AWC to AWC-cum-Creche
• Extend timings
• Enhance the grants-in-aid scheme amount_____
• Ensure minimum infrastructure at anganwadi
• Helpers: improve selection, training and job
responsibility
• Improve linkage with primary school_________
• State to target for universal preschool education
at every Anganwadi
• Improve quality of preschool education in AWC
using resources of Dept of Education_________
• ICDS centre to improve in nutrition, hygiene,
and immunisation
• Advocate for increasing the age of marriage, and
better prenatal care for women
• Ensure access and inclusion of disabled at AWC
14
-
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7
Facts and figures:
the young child in Karnataka
Archana Mehendale
K
i
Facts and Figures
CONTENTS
Page
1. Introduction
4
2. Size and characteristics of the young child population
5
3. Birth registration
9
4. Health indicators
9
5. Mortality
12
6. Nutrition
22
7. Immunisation
23
8. Children living in slums
24
9. Education/economic activity
26
10. Concluding summary
29
References
31
2
Facts and Figures
BOX
Page
Box: Facts and figures related to the young population in Karnataka
30
TABLES
Table 1: Number of children in under 6 years age group by social groups
5
Table 2: Child population under 6 years by residence and sex (2001)
6
Table 3: Distribution of 175 talukas by child population size
7
Table 4: Percentage distribution of child population over the decades
7
Table 5: District wise sex ratios for 2001-Karnataka
8
Table 6: Percentage of birth registration
9
Table 7: Percentage of institutional deliveries for 1996-97
10
Table 8: Place of delivery and attendant at birth (1992-93)
11
Table 9: Institutional and safe deliveries
11
Table 10: Initiation of breastfeeding and feeding of colostrum, 1998-99
12
Table 11: Crude death rates in Karnataka
13
Table 12: Age specific death rates in Karnataka
13
Table 13: Neo-natal mortality rate in Karnataka
14
Table 14: Post neo-natal mortality rate in Karnataka
15
Table 15: District wise infant mortality rates for 1981 and 1991
16
Table 16: Infant mortality rate 1999 and 2000
17
Table 17: Estimated infant mortality rate (sex and rural-urban status, 1999)
18
Table 18: Infant deaths by major cause groups for 1997
19
Table 19: Child mortality in Karnataka
20
Table 20: Under five mortality rate in Karnataka
21
Table 21: Under five mortality rates for Karnataka, district wise
21
Table 22: Nutritional status of children in Karnataka and India
22
Table 23: Immunisation coverage in Karnataka
24
Table 24: Child population (under 6 years) living in slums by districts, 2001
25
Table 25: Children going to school in urban and rural Karnataka, 1991
26
Table 26: Children working by age, schooling and economic activity (1991)
27
Table 27: ICDS beneficiaries of Central Sector Projects, 2002
28
3
Facts and Figures
1. Introduction
Children, by and large, are an ignored sub-group of our society. The young child
population is even less visible within this sub-group. One of the main reasons for this
lack of acknowledgement is the lack of recognition of young children as separate entities.
Since they are highly dependent on their families for meeting their basic needs, they are
often treated as attributes of their families.
But the young child population is not a homogenous sub-group. Its members range from
babies who are completely dependent on their families for their nourishment, care and
survival, to children who leave their families during most of the day and go to school or
work. Each phase of early childhood offers unique needs and problems which the
immediate family, society and the state are expected to address. In the Indian context,
early childhood is celebrated within the private sphere but lies almost unattended to in the
public sphere.
To a large extent, government indifference is due to the lack of sufficient data and
understanding about the issues of early childhood. Available statistical data is
restricted to highlighting a few key vital health indicators. As a result, even the policies
and programmes are addressed largely to ensuring health standards among young
children. Apart from this, children below the age of six years do not receive adequate
attention of planners and policy makers.
A review of existing official data on the young child indicates the following:
1. Data about this group is insufficient. Data on the overall status of the young child is
lacking and statistics are restricted to a few key demographic indicators.
2. The young child is almost treated as a residual category. One of the senior officers
from the Directorate for Census Operations explained it to this researcher. The
Census is supposed to compute the number of literate persons. Since a literate person
is defined as a person above seven years of age, the census authorities have to take
away the category of 0-6 years from the population. Whatever data is thus made
available for young children is because they were left out from the entire population
to facilitate computation of other key demographic indicators.
3. Data collection does not happen frequently. Even a period of five to ten years
between surveys leaves the young child at a disadvantage since s/he happen to be in
this category only for six years.
4. Policy making is restricted to issues where data is available, and correspondingly,
data collection happens only within areas of policy concern. Thus, there is no official
data on certain areas such as play or child abuse which actually happen to be very
important for the young child’s overall growth and development.
The purpose of this paper is to collate data from all official sources and contribute
towards an understanding of the nature and characteristics of young children in
Karnataka. In doing so, it seeks to identify problems and specific trends on various
dimensions of early childhood.
4
Facts and Figures
The paper draws upon official data in the form of Census reports. National Family Health
Surveys, and government publications. Certain statistical tables have been additionally
computed using data from various sources. Descriptive statistics are used to analyse and
present the broad trends and patterns.
This paper presents a demographic profile of the young child population in Karnataka by
elaborating on their size and characteristics, their health and nutrition, education and
other demographic indicators.
2. Size and characteristics of the young child population
Typically, demographers depict the characteristics of a population with the help of a
pyramid. The base of the pyramid indicates the percentage of the youngest in the
population and the top peak indicates the percentage of the oldest in the population. In
most developed countries with the reduction in fertility rates, the pyramid is slowly
shrinking at the bottom and bulging on the top. Increased longevity amongst the
population also contributes to this demographic change. Indian demographers have
indicated since the past several years that the population pyramid in our country is also
narrowing at the base. This is because the percentage of the young child population
throughout the country is slowly declining. In India, the proportion of children in the age
group 0-6 decreased from 18% in 1991 to 15% in 2001. A fairly strong positive
correlation is now established between the percentage of child population in 0-6 years
and the level of fertility. In 1991, only four states/UTs had child population (0-6 years)
below 14% but by 2001, 16 states had a child population below 14%. This indicates a
widespread lowering in fertility rates across many states in the country.
As per Census 2001, there are 15,78,63,145 children between 0-6 years in India.
Karnataka has 68,26,168 young children, comprising 4.32% of the total child population
in 0-6 age group in India. Of this, 47,12,109 children (69.03%) are in rural areas and
21,14,059 children (30.97%) are in urban areas. Thus, we see that the young child
population is predominantly rural in the context of Karnataka.
Of the entire child population in Karnataka, 35,01,499 are boys and 33,24,669 are girls.
Table 1: Number of children in under 6 years age group by social groups
State
Boy
Girl
India
Scheduled Castes______
Total_____ Rural
14,23,576
11,21,505
7,24,113
5,69,565
5,51,940
6,99,463
2,71,26,742 2,23,75,066
Urban
3,02,071
1,54,548
1,47,523
47,51,676
Scheduled Tribes______
Total_____ Rural
3,62,101
31,3,634
1,83,767
1,58,983
1,78,334
1,54,651
1,36,72,709
1,27,65,258
Urban
48,467
24,784
23,683
9,07,451
5
Facts and Figures
In terms of social groups, Table 1 shows that 17,85,677 children belong to Scheduled
Castes (SCs) and Scheduled Tribes (STs). Of this 79.72% belong to the SC communities
and the remaining 20.27% belong to the ST communities. Young children from SC
communities in Karnataka comprise 5.25 per cent of the overall SC young child
population in India. The young child ST population in Karnataka is only 2.6% of the total
young child ST population of India. The table also shows that a majority of young
children from SC and ST communities live in the rural areas. It also indicates that there
are more young boys than young girls in the SC and ST communities in Karnataka.
Table 2: Percentage of child population (under 6 years) by residence and sex (2001)
Total
12.94
14.28
15.40
15.07
16.30
15.62
16.22
16.64
13.65
12.93
12.52
13.49
14.87
12.53
12.68
12.12
9.80
11.50
11.30
12.60
11.17
11.39
10.88
11.18
11.25
Persons
Rural Urban
13.54 11.8
14.89 12.36
16.16 13.55
15.42 13.83
17.02 14.35
15.76 15.13
16.98 14.01
17.09 14.41
14.02 12.95
14.04 12.02
12.94 11.48
13.50 13.45
15.94 12.88
12.75 11.53
12.95 12.04
12.58 11.27
10.06 8.70
11.63 10.99
11.35 11.07
12.81
11.99
12.40 11.00
11.19 12.15
10.84 11.11
11.25 10.89
11.79 10.37
Total
13.04
14.54
15.7
14.89
16.52
15.47
16.37
17.02
13.77
12.96
12.68
13.36
15.03
12.58
12.69
12.24
10.67
11.62
11.38
12.57
10.97
11.46
11.15
11.42
11.65
Males
Rural
13.69
15.18
16.43
15.12
17.31
15.58
17.19
17.53
14.17
14.03
13.10
13.33
16.13
12.82
12.97
12.74
11.06
11.77
11.47
12.73
12.11
11.26
11.16
11.51
12.30
Urban
11.8
12.54
13.95
14.07
14.44
15.10
14.03
14.47
13.02
12.07
11.63
13.47
12.99
1 1.52
12.03
11.30
9.03
11.00
11.00
12.06
10.82
12.21
11.10
11.03
10.62
Total
12.85
14.00
15.09
15.26
16.07
15.78
16.07
16.25
13.52
12.90
12.37
13.62
14.71
12.47
12.67
12.01
9.04
11.39
11.21
12.64
11.39
11.32
10.60
10.95
10.85
Females
Rural Urban
13.38 11.79
14.58 12.17
15.89 13.14
15.73 13.58
16.73 14.25
15.96 15.16
16.77 13.99
16.63 14.35
13.87 12.87
14.04 11.97
12.79 11.32
13.67 13.43
15.74 12.76
12.67 11.54
12.93 12.05
12.42 11.23
9.18
8.39
11.49 10.97
11.23 11.15
12.89 11.90
12.73 11.21
12.09
11.11
11.12
10.51
10.99 10.74
11.30 10.13
12.25
11.63
11.19
12.38
12.31
11.24
11.47
10.46
10.91
12.37
I 1.60
11.25
12.55
12.24
11.30
11.28
10.50
10.99
12.13
11.66
11.13
12.20
12.38
11.18
State/District
Karnataka
Bel gaum______
Bagalkot______
Bijapur_______
Gulbarga______
Bidar_________
Raichur_______
Koppal________
Gadag________
Dharwad______
Uttar Kannada
Haveri________
Bellary________
Chitradurga
Davangere
Shimoga______
Udupi_________
Chikmagalur
Tumkur_______
Kolar_________
Bangalore_____
Bangalore Rural
Mandya_______
Hassan________
Dakshina
Kannada______
Kodagu_______
Mysore_______
Chamrajnagar
11.67
10.42
10.83
6
Facts and Figures
The total percentage of the young child population, i.e. children below six years is
12.94% in Karnataka. A district-wise study shows that the young child population is
not evenly spread across the state (see Table 2). Certain districts have a very high
percentage while in other districts, the young child population is dwindling.
Among the districts, Koppal has 16.64% of its entire population in the age group of 0-6
years. This is the highest proportion among all the districts and much higher than the state
where the young child population is 12.74% of the total population. Koppal district with
17.09% of its rural population in 0-6 years age group tops the rural child population. The
lowest percentage of rural child population is in Udupi (10.06%). In urban areas, Bidar
has the highest percentage (15.13%) of child population and the lowest is 8.70% in
Udupi. In the state as a whole, 11.80% of the total urban population is in the age group 06 years. Thus, we see that the percentage of young child population is higher in rural
areas than in the urban areas, among boys as well as girls.
Table 3: Distribution of 175 talukas by child population size
Population range
Number of talukas in each
range__________________
7______________________
24_____________________
48_____________________
42_____________________
22_____________________
28_____________________
4
Upto 9999________
10,000-19,999
20,000-29,999
30,000-39,999
40,000-49,999
50,000-99,999
1,00,000 and above
Among the 175 talukas in the state, Bangalore North and South talukas in Bangalore
district, Mysore taluka in Mysore district and Mangalore taluka in Dakshina Kannada
district are the most populous talukas for the 0-6 years child population. Sringeri and
Gudibanda talukas have the lowest child population for 0-6 years. Table 3 above shows
that half the talukas in Karnataka have a child population within 20,000 to 40,000 range.
Knowing the most frequently appearing value of child population at the taluka level is
important for planning services for the young child at the local, decentralised level.
Table 4: Percentage distribution of child population over the decades
Ages
0-4
5-9
M
14.5
14.9
1961
F___
15.0
15.7
T__
14.7
15.3
M
14.2
14.6
1971
F___
14.6
15.1
T__
14.4
14.7
M
12.3
13.8
1981
F___
12.6
14.2
T__
12.4
14.0
M
11.4
12.4
1991
F___
11.4
12.9
There is a gradual decline in the proportion of children of the age group of 0-4 years and
5-9 years from 1961 to 1991. This indicates that the number of young children in our
population is reducing slowly, a phenomenon noted across the country as we have seen
earlier. Table 4 shows this decline in terms of the sex differentials.
7
T__
11.4
12.7
Facts and Figures
There has been a significant reduction in the percentage of girls over the decades.
The percentage of girls under-4 yrs has been consistently reducing in relation to boys in
same age group. In 1961, girls were 15 % and boys were 14.5 % of the total female and
male population respectively. By 1991, the percentage of girls had reduced and was equal
to that of boys: 11.4%. The reduction of girls is not as drastic for children of 5-9 years.
The adverse adult sex ratio (964 females per 1000 males, Census 2001), shows there are
fewer women than men in the state. A reducing proportion of girls from a reducing
population of women indicates increasing adversities against girls. This alarming trend
of the declining proportion of girls indicates widespread gender discrimination.
According to 2001 census, the child sex ratio was 949 in Karnataka, 954 in rural
areas, and 939 in urban areas. Table 5 shows district-wise child sex ratios and sex
ratios for the total population.
Table 5: District wise sex ratios for 2001-Karnataka
District
Sex Ratio of Total Population
Urban
Total
Rural
962
948
Belgaum________ 959
982
966
Bagalkot________ 977
948
948
Bijapur
948
932
Gulbarga________ 964
976
948
957
919
Bidar__________
949
Raichur_________ 980
991
971
Koppal_________ 982
985
Gadag__________ 968
969
967
Dharwad________ 948
945
950
Uttar Kannada
970
970
969
941
945
Haveri__________ 942
Bellary_________ 969
977
955
955
956
948
Chitradurga_____
Davangere______ 951
956
939
967
982
Shimoga________ 977
1149
1038
Udupi__________ 1127
Chikmagalur____ 984
990
958
Tumkur________ 966
974
937
966
Kolar__________ 970
971
Bangalore_______ 906
911
905
Bangalore (Rural) 953
957
938
989
966
Mandya________ 985
1014
962
Hassan_________ 1005
1034
Dakshina Kannada 1023
1005
Kodagu_________ 996
1003
952
Mysore_________ 965
965
965
968
969
966
Chamarajnagar
Child (under 6 yrs) Sex Ratio
Total
Rural
Urban
924
924
921
949
939
910
986
971
914
920
937
943
967
980
923
962
946
967
934
938
963
951
948
957
944
945
943
947
943
946
966
961
942
954
949
937
949
946
945
940
953
949
958
959
961
964
953
955
964
956
966
949
952
953
976
983
953
940
957
937
941
945
928
937
931
968
964
937
969
949
952
958
986
976
977
970
958
976
952
957
958
8
Facts and Figures
Among the districts in the State, Kodagu district has the highest child sex ratio of 977
whereas Belgaum with a ratio of 924 has the lowest child sex ratio. Among the rural
population, Bijapur with 986 has the highest and Belgaum with 924 has the lowest child
sex ratio. Among the urban population, the highest child sex ratio is 986 in Kodagu and
the lowest is 910 in Bagalkot. It is important to note that in all districts except Bidar,
Bangalore, Bijapur, Haveri, Kolar and Mysore, the total child sex ratio is
consistently lower than the total sex ratio of the general population.
3. Birth registration
Civil Registration of births is compulsory under the Births and Deaths Registration Act.
The Convention on Rights of the Child recognises every child’s right to name and
nationality. Registration of children is important for various reasons. Firstly, it establishes
the age of the child which is required for school admissions and for availing of various
health, nutrition and social welfare services. Registration of the child after birth is not
common and almost half of the births in India were not registered in 1995.
Table 6: Percentage of birth registration
Year
1995
1998
Karnataka
85.0
102.7
Total
55.0
NA
The above table shows how Karnataka has made a big leap in birth registration from
85% in 1995 to 102.7% in 1998. This is way ahead of the national figure for 1995 which
is just over fifty percent. However, the registration percentage exceeding hundred is
indicative of over-registration of some kind or lack of proper documentation.
4. Health indicators
Given the phase of development of the young child, health indicators are key to
understanding the characteristics of needs and problems at this stage. Reading data
collected right from the birth of the child (or even pre-natal data) is important to
understand the broad conditions of child health and well-being.
4.1. Antenatal care
Antenatal care is extremely critical for ensuring the birth of a healthy baby as well as a
healthy post-partum recovery of the mother. The NFHS survey reveals that the
percentage of mothers who received antenatal care in Karnataka increased from
83.4 per cent in 1992-93 to 86.3 per cent in 1998-99. Although this is definitely a large
coverage, it is important to understand the quality of these services and the reasons why
the remaining 13% per cent mothers do not have access to these services. Data on these
issues is not readily available and this remains an area for further study.
9
Facts and Figures
4.2. Place of delivery
One of the main reasons for maternal and neonatal deaths is complications arising during
the birth process. When deliveries take place at home, with the assistance of untrained
personnel, in an unhygienic manner, the risks to both the mother and the baby are very
high. Thus, the percentage of deliveries taking place in institutions (such as hospitals,
primary health centres) indicates the extent to which mothers and new-born babies are
exposed to such risks. Data for Karnataka is dismal in this regard.
Table 7: Percentage of institutional deliveries for 1996-97
District________
Bangalore_______
Bangalore Rural
Belgaum________
Bellary_________
Bidar___________
Bijapur_________
Chikmagalur____
Chitradurga_____
Dakshina Kannada
Dharwad________
Gulbarga________
Hassan_________
Kodagu_________
Kolar__________
Mandya_________
Mysore_________
Raichur_________
Shimoga________
Tumkur________
Uttar Kannada
State
Percentage of Institutional deliveries
89.3 __________________________
48.9__________________________
40.8__________________________
27.5__________________________
11.4 _________________________
22.2__________________________
53.7 __________________________
37.5 __________________________
77.0__________________________
39.8 __________________________
12.7 __________________________
45.6 __________________________
76.0__________________________
36.1 __________________________
48.8 __________________________
51.4__________________________
11.9 _________________________
45.0__________________________
41.1 _________________________
72.2 __________________________
41.8
Institutional deliveries are far lower than deliveries attended by traditional birth
attendants or other persons. Only 42% of all deliveries in the entire State take place in
institutions. Districts like Raichur, Gulbarga and Bidar have only 11-13% deliveries
conducted in institutions. The percentage of institutional deliveries is high in Bangalore
(89.3%), Dakshina Kannada (77%), Kodagu (76%) and Uttar Kannada (72%) where
people in general have better access to health facilities. These are also districts where the
status of women’s health is relatively high.
10
Facts and Figures
Table 8: Place of delivery and attendant at birth (1992-93)
Karnataka
India
Institutional Deliveries
Total
Govt.
Private
15.9
37.6
21.7
25.6
15.7
10.9
Home Deliveries
Qualified
Total
62.4
13.8
74.4
9.1
Other
TBA*
21.8
35.1
26.8
30.2
*TBA is Traditional Birth Attendant
Data available for 1992-93 for Karnataka and the country as a whole present a different
picture. The figures show that the situation in Karnataka is better than the rest of the
country. In 1992-93, only 25.6% of deliveries in India took place in institutions, while
this percentage was 37.6 for Karnataka. Table 8 shows that the number of home
deliveries in India (74.4%) was higher than the number of home deliveries for Karnataka
(62.4%). The number of deliveries carried out by traditional birth attendants as against
qualified persons was higher for the country as a whole (35.1%) than the figures for
Karnataka (21.8%). This data reveals that safe deliveries conducted in Karnataka,
although more than those noted for the country as a whole, are still few in an absolute
sense since a majority of mothers and new-born babies continue to be exposed to risks.
Table 9: Institutional and safe deliveries
Percentage of Institutional
Deliveries______________
Percentage of Safe
Deliveries
NFHS-1 (1992-93)
37.5
NFHS-2 (1998-99)
51.1
50.9
59.2
The National Family Health Survey data also reveals that the percentage of institutional
deliveries and safe deliveries has gone up over the years. Table 9 shows that the
percentage of institutional deliveries increased from 37.5 per cent in 1992-93 to 51.1 per
cent in 1998-99. Percentage of safe deliveries which are conducted by qualified birth
attendants increased from 50.9 per cent to 59.2 per cent. Despite this increase, the risks
of delivery remain fairly large because about half of the deliveries in Karnataka still
take place at home and in an unsafe manner.
4.3. Breastfeeding
The importance of breast-feeding for the first six months of life is well established.
Breast-feeding offers babies essential nutrients which help their overall growth and build
their immune system. It is also considered to be safe and hygienic. The first milk, known
as the ‘colostrum' contains a unique combination of nutrients which provides the new
born baby all the vital elements for growth. The practice of breast-feeding, including
nursing the baby with ‘colostrum’, is not very common in Karnataka. In 1998-99, only
18.5% of the mothers in Karnataka could start breast-feeding within an hour of birth
while 41.5% could start breast-feeding within a day of birth.
11
Facts and Figures
Table 10: Initiation of breastfeeding and feeding of colostrum (in percentages)
1998-99
Percentage started
Percentage started Percentage whose
mother squeezed and
breastfeeding
breastfeeding
within one hour of within one day of
discarded the first milk
birth___________
birth*__________ from breast_________
Karnataka
18.5___________
41.5___________ 61.4_______________
India
15.8___________
37.1
62.8
* Includes children w io started breastfeeding within one hour of birth
Source: NFHS-2
Table 10 shows that the percentage of mothers breast-feeding in India is lower than those
breast-feeding in Karnataka. The highly rich ‘colostrum’ is squeezed out and discarded
by most mothers (61.4% for Karnataka and 62.8% for India) indicating prevalent
misconceptions regarding its use and a lack of awareness about its nutritional importance.
5. Mortality
Data on mortality is useful for identifying priorities for health action as well as for
resource allocation. This data is subject to certain limitations; namely, incomplete
reporting of deaths, lack of accuracy in recording age and cause of death, lack of
uniformity and standardised methods in collecting data. The various parameters used to
understand mortality are crude death rates and age-specific death rates. For understanding
childhood mortality; indicators such as pre-natal mortality rates, neonatal mortality rates,
post-neonatal mortality rates, infant mortality rates, child mortality rates and under-five
mortality rates are used. Let us look at each of these in detail.
Crude Death Rate: Crude Death Rate (CDR) is the simplest measure of mortality. It is
defined as the number of deaths (from all causes) per 1000 estimated mid-year population
in one year in a given place. The NFHS calculates death rates on the basis of the average
annual number of deaths occurring to usual residents of the household during the two
year period preceding the survey; i.e. 1991-92 for NFHS-1 and 1997-98 for NFHS-2. The
Sample Registration System calculates death rates on the basis of deaths to the usual
resident population in that year, i.e. 1997.
12
Facts and Figures
Table 11: Crude death rates in Karnataka
Crude
Death
Rate
NFHS-1 1991-92
Male Female Total
8.3
6.6
7.5
NFHS-2 1997-98
Male Female Total
8.7
7.0
7.9
SRS 1997
Male Female
8.1
7.0
Total
7.6
For the entire state of Karnataka, the CDR was marginally higher in 1997-98 than it was
in 1991-92 according to the NFHS data. According to NFHS-2, in most countries, male
death rates are higher than female death rates at nearly all ages. South Asia is an
exception with higher death rates for females over much of the age span. But in
Karnataka, according to NFHS-1, NFHS-2 and SRS, the CDR for males is higher than
CDR for females.
Age Specific Death Rates: Age Specific Death Rates are calculated as the number of
deaths of persons in the given age group divided by the mid year population of persons in
that age group and is expressed as a rate per 1000.
Table 12: Age specific death rates in Karnataka
Age
<5
years
5-14
NFHS-1 1991-92
Male Female Total
16.3
10.9
13.7
NFHS-2 1997-98
Male Female Total
11.3
13.2
12.2
SRS 1997
Male Female
15.6
17.2
Total
1
1.4
1.5
1.2
1.1
1
0.6
1.0
1.0
16.4
The Age Specific Death Rates for Karnataka show that there is a greater inconsistency in
data from National Family Health Surveys and Sample Registration System for the
younger age group (< 5 years) than for the higher age group (5-14 years).
•
•
Below 5 years: The death rates among children below five years was higher for boys
than for the girls during 1991-92. But after 1997, both NFHS-2 and SRS data
indicates a reversed situation wherein the death rates are higher for girls than boys.
Between 5-14 years: Within the age group of 5-14 years, a reverse trend is observed.
While the number of deaths among girls was slightly more than that among boys in
1991-92, the post-1997 period shows an entirely different picture. The number of
deaths among boys show an increase since 1991-92 and are also more than the deaths
among girls.
In Karnataka, as of 1997, both the NFHS-2 and SRS surveys show that the death
rates are higher for girls than for boys below five years and higher for males than
for females at all other ages. But in contrast to Karnataka, the NFHS-2 data indicates
that the female mortality is higher than male mortality in every age group less than 30
years for the country as a whole.
13
Facts and Figures
5.1. Mortality indicators
Specific childhood mortality indicators are helpful in strategising for child health care
policies. It is customary to consider mortality in and around infancy at different stages of
growth from both the analytical and programmatic point of view. The specific mortality
indicators are as follows.
Peri-natal mortality’ rate: The peri-natal mortality rate is the number of deaths occurring
from 28 weeks of gestation to seven days after birth per 1000 live births in the same year.
It includes still-births as well as foetal deaths towards the end of gestation when the
foetus weighs more than a 1000 grams. It is a sensitive index reflecting standards of
health care prior to and during pregnancy and child birth. The peri-natal deaths in
Karnataka increased from 43.2 deaths per 1000 live births in 1981 to 47.8 deaths to
1000 live births in 1994. This indicates falling levels of health care, particularly ante
natal and post-natal services available and utilised.
Neonatal mortality rate: The Neo-natal Mortality Rate (NMR) is calculated as the
number of deaths occurring during the neonatal period i.e. birth to 28 days of life in a
given year per 1000 live births in that year. The NMR gives the probability of dying in
the first month of life or 28 days of life. These deaths are determined by endogenous
factors such as gestational age, ante-natal care available, birth weight of the baby and so
on. The risk at birth is the highest during the first 24 to 48 hours of life. Two important
aspects related to neonatal deaths are; firstly, a majority of deaths that occur during the
first year, occur during this neo-natal period and hence neonatal mortality is the highest
contributor of infant mortality. During 1996, 74.5% of all infant deaths in Karnataka
occurred during the neonatal period while 64.6% of all infant deaths in India took
place during the neo-natal period. Secondly, the NMR is greater for boys than for girls
throughout the world because new born boys are biologically more fragile than girls. In
Karnataka, the NFHS-2 found that the NMR for boys is 53.4 per 1000 live births and that
for girls is 34.8 per 1000 live births.
Table 13: Neo-natal mortality rate in Karnataka
Year
1994-98
1989-93
1973-88
Urban
32.1
38.7
42.2
Rural
39.3
56.2
42.6
Total
37.1
50.8
42.5
The neonatal mortality is 22% higher in rural areas than in urban areas. While the ruralurban difference in NMR was minimal between 1973-88, the difference increased
significantly during 1989-93. Between 1994-98, the difference was reduced but persisted
with 32.1 neonatal deaths per 1000 live births in urban areas and 39.3 neo-natal deaths
per 1000 live births in rural areas.
14
Facts and Figures
Post Neo-natal Mortality Rate'. The Post Neo-natal Mortality Rate (PNMR) refers to
deaths occurring from 28 days to under one year. It is defined as the ratio of post neo
natal deaths in a given year to the total number of live births in the same year, usually
expressed as a rate per 1000. The PNMR indicates the probability of dying after the first
month of life but before the first birthday. The post neo-natal deaths are caused by
exogenous factors, namely the environmental and social factors. During this period, girls
die more frequently than boys, indicating a neglect of the female child. According to the
NFHS-2, the PNMR among boys was 16.5 deaths per 1000 live births and that for girls
was 19.3 deaths per 1000 live births.
fable 14: Post neo-natal mortality rate in Karnataka
____ Year
1994-98
1989-93
1973-88
Urban
8.1
8.9
17.6
Rural
17.2
26.3
32.3
Total
14.4
21.0
27.7
The rural and urban difference in PNMR is striking. Between 1989-93, the rural PNMR
was more than thrice the urban PNMR. In 1994-98, the rural PNMR was over twice as
much as the urban PNMR indicating poor post-natal care services available and utilised
in the rural areas. The urban PNMR has not reduced much between the decade of 1989
and 1998.
It may be noted that the Neo-natal Mortality Rate has been more than twice the level of
the Post Neo-natal Mortality Rate in Karnataka.
Infant Mortality’ Rate: The Infant Mortality Rate (IMR) is one of the most critical
indicators of the health and development status of any given society. The IMR is the ratio
of infant deaths registered in a given year to the total number of live births registered in
the same year, usually expressed as a rate per 1000 live births. It indicates the probability
of dying before the first birthday. As per NFHS-2 (1998-99), the national infant mortality
rate was 68 deaths per 1000 live births.
In Karnataka, the National Family Health Survey-2 (1998-99) data reveals that the Infant
Mortality Rates (IMR) declined from 70 deaths per 1000 live births during 1984-88
to 52 deaths per 1000 live births during 1994-98 - an average decline of nearly two
infant deaths per 1000 live births per year. In recent years the IMR in Karnataka has
been declining twice as fast as in India as a whole. Despite this decline, one in every 19
children born during the five years before NFHS-2 died within the first year of life and
one in every 14 died before reaching five years.
Sex differentials in IMR: In Karnataka, the IMR was 70.1 deaths per 1000 live births
among boys and 54.1 deaths per 1000 live births among girls. Higher IMR among boys
than girls is a result of higher neo-natal mortality rates among boys and the fact that over
74% of all infant deaths occur during the neonatal period.
15
Facts and Figures
There are wide inter-district variations with respect to the IMR in Karnataka. Table 15
presents these variations along with sex differentials and changes in the IMR over the
decade. The male infant mortality rate for the state has been consistently higher than that
of females in 1981 as well as 1991. Districts such as Bellary (79) and Bijapur (75) have
higher rates than the state average of 73 infant deaths per 1000 live births.
Table 15: District wise infant mortality rates for 1981 and 1991
1981
State/
District
Male
65____
65____
72
100
Bangalore_______
Bangalore Rural
Belgaum________
Bellary_________
Bidar__________ 86 ____
Bijapur_________ 104
Chikmagalur____
84
Chitradurga_____
79____
Dakshina Kannada 69____
Dharwad________ 84____
Gulbarga________ 87 ____
Hassan_________ 89____
Kodagu_________ 57____
Kolar__________ 71 ____
Mandya_________ 93____
Mysore_________ 80
Raichur_________ 73____
Shimoga________ 93____
Tumkur________ 72 ____
Uttara Kannada
81____
87
State
1991
Female
55_____
55_____
63 _____
82_____
75_____
95_____
Total
60
60____
69_____
64 _____
40_____
86_____
73 _____
55_____
57_____
77____
71____
55____
85____
80____
83 ____
57____
66_____
69
75 _____
74 _____
84 ____
77____
67____
90
83____
77____
81
62
76 _____
92_____
73_____
74
67___
92____
81____
100
Male
51____
51____
48___
84___
67___
80 ___
56 ___
51____
20___
74___
59___
73___
43___
54___
76___
57 ___
58 ___
81 ___
Female
49____
49____
54 ____
73____
73____
Total
50___
50 ___
50
79___
69____
75___
55 ___
51 ___
29___
74___
59___
66___
60 ____
49____
69___
64___
49___
72
73
50___
74
55 ____
52
30____
75____
59____
44
42____
57 ____
59 ____
58 ____
52____
73____
66 ___
61___
41___
56 ___
67 ___
57 ___
59___
The lowest infant mortality rate (29) is found in Dakshina Kannada, where the female
1MR (30) is higher than the male IMR (20) for the year 1991. Other districts where the
female IMR is higher than the male IMR are Belgaum and Bidar (with a difference of six
points each), Kolar (with a difference of three points) and Chitradurga, Dharwad and
Mysore (with a difference of one point each).
The male infant mortality rate ranges from a high of 84 in Bellary to a low of 20 in
Dakshina Kannada. The female infant mortality rate ranges from a high of 75 in Dharwad
to a low of 30 in Dakshina Kannada. Some districts have been able to improve their
infant mortality rates significantly from 1981. Dakshina Kannada is the only district
which has been able to almost halve its IMR during the ten years.
16
Facts and Figures
Data from other states show that the female IMR average in Karnataka is higher than in
other states like Kerala, Gujarat, Haryana, Punjab, Maharashtra, West Bengal and Tamil
Nadu. However, the overall female IMR for India is higher than that of Karnataka. The
difference between rural and urban areas with respect to infant mortality rates is
significant.
Rural-Urban Differentials in IMR:
Fable 16: Infant mortality rate, 1999 and 2000
Karnataka
Male
58.6
73.4
18.5
India
Total
Female
Total
Total IMR (1999)
57.7
56.7
70.0
Rural_______
69.4
65.1
75.4
Urban______
24.5
31.5
43.8
Total IMR (2000)
57.0
68.0
Rural_______
68.0
74.0
Urban______
24.0
43.0
Source: India, Registrar General (2001) Sample Registration System Bulletin, April
2001, New Delhi. Page 1.
Table 16 shows that the rural IMR during 1999 and 2000 for Karnataka was more
than double of the urban IMR. The national figures also indicate a rural-urban
difference in IMR during 1999 and 2000, but this difference is less than half. This
suggests that the rural-urban differentials in Karnataka for infant mortality are
larger than those seen for the country as a whole. According to NFHS surveys, the
IMR in Karnataka decreased by 33% in urban areas and by 25% in rural areas between
1984-88 to 1994-98.
When the rural-urban differentials are studied along with sex differentials, the picture
with respect to Karnataka in comparison with the national status is interesting.
17
Facts and Figures
Table 17: Estimated infant mortality rate by sex and rural-urban status, 1999
Karnataka
57.7
58.6
56.7
69.4
73.4
65.1
24.5
18.5
India
Total
70.0
69.8
Male
Female
70.8
Rural
75.4
75.6
Male
Female
75.2
Urban
43.8
47.4
Male
Female
31.5
39.7
Source: India, Registrar General (2001) Sample Registration System Bulletin,
April 2001, New Delhi. Page 1-6.
Table 17 shows data for 1999. The situation with respect to the infant mortality rate is
better in Karnataka (57.7) than that for the country (70). In Karnataka as a whole, we find
the male IMR (58.6) is higher than female 1MR (56.7) unlike the national trend of female
IMR being higher than the male IMR. The rural IMR (68) continues to be more than
double of the urban IMR (24). The rural areas also show a corresponding trend with the
male IMR (73.4) being higher than the female IMR (65.1). This trend is reversed in urban
areas where the female IMR (31.5) is much higher than the male IMR (18.5).
The national data presents a mixed picture. The overall picture shows that female IMR
(70.8) is marginally higher than male IMR (69.8), and the rates are almost comparable in
rural areas. In the urban areas, the male IMR (47.4) is higher than the female IMR (39.7).
The differential between the urban male IMR in Karnataka and the urban male IMR in
India is very high. The urban male IMR in Karnataka (18.5) is less than half of the urban
male IMR (47.4) for the country. This differential is the least among the rural males in
Karnataka and India. The IMR for rural males in Karnataka is 73.4 and that of rural males
in India is 75.6. This table shows that the situation with respect to IMR is better among
girls in rural areas and boys in urban areas. Although the conditions are better in
Karnataka than in India as a whole, the rural-urban difference is more pronounced in
Karnataka than in the country.
Factors contributing to IMR: In Karnataka, the NFHS-2 states that the IMR declines
sharply with increasing education among mothers from a high of 76 deaths per 1000
live births for illiterate mothers to a low of 38 deaths per 1000 live births for mothers
who have at least completed high school education. The survey data also shows that the
IMR is 32% higher among Hindu children than among Muslim children in Karnataka.
Children from the scheduled caste and scheduled tribe families have higher mortality
rates than children belonging to other backward castes and other castes.
18
Facts and Figures
Causes ofInfant Deaths: When one looks at the causes of infant deaths, the data available
for 1997 indicates that a majority of deaths (42.4%) in Karnataka are due to pre-maturity
among babies. Respiratory infections of new-borns cause 18.7% of infant deaths. It
should be a matter of grave concern that over one-fourth of all the infant deaths in
Karnataka occur due to ‘other causes’. Congenital malformations and diarrhoea among
new boms claim 4% of deaths each.
When compared to the national figures, pre-maturity as a cause of death is not as highly
prevalent in the country as it is in the state. But pneumonia among infants, which causes
14.5% of all infant deaths in India; anaemia which causes 2.9% of all infant deaths in
India; typhoid and paratyphoid as well as bronchitis and asthma which cause one per cent
of all infant deaths each in India have not been observed to cause infant deaths in
Karnataka.
When one examines the situation in rural Karnataka for the year 1996, the causes of death
range from pre-maturity (45.8%) to neonatal tetanus and bronchial asthma (claiming one
per cent of infant lives each). Acute Respiratory Infections were seen to cause 23.2%
infant deaths in rural Karnataka. Over 18% of infant deaths were caused by ‘other
causes’, a matter that deserves further elaboration and study.
Fable 18: Percentage distribution of infant deaths by major cause groups for 1997
Cause
Rural
Karnataka
(1996)
45.8
Karnataka
India
Pre-maturity_________________
42.4
29.9
Pneumonia__________________
14.5
Respiratory Infection of new born
23.2
18.7
11.0
Congenital malformation_______
4.9
4.0
3.1
Anaemia____________________
1.0
0
2.9
Diarrhoea of new born_________
3__
4.0
2.9
Birth Injury_________________
2.9
3.0
1.9
Tetanus Neonatorum__________
0.5
2.5
1.6
Typhoid and Para-typhoid______
0__
1.0
Bronchitis and Asthma________
0.5
0__
1.0
Other Causes________________
18.2
25.3
30.2
Source: India. Registrar General, Vital Statistics Division, (2000), Survey Causes of
Death (Rural): Annual Report 1997, New Delhi. Page 28.
A considerably large proportion of infant deaths due to pre-maturity may be linked to
poor antenatal care and an early age of marriage among girls in Karnataka. The NFHS-2
survey indicates that the age at first cohabitation with the husband was 17.4 years for
women in the age group of 20-49 years. The age at which women start child bearing is
the median age at first birth for any group of women and is defined as the age by which
half of all women in the group have had a first birth.
19
Facts and Figures
The NFHS-2 shows that the median age at first birth is 19 years in Karnataka among
women in the 25-49 years age group. It is particularly low among illiterate, Muslim,
Scheduled Castes and Scheduled Tribes. In rural areas, the median age at first birth is
18.3 years; and in urban areas, it is 20.2 years.
Child Mortality Rate: Child Mortality Rate (CMR) is also sometimes referred to as the
child death rate. It is the number of deaths of children between one to four years per 1000
children in the same age group in a given year. It excludes infant mortality and is
expressed as a rate per thousand. CMR is a more refined indicator of deaths due to
exogenous factors since it excludes the infant mortality rate and particularly the
neo-natal mortality rate.
Table 19: Child mortality in Karnataka
Year
Urban
1994-98
9.0
15.0
1989-93
12.3
1973-88
Source: NFHS-2
Rural
23.9
30.1
54.0
Total
19.3
25.3
40.4
Although the CMR has reduced over a period of time, the urban CMR is less than half of
the rural CMR. The male CMR was 21.1 deaths while the female CMR was 23.8
according to the NFHS-2 survey (1998-99). This confirms that girls are more likely to die
due to neglect and discrimination than boys. The Child Mortality Rate is also found to be
41% higher among Hindu than Muslim children in Karnataka.
Under-Five Mortality Rate'. The Under-Five Mortality Rate (U5MR) is the probability of
a new born dying before the fifth birthday. It is expressed as a rate per 1000 live births.
The Under Five Mortality Rate is an important comprehensive indicator of children’s
health. In Karnataka, as per the NFHS-2, the male U5MR was 89.7 and the female U5MR
was 76.6 deaths per 1000 live births. This means that the probability of boys dying before
their fifth birthday is higher than the probability of girls dying before their fifth birthdays,
primarily because boys are more likely to die around their infancy and these deaths are
also included while computing the U5MR.
We know that death rates are higher for girls than for boys below five years, not
only in Karnataka but also for the country as a whole. However, the U5MR is higher
for boys than for girls in Karnataka, contrary to the national figures. This inconsistency
may be due to medical and nutritional neglect of the girl child in the early years of life.
NFHS surveys have shown that girls are less likely to receive medical attention and
treatment than boys and that they are more likely to be deprived of basic nutrition and
care.
20
Facts and Figures
Rural-Urban Differentials: Overall the Under Five Mortality Rate is 62% higher in
rural areas than in urban areas. The decline in this rate has also been faster in rural
areas (37%) than in urban areas (32%).
Table 20: Under five mortality rate in Karnataka
Year
1994-98
1989-93
1973-88
Urban
48.8
61.8
71.4
Rural
79.0
110.1
124.9
Total
69.8
95.2
107.7
Inter-District variations in U5MR: Data for 1981 and 1991 show that the total U5MR for
Karnataka decreased from 142 in 1981, to 90 in 1991. Table 21 shows the inter-district
variations in the Under Five Mortality Rates (U5MR) in Karnataka.
Table 21: Under Five Mortality Rates for Karnataka
Districts
Males
Bangalore_______ 109
Bangalore Rural
Belgaum________ 135
Bellary_________ 179
Bidar___________ 144
Bijapur_________ 164
Chikmagalur_____ 152
Chitradurga______ 160
Dakshina Kannada 90
Dharwad________ 166
Gulbarga________ 158
Hassan_________ 144
Kodagu_________ 134
Kolar__________
139
Mandya_________ 132
Mysore_________ 138
Raichur_________ 183
Shimoga________ 147
Tumkur_________ 142
120
Uttar Kannada
State
143
1981
Females
100
141
183
144
166
136
162
83
170
168
122
128
129
126
132
184
133
148
113
140
Total
105
105
138
181__
144
165
144
161
86___
168
163
133
131
134
129
135
184
140
145
117
142
Males
66___
66 ___
67 ___
118
84___
88____
77___
102
45____
94___
8_l____
80___
72____
101
86___
97___
79___
93____
99___
70___
91
1991
Females
69____
69 ____
70 ____
121
86____
89____
73____
108
47____
97____
91____
76____
59____
99____
85 ____
86 ____
84 ____
85 ____
108
69____
88
Total
67___
67___
69___
119
85 ___
88 ___
75___
104
46___
95___
86 ___
78___
66___
100
84___
89 ___
80___
88___
102
69___
90
In 1991, four districts had a total U5MR of 100 and more. These districts were Bellary
(119), Chitradurga (104), Tumkur (102) and Kolar (100). The lowest total U5MR in 1991
was seen in Dakshina Kannada (46), which was almost half of the total rate for the state
(90).
21
Facts and Figures
The sex differentials for U5MR in the state present an interesting picture. In both the
years, the male U5MR was higher than the female U5MR in Karnataka. In 1991, the
three districts with a total U5MR of over 100 had a higher female U5MR than the male
U5MR. The districts were Bcllary (118 male U5MR and 121 female U5MR), Chitradurga
(102 male U5MR and 108 female U5MR), and Tumkur (99 male U5MR and 108 female
U5MR). The same districts had higher female U5MR than the male U5MR in 1981 also.
But in Dakshina Kannada which has the lowest total U5MR, female U5MR (47) is higher
than the male U5MR (45) in 1991. In Bangalore and Dakshina Kannada, the female
U5MR was lower than the male U5MR in 1981, but this was reversed in 1991, when the
female U5MR became higher than the male U5MR.
5.2. Health goals of the state
The Karnataka State Plan of Action (1992) had laid down goals for child health to be
attained by the year 2000. One of the major goals was reduction of Infant Mortality Rate
to less than 50 and Child Mortality Rate (for ages one to four years) to less than ten per
thousand live births. The NFHS survey data shows that although the I MR dropped from
65.4 in 1992-93 to 51.5 in 1998-99, it was still well above the target of TMR less than
50’. The child mortality rates also dropped from 23.5 in 1992-93 to 18.9 (1998-99), but
they were nowhere close to the target of attaining the ‘Less than ten Child Mortality
Rate’. The efforts of the government in this regard need to be critically reviewed and
scaled up in order to attain the same goals in the next few years.
6. Nutrition
Basic nutrition is an important factor for maintaining health. However, the nutritional
status of children in Karnataka is very poor. Right from infancy, we find that children
receive less nutrition than what is required. Data published by the Department of Women
and Child Development, Government of India, 2003, shows that 22% per cent of all
babies born in Karnataka are below normal birth weight with some rural and urban
variations. The same data indicates that 38.4% of infants aged 6-9 months in Karnataka
received timely complementary feeding in 1999, while 33.5% of babies in India received
these feedings.
As per Gomez Classification, 47.6 per cent children from one to five years in rural
Karnataka were malnourished in 2002. Over 48 per cent of rural boys and over 46 per
cent of rural girls in Karnataka were malnourished.
Table 22: Nutritional status of ehildren in Karnataka and India
Indicator
Karnataka
India
Underweight
Stunted____
Wasted
43.9
36.6
20.0
47.0
45.5
15.5
£ H - too
<
/■
22
Facts and Figures
As per the NFHS survey (1998-99) data shown in Table 22, almost 44 per cent of
children below three years are underweight compared to 47 per cent in the country as a
whole (see box for definitions). The percentage children stunted in Karnataka (36.6%) is
lower than that in India (45.5%). But when we study the percentage of children
wasted, the situation in Karnataka is worse (20%) than that in the country (15.5%).
Definition of Nutritional Parameters
Underweight prevalence Proportion of under-fives who fall below minus two and
minus three standard deviation from median weight for age of NCHS/WHO reference
population.
Stunting prevalence Proportion of under-fives who fall below minus two and below
minus three standard deviations from median height for age of NCHS/WHO reference
population.
Wasting prevalence Proportion of under-fives who fall below minus two and below
minus three standard deviations from median weight for height of NCHS/WHO
reference population.
Anaemia in children is a major nutritional concern. In 1999, the percentage of children
below three years with anaemia was 70.6 for Karnataka and 74.3 for India. Although the
state figures are slightly lower than the national figures on anaemia, the fact that almost
three-fourths of children under three suffer from anaemia should be seen as a
situation demanding urgent action from the state. The NFHS-2 data shows that 42.4
per cent of women suffer from anaemia in Karnataka.
7. Immunisation
Immunisation of children against preventable diseases is one of the most important
strategies tor ensuring child health. The government has a goal of universalising
immunisation against diseases such as tuberculosis, diphteria, pertussis, tetanus, measles
and polio. Children who are immunised against all these diseases are considered to be
fully immunised. The NFHS data shows that the percentage of children fully immunised
increased from 52.2% in 1992-93 to 60% in 1998-99. These figures are, however, far
lower than the intended target of universal coverage.
23
Facts and Figures
Table 23: Immunisation coverage in Karnataka
Percentage of children
fully immunised________
Percentage of children
given BCG vaccination
Percentage of children
given DPT (3) vaccination
Percentage of children
given polio (3) vaccination
Percentage of children
given measles vaccination
NFHS 1 (1992-93)
52.2
NFHS 2 (1998-99)
60.0
81.7
84.8
70.7
75.2
71.4
78.3
54.9
67.3
The table shows that immunisation against tuberculosis (with BCG vaccine) is the
highest. Its coverage was 81.7% in 1992-93 which increased to 84.8% in 1998-99. This
high coverage may be due to the fact that this vaccine is usually given to children a few
days after birth at the place of birth itself. Since about half of the deliveries take place at
home, the high coverage of BCG vaccination indicates that immunisation drives and
outreach services have an important role to play in this regard. The percentage of children
vaccinated against diphteria, pertussis and tetanus (by three shots of DPT vaccine)
increased from 70.7% in 1992-93 to 75.2% in 1998-99. Vaccination against polio (by
three doses of oral polio drops) covered 78.3% children in 1998-99 as against 71.4%
children in 1992-93. The NFHS data also shows that the immunisation coverage is lowest
for measles (by measles vaccine) and only 67.3% of all children in Karnataka were
administered this vaccine by 1998-99. Thus, the state authorities have a long way to go
before they can declare that every child in the state is protected from major preventable
diseases.
8. Children living in slums
The conditions under which children grow up in urban slums typify utter marginalisation.
Some may argue that the ‘urban advantage’ enjoyed by them improves their quality of
life. While the fact that urban areas have more facilities and opportunities on the whole
cannot be disregarded, the question of their accessibility, quality, distribution and
ownership merits closer scrutiny. Various studies have pointed out that inadequate
provision of basic services for the urban poor in India remains a fundamental problem
that has compounded their daily struggles.
The 2001 Census shows that there are over 1,80,000 children (between 0-6 years) living
in slums across the state. Of this, over 92,000 (51.4%) are boys and over 87,000 (48.5%)
are girls.
24
Facts and Figures
Table 24: Child population (0-6 years) living in slums by districts, 2001
District________
Karnataka_______
Bclgaum________
Bagalkot________
Bijapur_________
Gulbarga_______
Bidar__________
Raichur________
Koppal_________
Gadag__________
Dharwad
Uttar Kannada
Haveri__________
Bellary_________
Chitradurga_____
Davangere______
Shimoga________
Udupi__________
Chikmagalur____
Tumkur________
Kolar__________
Bangalore_______
Bangalore Rural
Mandya_________
Hassan_________
Dakshina Kannada
Kodagu_________
Mysore_________
Chamarajnagar
Total
1,80,157
4,147
4,041
4,890
4,200
5,942
7,453
7,148
1,372
15,746
676
I, 591
20,475
3,489
II,948
7,947
Boys
92,613
2,129
2,155
2,507
2,155
3,092
3,916
3,680
709
8,203
350
794
10,620
1,722
6,149
4,057
Girls
87,544
2,045
1,886
2,383
2,045
2,850
3,537
3,468
663
7,543
326
797
9,055
1,717
5,799
3,890
1,382
1,774
7,222
47,751
3,050
2,085
4,985
194
732
929
3,647
24,469
1,596
1,022
2,548
113
650
845
3,575
23,282
1,454
1,063
2,437
81
10,622
5,269
5,353
The highest proportion of these children come from Bangalore (26.5%) which has over
47,000 children living in slums. This is followed by Bellary (11.36%) which has over
20,000 children living in slums. The census does not show any child residing in slums in
districts such as Udupi, Kodagu and Chamarajnagar. This perhaps indicates an absence of
slums in these districts. In all districts except Mysore, Haveri and Mandya, there are more
boys living in slums than girls.
25
Facts and Figures
9. Education/economic activity
Pre-school education for children is an important area which remains outside the mandate
of the state government. Given the importance of early education and a growth of early
learning centres, particularly in urban areas, many parents send their young children to
school. But as we shall see in the following data, this trend is largely restricted to the
urban areas. The 1991 Census data shows the trends in schooling among young children
in Karnataka.
Table 25: Percentage of children going to school in urban and rural Karnataka,
1991
Age Group
Urban Karnataka
Total
Male
0-4 years
2.04
2.08
5 years
18.5
19.31
40.1
41.08
6 years
Source: Census, 1991
Female
1.99
17.66
39.23
Rural Karnataka
Total
Male
0.38
0.37
3.68
4.03
22.35
24.66
Female
0.38
3.31
20.01
It is seen that a small percentage (2.04%) of urban children between 0-4 years went
to pre-school. About 2.08 percent of all urban boys and 1.99 percent of all urban girls in
this age group attended pre-school. In the rural areas, however, the percentage of children
in this age group attending school was minuscule. Less than half a per cent of rural
children, both boys and girls, attended pre-school.
At five years of age, the data shows greater school attendance among children. In urban
areas, 18.5% of five-year olds attended pre-school. Over 19% of all boys and over 17%
of girls attended pre-school in urban areas. In comparison with urban areas, pre-school
attendance among five-year olds in rural areas was extremely low. Of all the five-year
olds in rural Karnataka, 3.68% children went to pre-school. Over 4% of all the boys and
over 3% of all girls of this age attended pre-schools.
The percentage of children going to pre-schools shows an increase among six-year olds.
In urban Karnataka, about 40% of all children; 41% of all boys, and 39% of all girls
attended pre-schools. In rural areas also, a significant increase is evident in pre-school
attendance among six-year olds; with over 22% of all children: 24% of all boys and 20%
of all girls attending pre-schools.
These figures highlight three important trends. Firstly, the percentage of children
attending pre-schools is extremely low in Karnataka. The absence of pre-school
education from the government’s mandate for providing education for all could be
responsible for this scenario. The small section of children who are found attending pre
schools would most likely come from urban, middle and upper class families sending
children to privately run pre-schools.
26
Facts and Figures
With government formal schooling beginning at six years, the data shows an increase in
school attendance at that age. Secondly, the percentage of girls attending schools is lower
than that of boys for all age groups, in urban as well as rural Karnataka. The disparity
between sexes in education is seen to begin at this early stage. Thirdly, the difference
in school attendance between rural and urban areas is more stark than the sex
differentials at all ages. Even among six year olds, the percentage of rural children total, boys and girls - attending school is half of those in urban areas.
Public perceptions about child labour may not always include the realities of the very
young working child. The Census 1991 provides absolute numbers of children employed
even at an early age.
Table 26: Number of children working by age, school attendance and economic
activity (1991)
Place/Age
Total
Attending School_________________
Main Workers _______________ Marginal Workers
Male
Female
Total
Male
Female
Karnataka
5 years
6 years
10
70
10
50
0
20
0
80
0
40
0
40
Rural
5 years
6 years
10
60
10
40
0
20
0
60
0
30
0
30
Urban
5 years
6 years
0
10
0
10
0 __________ 0_________ 0
"_20________
0
10
0
10
Not Attending School
Karnataka
5 years
6 years
2160
2100
1250
1350
910
750
740
980
270
340
470
640
Rural
5 years
6 years
1810
1860
1080
1160
730
700
690
940
250
330
440
610
Urban
5 years
6 years
350
240
170
190
180
50
50
40
20
10
30
30
27
Facts and Figures
Table 26 indicates that there were 80 children below six years who along with attending
school worked as main workers (worked more than 183 days in a year), and another 80
worked as marginal workers (worked for less than 183 days in a year). A majority of
these children came from rural areas. Among children below six years who did not attend
school, more than 4,000 children worked as main workers and around 1,700 worked as
marginal workers. A majority of these children also came from rural areas.
This data brings out the following issues. Firstly, young child workers are often not
recognised as workers and their specific problems therefore go unattended. Even after we
discount under-reporting that commonly occurs during working children’s census, the
fact that there are several children reported to be employed is a cause of concern.
Secondly, the proportion of young children joining the workforce is higher in rural areas
than in the urban areas. This corresponds with the data on poor pre-school attendance
among children in rural areas which was presented above. Thirdly, the percentage of
children (among those attending school and not attending school) working as main
workers is more than that of children working as marginal workers. This shows that for
a majority of very young workers, employment is not just seasonal or for a short
duration, but an activity which takes up the entire time of the child.
ICDS coverage: Since 1979, the government has been implementing the centrally
sponsored Integrated Child Development Scheme (ICDS) in parts of Karnataka. By
March 2002, there were 39,878 ICDS anganwadi centres providing services to
underprivileged children from urban, rural and tribal parts of Karnataka. These
constituted 9.32 percent of the entire 4,27,862 anganwadi centres functioning in the
country.
Table 27: ICDS beneficiaries (0-6 years) central sector projects on March 2002
Service______________
Supplementary Nutrition
Pre-school Education
Karnataka
24,76,278
12,85,812
Males
Females
6,57,940
6,27,872
Total_____
3,15,03,764
1,66,55,533
Table 27 shows the number of children benefited by the ICDS programme by March
2002. In Karnataka, supplementary nutrition under the programme was provided to
24,76,278 children between 0-6 years in Karnataka. Pre-school education was provided to
12,85,812 children. In Karnataka, 51.1% of children in pre-school were boys and the rest
were girls.
28
Facts and Figures
10. Concluding summary
Young children in Karnataka, like elsewhere in the country, receive very little
government attention. At times, this lack of attention borders on government apathy
towards this sub-group of children. Problems such as insufficient data and official data
treating children as a residual category contribute to a vicious cycle where policies for
children do not get formulated because of lack of data and data gets generated in the
established policy domains. This paper highlighted the key demographic characteristics
of this group of children.
While the fertility rates are decreasing, over 12% of Karnataka’s population is below six
years of age. A majority of this population is rural. Even among the SC and ST
communities, the proportion of young children living in rural areas is higher than those
living in urban areas. The paper also highlighted a significant reduction in the percentage
of young girls in the female population. The child sex ratio for Karnataka (949 girls per
1000 boys in 2001) also confirms this widespread discrimination against the girl child.
Most of the data for the young child is available with respect to health indicators, an area
where most policies and programmes for early childhood operate. Young children are put
at risk right from birth. Half of the deliveries take place in non-institutional and unsafe
surroundings. Only half of the babies receive breast-feeding and a large proportion are
deprived of the rich first milk called the ‘colostrum’. Wide scale efforts to raise
awareness about the importance of breast-feeding and the nutritional values of colostrum
need to be undertaken. In addition, the state needs to provide work environments that are
conducive to breast feeding.
The infant mortality rate for the state has been on a decline, but the rate is significantly
higher in rural areas compared to the urban areas. The Under-Five Mortality Rate is
higher among boys than among girls but the post neonatal mortality and child mortality
rates are higher among girls than among boys.
There are wide-scale inter-district variations as well as variations in rural-urban areas
with respect to health conditions. A majority of infants are known to die due to pre
maturity, a condition which can be averted with adequate ante-natal care and increase in
the age of marriage. Anaemia and underweight children are a major source of concern in
Karnataka. Despite the campaigns for universal immunisation, only 60% of all children
below six years were vaccinated against the six major preventable diseases. Given these
problems, the state needs to re-energise its preventive medicine programmes, particularly
immunisation, management of acute respiratory diseases, diarrhoea and supplementary
nutrition.
The paper also presented a lack of pre-schools, especially in rural areas, and the induction
of young children as main and marginal workers. The existing policy framework
enunciates universalisation of education and an elimination of child labour; however, the
state has not been successful in preventing child labour at a very young age and ensuring
that all children have access to pre-schools.
29
Facts and Figures
While this data should help in identifying issues for change and lobbying with the
government thereafter, concerted effort must also go into identification of crucial areas
where data collection needs to be initiated. Absence of data has been an excuse for
governmental inaction on certain policy areas such as early childhood care and education.
This gap needs to be plugged in order to re-present the problems of the young child and
re- orient the existing policies for their overall growth and development.
Facts and Figures related to the Young Child in Karnataka
At a Glance...
•
The young child population (0-6 years) in Karnataka is 12.94%) as per the
2001 Census.
•
The child sex ratio is 949 girls per 1000 hoys as per 2001 Census.
•
Ofall infant deaths in Karnataka, 74.5%) occur during the neonatal period,
i.e. between birth and 28 days of life. The neonatal mortality rate for boys is
53.4 deaths per 1000 live births and for girls is 34.8 deaths per 1000 live
births as per NFHS-2.
•
The IMR for Karnataka is 52 deaths per 1000 live births as per NFHS-2.
The rural IMR was more than double the urban IMR during 1999-2000 in
Karnataka.
•
The Under Five Mortality Rate is 70 deaths per 1000 live births ( NFT1S-2)
•
Forty two per cent ofchild deaths in Karnataka are due to pre-maturity.
•
Half of all deliveries take place in non-institutional and unsafe
surroundings.
•
Only half of the babies receive breast milk and around 60% children are
deprived of ‘colostrum'.
•
Only 60% of all children below six years are vaccinated against six major
preventable diseases as per NFHS-2.
•
In 2003, 22% babies born in Karnataka were below normal birth weight.
•
About 44%o ofall children in Karnataka are underweight.
•
Almost three-fourth ofall children under three sufferfrom anaemia
•
The percentage of children attending pre-schools is extremely low in
Karnataka. The disparity between sexes in education is seen to begin at this
early stage. But the rural-urban differences in pre-school attendance are
more stark than the sex differentials at all ages.
30
Facts and Figures
REFERENCES
1. Department of Women and Child Development. 2003. The State of the Child in India.
New Delhi: Government of India.
2. Directorate of Census Operations. 1998. Census of India 91 Series-11 Karnataka Part
IV A-C Series Socio Cultural Tables. New Delhi: Directorate of Census Operations.
3. Director of Census Operations. 2001. Census of India 2001 Karnataka. Provisional
Population Totals Series 30 Paper 2 of 2001. Karnataka: Director of Census
Operations.
4. Government of Karnataka. 1994. The State Programme of Action for the Child.
Bangalore: Department of Women and Child Development, Government of
Karnataka.
5. Government of Karnataka. 1999. Human Development in Karnataka, 1999.
Bangalore: UBS Publishers.
6. International Institute for Population Sciences (UPS) and ORC Macro. 2001. National
Family Health Survey (NFHS-2), India, 1998-99: Karnataka. Mumbai: UPS.
7. National Council for Applied Economic Research. 2001. South India: Human
Development Report. New Delhi: Oxford University Press.
8. Population Research Centre, ISEC (PRC, Bangalore) and International Institute for
Population Sciences (UPS). 1995. National Family Health Survey (Maternal and
Child Health and Family Planning) Karnataka 1992-93. Bangalore: PRC and
Mumbai: UPS.
9. State Family Welfare Bureau, Directorate of Health and Family Welfare Services,
2001. Selected Indicators of Population and Health. Bangalore: Government of
Karnataka.
31
Sex selection and sex determination:
law and reality
A rch an a Mehen da le
Sex Selection
In the Indian context, some medical practitioners have abused these techniques by using
them to detect the sex of the foetus followed by abortion of the female foetus, making
quick profits from this practice. Advertisements blatantly suggest that couples could pay
Rs. 500 (for sex determination tests) now. and save Rs.5 lakhs (on dowry) later!
1 he nature ol technology is changing, and invasive techniques such as amniocentesis and
chorionic villus biopsy are getting replaced by non-invasive techniques such as
ultrasonography. Portable ultrasound machines can be easily carried to remote villages in
mobile clinics and can even be used by semi-skilled practitioners.
South India did not have sex determination clinics until the late '80s, unlike the northern
and western regions of the country. Since then, there has been a definite shift with the
proliferation ol these clinics and a falling child sex ratio. This paper attempts to
document this situation in the context of Karnataka and the implementation of the
Prenatal Diagnostics Techniques Act, 1994.
2. The situation in Karnataka
The decreasing number of girls in the overall population is the result of a number of
factors. A strong son preference, the neglect of the girl child resulting in higher mortality
at a young age, a male bias in the enumeration of population, female infanticide, and
female foeticide are some of the key determinants of an adverse sex ratio among children.
In the context of a declining fertility rate; a preference for a male child; an easy
availability of new sex determination and sex selection technology; and a strong
patriarchal bias which blames the woman for producing a female child; many women are
forced to find out the sex of the foetus and terminate it if it is female. In the absence of
adequate abortion facilities; women resort to unauthorised practitioners or even quacks,
thereby putting their health to grave risk.
These factors are examined in the context of Karnataka.
2.1. Fertility decisions and son preference
Phe National Family Health Survey-2 (1998-99) indicates that fertility levels are
declining in Karnataka. For women between the age of 15 - 44 years, the Total Fertility
Rate declined from 2.82 (1990-92) to 2.12 (1996-98). The decline of 0.7 children for
urban areas and 0.9 children for rural areas indicates that the absolute level of fertility fell
somewhat more rapidly in rural areas than in urban areas.
5
Sex Selection
Families in India are
known to prefer sons to
daughters
because of
Total Fertility Rate is defined as the average number of
various social, economic
children a woman would have if she were to pass through her
and cultural reasons. With
reproductive years bearing children at the same rate at which
respect to the prevailing
women in each age group of the population are now bearing
son preference, the results
children.
of the National Family
Health Survey-1 (199293) and National Family Health Survey-2 (1998-99) reveal that the preference for sons,
although still significant, has weakened in Karnataka.
Box 1: Total Fertility Rate
In 1995. data for the state revealed that among married women who wished for another
child (irrespective of earlier pregnancies), 44% wanted a son whereas only 16% wanted a
daughter. Almost 33% indicated no preference and 8% left it to God. The same data also
revealed that the preference for sons was particularly strong in rural areas where 48%
wanted a son, compared to urban areas where 34% wanted a son. In 1998-99 the NFHS-2
survey results showed that 37% of women who wanted another child said that they
wanted the next child to be a boy; 16% said that they wanted a girl and the rest said that
the sex of the child was either up to God (9%) or did not matter (39%).
The NFHS-1 and NFHS-2 survey data for the state also shows that the proportion of
women who desire a son decreases substantially with the number of living children. In
1995, women who did not have any living children were more likely to desire a son
(30%) than a daughter (only 5%). The desire to stop child bearing generally increased
with the number of living sons and also with the number of living daughters. However,
the desire to stop was more prevalent among women with two or more sons than among
women with two or more daughters. In 1998-99, 31% of women with no living sons
wanted no more children, compared to 90% of women with two living sons. 13% of
women wanted more sons than daughters, but only 2% wanted more daughters than sons.
On an average, women in Karnataka considered a family with one son and one daughter
to be ideal (UPS and ORC Macro, 2001: 63-65).
Compared to Karnataka, the preference for sons is found to be stronger in other states,
particularly the northern states of the country. Although on a decline, this preference for
sons has been consistent over the years in Karnataka. Field activists claim that women
worry that their husbands might get re-married, or throw them out if they give birth to a
female child. The women also feel that they have suffered and do not want to subject
their daughters to the same kind of suffering.
2.2. Sex ratio
The sex ratio for the total population indicates the number of women per 1000 men in the
population. It is affected by factors like migration. The child sex ratio indicates the
number of girls per 1000 boys in the 0-6 years age group. An adverse sex ratio is
considered to reflect the poor status of women and of social development.
6
Sex Selection
2.2.1. Sex ratio for the total population
According to the 2001 Census, the sex ratio of the total population for Karnataka was
964, for the rural population was 976. and for the urban population was 940 females per
males. The male bias in the urban population is often due to the migration of men to cities
horn villages in search of work, and does not necessarily reflect a better health status
among women in rural areas as compared to women in urban areas. It is seen that in three
districts and 25 talukas the sex ratio is positive; indicating the presence of 1000 or more
females per 1000 males. These districts are Udupi (1127). Hassan (1005) and Dakshina
Kannada (1023).
2.2.2. Child sex ratio
According to the 2001 census, the child sex ratio was 949 girls per 1000 boys for
Karnataka, 954 girls per 1000 boys in rural areas, and 939 girls per 1000 boys in urban
areas.
The table below presents the sex ratio for the total population and the child sex ratio for
the census years 1991 and 2001.
Table I: Sex ratios for 1991 and 2001 for Karnataka
Census
year
1991
2001
Total population sex ratio
Child (0-6 years) sex ratio
Total
960
964
Total
960
949
Rural
973
976
Urban
930
940
Rural
963
954
Urban
951
939
This table reveals that while the overall sex ratio has registered an increase, the child sex
ratio has registered a considerable decrease between 1991 and 2001. This is equally true
in the context of both rural and urban areas, although the decrease in the urban areas is
more rapid than that in rural areas. The child sex ratio in rural areas is better than that in
urban areas. This could be due to the easy availability of sex determination technology
and abortion facilities in urban areas compared to those available in rural areas.
Inter-district and intra-district variation in child sex ratios
•
•
•
Among the districts, Kodagu has the highest child sex ratio of 977, and Belgaum
the lowest at 924.
Among the urban population, Kodagu has the highest child sex ratio at 986, and
Bagalkot the lowest at 910.
Among the rural population, Bijapur has the highest child sex ratio at 986. and
Belgaum the lowest at 924.
7
Sex Selection
Table 2: District wise sex ratios for 2001-Karnataka
Sex ratio of total population
Rural
Urban
Total
962
Belgaum_____ 959
948
Bagalkot_____ 977
982
966
948
Bijapur______ 948
948
932
976
Gulbarga_____ 964
Bidar________ 948
919
957
991
949
Raichur______ 980
985
971__
Koppal______ 982
969
967
Gadag_______ 968
945
950
Dharwad_____ 948
969
970
Uttar Kannada 970
941
945
Haveri_______ 942
955
977
Be 11 ary______ 969
948
Chitradurga
955
956
939
Davangere
951
956
967
977
982
Shimoga_____
1149
1038
Udupi_______ 1127
958
Chikmagalur
984
990
937
974
Tumkur_____ 966
971
966
Kolar_______ 970
911
Bangalore
906
905
938
953
957
Bangalore
(Rural)
989
966
Mandya______ 985
1014
962
Hassan______ 1005
1034
1005
1023
Dakshina
Kannada_____
952
Kodagu______ 996
1003
965
Mysore______ 965
965
969
966
Chamarajnagar 968
District
Child (0-6 years) sex ratio
Rural
Urban
Total
921
924
924
910
949
939
971
914
986
920
937
943
980
923
967
962
946
967
963
934
938
951
948
957
944
943
945
947
943
946
942
961
966
949
954
937
949
945
946
949
940
953
959
958
961
964
955
953
964
966
956
952
949
953
953
976
983
940
957
937
941
945
928
937
964
952
931
969
949
968
937
958
977
970
957
976
976
958
986
958
952
Except for Bidar, Bangalore, Bijapur. Haveri, Kolar and Mysore, the total child sex ratio
in all districts is consistently lower than the total sex ratio of the general population
of Karnataka, which is 964 females per 1000 males.
Taluka level variations in Child Sex Ratio: When one examines the child sex ratio for the
various talukas in Karnataka, it is seen that there are two talukas below 900 (Chikodi in
Belgaum with 879 and Siddapur in Uttar Kannada with 896 girls per 1000 boys). Seven
talukas have a positive child sex ratio, i.e. more than 1000 girls per 1000 boys, the
highest being 1182 in Indi taluka of Bijapur, followed by 1149 in Malur taluka of Kolar.
8
Sex Selection
Table 3: C hild sex ratio (0-6 years) for talukas in Karnataka, 2001
Sex ratio______
1000 and above
Between 975-999
Between 950-974
Between 925-949
Between 900-924
Less than 900
Number of talukas
7_______________
12 ______________
73______________
67______________
13 ______________
2
There are intra-district variations in the child sex ratio as per the 2001 census figures. For
instance; in Bijapur district, the child sex ratio ranged from 915 in Bijapur taluka to 1182
in Indi taluka; in Koppal district, it ranged from 900 in Gangawati taluka to 964 in
Koppal taluka; in Uttara Kannada district, it ranged from 896 in Siddapur taluka to 974 in
Supa taluka.
Declining proportion of younu girls
If one examines the young child (0-6 years) population over the last decade in Karnataka,
it is clear that although there is an absolute increase in the number of both boys and girls
from 1991 to 2001. their proportion to the total population reflects the following picture:
1. I he proportion of young children within the total population is decreasing,
which is the result of declining fertility rates.
2. In 1991, the proportion of young girls in the total population was higher than
the proportion of young boys; but in 2001, the proportion of girls was lower
than that of young boys.
Table 4: Proportion of child population in Karnataka
Total 0-6 years
Population (Absolute)
Children____________
Boys_______________
Girls_______________
Percentage of the total
population__________
Children____________
Boys_______________
Girls
1991
2001
150,421,175
77,322,151
73,099,024
157,863,145
17.94
81,911.041
75,952.104
17.77
15.42
15.47
18.12
15.36
While some research studies report an increasing practice of female foeticide as the cause
for an adverse sex ratio, others argue that the preferential treatment given to boys in the
intra-household allocations and neglect of young girls in terms of health care, nutrition
and related needs are equally significant reasons for this distortion (See discussion in
Dreze and Sen, 1995: 143-144).
9
Sex Selection
Although it is assumed that the deliberate girl child neglect often spares the first child,
research points out that the proportion of families aborting the female foetuses in the
first pregnancy has been increasing over the past five years (George, S. et al, 1992).
This is despite a decline in preference for sons as reflected in the National Family Health
Surveys. This inconsistency in data can be a result of methodological limitations of
inquiry into culturally deep-rooted problems. In other words, women may be ‘compelled'
to say they do not prefer sons since these are more politically correct and ‘expected'
responses. Thus, the declining son preference in Karnataka has not translated into child
sex ratios favouring girls.
2.3. Reasons for abortions
Repeated and late mid-trimester abortions are hazardous for women. Data on abortions in
Karnataka reveals that the percentage of cases where reasons for carrying out an abortion
was not available has increased significantly in a short period of time. From 1997-98 to
1999-2000. the percentage of such cases has gone up from 1.60 to 20.79 per cent. In fact,
this category of ‘reasons' is the second highest in 1999-2000. after ‘failure of any
contraceptive device’ which is the most commonly stated reason.
Table 5: Reasons for accepting Medical Termination of Pregnancy, Karnataka
Reasons______________________________________
Danger to the life of pregnant woman_______________
Grave injury to the physical health of pregnant woman
Injury to the mental health of pregnant woman________
Pregnancy caused by rape________________________
Substantial risk that if the child was born it would suffer
from physical abnormalities to be seriously handicapped
Failure of any contraceptive device_________________
Not available__________________________________
Total
1997-98
9.71
17.06
12.76
4.51
12.99
41.37
1.60
100
1999-2000
13.14
17.53
11.12
0.82
12.78
23.02
20.79
100
Such a high rate of cases where the reasons for abortion are not documented raises
questions on the possible use of sex determination followed by female foeticide. The fact
that a pregnant woman can find ways to terminate her pregnancy legally after illegally
determining the sex of the foetus should be a matter of legal concern.
3. The legal framework on the issue
1978
1988
Given the rapid advancement in medical technology on the one hand, and the
persistent bias against the girl child on the other, the Government of
Maharashtra issued a directive in 1978 which banned the use of amniocentesis
in government hospitals and laboratories.
The Slate passed the first law in the country to prevent sex determination tests.
The Maharashtra Regulation of Pre-Natal Diagnostic Techniques Act, 1988.
This law was meant to curb the practice of sex selective abortion.
10
Sex Selection
1994
2003
In 1994, Parliament enacted the Pre-Natal Diagnostic Techniques Act
(hereinafter referred to as the PNDT Act), which came into force from 1996.
The PND I Act was amended in 2003 to address inadequacies and
administrative difficulties. The amended law is intended to enlarge the coverage
by including other discriminatory practices such as sex selection, both before
and after conception, which was not covered under the earlier enactment.
3.1. A question of discrimination
Arguments on sex selective abortions can spill into the contentious area of the right to life
of the foetus. It is important to remember that the issue here is not concerning the foetal
right to life but that of discrimination against the female foetus. While women can legally
abort their foetus on certain grounds as per the Medical Termination of Pregnancy (MTP)
Act. 1971, determining the sex of the foetus is made a legal offence.
The underlying logic of
this is that if sex
On health grounds-if it involves a risk to the life of the pregnant
detection
is
not
woman or if it involves grave injury to her physical or mental health
permitted,
those
carrying
as in the case of pregnancy on account of failure of contraception, or
out abortions would not
pregnancy due to rape.
be doing so in order to
On eugenic grounds- if there is a substantial risk that if the child were
get rid of the female
born, it would suffer from such physical or mental abnormalities as to
foetus but for other
be seriously handicapped.
genuine reasons laid
Section 3 (i) and (ii) of the MTP Act
down in the MTP Act.
Thus,
discrimination
against the girl child will not begin in the womb and she would have an equal right to be
born alive. In other words, the objective is to prevent discriminatory abortions on grounds
ol sex by putting an end to sex detection technologies and practices.
Box 2: Grounds for termination of pregnancy
3.2. The legal provisions
The PNDT Act with the recent amendments is now titled the Pre-conception and Pre
natal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994. It aims ‘to provide
lor the prohibition of sex selection, before and after conception, and for regulation of pre
natal diagnostic techniques for the purposes of detecting abnormalities or metabolic
disorders or chromosomal abnormalities or certain congenital malformations or sexlinked disorders and for the prevention of their misuse for sex determination leading to
female foeticide and for matters connected therewith or incidental thereto’. The
amendment thus brings in the entire range of technology and practices pertaining to sex
selection even before conception. This enlargement was particularly required in the
context of newly emerging technologies which give couples an option on the sex of their
baby.
11
Sex Selection
3.2.1. Registration of genetic centres
The Act requires that all genetic counselling centres, laboratories and clinics be
registered; whether government-run, private, voluntary, honorary, part-time, contractual
or consultative. Registration should be accompanied by an affidavit undertaking that the
body shall not conduct any test or procedure for selection of sex before or after
conception, or for detection of the sex of the foetus except for certain diseases, nor shall
the sex of the foetus be disclosed to anybody. They are also required to prominently
display a notice indicating that they do not conduct any technique, test or procedure for
the detection of the sex of the foetus or for selection of sex before or after conception.
The Appropriate Authorities under the Act are required to inspect these centres/clinics
and ensure that they have adequate space, required equipment and are staffed by qualified
personnel. If the authorities are satisfied with the inspection, the application is placed
before the Advisory Committee for scrutiny and for final decision on the registration.
Box 3: Authorities under the PNDT Act
Appropriate Authority: Appropriate Authorities are statutory bodies appointed by the Central
Government for carrying out central functions and the State Government for carrying out
functions at the state level. At the state level, the Appropriate Authority is a multi-member team
comprising of an officer of or above the rank of the Joint Director of Health and Family Welfare
as the Chairperson, an eminent woman representing women's organisation and an officer of Law
Department of the State or the Union Territory concerned.
Advisory Committee: Advisory Committees are statutory bodies constituted by the Central
Government for functioning at the central level and by the State Government for functioning at
the state level. The Committee consists of three medical experts from amongst gynaecologists,
obstetricians, paediatricians and medical geneticists; one legal expert; one officer to represent
the department dealing with information and publicity of the state government; three eminent
social workers of whom not less than one shall be from amongst representatives of women's
organisations.
Supervisory Board: The Board is a statutory body meant to monitor the implementation of the
Act and oversee the performance of the Appropriate Authorities and Advisory Committees
under the Act. The Central Government constitutes a Central Supervisory Board and the State
Government constitutes the State Supervisory Board. At the state level, this Board consists of
the Minister in charge of Health and Family Welfare in the State, who is also the ex-officio
Chairperson; the Secretary in charge of the Department of Health and Family Welfare as the exofficio Vice- Chairperson; Secretaries or Commissioners in charge of Departments of Women
and Child Development, Social Welfare, Law and Indian System of Medicines and
Homeopathy; Director of Health and Family Welfare or Indian System of Medicines and
Homeopathy of the state government; three women members of Legislative Assembly or
Legislative Council; ten members appointed by the state government out of which two each
shall be from the following categories [a] eminent social scientists and legal experts [b] eminent
women activists from non-governmental organisations or otherwise [c] eminent gynaecologists
and obstetricians or experts of slri-roga orprasuti tantra [d] eminent paediatricians or medical
geneticists [e] eminent radiologists or sonologists; and an officer not below the rank of Joint
Director in charge of Family Welfare who is the ex-officio Member-Secretary.
12
Sex Selection
3.2.2. Prohibitions under the act
The Act prohibits sex selection before or after conception and the misuse of pre-natal
diagnostic techniques for determining the sex of the foetus. It recognises certain offences
which are as follows:
•
•
•
•
•
•
•
•
•
Issuing, publishing, distributing, communicating or causing to be issued, published,
distributed or communicated any advertisement, in any form, including advertising on
the internet, regarding the facilities of pre-natal determination of sex or sex selection
before conception.
Opening any centre having ultrasound or imaging machine or scanner or any
technology capable of undertaking determination of sex of foetus or sex selection
without due registration.
Conducting or causing to be conducted a pre-natal diagnostic technique for the
purpose of determining the sex of the foetus.
Olfering services for conducting or aiding another person to carry out any pre-natal
diagnostic technique at any place other than a registered place.
Seeking or encouraging any pre-natal diagnostic technique to be carried out except
for purposes specified in the Act.
Seeking or encouraging the conduct of any sex selection technique.
Conducting or aiding sex selection before or after conception, by whatever means.
Communicating the sex of the foetus to any person in any manner.
Selling, distributing, supplying, renting, allowing or authorising the use of any
ultrasound machine or imaging machine or scanner or any other equipment capable of
detecting the sex of the foetus whether on payment or otherwise to any centre or
person not registered under the Act.
The offences under this Act are
cognisable and non-bailable.
Besides
the
Appropriate
Pre-natal diagnostic techniques may be used for detecting:
and
Authority,
and
officers
• chromosomal abnormalities;
authorised in this behalf by the
• genetic metabolic diseases;
Government, any
any person or
• haemoglobinopathies;
organisation
can
make
a
• sex-linked genetic diseases;
complaint under this Act by first
• congenital anomalies;
giving a notice of at least fifteen
• other abnormalities or diseases as specified by the
days
to
the
Appropriate
Central Supervisory Board.
Section 4 (!) and Section 4 (2) of the Act
Authority of the alleged offence
and his/her intention to make a
complaint in the court. The
offences under this Act are tried only in a court of the Metropolitan Magistrate or a
Judicial Magistrate of the First Class.
Box 4: Conduct of Pre-natal Diagnostic
Techniques
13
Sex Selection
3.2.3. Structures for implementation
The Act stipulates the formation of a Central Supervisory Board at the national level to:
1. advise the central government on policy matters
2. review and monitor the implementation of the Act
3. create public awareness on the issue and oversee the performance of Appropriate
Authorities and Advisory bodies constituted under the Act.
I he State Supervisor)' Boards cany out similar functions at the state level.
fhe Board has also laid down a Code of Conduct to be followed by all persons working
at any of the facilities that use pre-natal diagnostic techniques. This Code requires such
personnel to refrain from conducting, associating, helping in carrying out procedures for
sex detection or selection, before or after conception, except for purposes specified in the
Act. It also requires such personnel to ensure that no provision of the Act is violated and
that they help law enforcing agencies to book violators.
Recent amendments call for one or more multi-member Appropriate Authorities for
each State. This body should:
1.
2.
3.
4.
5.
grant, suspend or cancel registration
enforce the standards for the clinic as prescribed
investigate into complaints, take appropriate action suo moto or on complaints
recommend modifications in the rules
create public awareness about the issue.
The Appropriate Authorities have the powers to summon any person in possession of any
information related to the violation, produce any document or material object, issue
search warrants for any place. They are also expected to provide quarterly reports on
clinics/laboratories surveyed, registered, action taken on complaints, etc.
fhe Act also provides for Advisory Committees at the Central and State level to aid and
advise the Appropriate Authority.
14
Sex Selection
3.3. Enforcing the act
3.3.1. Plie Supreme Court Order in CEHAT and others versus Union of India and
others
Although the PNDT Act was enacted in 1994 and brought into operation in 1996, its
enforcement was not satisfactory. A Public Interest Litigation was filed by two NGOs
C 1J IAI and MASUM, and activist Dr. Sabu George. Some of the landmarks in the case
are as follows:
4 May 2001: The Supreme Court asked the Central and the State governments to
effectively implement the Act by appointing an Appropriate Authority at district and sub
district levels in all the States and Union Territories.
11 December 2001: I he Supreme Court asked all States to furnish district-wise
information about the implementation of the Act. It stated that information about buyers
ol ultrasound machines may be obtained from manufacturers, importers, suppliers, etc. of
such machines. The help of the Indian Medical Association, Indian Radiologists
Association, and the Federation of Obstetrics and Gynaecologists Societies of India for
identifying users of ultrasound machine was sought.
29 Jan 2002: The Supreme Court directed companies to supply information on how
many machines they have sold to various clinics in the last five years; their names,
addresses and also their service contracts. Some of the manufacturers listed were: Wipro
GE Medical Systems, L&T, Seimens, GE. A list of over 11.000 buyers of ultrasound
machines received from manufacturers and suppliers was forwarded to the states for
follow-up.
3.3.2. Implementation in Karnataka
3.3.2.1. Government Action
I he Supreme Court while hearing the PIE also observed an utter slackness by the
administration in implementing the Act. As per the Supreme Court order dated
September 19, 2001, Karnataka had not issued a notification for appointing Appropriate
Authorities at the sub-district level and had not constituted these bodies at the sub-district
level. Thereafter, one of the areas of work undertaken by the state government was the
setting up of district wise bodies for the implementation of the Act. At present, the
District Health Officers are the Appropriate Authorities at both the district and sub
district level.
There are District Advisory Committees and the District Health Officer is the
Chairperson of the Committee. Meetings of these Committees are expected to be held
regularly, every two months. However, district-wise data shows that not all districts have
been regular in this regard.
15
Sex Selection
Table 6: Frequency of District Advisory Committee Meetings in 2003
Frequency of
meetings_____
Every 2 months
Every 3 months
> 3 months
Number of Districts
Districts
Bangalore Urban, Kolar. Shimoga, Tumkur,
9
Mysore, Dharwad, Haveri, Bidar, Raichur
Bangalore Rural, Davangere. Mandya, Dakshina
13
Kannada, Chikmagalur, Hassan, Bagalkot.
Bijapur, Gadag, Uttar Kannada, Gulbarga,
Koppal, Bellary____________________________
Udupi, Belgaum
2
Note: The frequency has been calculated on the basis of duration between meetings held during 2003.
Source: Directorate of Health and Family Welfare, Government of Karnataka, PNDT Act 1994 District
wise Report as on 30 June 2003.
The table above shows that a majority of the District Advisory Committees in the State
have not met regularly as per the Act. The districts of Chitradurga, Chamarajanagar and
Kodagu have had meetings only once during 2003.
The State Advisory Board has been constituted by the Government. Information,
Education and Communication (IEC) activities have been undertaken such as hoardings,
slides in cinema halls, posters, etc.
Another area where the state government has focussed its efforts since the Supreme Court
directive is the registration of genetic clinics, genetic counselling centres and genetic
laboratories. In 2002, available data showed that 1090 centres were registered in the state.
By June 2003, 1475 ultrasound machines have been registered in the state after 1500
ultrasound machines were found through the survey conducted by the District
Appropriate Authorities.
16
Sex Selection
Table 7: District-wise status of registration of ultrasound machines in 2003
District
Bangalore Urban
Bangalore Rural
Chitradurga______
Davangere_______
Kolar___________
Shirnoga_________
Tumkur_________
Mysore__________
Mandya_________
Dakshina Kannada
Chikmagalur_____
Chamarajnagar
Kodagu__________
Hassan__________
Udupi___________
Belgaum_________
Bagalkot_________
Bijapur__________
Dharwad_________
Gadag___________
Haveri___________
Uttar Kannada
Gulbarga________
Koppal__________
Bidar____________
Raichur__________
Bell ary__________
Total
No. of Ultrasound
machines as per
the District
Appropriate
Authority sur\ ey
490_____________
32 _____________
16_____________
29_____________
33 _____________
48 _______________
37_______________
76_______________
24 _______________
72_______________
Registration
Granted
480
32
16
29
33
48
36
76
24
71
25 __________ 25
13__________ 13
13__________ 13
33__________ 33
52__________ 50
118_________ 115
51__________ 51_
27__________ 23
67__________ 67
23__________ 23
13__________ 13
41__________ 41_
49 _____________ 45
11______________ 11_
26 _______________ 26
32_______________ 32
49_______________ 49
1500
1475
Registration
under Process
10
1
1
2 (1 rejected)
(3 rejected)
4
2
20
Source: Directorate of Health and Family Welfare, Government of Karnataka, PNDTAct 1994 District
wise Report as on 30 June 2003.
After Bangalore Urban, Belgaum has the highest number of ultrasound machines in
the state, and this is particularly a matter of concern since the child sex ratio in
Belgaum is 924. One of its talukas, Chikodi, has the worst child sex ratio (879) in the
state.
17
Sex Selection
There have been very few rejections of registration. One of the registrations was rejected
since the doctor was an Ayurvedic practitioner. The mobile scanning units are also
required to be registered, but this process has not been completed.
In 2002, the Appropriate Authorities had sealed and seized live machines, and five cases
were filed in the court for various violations under the PNDT Act. By June 2003. official
data indicates that 22 cases were filed in Bangalore Urban district, six in Belgaum, four
in Dharwad and two in Gulbarga. Among these, the two clinics of Gulbarga had not
applied for registration and they had obtained an interim order of status quo from the
Court of the Civil Judge, Gulbarga. The Appropriate Authority filed objections in the
Court and the case is still pending. However, most cases are filed with respect to non
registration. Booking cases against doctors for sex determination or sex selection has not
happened, primarily because of lack of evidence. Using decoys is one way of catching the
violators red-handed and the government is seriously looking at this possibility.
Box 5: Use of decoys for enforcing the PNDT Act
Using decoys is perhaps the most effective means to book cases against errant doctors
and other practitioners. Recently, Vimochana, a Bangalore based women's organisation,
sent decoys to well-known doctors and hospitals who were suspected of conducting sex
determination tests. One woman met a doctor seeking advice on how to conceive a male
child. This kind of counselling is not permissible under the PNDT Act. The transaction
was video recorded by the woman decoy. In another case, a pregnant woman volunteered
to visit a sonologist as a decoy. She carried a video camera for recording the transactions.
The sonologist was caught on tape revealing the sex of the foetus. Throughout this
operation, the decoys were extremely careful and did not let out their real identity. For
several weeks after gathering this hard evidence, Vimochana prepared a strategy to get
the doctors booked under the law. It informed the police as well as the Appropriate
Authority about the evidence but did not reveal the identity of the doctors concerned. The
organisation did not want the word to leak out and reach the concerned doctors, lest it
lead them to abscond, distort other evidence or evade the law. It worked with the media
so that they gave adequate coverage to the cases. On the selected day (both cases were
pursued separately), it released the evidence and immediately got the Appropriate
Authority to raid the premises and file cases against the two doctors. This was the first
instance of using decoys in the city of Bangalore and a significant one since it helped to
reinforce the rule of law among the medical community.
33.2.2. Medical Ethics and Practice
The medical community plays a very critical role in the declining sex ratios on account of
sex selective abortions. From presenting sex-selection as a possibility to the pregnant
woman to asking her to undergo sonography, even when it is not required; from detecting
the sex of the foetus to helping her undergo an abortion; medical practitioners are
involved, either discreetly or openly. In Karnataka, one does not come across blatant
advertising of ultrasound clinics which is prohibited by law. According to health activists,
the penetration of ultrasound clinics is so deep that women in even remote villages have
addresses of sonologists in their traditional pouches used for money and betel nuts.
18
Sex Selection
Mobile vans with ultrasound clinics have been found visiting villages. This has become
an extremely profitable venture and even untrained practitioners are known to perform
ultrasonography.
Sonologists are known to communicate the sex of the foetus by various means. The sex
of the foetus is conveyed to the pregnant woman and/or her family by drawing a leaf or a
flower, or asking for laddoo or barfly or by using a specific colour of ink for writing.
These signs are usually recognised by persons accessing the sonologist.
In the absence of adequate facilities for safe abortion, women visit quacks to get rid of
their female foetus. In some cases, abortions are carried out clandestinely by doctors even
after 20 weeks of pregnancy. There is no way of knowing the exact number of abortions
carried out in any given health centre, government or otherwise; or how many female
foetuses were aborted, because the records are often inaccurate and unreliable. Moreover,
the law does not oblige the doctors to record the sex of aborted foetuses.
Doctors at times use the law for vested interests and for settling personal scores against
their peers or even patients. Some complaints have been filed for such reasons. For
instance, doctors may falsely accuse their fellow practitioners for illegally practising sex
selective abortions. But such cases are rare. The government is unable to take action
unless there is concrete evidence and this often requires leads to work on. But the nexus
between medical practitioners as a community and that between medical practitioners and
their patients is difficult to confront and becomes one of the main obstacles in the
implementation of the Act.
The members of the Federation of Obstetrics and Gynaecologist Societies of India
(FOGSI) have taken an oath that they would not practice sex determination and anyone
doing so would be removed from the primary membership of FOGSI. The Medical
Council of India has warned doctors of de-registration if they are found defaulting. The
Indian Medical Association had circulated an appeal to its members which stated that of
nearly 20,000 ultrasound machines, only 1% were registered until a few years ago. It
therefore requested every hospital, nursing home or clinic to ensure that [a] pre-natal sex
determination by ultrasound, chorionic villi biopsy, amniocentesis and sex selection by
X-Y chromosome separation are not practised in their premises; |b] no second trimester
pregnancy termination should be done for indications other than genetic malformations,
pregnancy following rape or grave risk to the life of the mother. Yet the medical
community needs to be sensitised in this regard and must begin to view this as a problem
of medical ethics and not simply that of law.
3.3.2.3. The role of the media
The media, particularly the vernacular media, has not given adequate coverage to issues
involved in sex determination and sex selection and their social implications. With recent
amendments to the law and Supreme Court orders in this regard, the obligation on the
media to take a responsible position on this issue has been reinforced.
19
Sex Selection
REFERENCES
1. Department of Family Welfare, Government of India. 2003. Handbook on PNDT of
Act, 1994 and Amendments (Revised Edition). New Delhi: Government of India,
Department Family Welfare.
2. Director of Census Operations. 2001. Census of India 2001 Karnataka. Provisional
Population Totals, Series 30. Paper 2 of 2001. Karnataka: Director of Census
Operations.
3. Dreze, J and Sen, A. 1995. India: Economic Development and Social Opportunity.
New Delhi: Oxford University Press.
4. George, S., Abel, R., and Miller, B. D. 1992. ‘Female Foeticide in Rural South India'
in Economic and Political Weekly, May 30.
5. International Institute for Population Sciences (UPS) and ORC Macro. 2001. National
Family Health Survey (NFHS-2), India, 1998-99: Karnataka. Mumbai: UPS.
6. Population Research Centre, ISEC (PRC, Bangalore) and International Institute for
Population Sciences (UPS). 1995. National Family Health Survey (Maternal and Child
Health and Family Planning) Karnataka 1992-93. Bangalore: PRC and Mumbai: UPS.
7. State Family Welfare Bureau, Directorate of Health and Family Welfare Services.
2001. Selected Indicators of Population and Health. Bangalore: Government of
Karnataka.
22
Maternity provisions:
entitlements, benefits and healthcare
Vinalini Mathrani
Maternity Provisions
CONTENTS
Page
1. Introduction
4
2. The need for maternity provisions
4
3. Maternity provisions in ideal terms
5
4. Maternity provisions in the international context
5
5. The national context with a historical overview
6
6. The NGO sector stance
8
7. National and state level statistics on maternal health
9
8. Maternity provisions for working women: entitlement and benefits
8.1 The penalty-entitlement model: organised sector
8.2 Maternity protection through welfare funds
8.3 Maternity protection for women in the unorganised sector
8.4 Issues related to maternity provisions for working women
12
12
16
17
18
9. Maternity provisions for women outside the workplace
19
10. The nature of maternal health care services
10.1 fhe Integrated Child Development Scheme (ICDS)
10.2 The Reproduction and Child Health (RCH) programme
10.3 Issues related to maternal health services
21
21
22
25
11. Reflections and suggestions
26
12. Response of the Second Labour Commission
27
13. Summary and conclusions
28
References
30
Annexures
1. Glossary of legal terms
2. The Maternity Benefit Act, 1961 (Abridged version)
3. National Maternity Assistance Scheme
4. Circular regarding supplementary nutrition programme under (ICDS)
31
31
34
35
2
Maternity Provisions
TABLES
Page
Table 1: Shops and establishments
13
Table 2: Tea, coffee and rubber plantations
14
Table 3: Factories
14
Table 4: ESI disbursals for maternity benefits
16
Table 5: National maternity scheme in Karnataka
19
Table 6: District wise figures of national maternity scheme in Karnataka
20
Table 7: Mothers receiving supplementary nutrition through ICDS
21
Table 8: Implementation data under the RCH
23
BOXES
Box 1: The national context: a historical overview
6
Box 2: Maternal health care indicators as per the NFHS (II) India
10
Box 3: Maternal health care indicators as per the NFHS (II) Karnataka
11
Box 4: The Maternity Benefits Act, 1961
13
Box 5: The Employee State Insurance (ESI) Act, 1948
15
3
Matern ity Provisions
1. Introduction
The status of the young underprivileged child (under 6 years) is influenced by the
continuous interplay of multiple interrelated variables. One of these variables is the
nature of maternity provisions available in the country. This area needs to be approached
in the context of the mother and the child as it concerns both equally.
The title of this paper defines the scope, which has been kept broad deliberately. The
term maternity provisions, includes entitlements, benefits and services, in the current
scenario, maternity entitlements are restricted to working women and specifically only to
women within the organised sector. If women in the organised sector are denied their
entitlements, they have the right to legal recourse. For women in the unorganised sector
and for women who are not designated as workers by the government (i.e., women from
the care economy) maternity benefits and maternal health care services are available.
These benefits and services are dispensed subject to the availability of funds and the
political will of the issuing authority to dispense these services. If women are denied
these, they do not have the right to go to court.
The mandate of this study is women belonging to the lower socio-economic category
(within organised and unorganised sectors and even outside the working category), hence
the need for comprehensive coverage. This paper presents a picture of the nature of all
maternity provisions available to women in Karnataka and the extent to which these have
been accessed. Maternity provisions necessarily include related issues of infant health
and creches but these aspects are being examined in other papers.
2. The need for maternity provisions
Pregnancy is a period demanding a support system that ensures additional dietary
allowances, systematic antenatal care, absence of stress and a positive attitude from the
family and society. It is well established that the good health of the mother has a direct
bearing on that of the infant. It ensures the availability of nutrients to the foetus, a full
term well developed baby at birth, a risk-free delivery and breast milk of good quality
and adequate quantity during lactation (NIN, 1982). Pregnant women rarely get the
necessary care, attention, diet or rest, which affects their own and the nutritional and
health status of the children they deliver. A mother’s health is closely linked to the child’s
welfare, and maternity provisions are the lifeline to ensure proper survival and
development of the child.
Women, especially poor women, perform multiple roles as workers, homemakers, child
bearers and care givers. The reproductive period of women’s lives is also the time they
are likely to be the most productive as workers and under most pressure as homemakers.
In the absence of adequate provisions for maternity leave; a woman worker often leaves
her job to have a child. Poor health, additional medical expenses and the loss of
employment, make her vulnerable during the period of childbirth, plunging her into an
economic crisis of borrowing at high interest rates, which has social and emotional
ramifications.
4
Maternity Provisions
The repeated neglect of a woman's health during pregnancy and childbirth results in high
mortality rates, anaemia and low birth weight of the new born (Shram Shakti, 1988). The
period of maternity is probably best dealt with through various supportive arrangements
to enable the woman to carry out her reproductive and productive roles. Therefore, all
maternity provisions need to be examined in this context (Swaminathan, 2001).
3. What are maternity provisions?
All working women (paid or unpaid) whether located in the organised or unorganised
sector should be entitled to twelve weeks leave with full pay of which six weeks can be
taken prior to delivery. They should be assured job security during this period. They
should be entitled to medical maternity benefits i.e., cost of antenatal, postnatal care
and cost of delivery (along with cost of associated complications) should be covered.
All lactating mothers should have access to creche facilities, which will enable them to
breastfeed their babies. Additionally, poor women subsisting below the poverty line and
those not designated as workers (women working in the care economy), should be
entitled to cash compensation to tide them through this period.
FORCES, 2001
It needs to be reiterated that this definition remains restricted to the rhetorical realm. It is
anticipated that over time rhetoric will translate into reality. Also, what constitutes
maternity provisions varies, depending upon where women are located in the socio
economic and occupational ladder. The different entitlements and services available to
different categories of women are described in the paper. Prior to looking at what is
happening in the country, it is useful to examine provisions in the international context.
4. The international context
In the international context, the main convention covering maternity provisions is the
International Labour Organisation’s (ILO) Maternity Entitlement Convention, 2000. The
Convention includes the following provisions:
a) Maternity benefits should be available to all women workers whether full time or part
time or employed in atypical dependent forms of work.
b) Leave should be granted for a period of up to 14 weeks with a minimum of six weeks
as compulsory in the postnatal period and cash benefits should include not less than
two-thirds of a woman’s insured earnings. It should cover prenatal, postnatal and
hospitalisation care where necessary.
c) Employment security should include protection from dismissal. The woman should
have the right to the same job. No dismissal should take place if the woman is
pregnant or ill. In the case of dismissal, the burden of proof should lie with the
employer.
d) Maternity entitlements should not be a source of discrimination in employment
(FORCES, 2001).
India is yet to agree to all these provisions.
5
Maternity’ Provisions
5. The national context: a historical overview
BOX 1
Provisions
Context and key features
1940-1965
•
Article 42 of the
Directive
Principles
•
The 11th Schedule
of the 73rd and 74lh
Amendment.
Employees State
Insurance Act
(ESI) 1948 and
Maternity Benefit
Act (MBA), 1961.
•
1965-1970
•
Beedi and Cigar
Workers Act, 1966
Article 42 in the Constitution of India provides a
comprehensive understanding of women and children’s
rights. It requires that the states should provide just and
humane conditions of work and maternity relief.
The 11th Schedule places ‘women and child development’
among the 29 subjects which are to be the responsibility
of local state governments while labour legislation is a
central responsibility (MSSRF, 1993). These two large
statements of intent were narrowly interpreted only in the
context of ‘labour’ or workers; hence maternity
provisions formed a part of labour legislation and
policy. Even in the international context, the ILO dealt
with maternity provisions. These did not feature in
policies for women or children.
The ESI and the MBA were modeled along acts prevailing
in the erstwhile colonial societies, which were on the brink
of industrialisation. It was assumed that women were
employed only in the formal sector. It needs mention that
the term ‘benefits’ was in currency at this stage because
under these two acts, women were treated as beneficiaries
rather than as persons asserting their rights. Technically,
these are the only two acts, which can feature in the realm
of entitlements as women can take legal recourse if the
provisions are not adhered to. The notion of the informal
sector did not feature in the minds of the Indian policy
makers even though it existed in real terms.
The Beedi and Cigar Workers Act brought some
awareness regarding the role and magnitude of the
informal sector and the large presence of women within it.
Till date, laws and schemes in the informal sector have
been slow in coming and inadequately implemented.
6
Maternity Provisions
1970-1980
•
Integrated Child
Development
Scheme (1CDS)
and the Maternal
Child Health
Programme.
•
National Policy on
Children (1974)
1980-1990
Different schemes
in different states
(e.g.. National
Maternity
Assistance
Programme)
•
•
Maternity and
Child Care Code
(MCCC)
•
Maternity Fund
•
The seventies saw the burgeoning of anti-poverty
schemes, which embodied a welfare approach towards
women. These programmes did not recognise that
‘mothers’ are ‘women’ and a number of them are also
‘workers’. Hence the emphasis is on health i.e., ante and
postnatal care (ANC, PNC), safe childbirth and
breastfeeding rather than on support services and day care.
This policy emphasised the responsibility of the state to
provide adequate services to children, both before and
after birth to ensure their full physical, mental and social
development. However specific acts were not
promulgated towards attaining this goal.
In the eighties, many of the states adopted schemes to
offer minimal assistance to women at childbirth. These
schemes are intended for the poor, destitute and indigent
i.e., these recognise women’s poverty rather than their
double roles or their need for support services.
This code was first put forward in Shram Shakti (1988),
the Report on the National Committee on Women in the
Unorganised Sector. It was the first official recognition
that the needs of women and young children are intimately
interlinked and need to be considered together.
The MCCC deals with the totality of a woman’s
reproductive function, from pregnancy till the child is able
to go to school. This speaks of the woman’s right to health
care, wage protection and adequate working conditions
during maternity. The MCC Code has not yet been
translated into a concrete programme for action.
From the non-governmental sector (NGO) Mina
Swaminathan proposed a maternity fund as an alternative
to the MCCC. Every woman should be able to draw upon
this fund regardless of income, number of children or any
other consideration. If she is working her income should
be protected to enable her to withdraw temporarily,
partially or wholly from the workforce, in the interest of
childcare (Swaminathan, 2001). These recommendations
remain restricted to paper.
7
Maternity Provisions
1990-2000
•
The World
Summit for
Children, 1990.
Convention of the
Rights of the Child
(CRC) 1992.
•
India was a signatory at this summit. For the first time in
history, 71 heads of state met at the United Nations
Headquarters in New York. They declared their
determination to protect the physical and mental
development of children throughout the world. The
summit goals included: halving the 1990 maternal
mortality rate; reducing child mortality for children under
5 years by one-third; and halving severe and moderate
malnutrition among children under 5 years.
The Convention looks upon children not merely as
extensions or dependents of adults but as human beings
and rights holders who can play an active part in the
enjoyment of their rights. Owing to their vulnerable
position, they need protection. But they also have their
strengths and, if allowed and encouraged, are able to
participate in decisions that concern them. The first three
key principles of the Convention directly relate to
maternity provisions: the right to survival, development
and protection. The Convention views parents as primary
carers and protectors who must be supported in doing the
best for their children. (Thukral, 2002).
Subsequent sections of this paper examine the entitlements, benefits and services and the
manner in which these have been implemented in Karnataka. Prior to that, the stance
within the Non-Governmental Organisation (NGO) sector is presented, as it has a key
role to play in lobbying for change.
6. The NGO sector stance
FORCES (Forum for Creche and Childcare Services), an informal national level
advocacy network committed to securing the rights of the underprivileged child (0-6
years) has played a key role in this area. It focuses on the rights of both women (with
their multiple roles) and children. The mother and child are regarded as a dyad who need
to be together continuously during the first few months of life, for both nourishment and
for psychosocial reasons. FORCES is responsible for mooting a shift from the term
benefits to the notion of entitlements wherein, all women should have the right to avail
of maternity provisions rather than feel that they are receiving these in the form of
largesse on the part of the dispensing body.
8
Ma tern i Pro visions
Women’s organisations and the women’s movement have taken little interest in this
subject. This can be attributed to two primary reasons. Firstly, they feel that they are still
dealing with larger issues of bonded labour and minimum wages. Until these are
addressed, it is premature to lobby for maternity entitlements. Secondly, they have
entered the area of reproductive issues as they have fought for the right to abortion and
the right to exercise reproductive choices but most groups feel that lobbying for maternity
entitlements amounts to ‘glorification of motherhood’ rather than ensuring women equal
rights (perscom. Mina Swaminathan, October 2003).
This historical overview and the NGO stance constitute the backdrop for examining the
reality on the ground. The national and state maternal health status is a valuable starting
point for examining reality.
7. National and state level statistics on maternal health
Maternal health care is only one aspect of maternity provisions. However, in real terms it
is only maternal health care that is getting addressed as maternity provisions for a
majority of women from the lower socio-economic category.
7.1 The all-India picture
In a patriarchal society, women subsist within the constraints of their poor nutritional and
health status, the low educational status of young girls, early marriage, early motherhood,
multiple pregnancies and closer spacing of children.
• The maternal mortality rate (MMR) was 540/100,000 in the two year period
preceding the National Family Health Survey II, 1998-99 (UPS and ORC Macro,
2000)
• The Indian MMR is 50 times higher than developed countries and six times
higher than Sri Lanka.
• Anaemia, haemorrhage, eclampsia, obstructed labour and infection account for 80
per cent of maternal deaths in India (HDR, 1999).
• 75 per cent of pregnant women are anaemic. This increases maternal mortality
risk, foetal growth retardation, pre and perinatal morbidity, low birth weight
babies (LBW-one third of the children in India are LBW), child growth failure,
poor physical and mental development, even infant mortality (Shiva, 2002).
• 75 per cent of children between 6-35 months are anaemic in India. Micronutrient
deficiency (silent hunger) is most devastating in pregnant women and pre-school
children (Vir, 1995).
9
Maternity Provisions
BOX 2: Maternal healthcare indicators
(NFHS H, 1997-98, India, UPS and ORC Macro, 2000).
Antenatal care (ANC):
A minimum of four
visits are recommended
by WHO
•
Iron and folic acid tablet
dispensation.
Tetanus toxoid (TT)
injections:
Two doses are
recommended________
Place of delivery and
type of assistance
•
•
•
•
•
•
•
•
•
Postnatal care:
Three PNC visits are
recommended
•
•
65 per cent of the women who gave birth in the two
years preceding the survey received one antenatal
checkup.
44 per cent received three or more antenatal checkups.
33 per cent received antenatal care in the first
trimester._____________________________________
58 per cent women received iron and folic acid for
more than three months._________________________
67 per cent received two or more TT injections.
33 per cent women delivered babies in a medical
institution.
The rest of the babies were delivered at home (either
in the natal or marital home).
Health professionals assisted 42 per cent of the births.
35 per cent of the births were attended by trained or
untrained dais.
23 per cent of the births were attended by friends and
relatives.
17 per cent women who had non-institutional
deliveries received postnatal care within two months
of delivery.
14 per cent of the women who had non-institutional
deliveries received postnatal care within two days of
birth.
7.2 The Karnataka situation
The situation in Karnataka is an improvement on the average national data.
• NFHS 11 does not present data on maternal mortality. However, Sample
Registration Survey 1998 places this figure at 198/100,000 while according to
UNESCO it is 450. The former figure is significantly lower than the national
average of 540/100,000. Even the latter is lower but only by 90 (GOK, 2001).
• 42 per cent women are anaemic and 18 per cent pregnant women are anaemic
(UPS and ORC Macro, 2000).
• 71 per cent children between 6-35 months are anaemic. This can be attributed to
the mother’s poor nutritional status to some extent (UPS and ORC Macro, 2000).
10
Maternity Provisions
BOX 3: Maternal healthcare indicators
(NFHS-II, 1997-98, Karnataka, UPS and ORC Macro, 2000).
Antenatal care (ANC)
•
•
•
Iron and folic acid tablet
dispensation.
Tetanus toxoid (TT)
injections._____
Place of delivery and
type of assistance
•
•
•
•
•
•
Postnatal care (PNC)
•
•
Breastfeeding
•
•
•
86.3 per cent of the women who gave birth in the four
years preceding the survey received one antenatal
checkup.
71.4 per cent received three or more antenatal
checkups.
52.7 per cent received antenatal care in the first
trimester._____________________________________
74.2 per cent women received iron and folic acid for
more than three months._________________________
74.9 per cent received two or more TT injections.
51.1 per cent women delivered babies in a medical
institution.
The rest of the babies were delivered at home.
59.1 per cent of the births were assisted by health
professionals
The rest of the births were attended by trained or
untrained dais.
35.3 per cent women who had non-institutional
deliveries received postnatal care within two months
of delivery.
3.6 per cent of the women who had non-institutional
deliveries received postnatal care within two days of
birth.
18. 5 per cent of the babies were breastfed within one
hour of birth.
41.5 were breastfed within one day of birth.
61.4 per cent mothers removed the colostrum.
On all counts, women in Karnataka fare better than the average Indian except with regard
to early PNC.
11
Ma tern ity Pro visions
Maternity provisions are available only to women above the age of 18; therefore it is also
relevant to look at the age of marriage. According to NFHS I:
• At the age of 15-19, 38 per cent of women are married. This figure stands at 43
per cent in rural areas and 27 per cent in urban areas.
• Child bearing in Karnataka is concentrated in the age group 15-29 where fourfifths of the births occur.
• 23 per cent of the births are in the age group of 15-19. Slightly more than onefifth of all women aged 15-19 and 72 per cent of ever married women aged 13-19
have begun childbearing.
This data indicates that there is a significant proportion of underage women who need
maternity provisions (ISEC and UPS, 1995).
Despite the advantage women in Karnataka have over the average Indian woman, it is
clear that there is scope for improvement. This is possible only if the state assumes
certain responsibilities and there is community participation. At this juncture, it becomes
relevant to examine the specific provisions devised by the government and to see how
these have been implemented in Karnataka.
8. Maternity provisions for working women: entitlements and benefits
Three types of statutes prevail which address the needs of women within the workplace.
(Details on and implications of all legal terms (e.g., statutes) are provided in Annexure 1.)
8.1 The penalty-entitlement model: provisions for women in the organised sector
The first set of statutes enable the promulgation of acts, which feature within the
entitlement-penalty model. These statutes specify who the beneficiary is, the statutory
benefit and the penalty for non-observance. Any amendments in these acts require the
sanction of the legislature (Dhanda, 2001). The provisions of the Maternity Benefit Act
(MBA), 1961 and the Employees State Insurance Act (ESI) 1948 have been
formulated in non-negotiable terms. Both these acts apply only to women who work
within the organised sector.
12
Maternity Provisions
BOX 4: The Maternity Benefits Act, 1961
•
•
•
•
The MBA applies to all workers in regular employment in factories,
commercial establishments, plantations, mines, circuses and every shop and
establishment in which 10 or more persons are or were employed on any day
in the preceding 12 months.
Every woman employee who has worked for a period of 80 continuous days
in one year is eligible to be covered under the Act.
A commercial establishment is a premises where any trade or business or
profession is carried out. In legal terms, contract work is also included in
this definition. Unfortunately, this Act is implemented only in the organised
sector.
The salient features of the Act include:
1. Protection from dismissal during pregnancy.
2. 12 weeks paid leave of which six weeks may be taken in the period
preceding childbirth if the mother so desires.
3. The employer will not compel the woman to engage in any arduous
work during pregnancy, or give notice for discharge or dismissal
during this period.
4. Two nursing breaks of 15 minutes each, once the mother goes back
to work.
5. To obtain the benefit, the woman has to give notice in Form D and
the employer is obliged to pay the amount and grant leave to the
concerned applicant.
6. Any employer who infringes the provisions of the statute can be
punished with imprisonment for a period of not less than three
months and with a fine of not less than Rs. 2,000. An Inspector under
this statute (from the Labour Commissioner’s office) can initiate
action for contravention (Dhanda, 2001). (Annexure 2 contains
additional details on the Act.)
Implementation of the MBA, 1961 in Karnataka.
This data has been obtained from the State Labour Commissioner’s Office. It indicates
the extent to which the MBA has been implemented.
Table 1: Shops and Establishments
Year
1998
1999
2000
2001
2002
No, of Units Inspected
13________________
37________________
201_______________
95________________
149
No. of Violations
Nil___________
Nil___________
Nil___________
Nil___________
Nil
13
Maternity Pro visions
Data compiled in this manner throws very little light on the actual situation on the
ground. It does not indicate how many women have received the benefit. It is also not
clear how many inspections are mandatory. (The staff maintains that they have 22 issues
to be inspected. Maternity benefits are one of the less important issues; hence a specific
number of inspections are not prescribed.) It is unlikely that there are no violations.
Table 2:Tea, coffee and rubber plantations
Year
1998
1999
2000
2001
Number of applications and number of claims processed
742__________________________________________
625__________________________________________
509__________________________________________
445
Data for 2002 is still being compiled. This data does not indicate whether all plantations
have been covered or how many women got pregnant. According to this data, all claims
of all the women who applied have been accepted and the money has been disbursed.
However, a declining trend in the number of claims is evident.
Table 3: Factories
Particulars
1.
2.
Year
1998
Number of applications and
number of claims processed 229
Inspections by the officers
5201
during the year
1999
2000
2001
296
251
77
5951
5766
5398
The data for 2002 is yet to be compiled. This data pertains to women working in
factories. This table indicates that all women who have applied for the benefit have
received it. It is unlikely that only 77 women needed the benefit in 2001 as opposed to
296 women in 1999. The number of mandatory inspections is not indicated or available.
Apparently there are no prescribed targets. This data needs a context to engage in any
detailed analysis. However the small number of claims is a cause for concern.
14
Ma tern ity Provisions
Maternity provisions are also provided for women in the organised sector under the ESI
Act, 1948.
BOX 5: The Employees State Insurance (ESI) Act, 1948
•
•
•
This Act only applies to non-seasonal factories using power and employing
10 or more persons; and also to factories not using power and some other
establishments employing 20 or more persons.
The ESI facilities are usually available in areas of industrial concentration.
The medical facilities are set up only if there are at least 1000 workers in the
vicinity to make this an economically viable proposition.
The categories of women to which the provisions of the ESI schemes apply
are excluded from the purview of the MBA. Women drawing wages above
the wage ceiling under the ESI Act are entitled to the benefits under the
MBA. The provisions in the ESI Act are more comprehensive than those
under the MBA as they include medical care and pre and postnatal care.
Key features
1) The Act applies to employees whose earn less than Rs. 6,500 per month.
2) Both the employer and the employee contribute an amount to the ESI
Corporation. The employee contribution is 1.75 per cent of her salary/per
annum and the employer contribution is 4.75 per cent of the salary. The
contributions are remitted every six months to the ESI/SBI account. If the
deposits are made regularly, the ESI staff does not go on inspections.
Usually inspections are made once in two years.
3) In the case of non-adherence, the woman has the right to either file a
complaint directly or she can register the complaint through an office bearer
of the registered trade union of which the woman is a member, a voluntary
organisation registered under the Societies Registration Act or an Inspector.
4) The woman has to apply to the ESI Corporation to avail of the benefit. State
governments administer the Act.
5) An insured woman is entitled to maternity benefit in the form of periodical
payments in the case of confinement, miscarriage or sickness arising out of
pregnancy. Payments are made for actual absence up to 12 weeks on
average daily wages (minimum wage or Rs. 10). Women are also entitled to
medical care and where medical facilities are not available, they are paid a
sum of Rs. 250 for the purpose.
Implementation of the ESI in Karnataka,
Approximately 20,000 employers are covered by the ESI (perscom. Mr. Hegde, Deputy
Director ESI, October 2003). According to Mr. Hegde, 25 per cent of the employers are
defaulters. The question of the employee defaulting does not arise as the employer is
supposed to deduct the contribution at source.
15
Ma tern ity Pro visions
Table 4: ESI disbursals for maternity benefits
Year
1999
2000
2001
2003
Number of payments
25,304______________
28,444______________
26,177______________
24,856
Amount in rupees
2,51,64,250
3,13,60,834
3,57,15,960
3,86,76,642
This table throws light on the number of payments made to women who are availing of
the benefit. Usually two payments are made per woman but this figure can vary. It is
therefore not possible to extrapolate how many women have received the benefit. It is
evident that over time there is an increase in the quantum paid to the women, which is
reassuring.
It needs to be reiterated that only these two Acts feature in the realm of entitlements as
women have the right to legal recourse if they arc denied any of the provisions
described above. In real terms these continue to remain benefits, as most women do not
have the wherewithal to assert their rights. Moreover, if they feel that their jobs are in
jeopardy, they would rather forgo these.
8.2 Maternity proteetion through welfare funds
The second set of statutes provides maternity protection to vulnerable working groups
through the setting up of Welfare Funds.
• The Welfare Fund statutes indicate how to set up the funds and provide the
structures for their administration.
• These schemes can be altered on the basis of experience without going back to the
legislature. These include the Beedi and Cigar Workers Welfare Fund, 1966;
Working Journalists and other Newspaper Employees and Miscellaneous
Provsions Act, 1955, etc.
• To avail of benefits the employees have to be registered as workers with a
specified statutory authority. Under the Building and other Construction Workers
Act, 1996, every registered building worker should receive the benefits provided
by its Fund. The other mode of establishing worker status is through identity cards
issued by the employer. The worker can also obtain the worker status certificate
from a state functionary (village officer, executive officer of the panchayat,
municipal commissioner or corporation commissioner of the area).
• In the case of non-adherence under these statutes, there is no provision for the
woman to file a complaint directly. She has to register the complaint through an
office bearer of the registered trade union of which the woman is a member, a
voluntary organisation registered under the Societies Registration Act or an
Inspector.
• The Welfare Fund statutes do not just provide benefits to vulnerable population
but also accord the government an opportunity to distribute these.
In Karnataka, none of the welfare funds has any provision for maternity benefits.
16
Ma tern ity Pro visions
8.3 Maternity protection for women in the unorganised sector
A third variety of statutes are those, which enjoin the state to launch schemes to address
the needs of people in the unorganised sector (Tamil Nadu Workers Act, 1982).
• The statute only identifies the need. Once the need is recognised, the scheme has
to be devised for its realisation i.e., the formulation of the scheme becomes a
statutory obligation.
• The actual entitlements and procedure for obtaining these are provided in the
scheme. In these statutes, the funding source is not mentioned and these schemes
do not have the force of law and thus benefits accruing cannot be claimed as
entitlements or be contested in court.
• The government can alter the schemes without legislation.
• The content of the schemes can vary from state to state and allow’ for greater
location specificity. This aspect assumes relevance only if the local population is
aware of its rights and people’s groups maintain pressure on the government to
ensure that benefits are provided.
The Karnataka government has not devised any maternity benefit schemes under
the third set of statutes.
In 2003, a bill for workers in the unorganised sector (Unorganised Workers Act) was
placed before the Karnataka state legislative assembly. This will cover 70 categories of
unorganised workers. Provision of maternity benefits will be addressed in this bill. How
the benefits will reach this category of workers needs to be examined when the bill is
passed and converted into an act. The process of passing the bill is still underway. In
neighbouring Tamil Nadu, an Unorganised Workers Sector Bill was formulated in 2003
as an outcome of the Second National Labour Commission’s recommendation. This bill
classifies 37 crore workers in the unorganised sector into 122 categories. It can serve a
valuable reference source.
The major gain of statutory schemes over non-statutory ones is that they introduce a
modicum of non-negotiability. Whilst the content of the scheme can change, the scheme
itself cannot be withdrawn.
17
Ma tern ity Pro visions
8.4 Issues related to maternity provisions for working women
NGOs including FORCES members from all over the country have analysed the
provisions in detail. As the second and third statutes are not being implemented in
Karnataka, issues pertaining to these are not being presented.
1) To obtain maternity benefits/entitlements, a person has to first establish the status
of the worker. This depends upon how the term worker is defined under the
statute. The statutory procedures are geared to weed out wrongful claimants.
There is no urgency to ensure that rightful claimants get their just due. The burden
of proving such a status always resides with the person seeking the benefit. This is
not easy given the woman’s lower socio-economic and sometimes non-litcrate
status.
The MBA and the ESI Acts only apply to workers in the organised sector
where only 10 per cent women work. Even within the organised sector, a very
tiny group avails of the MBA. A national study by Niru Chaddha shows that only
0.25 per cent of women who are entitled actually avail of maternity benefits. Here
the term worker tends to exclude contract labourers though in real terms they may
actually be entitled.
2) Further, the functional efficacy of the MBA and ESI depends on the existence of
efficient inspectorate and diligent prosecution. If there are inadequacies on this
score, then guaranteeing that the benefits reach the women cannot be ensured. For
questioning violations, the woman has to first be aware of her rights. She then has
to know who is the Appropriate Authority to be contacted in the case of violation.
For the MBA, the woman needs to inform the State Labour Commissioner’s
office. These officers are not always responsive. Lengthy court procedures are not
a viable option for women from the lower socio-economic category. A real
consequence of the inability to question violations has led many women to leave
their jobs when they are pregnant or they have not been hired to avoid providing
maternity benefits during and after pregnancy. As the MBA is an employer
liability scheme, it has often worked adversely for the employment of women.
Employers would rather not employ women than ensure that they receive their
entitlements.
An important mechanism for ensuring observance of statutory requirements under
the ESI is registration or licensing. All factories can function only if they have the
relevant license. Licenses can be revoked if the ESI Act is infringed. This clause
is relevant only if the factory inspectors choose to take their role in this regard
seriously.
18
Mcitern ity Pro visions
3) With regard to the amount of benefit provided by the ESI and MBA Acts, it is
inadequate as women are not able to cover the cost of extra nutrition required
during pregnancy. According to Brinda Karat (AIDWA) food entitlements should
be an important component of maternity benefits (FORCES, 2001).
4) Often the factory owners and contractors find it easy to avoid the ESI scheme by
employing 9 rather than 10 women. Also a number of factories owners pay their
employees Rs. 6,501/- per month to avoid implementing this scheme.
5) Currently no maternity leave is granted if the child is adopted. Maternity leave
should be granted if the child is less than six months old. The scope of the acts
needs to be extended to include adopted infants.
The
two-child norm population policy has an intimate relationship with this area.
6)
The recent pronouncement of the government restricting all maternity benefits to
only two children seems to be in contradiction to the policy flowing from the
CRC, since it discriminates against a group of children. Such a unilateral decision
on the part of the government without the usual consultation any other
institutional forums has disturbing implications and can be contested on
constitutional grounds.
9. Maternity provisions for women outside the workplace
In addition to these statutory workplace related schemes, different states have different
schemes, which address the needs of women outside the workplace.
The National Maternity Assistance Scheme (1995) has been introduced under the
National Social Assistance Programme (NSAP) to provide financial assistance (a one
time payment of Rs. 500) to women below the poverty line (BPL). The government of
Karnataka is also implementing the National Maternity Assistance Scheme for pregnant
women who are above the age of 19 and belong to BPL families (Annexure 3).
Implementation of the National Maternity Scheme in Karnataka
This data is currently maintained by the Women’s Welfare Department. They only have
data for 2001 and 2002.
Table 5: National Maternity Scheme in Karnataka
Year
2001
2002
Number of women
who received the
benefit__________
46,941___________
59,059
Total number of
pregnant BPL women
Percentage of women who
have received the benefit
2,15,337
22
Despite the fact that over time more women are receiving the benefit, this table
establishes that this scheme has an inadequate outreach (22 per cent in 2001). (The total
number of pregnant BPL women is a proxy figure as it has been computed by using the
WHO formula: total BPL population multiplied by 17.3 (Crude Birth Rate) divided by
1000. Total BPL population has not been compiled for 2002.
19
Ma tern ity Pro visions
FORCES groups have undertaken sample studies in four locations: Delhi (sample size
152), Orissa (181), Bihar (57) and Uttar Pradesh (53). Their study reveals that this
scheme is poorly implemented in all states. Surprisingly Bihar fares the best with a 44 per
cent implementation rate. Delhi (21.7 per cent) and Uttar Pradesh (20.7 per cent),
implementation figures resemble Karnataka (22 per cent). Orissa is the lowest with 9.4
per cent. These figures are actually not comparable due to variation in sample size but
this gives an indicative picture.
The state figure in Karnataka of 22 % hides inter-district variations. Data from a few
select districts has been presented to reveal the variation. As the BPL population has not
been compiled for 2002, 2001 data has been used which will only be an underestimate.
Table 6: District wise figures of national maternity scheme in Karnataka
Name of district
Raichur
Mysore
Tumkur
Bel I ary
Kodagu
Koppal
Bagalkot
Bijapur
Number of women
who received the
benefit in 2002
1,490__________
5644___________
5,909__________
3,347__________
522____________
1,258__________
867____________
990
Total number of
pregnant BPL
women in 2001
1,767________
10,878________
12372________
10,571________
1,672_________
7,175_________
5,574_________
9,700
Percentage of
women who have
received the benefit
84_____________
52______________
47.7____________
31.6____________
31______________
17.5____________
15______________
10
It is evident that the poorer districts (Bijapur, Bagalkot, Koppal) suffer from inadequate
implementation of this scheme. BPL women in the richer districts (Mysore and Kodagu)
seem to fare better. It is difficult to explain the wide variation in implementation between
Raichur (84 per cent) and Koppal (17.5 per cent). These are neighbouring districts with a
similar socio-economic profile. On the whole, the scheme is inadequately implemented.
9.1 Issues related to maternity provisions for women outside the workplace
• Minimal provisions arc available to women outside the workplace, that too only for
BPL women. Women who subsist even slightly above the poverty line are not entitled.
• The benefit of a fixed sum of Rs. 500, as a one-time payment, does not sustain the
mother or the child in real terms.
• The money can be obtained only if the woman fills up form M.B-1 and submits it to the
anganwadi worker within six months from the date of conception. If she fails to do so,
she forfeits even this minimal benefit. Given these women’s lack of awareness and non
literate status, this condition is often not fulfilled.
• The woman should have lived in the concerned district for three years prior to the
application. Inter-district marriages are not uncommon, and most women conceive soon
after their marriages. This eliminates a large number of women. Many women go to
their natal homes for delivery, hence forgo this benefit.
20
Ma tern ity Pro visions
10. Maternal health services
In addition to the provisions described above, the government also has the responsibility
of providing women with maternal health services. It focuses on maternal health through
two schemes: Integrated Child Development Services (ICDS) Scheme and the
Reproductive Child Health (RCH) programme.
10.1 The Integrated Child Development Scheme (ICDS)
The Department of Women and Child Development implements this scheme. It is a
centrally sponsored scheme, which has been in operation since 1975. This scheme has the
most extensive and comprehensive network of childcare services in any developing
country and reaches about 15 per cent of all children in the age group 0-6 and two-fifths
of those most in need. The scheme is executed through local anganwadi centres. This
programme provides support to the woman during pregnancy and lactation (Annexure 4).
(Details on the ICDS are available in another paper.).
Implementation of the ICDS in Karnataka
In Karnataka, the ICDS department has data pertaining to nutrition for pregnant and
nursing women for the years 2002 and 2003.
Table 7: Percentage of mothers receiving supplementary nutrition through ICDS
Year
2002
2003
Supplementary nutrition to pregnant women
93.27 per cent________________________
93.88 per cent
To nursing mothers
93.21 per cent____
92.32 per cent
A district wise break up is attached to Annexure 4. No significant trends are evident
across districts. In fact in some areas, the achievements exceed the targets. These figures
indicate that almost all pregnant and nursing mothers who avail of the ICDS are
adequately nourished. This data however does not indicate the quality of the nutrition and
whether the women actually consume the supplements. Karnataka FORCES undertook a
small study of some anganwadi centres in September 2003. This indicated that women
only get bread in the Bangalore (urban). According to the staff of Belaku Trust (an NGO
working on reproductive and child health), the health services dispensed by the rural
anganwadis in their area, Bangalore (rural), are also inadequate.
21
Maternity Provisions
10.2 The Reproductive and Child Health (RCH) programme
Maternal health for the lower socio-economic category has been subsumed in the
government’s population control and family planning efforts. Family planning and
immunisation programmes were amongst the earliest health programmes initiated in the
1960s. Sterilisation was the focus of the National Family Planning Programme. In 1979,
the Family Planning Programme was renamed as Family Welfare Prgramme and
initiatives were taken to improve the health and nutritional status of women and children.
The National Health Policy of 1983 stressed on maternal and child health (MCH). The
MCH programme of the 80s was renamed as the Child Survival and Safe Motherhood
(CSSM) programme in 1992. As reproductive health care became the focus post-ICPD
(International Conference on Population and Development, Cairo, 1994), CSSM was
brought under the umbrella of the present Reproductive and Child Health (RCH)
programme of the Ministry of Health and Family Welfare (Shiva, 2002).
The RCH is a composite programme, incorporating inputs from the Government of India
(GOI), funding from the World Bank and the European Commission. Under the RCH
programme women should be able to go through pregnancy and childbirth safely and the
outcome of pregnancies should be successful in terms of maternal and infant survival. It
was anticipated that this approach would provide beneficiaries with need-based, clientcentred, demand-driven, high quality and integrated RCH services. This programme is
being projected as a target free one but in reality the staff are compelled to direct their
efforts at reaching pre-set targets.
22
Maternity Provisions
Table 8: Implementation data under the RCH
Year
1
1997-98
Expected
Antenatal
%
level of
registration
acceptance
12,07,900 1 1,89,282 98.46
2
1998-99
12,31,200
11,42,155
92.77
62,932
5.51
11,57,490
94.01
6,93,789
56.35
9,30,270
3
1999-00
12,93,000
12,75,161
98.62
1,19,444
9.37
12,10,883
93.65
12,79,809
98.98
10,80,854
4
2000-01
12,32,000
12,37,252
100.43
1,25,909
10.18 11,94,472
96.95
13,78,752
111.91
9,31,784
High risk
Identified &
referred
58,679
%
T.T to P W
%
IFA to P W %
4.93
12,23,188
101.27
11,62,165
96.21
ANC with 3
completed
visits by HAF
10,41,324
Deliveries conducted by
Year
Total
Deliveries
Institution. %
HAF
/LEV
%
Trained dai %
Untrained dai
%
Total
Live Births
1
1997-98
8,76,894
3,80,939
43.44
2,37,264
27.06
2,21,939
25.31
36,752
4.19
8,60,828
2
1998-99
8,08,361
3,68,141
45.54
2,12,456
26.64
1,98,810
24.59
25,971
3.21
7,92,606
3
1999-00
9,05,394
4,26,994
47.16
2,35,198
25.98
2,22,271
24.55
20,931
2.31
8,52,563
4
2000-01
9,11,376
4,61,472
50.63
2,20,131
24.15
2,11,192
23.17
18,724
2.05
8,70,352
23
Maternity Provisions
2
2
4
Infants Birth Wt. LBW Babies less Infant
Recorded
than 2.5 kg
Deaths
Maternal Deaths IFA for Children below 5 years
6,19,227
6,40,520
7,73,961
7,89,954
1,050
1,112
1,180
1,177
62,299
40,890
48,261
43,174
16,163
16,249
16,027
16,340
Below 5 years
Expected
24,07,920
25,62,000
26,95,000
27,27,000
Total
1 1,52,085
9,44,415
11,07,196
13,46,133
%___
47.85
36.86
41.08
49.36
T.T. to PW: Tetanus Toxoid to Pregnant Women.
HAF/LHV: Health Assistant Female/Lady Health Visitor
IFA: Iron and Folic Acid
ANC: Antenatal Care
LBW: Low Birth Weight
24
Mci tern ity Provisions
•
•
•
•
•
•
This table reveals that the antenatal registration ranges from 92 to over 100 per cent.
RCH staff attributed the data exceeding 100 per cent to the fact that sometimes the
targets set for the scheme are based on guesstimates. These guesstimates may be
lower than the actual number of pregnant women. It is not clear whether all the
components of ANC are being provided.
Five to ten per cent deliveries are identified as high risk.
This data shows that almost all women get their tetanus toxoid doses.
In the case of iron and folic acid dispensation a sudden dip is noted in 1998-99,
which the authorities could not explain.
This table reveals that half the babies are delivered in hospitals. The Health
Assistant Female and the Lady Health Visitor attend one-fourth of the deliveries.
One-fourth of the babies are delivered by trained dais and the rest have untrained
dais attending.
The number of low birth babies shows a steady decrease over time from 10 to 5.4
per cent of the babies being born with a birth weight of less than 2.5 kg. The
maternal mortality rate shows an increasing trend from 119/100,000 in 1997-98 to
255/100,000 in 2000-01. This however, is still lower than the figure projected by
UNESCO (450/100,000).
10.3 Issues related to maternal health services
With regard to the facilities created for maternal health care for poor urban and rural
women, both the ICDS and the RCH arc dogged by problems associated with most large
government programmes.
•
•
•
•
•
These schemes do not specifically recognise or cater to work done by women or
their needs or responsibilities as mothers. The timings or location of the centres
are not geared to the convenience of working women of any category, to seasonal
changes in their work schedules, migration patterns or any other work related
factors.
The anganwadi worker expends a lot of energy helping the ANM meet her targets
in the ostensibly target-free RCH programme. This coupled with other
administrative responsibilities leaves her with very little time to implement the
ICDS.
Moreover, culturally the rural population is uncomfortable with handouts. The
women feel that they are being reduced to beggars rather than getting what is their
entitlement because of the manner in which the programmes are implemented.
The anganwadi worker gives little or no advice on breastfeeding. As a result,
breastfeeding is delayed; and poor quality and unhygienic supplementary feeding
begins very early. The end result is that malnutrition starts between one and four
months and peak malnutrition sets in by one to two years.
NGOs (Mahila Samakhya and Belaku Trust) working on maternal and child health
are of the view that this data does not reflect ground realities in terms of access to
maternal health care and outcomes described above.
25
Ma tern ity Pro visions
Sections 6-12 establish that there are a series of issues arising, which pertain both to
inherent problems within the acts and schemes; and there are problems emerging from
the manner in which these provisions are dispensed. Further, most of the data on
implementation cannot be interpreted in real terms, as it does not provide the context for
understanding it. It is against this backdrop, groups working on maternity provisions have
put a series of suggestions forth.
11. Reflections and suggestions
FORCES has been a pioneering network in contributing to thought in this realm.
At a broad and theoretical level, FORCES has made the following suggestions.
1) At the very outset, there is a basic question as to whether maternity and childcare
should be considered a part of labour legislation or should be treated as social
welfare. From the perspective of women’s multiple roles, an integrated approach
would be considered most productive. While the positive features of the laws
acquired after long years of struggle should be preserved, it must be accepted that
present labour legislation needs to be more mother and child friendly. At the same
time, where laws are inadequate either in scope or nature, maternity and childcare
should be considered a national and state responsibility not only left to the
employers, especially as the employer-employee relationship is often not clearly
established in the unorganised sector.
2) Women located within the economically productive economy have to constantly
prove their status to obtain benefits. This indicates the need for law reform at two
levels. One level would require the ideology (i.e., a philosophy of largesse and a
psychology of suspicion) of existing statutory regimes to be examined. The other
would need changes to be introduced in the substantive provisions. The present
statutory suspicion should be replaced with a statutory recognition of the dignity
of claimants. Statutory duties should be placed upon state officials wherein they
seek out claimants and inform them of their entitlements and provide them the
same. Failure to fulfill these duties should invite penalty. The statutes should also
provide that whenever the authorities do not accept a claim they should be obliged
to supply reasons for the same.
3) Majority of the provisions are relevant only to women within the workplace.
Therefore it is important to sensitise people and the government regarding
women’s unpaid work. The government has taken the first step by including the
care economy in the Economic Survey of 2000-2001. Women in the unorganised
sector and women in the care economy need maximum support.
26
A/a ternity Pro visions
In concrete terms, FORCES also submitted a memorandum to the Second Labour
Commission (instituted by the government in 2000). The members suggested that:
a) the GOI should ratify the ILO Maternity Convention 2000.
b) a six-month leave period should be provided to enable exclusive breastfeeding in
view of the WHO recommendation.
c) the concept of maternity entitlement should be enlarged to include childcare and
the two should be given the same status in law and policy. The health and the well
being of the mother and infant require cash support as well as creches and
childcare services on work sites and labour camps.
d) institutions should be set up cover smaller establishments.
e) welfare funds can be an important model for providing social security to workers
in the unorganised sector. Welfare Funds can be set up for each of the major
sectors (agriculture, building and industry, handlooms and power looms, railway
porters, etc.). With regard to the minor sectors, it may not be practical to set up a
Welfare Fund for each. It would be necessary to bring them under an umbrella
type of legislation with a common Welfare Fund.
12. Response of the Second Labour Commission
The Commission has responded to these demands by suggesting two broad approaches through occupation-based welfare boards and through area-based schemes. Both
should be schemes that follow the insurance model, i.e., these should be contributory in
nature and tripartite in structure. Contributions should come from employers; employees;
and supplementary funding should come through tax or cess. It also indicated alternative
ways of identifying beneficiaries and getting workers contributions through identity
cards. For example, in Tamil Nadu and Kerala, the Construction Workers Welfare Board
provides entitlements.
•
•
The government should set up welfare boards at the district and state level.
FORCES has recommended that these Boards have to be welfare boards and
different networks will have to campaign for setting these up where they do not
exist. It is not possible to have a single national policy (Swaminthan, 2002).
The area-based schemes will cover workers who do not fall easily into any of the
occupational categories. Such schemes could also cater to the self-employed,
casual labourers, migrants and those situations where employers are not readily
identifiable. It emphasises that when offering membership to all adult workers in
a given geographical area, regardless of the nature of work, special focus should
be on the inclusion of women as workers and women should not be treated merely
as members of a family unit.
27
Maternity Provisions
In addition, a third level has been identified by the Commission for below poverty line
women who are not in a position to make any contribution for various reasons and for
whom social assistance is to be provided wholly at government expense. This has been
articulated as Social Assistance Scheme, which was proposed first by Mina
Swaminathan. Women should be able to avail of benefits irrespective of whether they can
contribute or not. Cash is the minimum benefit that all women should get. The
responsibility of implementation should lie with the state. This proposed scheme is yet to
be codified.
It should be accessed through multiple channels and agencies like the panchayat office,
post offices, banks, health centres, ICDS centres, government departments and banks.
The sources of funding should be the employees and the government at the central, state,
district (or municipal) and local (ward or panchayat) level. The China and Thailand
module can be followed where the community sponsors one worker for every 100
families to ensure the proper delivery of benefits. The scheme should also provide for the
setting up of a Monitoring and Grievance Committee with representatives from workers,
employers and local authorities.
The desire to devise provisions for women in the unorganised and care sector indicates
that this is a concern area. The details of these provisions are yet to be worked out. At this
stage, it needs to be reiterated that accessing maternity benefits for women in the
organised sector has been problematic. It likely that these problems will be exacerbated
for women outside the organised sector. Further, all the recommendations of the Second
Labour Commission and FORCES prevail at the level of discussions. These
suggestions have not yet been translated into concrete policies or schemes till date.
13. Summary and conclusions
1. This paper establishes that in India, there is no uniform notion or absolute description
of what constitutes maternity provisions. Maternity provisions vary depending upon
where women are located in the socio-economic and occupational ladder. It is ironic
that women in the organised sector who are at the top of the ladder receive the most
protection.
2. Maternity provisions for women in the international context (as recommended by the
ILO) are much more comprehensive than what is prescribed by the Indian
government.
3. The historical overview to this area indicates that considerable thought has been
devoted to this realm. It also reflects that the government has interpreted larger
commitments in narrow terms. Maternity provisions are seen largely in the context of
working women. It becomes evident that there were no provisions for women outside
the organised sector till 1965. Till date, these women receive virtually no protection
during the period of child bearing and rearing in the early years.
4. Despite the critical nature of this issue, the NGO sector has not given it the
importance it merits. Apart from FORCES members, few NGOs are working actively
in this area.
28
Ma tern ity Provisions
5. National and state maternal health statistics indicate that women in Karnataka fare
better than the average Indian woman. Despite this, there is scope for improvement in
Karnataka. It also evident that maternity provisions are not available to some key
groups of women (e.g., underage mothers) in Karnataka.
6. There are multiple issues, which need to be addressed for both the organised and the
unorganised sector. Women are subsisting within a context of discrimination. With
regard to maternity provisions for women within the workplace, in Karnataka only
the organised sector has been acknowledged. For these women, legally the provisions
do constitute entitlements. However, the manner in which these are designed and
implemented; the awareness levels of women; the compulsions guiding women’s
lives; political will (or the lack of it) of dispensing authorities tend to reduce these
entitlements to benefits.
7. Maternity provisions for women outside the workplace are available only to BPL
women in Karnataka indicating a minimal outreach. Thus women in the unorganised
sector and outside the worker category are highly neglected.
8. These two groups receive some redressal through the two schemes (ICDS and RCH),
which extend maternal health care services. The two schemes, which have a limited
mandate, appear to be efficiently implemented but NGOs working in the field
maintained that these do not have the required impact in reality. A juxtaposition of
the RCH data (1997-98) and the NFHS II (1997-98) data reveals some
inconsistencies. The validity of the fonner becomes questionable.
9. This chapter clearly establishes that all data on implementation is collated in a format
that obfuscates reality. Interpretation becomes problematic as it lacks contextual
underpinnings. Therefore, it is not possible to effectively assess the impact of acts and
schemes. Lobbying for change and planning for the future becomes difficult.
10. One of the challenges facing groups working in this area is to collate and compile
contextual information, as this will act as a powerful instrument for advocacy.
11. The FORCES network members have played a crucial role in directing the
government’s attention to lacunae in this area.
12. The Second Labour Commission has responded to the issues raised by FORCES but
the response remains at the discussion level. No changes have been introduced on the
ground.
13. It is evident that unless a multi-pronged approach is brought into play, it is unlikely
that any real change will be effected. The formulation of laws, policies and schemes
addresses only one dimension of the problem. The conversion of maternity benefits
into maternity entitlements will arise only when there is a penalty associated with
non-adherence and when women are sufficiently empowered and aware of their rights
to make these demands.
29
Maternity Provisions
REFERENCES
1. Dhanda, Amita, 2001, Legal Intervention for Maternity and Child Care: Existing
Strategies and Future Directions, New Delhi: FORCES.
2.
FORCES, 2001, Proceedings of a Policy Dialogue on Maternity Entitlements and
Women in the Unorganised Sector: MCC Code: Unpublished Report.
3. Government of Karnataka, 2001, Karnataka. Towards Equity, Quality and
Integrity in Health: Final Report of the Task Force on Health and Family Welfare,
Bangalore:GOK.
4. HDR, 1999, Human Development Report in Karnataka, 1999, GOK: Bangalore.
5. International Institute of Population Sciences and ORC Macro, 2000, National
Family Health Survey II: India (1997-98), Bombay: UPS.
6. International Institute of Population Sciences and ORC Macro, 2000, National
Family Health Survey II: Karnataka (1997-98), Bombay: UPS.
7. Institute for Social and Economic Change, International Institute for Population
Studies, 1995, National Family Health Survey I, 1992-1993, Bangalore, Bombay:
ISEC, UPS.
8. M.S. Swaminathan Research Foundation, 1993, Maternity and Childcare Support
Services: Proceedings of the NGO Consultation at Madras, Proceedings No. 8,
Madras: M. S. Swaminathan Research Foundation.
9. National Institute of Nutrition, 1982, Report of the Year 1982, Hyderabad:
National Nutrition Monitoring Bureau.
10. Shram Shakti, 1988, Report of the National Commission on Self Employed
Women and Women in the Informal Sector, New Delhi: GOI.
11. Shiva, Mira, 2002, Health’ in ‘Children in Globalising India, ed. Enakshi Ganguly
Thukral, New Delhi: HAQ, Centre for Child Rights.
12. Swaminathan, M. 2001,Worker, Mother or Both, FORCES.
13. Swaminathan, Mina, 2002, Policy Issues: A Report of the Eighth Policy
Committee Meeting of the FORCES, Ahmedabad, New Delhi: FORCES.
14. Thukral, E., 2002, Children in Globalising India, New Delhi: HAQ, Centre for
Child Rights.
15. Vir, Sheila, 1995, Iodine Deficiency in India, India Journal of Public Health
39(4): 132-134.
30
Mci ternity Pro visions
ANNEXURE 1: Glossary of legal terms
Statutes: A law always exists in a written form, called a statute or an Act. Individuals
and the government have to comply with these acts.
Rules: Statutes or Acts describe the main components of the law. Detailed aspects like
procedures are written in Rules. The Maternity Benefit Act, applicable to the whole
country, lays down general aspects. Different states make their own Rules. Karnataka’s
rules on maternity benefit are the Maternity Benefit Karnataka Rules.
Orders: Many decisions are taken in the day-to-day functioning of government. The
executive has to make orders for taking these decisions. Orders are generally made from
one official to another, or from an official to a department. Orders must also be in
accordance with the law, in writing. There are different types of orders. Some are made
for the internal working of a department. Some are made for public dealing.
There are administrative orders and judicial orders. Administrative orders are passed by
government officers. Officials can only pass those orders for which they have the power
to do so. Only orders made by the person who has the power by law to pass such an order
is legal, otherwise it has no meaning. Judicial orders are passed by courts.
Circulars: are like orders, made for wider circulation through a printed format.
Notifications: Laws or rules must be notified, i.e, made public officially. Some orders
also need to be notified. This is done by putting them in a document called the “Gazette”.
Policy: Policy is the intention of the government, which becomes effective by issuing an
administrative order. The government can change its policy by amending the prevailing
government order. Only a legislature can amend a statute, which is more difficult to do.
ANNEXURE 2: The Maternity Benefit Act, 1961 (Abridged Version)
1. Object
An Act to regulate the employment of women in certain establishments to provide for
maternity benefit and certain other benefits.
2. Applicability
It extends to the whole of India and applies to:
every factory, mine or plantation and to every establishment wherein persons are
(i)
employed for the exhibition of equestrian, acrobatic and other performances.
(ii)
to every shop or establishment in which ten or more persons are employed or
were employed on any day of the preceding twelve months.
Government of Karnataka extended the applicability of this Act to the following
establishments, vide notification No. SWL 151 LBW 83, dt. 1.8.89.
31
Maternity Provisions
1. Private hospitals nursing homes and dispensaries
2. Private schools and other education institutions
3. Employment of or work by women prohibited during certain periods
six months immediately following her delivery or miscarriage.
i.
11.
in any work, which may interfere with pregnancy or health of the women, one
month immediately, preceding the period of six weeks before the date of her
expected delivery.
in.
Any period during the period of six weeks for which the pregnant women does
not avail of leave of absence. (Section 4)
4. Payment of maternity benefit
Every women shall be entitled, to and her employer shall be liable for the payment of
maternity benefit if the women has actually worked not less than eighty days in the
twelve months immediately preceding the date of her expected delivery.
Maternity benefit shall be paid at the rate of the average daily wage for the period of her
actual absence and maximum period shall be twelve weeks of which not more than six
weeks shall precede the date of her expected delivery (Section 5).
5. Other benefits
(i)
Medical bonus: In addition to maternity benefit every women shall entitle to a
medical bonus of Rs. 250/- if no prenatal confinement and postnatal care is
provided by the employer (Section 8 read with Rule 5).
(ii)
Leave for miscarriage: A women shall on production of a certificate signed by a
registered medical practitioner or medical officer of the Government in Form B as
proof of miscarriage, is entitled to leave with wages at the rate of Maternity
benefit for a period of six weeks immediately following the day of her
miscarriage (Section 9 read with Rule 4)
(iii)
A woman, suffering from illness arising out of pregnancy, delivery, premature
birth of child or miscarriage shall on production of a certificate from a
government, medical officer/registered medical practitioner as proof, be entitled
to leave with wages for a period of one month (Section 10 read with Rule 4).
(iv)
Nursing breaks: In addition to the interval for rest, a woman shall be allowed in
the course of her daily work two nursing breaks of 15 minutes duration for
nursing the child until the child attains the age of fifteen months. A journey time
of 5 to 15 minutes is also provided under the Act (Section 11 read with Rule 6).
32
Ma tern ity Provisions
6. Notice of claim and payment thereof
A women entitled to maternity benefit shall give notice in Form D and employer shall
pay the maternity benefit or any other amount to the women concerned or to her nominee
in case of her death.
7. Appeal
Any person aggrieved on the decision of the Inspector may, within thirty days, appeal to
the authority appointed under Section 17 or section 12 as the case may be. (Section 17)
8. Registers and records to be maintained by the employers.
i.
Maintain a muster Roll in Form A
ii.
Display of the abstract of the Act in Form J
iii.
Submit an annual return on or before 31s' January every year to the competent
authority in Form K, L and M
9. Penalty
Offences under this Act be punishable as follows:
Fails to pay maternity benefit or
(I)
Discharges of dismisses a women
During the period of maternity
(H)
Contravenes the provisions of the Act
or the Rules
(HI)
Obstruction to inspector or fails to
produce the registers or documents, etc.
With imprisonment not less than
3 months but may extend to one year
or with fine not less than Rs. 2000/but may extend to Rs. 5000/With imprisonment which may
extend to one year or with fine which
may extend to Rs. 5000/- or both.
With imprisonment which may
extend to one year or with fine which
may extend to Rs. 5000/- or both.
10. Who can file prosecutions
1. any aggrieved woman
2. an office bearer of a trade union
3. a voluntary organisation registered under the Societies Registration Act, 1860
4. an Inspector
Complaint shall be filed within one year from the date of offence and no court inferior to
that of a Metropolitan or a Magistrate of the First Class shall try an offence under this
Act.
11. Authorities under the Act
1. Inspectors under the Act 1) Labour Commissioner 2) Addl. Labour Commissioner
3) Joint Labour Commissioners 4) Deputy Labour Commissioners 5) Asst. Labour
Commissioners 6) Labour Officers
2. Appellate Authority (under Section 17(3); Assistant Labour Commissioners in
relation to plantations
3. Competent authority (Rule 2(b): Asst. Labour Commissioner in relation to plantation,
Chief Inspector of Factories in relation to other establishments.
33
Maternity Provisions
ANNEXURE 3: Circular to implement national maternity assistance scheme
No: MME:132:MMA:98
Office of the Government of Karnataka
MS Building, Bangalore, dated 7.9.1998
Circular
Sub: Simplified directions to implement National Maternity Assistance Scheme
Eligibility: Pregnant women who are 19 yrs and above, income limit as suggested by
central government, should be members of the family below the poverty line. Such
women should submit a form MB-1 to avail the facilities of this scheme. The annual
income of the family of such women should be as recommended in IRDP, Rs.24,000 in
urban areas and Rs. 11,500 in the rural areas. The women should have lived in the
scheduled district for not less than 3 years from the date of application. This facility is
given for the first two children only.
Sum: The beneficiaries under this scheme will get Rs. 500/- from 1/8/98 onwards.
Procedure: The applicant should register her name in the nearby anganwadi. Within six
months from the date of conception, she should fill up form MB-1 and submit it to the
anganwadi worker. After receiving the form, the anganwadi worker should verify the
income of the applicant’s family, her caste and the number of years of her stay in that
district. Such women should be considered as living below the poverty line if she has
registered her name in the anganwadi centre. If not it could be verified by looking at the
income of her family, ration card and the assets that her family owns. Later the
application should be handed over to the respective ANM within a week’s time. After
receiving the application, the ANM should verify the number of children the women has
given birth to and whether the pregnant woman has undergone the primary health check
ups and then recommend the application to the CDPO within ten days. The CDPO should
record all the applications in MB-2 and should record details of beneficiaries in MB-3.
Sanction and Distribution: CDPO should verify the details provided in the application
as per the guidelines of this scheme and if it is found satisfactory should sanction the
maternity assistance. The copies of the sanction order should be sent to District
Commissioner, Assistant Director- Department of Women and Child Development and
Medical Officers of the Taluk. In case the application is rejected, the scheduled
application should be returned to the ANM with the reasons for rejection on it.
District Commissioner should send the sanctioned amount by cheque through the
CDPO’s office. The CDPO’s office should disburse the sanctioned amount to the
beneficiary through money order, cash, bank account or savings account in the post
office. If the money is disbursed as cash, it should be done in public meetings primarily
during gram sabhas in rural areas and in mohalla committee meetings in the urban areas.
(Gectha Ramesh),
Assistant Secretary to the government (Pr)
Department of Women and Child Development
Bangalore
34
Maternity Provisions
ANNEXURE 4 A: Circular regarding supplementary nutrition under ICDS
Government of Karnataka
No: DWC:ICD:PRC:3:03-04:
Office of the Director
Department of Women and Child Development
MS Building, Bangalore-1 Date: 21.5.2003
Circular
Sub: To initiate supplementary nutrition programme under Integrated Child Development
Scheme.
Note: 1. Government order no: MME 208 ICD 2001
Bangalore, dated 17-10-01 and amendment dated
30-11-2001
2. Official circular no: MMI:ICD:PRC:34:01-02: dated
10-12-01
3. Office letter no: DWC:ICD:PRC:4:2000-01 dated 13-22001 and 3-3-2001
4. Official circular no:DWC:ICD:PRC:34:1999-2000 dated
27-4-2001
Note 2, 3, 4 in the circular sent from this office regarding distribution of supplementary
nutrition to all the beneficiaries under Integrated Child Development Scheme in the
whole state. The following instructions have been incorporated by changing the previous
instruction to be implemented in all the anganwadis in the state regarding the
supplementary nutrition programme.
1. Six months to 3 year old children:
Six months to 3 year old children be given A.R.E.F six days in a week. 2 to 3 year old
children present in the anganwadi to be given food prepared at the centre. (The incidental
expense Rs. 1.50)
2. For 3 to 6 year old children:
2 days in a week A.R.E.F
1 day egg / food made of rice
3 days food made of rice
3. Pregnant and lactating mothers:
A.R.E.F 2 days in a week, 4 days rice with green gram, which can be taken home.
35
Maternity Pro visions
4. Anganwadi worker and Anganwadi helper:Food prepared in anganwadi centre i.e., A.R.E.F 2 days.
Iday boiled egg / food made of rice.
3 days food made of rice.
The food items should not be taken home.
5. 3rd to 4'11 grade children: 3 to 6 year old children
1. One portion of the food prepared in the anganwadi for all the children
2. One portion of A.R.E.F.
6 months to 3-year-old children:
One portion of A.R.E.F /one egg every day, if there is no egg then another portion of
A.R.E.F.
To distribute 50% of A.R.E.F and 50% of green gram if the ration rice is not available
(0.75 Raise A.R.E.F and 0.75 paise green gram). Green gram should not be purchased in
larger quantity for any reason.
Centres where egg is not available, food made of rice should be given 4 days in a week.
The incidental expense of the food is Rs. 1.50. Upto Rs. 3/- for double food: can be
spent.
If the incidental expenses are Rs. 2/- for children between 6 months to 3 years, Rs. 1.50
should be spent from the state budget and 0.50 paise from P.M.G.Y. Expenses towards
transport and fuel should be spent under contingency. It’s been informed not to exceed
incidental expenses for any reason.
Approved by Director
for the Director
Department of Women and Child Devpt
Copy of this has been sent to the following for their information and implementation:
1. To the Sub-Assistant Directors, Dept of Women and Child Development of all the
2.
3.
4.
5.
districts
To all the Program Officers, ICDS program
To all the CDPOs
The Principal Secretary of all the Zilla Panchayats
To all the Nodal Officers, Central Office, Bangalore
36
Ma tern ity Pro visions
ANNEXURE 4 B: Physical target for supplementary nutrition for pregnant women and mothers, ICDS
March 2002
PW
District
PW
(Achieve %
(Target)
ment)
Bagalkot
________
1_
7458
6979
93.57
2_ Bangalore (R)
8189
7681
93.79
3 Bangalore (U)
5368
5274
98.24
4 Belgaum_______ 19129
16897
88.33
5_ Bellary_________ 6802
6710
98.64
6_ Bidar__________ 8705
6981
80.19
7_ Bijapur_________ 6476
5930
91.56
x ~ Chamrajnagar
6605
6419
97.18
9_ Chickmagalur
4589
4630
100.8
10 Chitradurga_____ 8265
8106
98.07
H_ Dakshina Kannada 6806
7878
115.7
Davanagere
_____
6647
6161
92.68
11
Dharwad_______ 5606
5177
92.34
14 Gadag__________ 6600
5694
86.27
15_ Gulbarga_______ 14386
12666
88.04
16 Hassan_________ 8219
7829
95.25
Haveri
__________
6913
6426
92.95
12
3089
91.58
12 Kodagu_________ 3373
Kolar
__________
13762
12849
93.36
12
20 Koppal_________ 4651
4304
92.53
8819
91.43
IL Mandya________ 9645
22 Mysore_________ 10833
9683
89.38
Raichur
________
91.72
6535
5994
12
24 Shimoga________ 5887
5083
86.34
12 Tumkur________ 11881 11299 95.10
26 Udupi__________ 3860
4686
121.4
27 Uttar Kannada
5270
4928
93.51
28 Total___________ 212460 198172 93.27
SI
No
March 2003
NM
NM
(Achieve
(Target)
PW
%
PW
(Achieve
(Target)
NM
%
NM
(Achieve
(Target)
%
ment)
ment)
ment)
'7368
7496
98.29 10339
8991
86.92 11568
9782
84.56
'8918
'93.74 8428
9513
9455
112.2 9539
10722 '112.40
'5785
'97.32 6026
5944
6010
99.73 6317
6424
101.69
'16677
'87.64
19028
21322
91.74 21659
19561
19483
89.95
'6666
'99.31 9374
6712
9765
104.2 9139
9330
102.08
'7311
'83.72 11757
8732
9080
77.23 11585
9215
79.54
'93.28 6797
'6178
6623
6579
96.79 6895
6664
96.64
'6526
93.79 6458
6958
6354
98.38 6935
6178
89.08
'4805
4760
100.94 5159
5085
5370
98.56 4949
108.50
'8607
'94.03 9416
9153
8588
91.20 10239
9040
88.28
'8799
8301
105.99 8634
8803
101.9 9544
9108
95.43
'6324
'94.37 7240
6701
6496
89.72 7009
6341
90.46
'5148
5454
94.38 7159
6740
94.14 7188
6429
89.44
6668
5827
87.38 6727
6514
96.83 6792
95.67
6498
14282
12865
90.07 18431
15170
82.30 18484
15372
83.16
8365
7829
93.59 8223
8039
97.76 8020
7794
97.18
'6264
6552
95.60 9685
8861
91.49 9744
8254
84.47
'3409
3587
95.03 3533
3104
87.85 3477
3167
91.08
14792
13608
91.99 13499
13872
102.9 14522
14733
101.45
4676
4368
93.41 5966
5458
91.48 6138
5535
90.17
'8484
9235
91.86 9594
9154
95.41 9259
8935
96.50
'87.77 11058
10631
9331
9680
87.53 10762
9466
87.95
6750
6016
89.12 7151
95.87
6856
7165
6987
<97.51
'81.60 7917
5360
4374
6804
85.94 6908
5513
:79.80
13678
12873
94.11 11944
12697
106.3 13719
13298
<96.93
'5743
4710
121.93 5144
5115
99.43 5836
5798
j99.43
5288
4914
92.92 5663
4670
i81.88
4980
87.93 5703
219949 205017 93.21 242644 227811 93.88 249095 230106 <92.37
Source: Dept, of Women and Child Development
PW: Pregnant Women NM: Nursing Mothers
37
Creches and day care centres
A rch an a Meh en dale
Creches
CONTENTS
Page
1. Introduction
4
2. The importance of creches
5
3. Important policy declarations related to creches
7
3.1. Article 45, Directive Principles of State Policy, Constitution of India
3.2. The United Nations Convention on the Rights of the Child, 1989
3.3. The National Policy for Children, 1974
3.4. The National Policy on Education, 1986
7
8
8
9
4. Creches in India
9
5. Creches in Karnataka
10
5.1. Grant-in-aid creches
5.1.1. Central scheme for assistance for working and ailing mothers
5.1.1.1. Description of the scheme
5.1.1.2. Implementation of the scheme at the national level
5.1.1.3. Implementation of the scheme in Karnataka
5.1.1.3.1. Karnataka State Social Welfare Advisory Board (KSSWAB)
5.1.1.3.2. Karnataka State Council for Child Welfare (KSSCW)
5.1.1.4. Critique of the scheme
5.1.2. National Creche Fund
5.1.3. Karnataka government scheme of assistance
to voluntary organisations for creches for working women’s children
11
11
11
12
12
12
15
16
16
19
5.2. Statutory creches
5.3. Voluntary creches
5.4. Commercially run creches
25
29
30
6. Key problems and issues
31
7. Conclusion
34
References
35
Annexure: Legislation related to creches
37
2
Creches
BOXES
Page
Box 1: Creches in India: a timeline of progress
7
Box 2: Incentives for creches
8
Box 3: Some recent legal amendments in Karnataka
27
TABLES
Table 1: Status of child care facilities in India in 1996-97
10
Table 2: Budgetary break-up of central scheme
12
Table 3: Number of creches receiving aid from the board, 2002-3
13
Table 4: Creches run by KSCCW in Karnataka
15
Table 5: Number of creches under the state scheme for
assistance to working and ailing mothers in Karnataka
22
Table 6: State scheme on creches (2002-03)
23
Table 7: State scheme for creches: expenditure in 2002-03
24
Table 8: Number of workers in Karnataka
27
Table 9: Status of creches in factories, 2001
28
3
Creches
1. Introduction
Traditionally, child bearing and child rearing have been considered to be primary
responsibilities of the woman. In most patriarchal societies, there is a strong gender
demarcation in roles performed and work assigned within the household. In the event that
the mother is unable to look after her children, the responsibility is taken up by female
members of the immediate family.
Women, all over the world, perform multiple roles in addition to their roles as mothers.
With an increasing number of women seeking paid employment and leaving their homes
for most part of the day, there is a growing need for child care services. In most Indian
families, women struggle to balance their work and child care roles. This applies to
women from all socio-economic strata, and barring a few who can hire personal child
care services, most women have to face the nagging question of substitute child care
while they are away at work.
As some research points out, exclusive maternal care became an option for a small
privileged segment of society; but it gradually came to be labelled as a traditional and
natural form of human child care, and all deviations from this were portrayed as
unnatural and potentially dangerous (Lamb and Sternberg, 1992). In the Indian context
too, the general reaction towards women who seek substitute child care is that of
prejudice, leaving a sense of guilt amongst most working women who leave their children
under someone else’s care. Many a times, there is a tendency to romanticise the joint
family system and view extra-domestic child care services as a western concept. This
clearly shows a strong class bias and a lack of understanding of how poor families in
rural and urban areas handle these issues (Swaminathan, 1998:27).
In India, the issue of providing universal child care services has not been addressed
comprehensively. Questions about whose responsibility it is to care for the young child,
what is the responsibility of society and what is the responsibility of the State are left
unanswered. At present, women’s needs in relation to child care are hardly attended to,
except by the creche programmes and the Integrated Child Development Scheme which
between them cover an estimated 14% (Muralidharan and Kaul, 1993) to 19% (Kaul,
2002) of the pre-school child population in the country. This dismal coverage reflects that
child care services have not received the attention from policy makers that they deserve.
Groups like FORCES, which is a network for creches and child care services, have been
advocating and lobbying for enhanced child care services at the national level. FORCES
believes that a child deprived of critical inputs in the first few years of life weakens the
foundation for the child’s future growth and development. It also adversely affects the
family and the community in the long run. Malnutrition that sets in between the ages of
six months to two and a half years is most often caused not by lack of calorics but by the
lack of a caregiver with time to feed the child appropriately.
4
Creches
The chances of child survival increase with child care support services, and there is
evidence that higher child survival leads to a lowered birth rate, increased productivity of
women, improvement in economic status, better educational access and school
achievement for girls. The network points out that children below three years of age
are relatively neglected in the early childhood programmes of the State. Good child
care is also endangered where families are stressed by work and economic pressures. It is
therefore important to lobby for improved child care services for children in the country.
This thematic study looks at the provision of creches and day care centres in Karnataka. It
attempts to document the status of child care services in the state and is expected to serve
as a reference tool for those interested in advocating and lobbying in this area. The first
section highlights the importance of child care facilities such as creches. The national and
international policy proclamations related to creches are presented in the second section.
The third section elaborates on the different types of creches, namely:
1. creches set up using the grants-in-aid schemes of the central and state government
2. statutory creches
3. creches set up by voluntary organisations
4. creches run on a commercial basis
The key issues and problems related to child care in general and the provisions of creches
in particular are discussed in the next section. The last section offers concluding remarks
that could stimulate further research and action in this area.
2. The importance of creches
Industrialisation accompanied by migration and urbanisation, has significantly changed
the family structure and composition of Indian society. Extended families are on the
decline. Nuclear and single parent families are becoming more and more common. While
child care was not always a pressing issue in traditional joint families, it has always been
an issue for most working couples from lower socio-economic strata of society.
To some extent, child care was a concurrent task with all the other daily chores related to
home (Sriram, 1998). But with an increasing participation of women in the paid labour
force, new demands for programmes of early childhood care have been created within all
sections of Indian society. Changes in the nature of women’s employment have had
certain implications on child care as well. It is seen that industrial employment makes it
more difficult to combine work and parenting roles than agrarian work. Even in the
agricultural sector, with an increasing number of women working as wage labourers,
carrying along young children to work is becoming more and more difficult. The overall
separation of work and home has adversely impacted child care within the
household.
For many women, giving up work in order to look after children is not an option and
children have to be left behind, irrespective of the availability of child care services.
Working is the only way to ensure the survival of the family.
5
Creches
Studies on poor rural women show that only a small percentage of women do not take up
work due to conflict between economic activities and child care. Data shows that the
number of women in the unorganised sector is increasing, and one-third of all
households in the country are headed by women. For these women, child care
services are not easily available or often unaffordable. The responsibility of child care
then falls on the shoulders of the elder sibling, very often the older girl child. Research
shows that children in the age group of 6-14 years, especially girls, are deprived of
schooling because of caring for younger children (Arulraj and Samuel, 1995).
Creches and childcare services are thus an essential facility for the children of working
mothers, both as a support service for working women and as a strategy for the
protection, care, and healthy, all-round development of young children. With the human
rights discourse gaining ground, child care services are viewed as an intersection of
women’s rights and children’s rights. Creches and day care centres are seen as
strategies which will ensure the right of the woman to work and the right to
survival, growth and development of the child. The care of the young child is no
longer a private, family matter of adjustments but a crucial social need.
With the onset of globalisation and the State withdrawing itself from performing its basic
welfare functions, the magnitude of the need has not fully registered. Moreover, since it
challenges the conventional norms about child care and the role of the woman, the need
for child care services is met with apathy or indifference.
Providing substitute care of children is intrinsically linked to women’s development and
empowerment processes. Yet available data shows that no institutional care exists for
nearly 235 lakh pre-school children of working mothers (NIPCCD, 1978). Between
1996-97, there were only 14,313 centres in India providing creche and day care services
for children below five years. Earlier studies have shown that in the absence of child care
support, children are left to look after themselves. About 42.4% of families leave their
children unattended and around 28.8% carry them to work (NIPCCD, 1978). Among
migrant women in Delhi, it was reported that as many as 78% had no other help for their
children and 40% had to leave their child unattended (D’Souza, 1979). However, the
government estimates on the number of children left unattended are much lower. Official
data collected from lower class working women indicates that while the major caretakers
are mostly mothers, their grandparents, and other relatives; the incidence of children left
unattended in urban areas varies from 1.9% male and 2.16% females under one year to
11.4% males and 11.5% females at six years, with a similar trend in rural areas
(Government of India, 1985). This data must be read with caution since it departs
significantly from the trends observed in other studies. Forty percent of women stated
that lack of child care was a constraint to employment (Sriram, 1994).
Child care outside the home, by people other than parents, has proliferated because of the
need to release parents for economic roles. Support for child care is a must in helping
women forward their own interests as well as that of their children; and allowing them to
be released from the vicious cycle of poverty. The following sections present the
government policies with respect to child care services in India.
6
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V< z
Creches
Box 1: Creches in India: A timeline of progress
Period 1965-75
♦ Schemes launched for the provision of day care centres and statutory obligation to
provide creches extended to women in the unorganised sector. The difficulties
faced by working women in the absence of day care centres was first noted.
♦ Beedi and Cigar Workers Act, 1966, Contract Labour Act 1970, Hostels for
Working Women with Day Care centres in 1973. Central Social Welfare Board’s
scheme for creches in 1974-75
Period 1975-84
♦ Setting up of child care centres as a part of the Minimum Needs Programme was
recommended. Planning Commission Report of Working Group on Employment
of Women.
♦ The Committee for the Status of Women in India (1974) recognised that day care
services as a pre-requisite for women’s development was inadequately perceived.
Period 1985-1994
♦ The National Creche Fund to support the voluntary sector was started in 1994
even though a Working Group of the Planning Commission had already provided
guidelines for creche operations as far back as 1972.
Source: Swaminathan, M. (1998)
3. Important policy declarations related to Creches
Policy directives on the provision of child care services present a mixed picture. The lines
between early childhood care and pre-school education are blurred. Early Childhood Care
and Early Childhood Education are sometimes viewed synonymously, and at other times,
complementary to one another. The two are rarely viewed by themselves. However, the
importance of child care and the role of the State in providing child care support and
services has been recognised in several legal documents.
3.1. Article 45, directive principles of state policy, constitution of India
The Constitution of India, subsequent to the 86th amendment, does not recognise the
fundamental right to education as applicable to children below six years of age. However,
Article 45 says that the State shall endeavour to provide early childhood care and
education to all children until they complete the age of six years. This provision which
appears in the Directive Principles of State Policy is expected to guide the formulation of
policies and programmes. There is a significant departure here from the pre-amendment
provision. Prior to the amendment, early childhood care was not recognised within
Article 45 and the reference was merely made to education of children below six years.
While re-wording the provision for the amendment, the idea of the State endeavouring to
provide early childhood care (along with early childhood education) has secured a place
in the Constitution.
7
Creches
3.2. The United Nations Convention on the Rights of the Child, 1989
The United Nations Convention on the Rights of the Child, which is an international law
ratified by India, also emphasises the role of the State in supporting child care functions
of the family. Article 18 recognises the principle that both parents have a common
responsibility for the upbringing and development of the child. Furthermore, ensuring the
best interests of the child should be their basic concern. For the purposes of guaranteeing
and promoting child rights and interests, the Article states that ‘States Parties shall render
appropriate assistance to parents and legal guardians in the performing of their child
rearing responsibilities and shall ensure the development of institutions, facilities and
services for the care of the children’. It continues by referring to the State’s obligations
towards children of working parents; .‘States Parties shall take all appropriate measures to
ensure that children of working parents have the right to benefit from child care services
and facilities for which they are eligible’. It is important to note that firstly, this
entitlement is broadly worded with phrases such as ‘appropriate assistance’ and ‘child
rearing responsibilities’. Secondly, it refers to the State’s obligation towards the working
parents and not working mothers. This gender neutral criteria is not reflected in the case
of Indian statutes (see section on statutory creches in this paper). Thirdly, it leaves the
clause of eligibility loose-ended and does not restrict the right to parents belonging to a
particular socio-economic stratum.
Box 2: Incentives for creches
3.3. The National Policy for Children,
1974
As a fiscal incentive for women and child
welfare, full deduction from income tax has
been granted by the central government on
payments to projects engaged in establishing
and running educational institutions and
hospitals in rural areas for women and
children, and for creches and schools for
children of workers employed in factories or
at project sites.
The first official reference to creche and
day care facilities was made in the
National Policy for Children in 1974
where it resolved that ‘it shall be the
policy of the State to provide adequate
services to children both before and after
birth and through the period of growth to
ensure their full physical, mental and
social development. Although the
Source:
specific policy measures did not mention
http://www. bharatguru. co./Newbuzz/watch/achiev
provision of child care services, the
ements.htm accessed on 12 Feb 2004.
‘priorities in programme formulation’
pronounced within the policy stated that
while formulating programmes in
different sectors, priority shall be given to programmes related to creches and other
facilities for the care of children of working or ailing mothers. As a direct
consequence, grant-in-aid schemes for creches and day care were launched by the central
government (discussed in the following section on Creches under Grants-in-Aid).
8
Creches
3.4. The National Policy on Education, 1986
The linkages between early childhood care and early childhood education were first
recognised in the National Policy on Education in 1986 and reiterated in the Plan of
Action, 1992. It stated, ‘day care will be provided as a support service for the
universalisation of primary education to enable girls engaged in taking care of siblings to
attend school and as a support service to working women belonging to poorer sections.
Full integration of child care and pre-primary education will be brought about, both as a
feeder and a strengthening factor for primary education and for human resource
development in general’. This reference continues to be the only one which so cogently
emphasises the importance of child care facilities from the perspective of early childhood
development, girls’ education as well as a support for working women.
These linkages between the components of care and education have got reinforced even
subsequently under various international commitments. The Framework of Action
adopted in the Dakar Conference of the World Education Forum, 2000, to which India
was a party, identifies six goals, one of them being ‘expanding and improving
comprehensive early childhood care and education, especially for the most vulnerable
and disadvantaged children’. Subsequently, India charted out national goals
corresponding to the six Dakar goals. The universalisation of the Integrated Child
Development Scheme (ICDS) with an early childhood care and education component is
one of the goals adopted. Even the Ninth Five Year Plan had stated that there is an urgent
need for creches and day care services as a support to women and young children.
Like most welfare goals, there is a wide gap between intent and actual operationalisation
of the intent. While the goals and commitments towards early childhood care appear to be
in place, they have not been supported with adequate programmes in terms of both the
quality and quantity of schemes for providing child care facilities. Although the
Convention on the Rights of the Child purports a ‘first call to children’ while allocating
resources, the ground realities show that children in general and child care in particular is
hardly a priority. This gap at the level of programme definition and resource allocation is
further broadened at the level of programme implementation. The following section
presents the available range of child care services and brings out the inadequacies in their
design and coverage.
4. Creches in India
Pre-school centres and balwadis are also referred to as creches in government parlance.
This distorts estimates on the number of creches that serve as child care support to
children below six years of age. According to Government of India (Programme of
Action, National Policy on Education, 1992, the Ministry of Human Resources
Development) there were 12,470 creches in 1991-92 serving about 3 lakh children in
India.
9
Creches
These figures, which include both statutory and voluntary creches, neither specify the
number of children in each group nor do they give the number of working mothers who
have benefited from them. Another national estimate (Swaminathan, 1991) indicates that
about 2.5 lakh children are found in 10,000 creches in the voluntary sector and only about
50,000 children are in creches in the statutory sector. The table below shows that the
actual coverage of these schemes is very little.
Table 1: Status of child care facilities in India in 1996-97
Provision
Number of centres
Creches and day care centres
(0-5 years)________________
Statutory creches (0-6 years)
Source: Kaul, 1998
14,313
Number of beneficiaries
(in millions)___________
0.342
5000 (approx.)
0.050 (approx.)
Although these figures may not be highly accurate due to reasons such as poor record
keeping, and ambiguity in defining creches as distinct from pre-schools, they indicate that
efforts to provide child care services are far short of the existing need.
Another important aspect to be noted is that day care was not originally a component of
the Integrated Child Development Scheme. The National Policy on Education and the
Plan of Action stated that a fixed number of Anganwadis (25%) would be turned into
Anganwadi-cum- creches by year 2000. Till the end of 1996, only 659 Anganwadi-cumcreches had been approved for the entire country, although 25% would imply 100,000
centres.
5. Creches in Karnataka
There are several types of creches in Karnataka: those set up by organisations with grants
received from the central and state government; creches set up under various labour
legislation for the benefit of women employees; there are some set up by voluntary
organisations with funding received from private donor agencies; and there are creches
set up on commercial lines. These categories may appear broad and reaching out to a
large segment of the deserving population. This section discusses in detail the following
types of creches.
1) Grant-in-aid creches: This category covers creches set up under:
• Central Scheme for Assistance for Working and Ailing Mothers: implemented by
two agencies in Karnataka, the Karnataka State Social Welfare Advisory Board and
the Karnataka State Council for Child Welfare (407 and 50 creches respectively)
• National Creche Fund: a central government scheme implemented by various
voluntary organisations in Karnataka (93 creches are run under this category).
• Karnataka Government Scheme of Assistance to voluntary organisations for
creches for working women’s children (193 creches are run under this scheme).
10
Creches
2) Statutory Creches set up under various labour legislations eg. plantations, mines,
Victories (550 creches have been set up in factories)
Creches
run by voluntary organisations
3)
4) Commercially run creches
The section looks at the coverage, allocations and implementation of these services.
5.1. Grant-in-aid creches
Grant-in-aid creches are those set up by organisations with grants from the central and
state government. As noted above, the national coverage is much lower than the need and
there are only 13,700 creches (12,500 under the Scheme for Assistance to working and
ailing mothers and 1200 under the National Creche Fund) catering to about 3,50,000
children throughout the country. In Karnataka there are approximately 742 grant-in-aid
creches reaching out to 18,550 children below six years of age. Let us look at the
provisions of these schemes and their implementation in Karnataka.
5.1.1. Central Scheme for Assistance for Working and Ailing Mothers
The Scheme for Assistance for Working and Ailing Mothers is a central government
scheme formulated in 1975 after creches got identified as a priority area of action under
the National Policy for Children, 1974. It is also referred to as the Scheme of running
Creches/Day Care Centres.
5.1.1.1. Description of the scheme
The scheme aims to provide day care services for the children (0-5 years) of mainly
casual, migrant, agricultural and construction labourers. The children of those women
who are sick or incapacitated due to sickness or suffering from communicable diseases
are also covered under the scheme. One creche centre is expected to run for 25 children
of working and ailing mothers. Most creches operate from 9 a.m. to about 4.30 p.m. The
scheme lays down that the creche must function for at least five hours. The children take
rest, and are provided basic recreational and educational material. Cradles and mats are
provided for the care of young infants.
Allocations
A small amount of Rs. 1.05 per child per day is provided under this scheme. Each centre
is given Rs. 18,480 per year as a recurring expenditure for providing sleeping facilities,
health care, supplementary nutrition and immunisation. An amount of Rs. 4000 is
provided for non-recurring expenses. After every five years, Rs. 2000 is given as a
replenishment grant for each creche. The budgetary break-up is as follows:
11
Creches
Procedures followed by KSSWAB
Any organisation which has a minimum work experience of three years in child welfare
can apply for grants with its annual reports and an audited statement of accounts. The
District member/representative of the Board forwards the proposal. The field officers of
the Board make a visit and file an appraisal report which is then taken up for discussion
at the State Board meeting. If the proposal is approved by the State Board, it is then sent
to the Central Social Welfare Advisory Board for its final acceptance. For the last ten
years, no additional creches have been sanctioned.
The amount is disbursed to the organisations in three instalments. The first instalment is
given after the proposal is sanctioned by the Board, the second instalment is given after
the field officer files his appraisal report, and the third instalment is extended after the
organisation sends its audited statement of accounts. One organisation may apply for
running more than two creches. In such cases, the proposal has to be presented to and
sanctioned by the Central Social Welfare Board.
Monitoring by KSSWAB
The implementation of this scheme is monitored by field officers of the Board. There are
eight field officers who are responsible for 4-5 districts each. They are expected to make
at least one annual visit to the creches covered in their respective districts and file a report
with the Board. Inspections carried out give the following details: location of the creche,
number of children enrolled according to sex and social group, number of children
present on the day of the visit and on an average during the last three months, age of the
children, staff employed, their qualifications, training, honorarium paid, presence of
creche workers, working hours of the centre, whether supplementary nutrition is
provided, accommodation, equipment for kitchen, sleeping, recreation, education, grants
received, health check ups by the Primary Health Centre doctor, medical register, records
maintained, opinion about the performance of the creche by the local panchayat, school
head master or community leader. General remarks, suggestions. Copies of these reports
are sent to the CSWB and the State Social Welfare Advisory Board.
Problems and complaints
According to one of the field officers, the most common complaints relate to the poor
quality and inadequacy of food since the budget provides a very small amount of
funds. Sometimes, there is a considerable gap between children registered with the
creche and those who actually attend the creche. This may happen because the scheme
does not allow the centres to function for less than 25 children. Thus, there is a tendency
to over-register in order to ensure that the creche survives.
The creche workers are also expected to be given training once in two years by the
Board. These training programmes have not been conducted for several years due to lack
of funds. The budget provides Rs. 1000 per trainee for a training of forty days. This
includes the training costs as well as their lodging, boarding and other incidental
expenses. While this amount is not sufficient for organising a 40 day training programme,
the Board has not even attempted to organise training for a shorter duration.
14
Creches
5.1.1.3.2. Implementation by the Karnataka State Council for Child Welfare
(KSSCW)
Since the last 22 years, the Karnataka State Council for Child Welfare has been running
creches throughout the state. Each creche caters to 25 to 30 children between two and a
half and five years. Each creche has a teacher and an assistant to run the pre-school
education programme and to provide mid-day meals. Parents’ meetings and health check
ups are conducted regularly. The creche teachers are also given in-service training. The
creches are open between 9-9.30 a.m. to 4-4.30 p.m. so that they coincide with the
working hours of the mothers.
Coverage of the scheme
At present, the KSSCW runs 50 creches in Karnataka with the grants-in-aid routed
through the Indian Council for Child Welfare. The geographical spread of these creches
is as follows.
Table 4: Creches run by KSCCW in Karnataka
District
Bangalore
Dharwad
Chikmagalur
Davangere
Bagalkot
Tumkur
Kolar______
Kudligi
Total
Number of centres
21______________
10______________
2 _______________
5 _______________
3 ______________
6 ______________
2______________
_1_______________
50
As the table above indicates, more than half of the total creches are located in Bangalore
and Dharwad districts of the state.
Problems and complaints
The main problem faced by the Council is lack of funds for buying toys and other
equipment. Teachers are unwilling to work for low salaries and often join NGOs where
they receive higher salaries. The salaries paid to the teachers and assistants are very low.
As per the programme, the teacher is to be paid Rs. 500 per month and the assistant is to
be paid Rs. 300 per month. The Council has raised additional resources on its own to
enhance the honorarium given to the staff. The scheme does not provide funds for travel,
rent or other programmes. In rural areas, the creches are mostly run in community owned
spaces; but in urban areas, it becomes difficult to find space and pay a high rent for
miming the creches.
15
Creches
5.1.1.4. Critique of the scheme
This central scheme was the first direct step undertaken by the Government after
adopting the National Policy for Children that identified creches as one of the strong
needs. But since its inception, nothing has changed in the overall framework of the
scheme as well as its implementation.
The Parliamentary Committee on Human Resources Development, 2001, had noted that
during 1999-2000, the budgetary provision of Rs. 20.50 crore was reduced to Rs.
17.00 crore at the revised estimates stage keeping in view the unspent balances
available with the implementing agencies as on 1.4.99 out of the earlier releases.
Expenditure incurred up to 31.1.2000 by the agencies was only Rs. 5.58 crore. The
Committee also stated, ‘the very fact that unspent balances are lying with the
implementing agencies indicates that this scheme is not being implemented properly... the
maximum number of creches are being run by the two national level voluntary
organisations and maximum grants are also being released to them. Both these voluntary
organisations are Delhi based. The Committee fails to understand the inability of the
Department to prevail upon these two voluntary organisations and other smaller ones too
to utilise the funds allocated to them within the prescribed time limit and thus
successfully implement the scheme. What is more worrying is that there has been no
increase in the number of creches, i.e. 12,470 continues since the 8lh Plan. The
Committee, therefore, is of the strong view that there is need for review and revamping of
this scheme. The Department should initiate corrective measures, without any delay’.
The issue of under-utilisation of allocated funds is a complex matter and the reasons for
this need to be studied. The amount sanctioned by the scheme is extremely meagre for
running creches of a decent quality. Voluntary organisations are required to meet the
additional expenses, which the scheme lays down to be 10 per cent. The question one
needs to ask is whether voluntary organisations can run creches with such a meagre grant.
It is very likely that organisations who are not able to raise the remaining amount (which
in practice is more than 10%) do not avail of these grants. The funds lying under-utilised
are officially seen to reflect either a lack of need for creches or a lack of capacity among
organisations to utilise the grants. This results in a lowered budgetary allocation such as
that recommended by the Parliamentary Committee, and pushes the allocations for such
services on a downward spiral.
5.1.2. National Creche Fund
In the early ‘90s, FORCES and some other social groups lobbied at the national level and
got the government to form a separate fund to support the creche programmes throughout
the country. The National Creche Fund (NCF) was thus set up in 1994 with a grant of Rs.
19.9 crore given to the NCF corpus. The scheme for administration of the National
Creche Fund is called the National Creche Funds Scheme, 1994.
16
Creches
Objectives of the scheme
The Fund was set up under section 4 and 5 of the Charitable Endowments Act, 1890, for
achieving the following objectives:
1. to administer grant-in-aid programmes for voluntary organisations, mahila mandals
and State Governments to implement the creche programmes especially in rural areas
and slums for the welfare and development of children below the age of five years
whose parents’ income does not exceed Rs. 1800 per month; children of agricultural
labourers, Scheduled Castes and Scheduled Tribes, and of women employed in
employment generating schemes, and persons who were victims of communal
violence
2. to convert some of the Anganwadis into Anganwadi-cum-creches
3. to organise programmes for training/refresher courses for creche workers through
specialised training institutions
4. to take up activities which promote the above objectives
Eligibility
Voluntary organisations and mahila mandals registered as a society or trust for at least
two years and with a known record of child welfare services are eligible for applying.
Programmes that are eligible for assistance under various labour laws cannot qualify for
financial assistance under the National Creche Fund scheme.
Allocations
Grants are given to two types of creches - the general creches and anganwadi-cumcreche centres. Financial assistance of Rs. 18,480 per creche per annum for voluntary
organisations and mahila mandals for general creche centre; and Rs. 8,100 per centre per
annum for an anganwadi-cum-creche is provided. The initial cost of establishing a creche
is provided as a one time non-recurring grant of Rs. 4000.
For the General Category Creches, the recurring grant includes the following:
Honorarium for two creche workers is Rs. 800 per month, provided entirely through
grants. The ceiling for supplementary nutrition is Rs. 687 per month; of which 90% i.e.
Rs. 615 is given as grants. This is Rs. 1.05 per child for 25 children for 26 days.
The ceiling of expenditure for contingencies and emergency medicines is Rs. 139 per
month of which 90% i.e. Rs. 125 is given as grants.
The government assistance for creches opened under the general category is limited to
90% of the schematic pattern (except honorarium of creche worker) or the actual
expenditure, whichever is less, and the remaining expenditure has to be borne by the
organisation/mahila mandal concerned. A non-recurring grant of Rs. 4,000 is given to
meet the initial cost of establishing the creche. Creches opened under the general
category are required to provide day care facilities, nutrition, pre-school education,
entertainment and medical facilities, and they are expected to work for eight hours per
day.
17
Creches
The anganwadi-cum-creche is managed by agencies that operate the ICDS, i.e. the
Department of Women and Child Development. Assistance for an anganwadi-cum-creche
includes an honorarium of Rs. 600 per creche for one creche worker. An amount of Rs.
75 per month is allocated for contingencies and emergency medicines. An initial cost of
establishing the creche is to be met with Rs. 4000 which is given as a non-recurring grant.
In the case of the anganwadi-cum-creche centre, 100% financial assistance is provided to
the concerned agency. The existing anganwadi-cum-creche centres presently working for
four hours are expected to work for eight hours. Additional workers are expected to be
provided for running the anganwadi centre for the remaining four hours. In Karnataka, no
anganvvadi has been converted into a creche even when the State Scheme provides
grants for the same. It may be noted that anganwadis in Tamil Nadu and Kerala
function for six to eight hours, thus providing child care services to the immediate
community.
Training of creche workers is also provided under the NCF. For 40 creche workers, an
amount of Rs. 25,200 is provided. However, no data is available with the State
Government on the kind of training programmes held under this scheme so far.
Management of the scheme
The NCF scheme extends to the entire country except the state of Jammu and Kashmir.
The Board of Management of the NCF is constituted by: Chairman who is the Minister of
State for Women and Child Development; a Working Chairman who is the Secretary,
Department of Women and Child Development; and other member who are the Joint
Secretary in charge of Nutrition and Child Development; Joint Secretary, Department of
Expenditure, Ministry of Finance; Director, National Institute for Public Co-operation
and Child Development; Executive Director, Central Social Welfare Board. The Deputy
Secretary/Director of the Department of Women and Child Development, in charge of the
Creche Scheme, is the Member-Secretary of the Board. There is no parallel
administrative structure at the State level and it is the Central Board that has all the grant
making powers.
Applications are sent by voluntary organisations/mahila mandals to the Department of
Women and Child Development (DWCD), Karnataka State Government. This
department forwards them to the NCF Board that finally approves the applications. The
DWCD at the State level is not involved in monitoring the scheme. The State DWCD
official says that the Department is not always informed about the sanctioned creches in
the State.
Communication between the NCF and the State DWCD is sporadic and not formally
established. The NCF Board also has the powers to withhold, reduce or stop the grants
being made.
18
Creches
Coverage
The grants are provided largely out of the interest accrued on the corpus of the Fund and
partially out of a small portion of the corpus fund. In 1995-96, the Fund had assisted 1856
general creches and 599 anganwadi-cum-creche centres in the country. During 19992000, the number of creches supported and the quantum of assistance remained the same.
In 2002, 3114 creches received grants under the NCF throughout India.
In Karnataka, the Fund presently supports 93 creches. The voluntary organisations
receiving these grants come from the following districts (figures in brackets indicate
number of creches); Mandya (16), Davangere (20), Belgaum (33), Kolar (5), Bagalkot
(3), Dharwad (3), Bijapur (7), Koppal (2), Chikmagalur (2), Bangalore (2). These
organisations receive grants directly from the NCF and hence no information is available
with the state government about these organisations and their beneficiaries.
Critique of the scheme
Since its inception, the number of creches supported has grown marginally but the
amount sanctioned has remained the same. There have been several proposals, both
from the government and groups such as FORCES, to increase the corpus amount.
One suggestion is that the contributions from the government to the Fund should be one
per cent of the Gross National Product. But this has not been taken seriously. The
Parliamentary Committee under the Department of Human Resources Development
wrote in its 2001 report, ‘this Committee is perturbed to note that a proposal to increase
the corpus amount has not yet been approved and only token provisions are being made
during the last several years. The Department informed that an amount of Rs. 20.00 crore
for National Creche Fund was proposed for the year 2000-2001. However, due to paucity
of funds only a token provision of Rs. 1.00 lakh has been provided and efforts would be
made to consider enhancement at a later stage. The Committee emphasises that concerted
efforts should be made to finalise the proposal regarding enhancement of corpus amount
under the National Creche Fund’. These observations reflect the fact that the government
accords a low priority to the provision of creches, despite an increasing need felt by a
cross section of the Indian population.
5.1.3. Karnataka Government Scheme of Assistance to Voluntary Organisations for
Creches for Working Women’s Children.
This scheme was initiated with a view to cater to the needs of children below three years
of age since children between 3-6 years are taken care of in balwadis or anganwadis. The
scheme is meant to address the various issues pertaining to the welfare of the very young
child, siblings, as well as the working mother.
It outlines its purpose as follows: to provide for a better and safe environment for young
children, to ensure their healthy growth and thereby a lower mortality rate, to free the
older siblings from their child care responsibilities so that they can attend school, and to
allow the mothers to work without having to take their children to the work spot. Given
the fact that child care services for children under three are extremely sparse, this scheme
holds great potential of filling in the void.
19
Creches
Eligibility
Any voluntary organisation which is registered under the Societies Registration Act,
1980, and which has a properly constituted managing body with their powers, duties and
responsibilities clearly defined in a written constitution can apply. It should have
facilities, resources, experience and personnel to initiate and execute the scheme. They
should provide a building with a big hall, kitchen, bathroom and toilet and enough space
outside for children to play. It should not run for profit to any individual or a body of
individuals.
Nature of assistance
Two types of assistance are provided under the scheme:
Class 1- Is for women who have no assistance at home and who belong to the lower
working status with monthly income of the family not exceeding Rs. 300 per month in
cities and Rs. 250 per month in rural areas.
Class 2- Is for children between 3-5 years, of working women who have no assistance at
home, who belong to middle income groups with a monthly family income not exceeding
Rs. 750 in cities and Rs. 300 in rural areas. The inclusion of this category of children
(between 3-5 years) does not fit into the very young child-focus expressed in the purpose
of the scheme.
Extent of assistance
Government assistance is limited and is expected to help the voluntary organisations to
initiate the programme. Subsequently, voluntary contributions are expected to increase
and form a substantial portion of the budgetary requirements of the organisations. In the
case of Class 1 creches, government assistance is limited to 90% of the expenditure of the
schematic pattern and the remaining 10% is to be borne by the organisation concerned. In
the case of Class 2 creches, government assistance covers only the non-recurring
equipment cost and recurring cost of remuneration of helpers and supervisors. The
voluntary organisation is entitled to collect maintenance charges of Rs. 20 per child in
rural areas and Rs. 30 per child in cities.
The grant is paid in two instalments. After submitting the accounts of the first instalment
and an inspection from the department, the second instalment is released.
These organisations are supposed to be open for inspection by any officer of the
Department of Women and Child Development. The equipment is to be used for the
specified purposes only. If not, the payment of grant can be stopped and earlier grants can
be recovered by the Department.
If any equipment/asset is to be disposed off, prior sanction of the department is
mandatory. The scheme states that the organisation must exercise reasonable economy in
the working of the approved creches.
20
Creches
Schematic pattern
The scheme lays down certain basic conditions that must be provided in these centres and
calls it the ‘schematic pattern’. The creches for babies (0-3) years should provide nursery
(play), sleeping facilities, health care, supplementary nutrition, immunisation for 25
babies from 8 a.m. to 5 p.m. or 9 a.m. to 6 p.m. The creche should provide cradles, and
beds for sleeping. It should provide facilities for health care, sanitation and nutrition. The
children have to be bathed and dressed. The nursery should have good play materials.
The supervisor should encourage children to play, teach good habits. A first aid kit
should be available at the creche. The creche should arrange and insist on weekly visits
by the doctors from the Primary Health Centre. Children from all castes should be
allowed to mix well. Daily visits must be made by the Health Visitor or the Auxiliary
Nurse-cum-Midwife. Growth charts and health records must be maintained for all
children.
Recurring expenditure
The scheme gives the following break-up for the recurring expenditure. One Supervisor
on a consolidated salary of Rs. 200 per month; two helpers on a consolidated salary of
Rs. 90 per month each; contingencies such as soaps, oil, brooms, fuels etc. are Rs 25 per
month; and medicines are Rs 25 per month. Supplementary nutrition is provided at the
rate of Rs. 1.25 per child per day for 300 days for 25 children. Non-recurring expenses
such as cradles, cupboards, glasses and plates, stove, containers, buckets, mats, toys, first
aid box, etc. are Rs. 2,930. The amount sanctioned per year is Rs. 14,535; and Rs. 2,930
for non-recurring expenses.
The scheme also suggests the diet schedule of children. For children below five months,
milk is to be provided at three hours intervals. There is no mention of breast-feeding.
For children between 5 to 10 months; mixed cereal porridge, vegetable juice, and milk
are to be given. For children between 10 to 18 months; milk, khichdi with green leafy
vegetables, and porridge are given; and for children between 18 to 30 months; milk, rice,
tied, vegetables, porridge, sprouts, and seasonal fruits are to be provided.
Coverage
The coverage of this scheme is presented in Table 5.
21
Creches
Fable 5: Number of creches under the state scheme for assistance to working and
ailing mothers in Karnataka
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
District________
Bangalore_______
Bangalore Rural
Bijapur_________
Bellary_________
Belgaum________
Bidar__________
Bagalkot________
Chamrajnagar
Chitradurga_____
Davangere______
Dharwad________
Gadag__________
Hassan_________
Haveri__________
Kolar__________
Karwar_________
Koppal_________
Mysore_________
Mandya_________
Raichur_________
Shimoga________
Tumkur
Gulbarga________
Chikmagalur____
Udupi__________
Dakshina Kannada
Kodagu_________
State
2001-2002
7_______
6 _______
2002-2003
11_______
7
10______
5_______
17 ______
3
10
30______
4_______
2_______
7 _______
14______
2 _______
4_______
3 _______
4 _______
16______
7 _______
18 ______
3 _______
9_______
36______
4 _______
8 _______
4
2
10
29
2
13
3
17
28
3
36
11
13______
8_______
NA
NA
NA
237
3
192
Source: File records at the Department of Women and Child Development, Govt, of
Karnataka. Data for all the districts is not available. NA indicates that data is not
available. - indicates that no creche facilities exist under the State Scheme.
The table indicates that the number of creches supported under this state scheme has
dropped from 237 in 2001-2002 to 192 in 2002-2003. Districts such as Bijapur, Bidar,
Kolar, Karwar, Mandya, Shimoga, Gulbarga and Chikmagalur were the worst affected.
While 97 creches were supported in these districts during 2001-2002, no creches were
supported the following year i.e. in 2002-2003 in these districts. In Belgaum and Bellary,
the number of creches receiving grants has also reduced.
22
Creches
No information is available regarding the reasons for stopping aid and its impact on the
former beneficiaries. Districts such as Bangalore, Bangalore Rural, Chitradurga,
Davangere, Gadag, Haveri, Koppal, Tumkur and Udupi had more creches supported
during 2002-2003 than the previous year. These fluctuations are serious, particularly
as the total number of creches supported under this scheme is extremely low.
Table 6: State scheme on creches, 2002-03
District
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Bangalore_____
Bangalore Rural
Bellary
Belgaum______
Bijapur_______
Bidar________
Bagalkot______
Chitradurga
Chikmagalur
Chamarajanagar
Dharwad______
Davangere____
Gulbarga______
Gadag________
Hassan_______
Haveri________
Karwar_______
Kolar________
Kodagu_______
Koppal_______
Mandya_______
Mysore_______
Dakshina
Kannada______
Raichur_______
Shimoga______
Tumkur_______
Udupi________
State
Total
creches
11
7_____
3_____
10
Total
Children
275
175
75_____
250
7
53
27
36
27
49
15
1 12
4
10
200
251
41
36
105
69
2
2
29
50
50
725
10
5__
140
2
2
68
11
74
38
32
443
13
3
17
326
75
425
97
2
150
9
2
115
63
49
65
117
22
95
28
700
95
79
63
463
3
75
18
12
5
40
36
805
224
140
175
230
11
3
192
278
67__
4,802
45__
28__
1038*
45
94
595*
873*
94___
39
1846*
SC
123
Children belonging to
ST
Minorities Others
22
93
37
* does not include children from Bangalore Rural and Bagalkot where the community
wise break-up is not available. - indicates that no creche facility exists under this scheme.
Source: Computed from the file records of the Department of Women and Child
Development.
23
Creches
Details about the beneficiaries are shown in the above table. The 192 state government
supported creches reached out to a total of 4,802 children in Karnataka in 2002-2003. The
highest number of child beneficiaries are in Raichur, Davangere and Koppal which also
have the highest number of grant-in-aid creches. There are 10 districts where no creche
facilities exist under this scheme at all. Children from ‘other’ communities were the
largest constituency of beneficiaries (1846 children) followed by children from
Scheduled Castes (1038 children). Children from Scheduled Tribes (595) and Minorities
(893) are relatively smaller sub-groups. This raises questions about whether the
scheme is actually reaching out to those who are most deserving. The distribution
among social groups is most skewed among creches run in Davangere and Koppal.
Table 7: State scheme for creches: expenditure in 2002-03
District
Bangalore_______
Bangalore Rural
Bellary_________
Bel gaum________
Bijapur_________
Bidar__________
Bagalkot________
Chitradurga_____
Chikmagalur____
Chamarajanagar
Dharwad________
Davangere______
Gulbarga________
Gadag__________
Hassan_________
Haveri__________
Karwar_________
Kolar__________
Kodagu_________
Koppal_________
Mandya_________
Mysore_________
Dakshina Kannada
Raichur_________
Shimoga________
Tumkur________
Udupi__________
State
Amount released Expenditure
(in lakhs)
(in lakhs)
3.77___________ 3.77_______
1.46___________ 1.46_______
1.23___________ 1.07_______
1.72
1.72
1.64
0.55
1.64
0.46
0.94
2.86
0.46
0.94
2.34
4.83
4.83
0.12
0.11
0.95
0.95
0.14
11.77
10.63
0.24
0.24
12.83
12.83
13.32
0.44
59.53
13.32
0.11
56.97
0.81
24
Creches
The table indicates the amount of money released and its utilisation by various districts
during 2002-2003. Of the Rs. 59.53 lakhs released for the entire state, Rs. 56.97 was
actually utilised and Rs. 2.56 lakhs was left unspent. The amount sanctioned to the
creches is extremely inadequate if the creches were to implement the entire schematic
pattern prescribed. But it is ironical that some creches have not been able to utilise even
this paltry amount. In a way, this reflects the poor quality of creche services offered to
young children, especially from poor families who do not have much choice. Districts
such as Bellary, Koppal, Bagalkot, Davangere and Udupi have been unable to spend a
part of the grant released while Kodagu has not spent any part of the grant received.
Implementation of the scheme
This scheme is implemented through the Zilla Panchayat (ZP). Proposals to set up
creches under this scheme are sent to the Taluka Panchayats who in turn forward them to
the ZP. The Child Development Project Officer (CDPO) conducts an inspection and
scrutinises the agency making the proposal. S/he then files an inspection report with the
ZP who finally decides who should receive the grants. This is a decentralised scheme and
the sanctioned amount is released directly by the State to the ZP. The State officials claim
that they know very little about the scheme and its day-to-day functioning since it is
completely handled by the ZP. Even when the CDPOs carry out routine monitoring of
creches, the reports are filed with the Deputy Directors of the Department of Women and
Child Development at the District level. The CDPOs normally check the attendance
register maintained at the creche. Whenever there are less than 25 children enrolled, there
is a pro-rata deduction in the grant released. At least two detailed inspections per year are
mandatory by CDPOs, following which grants are released in two instalments.
5.2. Statutory creches
Statutory creches are the oldest type of creches in existence. They refer to creches that are
set up under various statutes by employers of working women. Before looking into the
various statutes and their provisions with respect to creches with particular reference to
Karnataka, it is important to note some of the key aspects related to these kind of creches.
•
•
•
Firstly, creches of these kind are set up by the employers primarily to fulfil their
statutory mandate. Not respecting this mandate can invite legal action from the state.
Secondly, these creches are based on the premise that the working woman can ensure
her productivity if her young children are close to her and are being looked after. This
is in contrast with the grant-in-aid creches where the state supports the establishment
of creches primarily for the welfare of the child. Employers set up creches for their
own women employees and not for the community in general. Such creches are
essentially a labour welfare measure.
Thirdly, statutory creches are not gender neutral. Providing creches for young
children is perceived as a woman employee’s need, and not an employee’s need.
Hence, the provision of these creches is often determined by the number of women
employees rather than the number of employees (men or women) with very young
children who may need such assistance. Only in mines does an employer have to
provide a creche even for a single woman employee.
25
Creches
•
Fourthly, the statutory provisions with respect to creches do not apply to the large
pool of unorganised labour. According to the Shramshakti report (1988), there are
100 million working women of which 90% are in the unorganised sector, most of
whom do not have access to these creches. Furthermore, women workers often work
as supplementary workers and face difficulties establishing their status as a worker.
The absence of identity cards or their names on the employee muster roll are common
problems. Groups working on this issue have for long advocated that the onus should
be on the employer to prove that the person is not a worker if any of the labour
welfare measures are being denied.
Statutory provisions for creches
Creches are statutorily provided to women working in mines, factories and plantations
(under the Mines Act, the Factories Act, and the Plantations Act) and also to contract
labour and inter-state migrant labour (under the Contract Labour Act and the Inter-State
Migrant Workers Act). The statutory obligation applies to establishments where more
than a specified minimum number of women (see annexure) are employed (except in the
case of mines). Provision of creches at the workplace is also stipulated under the Builders
and Construction Workers Act, 1996. Many a times, employers try to avoid these
provisions by hiring a lower number of women than that prescribed for starting a creche.
A number of builders evade the law by providing labour camps off-site and hiring male
workers from distant parts of the country. There is no statutory provision for women in
the services and professions, who hence have to depend on creches in the voluntary and
private sectors.
Coverage of statutory creches
Research on statutory creches in different parts of the country reveal that creche
facilities are available to only 3-5% of women workers in the organised sector
(Khullar, 1991). It is estimated that about three lakh women (with six and a half lakh
young children) are covered by the existing laws related to creches at the workplace.
Many factories avoid implementation or do so in a haphazard manner, with poor facilities
and untrained workers (Bhatia, 1975). Moreover, the differential needs of children
below three and children from three to six is not recognised even in the statutory
creches. The best record as far as the provision for infants close to the mother’s place of
work is concerned, is in the plantation sector in South India (Swaminathan, 1985), that
also encourages the mother to breast feed her young infant.
26
Creches
Box 3: Some recent legal amendments in Karnataka
Rule 104B Karnataka Factory Rules: The Government of Karnataka has issued the following
notification on July 6, 2002 under the Factories Act, 1948.
Exemption from the provision of creche in certain cases- In factories where it is reasonably
not practicable to provide and maintain a creche in accordance with law, the Chief Inspector
of Factories may exempt such factories from the provision of creche if he is satisfied that
alternate arrangements are ensured by the factory. The occupier of the factory should take the
consent of the employee, furnish details of the places, owners or persons or NGOs who are
providing such a creche and the infrastructure facilities therein, bear the cost incurred by the
parent on the child and furnish the information of the child as and when s/he is admitted and
withdrawn. These alternate arrangements shall include a creche provided and maintained by
private agencies or persons or an individual or NGO. If the Chief Inspector finds that the
occupier of the factory has committed a breach of this rule, this exemption may be withdrawn.
Exemption under Section 25 of Karnataka Shops and Commercial Establishment Rules, 1963.
The exemption permits establishments of Information Technology and Information
Technology enabled services to engage women employees during night shifts; one of the
conditions is that the establishment should bear the cost of creche facility obtained by the
women employees from voluntary and other organisations. If there is a breach of this
condition, the permission to engage women during night shifts may be withdrawn by the
Labour Commissioner.
5.2.1. The situation in Karnataka
This section presents data with respect to creches under the Factories Act. The data for
creches under the Plantations Act and the Mines Act is not available.
Data for March 2003 showed that there were 9,478 factories registered in Karnataka.
These factories employed a total of over 90,000 workers. The sex-wise number of
workers in Karnataka is given below.
Table 8: Number of workers in Karnataka
Total Workers
Women
Workers
2000
9,01,448
1,47,235
2001
8,06,216
1,37,216
2002
9,11,221
2,23,799
2003
9,04,904
2,33,462
The number of women workers employed in factories in Karnataka has gone up over the
last three years. The increase has been particularly steep from 2001 to 2002. Women
workers account for one-fourth of the total workforce employed in factories in
Karnataka.
27
Creches
In 2001, there were 598 factories where creches should have been provided but only 525
factories were providing them. In the year 2002, there were 952 factories where creches
should have been provided, but only 550 factories were providing them. This data shows
that the number of factories which are evading the legal mandate on providing
creches is increasing.
Table 9: Status of creches in factories, 2001
Division
Bangalore Div. 1______
Bangalore Div. 3______
Bangalore Div. 5______
Bangalore Div. 6______
Bangalore Div. 7______
Bangalore Div. 9______
Bangalore Div. 10_____
Bangalore Div. 11_____
Bangalore Rural -Anekal
Bangalore Rural Doddaballapur________
Bel gaum_____________
Belgaum-2___________
Mangalore___________
SIF Mysore__________
Mysore______________
Mandya_____________
Tumkur_____________
Gadag_______________
Bijapur______________
Shimoga_____________
Raichur_____________
Be II ary______________
Davangere___________
Total
Number of factories with
more than 30 women
workers
Number of factories
where creches are
provided
13
85
70
37
19
47
42
43
11
2
9
84
69
23
19
35
40
38
11
2
2__
j__
J_
J_
36
11_
11_
N.A.
4 __
5 __
N.A.
20
4
32
9__
9__
9__
4__
6__
N.A.
20
4
4
467
4
429
Source: File records at the Department of Factories, Govt, of Karnataka
N.A= Not available
Note: Data for all divisions was not available and hence the total number of creches does
not add up to 525.
28
Creches
A look at the district-wise break-up of defaulters indicates that factories flouting these
provisions are located mainly in Bangalore, Mysore and Mangalore divisions. It must be
noted that this data pertains to only those factories that are registered under the Factories
Act.
The enforcement authority under the Act, i.e. the Factories Inspector under the Factories
Act or the Labour Inspector under the various labour statutes, visit the place of work and
check if the legally prescribed norms are met by the employer. If the employer is found
defaulting on any of the provisions, the Inspector gives an oral warning. If these warnings
are not heeded to, a show cause notice is given to the errant employer. So far, no case
has been registered against any factory owner for not providing creches in
Karnataka.
5.3. Creches run by voluntary organisations
Many voluntary organisations have set up creches in their areas of work in order to
ensure children’s well-being and also to free up women from domestic responsibilities so
that they can take up economic activities. Most of these creches are those running with
private donations and not with grants-in-aid schemes of the central or the state
government. Some of the characteristics of creches in the voluntary sector are:
•
•
•
Firstly, they may not operate for the whole day and their timings may not coincide
with the working hours of mothers.
Secondly, they usually do not cater to children below two years of age.
Thirdly, they may not be located in close proximity to mother’s work places.
(Swaminathan, 1985).
Mahila Samakhya has been running creches in Karnataka since 1992. These cater to the
needs of women daily wage workers and are run by mahila sanghas. However, every year
some creches are being closed down since anganwadis have started in these areas and the
creche beneficiaries now go to the anganwadis. Mahila Samakhya presently runs three
creches in Gulbarga and five in Bijapur.
Ashraya has run creches at construction sites since 1983. At present they run creches at
four construction sites, which provide education and care to children from infancy to 12
years. Since its inception, Ashraya has run creches at over 30 large construction sites in
the city of Bangalore. Since the past 4-5 years, there have been a lot of changes with
respect to labour hired in the construction sector. There are fewer female labourers and
the contractors bring in only male labourers from distant areas. Even in the case of
labourers with families, the contractors normally house them in off-site labour camps.
Ashraya runs creches in partnership with builders and contractors in the city of
Bangalore. The builders are asked to pay Rs. 5000 per month as a donation towards the
creche functioning on their site. Three staff members including a teacher, a worker and a
helper look after the children. Children are fed breakfast and lunch at each centre.
Doctors visit creches regularly for health check-ups and immunisations.
29
Creches
Parents are asked to contribute Rs. 5 per child per month. Children of construction
workers are also sent to Ashraya’s residential school near Kolar. In all, the organisation
reaches out to 150 children.
Some other voluntary organisations also have creches in Karnataka. Outreach has 17 day
care centres reaching out to 1200 children in Bangalore. Sumangali Sevashram ran 15
creches financed by the Swiss-based organisation, Shiftung Kindergarten Programme
(SKIP) between 1990-96. Under the India Population Project-VIIl it ran 19 creches in
and around Bangalore till 2003. These creches have now been closed down and most of
these children have been sent to the anganwadis. Presently, Sumangali Sevashram runs a
creche on its own premises for children of vendors and domestic workers. DEEDS,
another voluntary organisation, runs 19 day-care centres for 456 children between three
to five years, with special emphasis on the girl child. Of these, two are in the urban slums
of Bangalore, four are in Hassan and Tumkur districts and the rest are distributed in
Tamil Nadu.
There is very little information available on the exact number of creches run by
voluntary organisations. Data is particularly lacking from the districts. Since all
creches are not required to be registered with the Department of Women and Child
Development, there is no reference on the spread and quality of these creches.
5.4. Commercially run creches
Commercial creches are those creches that are run by individuals/organisations for profit.
These creches, which are also called day care centres or play homes, cater mainly to the
middle class population of working couples. Parents from lower classes are not able to
afford such child care services. They are either run as separate centres similar to pre
schools, or are run privately by caretakers out of their homes. The latter are very often
informal arrangements between the parents and the caretaker. Often these care
arrangements are located near the child’s residence and not near the mother’s place of
work. Caretakers are usually women sharing a similar socio-economic background of the
parents. These creches stay open for the whole day and are often flexible depending on
the needs of the parents. Children aged from a few months old to those who go to school
are looked after. School going children use creches mainly as an after-school care
arrangement. These creches charge fees ranging from a few hundred to a few thousand
rupees, depending on the type of services provided and the background of the children
catered to. Most of these creches are not even registered since there are no rules, or
policies governing the functioning of these creches. There is a complete lack of
regulation and standard setting with respect to services provided by these creches.
No reliable data on the extent of such child care arrangements in the state is
available.
30
Creches
Of late there is a growing concern among various groups, including activists and parents,
about the growth of these private-for-profit centres attending to young children, since
they are completely unregulated (Swaminathan, 1988: 21). With more and more
establishments preferring to reimburse working women for creche facilities instead
of setting up creches themselves at the workplace, and with the statutes supporting
such arrangements, the role of such commercially run creches is becoming
increasing significant.
6. Key problems and issues
Swaminathan (1998: 21) points out that there is a confusion of goals and objectives with
respect to child care services. Is the purpose of early childhood care and education in
order to get children into schools or in order to take care of them while their mothers are
at work, or a combination of both these reasons? Perspectives may indeed differ
depending on how the government views child care services; i.e. as a measure towards
women’s empowerment, or a strategy of ensuring universalisation of elementary
education, or a child development programme. In turn, these positions may influence the
specific programme of action as well as resource allocation. At present, the programme
seems to be defined for these three purpose, despite which there is insufficient
government action. Another problem is that none of the departments take full charge of
planning, designing, executing and evaluating the child care services that are in place.
These services are fragmented across the Department of Women and Child Development,
Department of Labour, Department of Factories and Department of Education. Inter
departmental co-ordination and planning is completely non-existent and there is a
tendency to pass the buck on.
Other issues related to creches are:
Inadequate coverage
Out of 6,50,000 children eligible in the country, creches cover only 50,000 children
(Sriram, 1998). In quantitative terms, the present laws and policies regarding creches
leave out the majority of working women in the unorganised sector and their children.
Another estimate is that there are 90 million women and 24 million are estimated to have
children below six years in need of child care support (Swaminathan, 1998:26). A large
majority of these women and children are without any child care service.
Timings and duration
Creches arc also found to function mostly like pre-schools. A lot of them work for three
to four hours per day. Moreover, the timings are not adapted to those of working women,
except in Kerala and Tamil Nadu where all creches are obliged to function for six hours,
usually 9.30 a.m. to 3.30 p.m. or longer. These arrangements are inconvenient for most
working mothers and creches in such instances offer only partial support.
31
Creches
Custodial care or holistic development
Given the fact that child care services focus on the most critical period in the life cycle, it
is pertinent to examine whether these services actually utilise this opportunity to provide
holistic development activities for children. In reality, inadequate resources make even
the simplest toys unaffordable. Lack of sufficient staff, their poor educational background
as well as lack of training in child development make it extremely difficult to convert
custodial creches into environments that provide stimulation for sensory, mental and
motor development.
Diversity of needs
Do creches cater to a diversity of needs required by children? Children coming to creches
come from varied backgrounds and belong to families of working mothers or are children
of ailing mothers. There are children who are differently-abled and children with various
health disorders. Most of these creches do not have the capacity to offer differentiated
care for such children. Thus, important psycho-social and health problems are likely to go
unidentified and therefore unattended.
Breast feeding
Breast feeding of very young infants by working mothers is extremely difficult and many
women have to resort to bottle feeding children left in creches. Creches have to be close
to the place of work in order to facilitate breast feeding. Apart from the statutory creches,
many of the creches are not close to the mother’s workplace. Even when women are
entitled to nursing breaks, it is often impractical to travel long distances to the creches for
nursing the babies. As a result, most women have to stop nursing as soon as they resume
work, and place the child under substitute care. Many a time, working women in the
organised and unorganised sectors cannot breast-feed since the environment is not
conducive.
ICDS and creche services
As the biggest early childhood programme in the country, the ICDS has not provided
adequately for a creche component in its scheme, particularly for 0-3 year olds. Day
care/creche facilities are not provided in most anganwadis although a beginning has been
made towards integrating the two. The government’s contention has been that day care
requires responsible skilled human inputs. With the limits on the availability of funds,
creches are not universally implemented. Even the ICDS as a scheme does not respond to
the mother’s work roles and timings and children under three years are neglected in
aspects other than health care.
Documentation and records
Since child care services are not high on the government agenda, there is little effort
towards collecting or maintaining records about creches. This researcher came across
several conflicting data from government sources. In Karnataka, no study/evaluation has
been done so far on the utilisation of grants-in-aid schemes for creches.
The government is therefore unclear about the implementation of these schemes and the
impact they have had so far in meeting the needs of working mothers and children.
31
Creches
Reliance on NGQs
The entire network of child care services in the country depends on the voluntary sector.
In some sense, the existence of creches or day care facilities is determined by the
presence of NGOs and their scope of work. If an NGO is not located within a particular
community, the chances of the community getting a creche are very remote. Moreover,
there is very little regulation in terms of standard setting and continuous monitoring of
creches run by these organisations. None of the schemes specify the need for community
participation in monitoring the functioning of the creche. The organisational staff is thus
accountable only to the government and not to the beneficiary community. The number
of NGOs running creches is also minuscule compared to the need.
Inadequate funding
Children are clearly not placed first in terms of budgetary resources. There is definitely a
need to increase the funding provided under the various grants-in-aid schemes of the
government. A meagre corpus of Rs. 19 crore towards the National Creche Fund
generates only Rs. 1.5 crore for creches. The funding pattern of the scheme for creches
makes it very difficult for NGOs to run creches satisfactorily without additional
resources. Even the remuneration offered to the creche staff is not lucrative enough to
attract the best. This low remuneration appears to be accepted by state as well as society
and there is very little unrest reported among creche workers for better wages. The small
size of this category of workers and their disparate locations also make their association
and lobbying as a group extremely difficult. A full day, high quality care would cost only
Rs. 5 per child per day. Even if this was provided to all the six crore children, the
expenditure would be less than 1% of the nation’s GNP (FORCES). Another issue is that
of the utilisation of funds. The relevant sections in the paper above show that the grants
are not fully utilised and this has also been noted by the Committee of Ministers. As the
grant given is too meagre to provide an adequate service, it results in the sorry state of
under-utilisation of grants released.
Care of the very young child
Another striking problem with the existing child care services is the lack of focus on the
very young child. Despite being the most vulnerable group within the young child
population, child care services for this group are highly inadequate. Most creches take
children between two and six years. Even the system of funding is not tailored for the
care of children below three years which requires more adult supervision, special diet,
health care, training and equipment. A direct fall-out of this is the withdrawal of elder
siblings from education in order to care for the very young child. If universalisation of
girl’s education is to be attained, providing child care for the very young is a pre
requisite.
33
Creches
Policies and legislation
Child care services in general have received scarce attention in national policies and
legislation. Children below three years are further marginalised since their independent
needs go unregistered and the mother’s need for support in child rearing responsibilities
is looked on with suspicion. The fact that child-rearing is seen as a private family affair
also contributes to this inaction. The CRC and the National Policy for Education lay
down sound goals to be achieved and the role of the State, but this has still not translated
into action.
Alternative approaches to centre-based child care
Experts have called for exploring alternate approaches to centre-based child care, but
these have not received adequate attention within official circles. Newer models of child
care such as creches attached to schools; family based, home based, community based,
women’s group based creches; and anganwadi-cum-creches have not been fully tried out.
In Karnataka, even the anganwadi-cum-creche model has not been adopted by the
government although separate allocations are provided for this. Decentralising the
administration of the state government’s scheme is not enough. The panchayat’s duty
towards maternal and child welfare, however discretionary it may be, needs to be
formalised and incorporated in the scheme itself.
7. Conclusion
Creches and child care have to be part of a holistic, integrated strategy for the
development of the poor in our country as they permit women to work and improve their
economic conditions (Pandit, ‘95). Given the criticality of the early years of life, child
care should be a priority for ensuring children’s survival, growth and development. In a
way, it not only intersects the needs of women and children, but also those of the family
and society. Yet, as this paper shows, child care services in India have largely failed to
meet the needs of working women in terms of the extent of coverage, provision of
services, and quality of service delivery. Most creches are reduced to providing only
custodial care. These weaknesses are mainly due to the faulty pattern of the schemes
themselves; their inadequate pattern of funding, staffing and training; and the failure to
spell out the methods, programme content and criteria in line with the stated objectives
(Swaminathan, 1993). Even as government funding for creches remains totally
inadequate, the issue of non-utilisation of government grants is also a matter of concern.
Furthermore, data about creches needs to be collected at all levels. This will help in
identifying the ground level lacunae and facilitate revamping and upgrading government
policy with respect to creches.
In sum, all child care services should aim at long hours of care that match mothers’ work
timings; location within half a kilometre from home, or proximity to the workplace to
facilitate breast-feeding; meeting the needs of various age groups; and the caregiver being
from the same social group. This basic standard of service to families in need would go a
long way in strengthening the state's pool of vital human resources.
34
Creches
REFERENCES
1. Arulraj, M. R. and Samuel. R.S. 1995. Balancing Multiple roles: Child Care strategies
of women working in the unorganised sector in Tamil Nadu. Research Report no. 1.
Madras: M. S. Swaminathan Rsearch Foundation (MSSRF).
2. Bhatia, K. K. 1975. Child Labour Statistics. New Delhi: Labour Bureau.
3. Department of Elementary Education and Literacy. 2003. Education for All National
Plan of Action India. New Delhi: Government of India, Ministry of Human Resource
Development.
4. D’Souza, A. 1979. Children in Creches. New Delhi: Intellectual Publishing.
5. FORCES stand (not dated)-What we stand for and our approach. A note.
6. Government of India. 1985. Child in India: A Statistical Profile. New Delhi: Ministry
of Social Welfare.
7. Government of India. 1988. Shramshakti, Report of the Committee on Self-employed
women and women in the Informal Sector. New Delhi: Dept of Women and Child
Development, Ministry of Human Resource Development.
8. Kaul, V. 1998. Training of Teachers, in Swaminathan, M. (Ed.) The First Five Years:
A Critical Perspective on Early Childhood Care and Education in India. New Delhi:
Sage Publications.
9. Kaul, V. 2002. Early Childhood Care and Education, in Govinda, R. (Ed.) India
Education Report: A Profile of Basic Education. New Delhi: Oxford University Press.
10. Khosla, R. 1992. Paper presented at the National Consultation on the Urban Child.
11. Khullar, M. 1991. Whither Child Care Services? New Delhi: Centre for Women’s
Development Studies, UNICEF India and Save the Children Fund UK.
12. Lamb, M.E. and Sternberg, J. K. 1992. Socio Cultural Perspectives on Non-Parental
Child Care, in M.E. Lamb et. al (Eds.) Child Care in Context: New Jersey: Lawrence
Erlbaum.
13. Murlidharan, R and Kaul, V. 1993. Early Childhood Care and Education, in T.S.
Saraswathi and B. Kaur (Eds.) Human Development and Family Studies. New Delhi:
Sage Publications.
14. National Institute for Public Co-operation and Child Development (NIPCCD). 1978.
Working Mother and Early Childhood Education. New Delhi: NIPCCD.
35
Creches
15. National Institute for Public Co-operation and Child Development. 1995. Child Care
Services in India: an Evaluation. Unpublished research proposal. New Delhi:
NIPCCD.
16. Pandit, H. 1995. Children of the Union: Creches for Women Tobacco Workers'
Children. SURAKSHA series. Madras: M. S. Swaminathan Research Foundation
(MSSRF).
17. Planning Commission. 1972. Analysis of the Report of the Study Teams-ICDS Pilot
Project Preparation. New Delhi: Government of India.
18. Proceedings of a policy dialogue on Maternity entitlements and Women in the
Unorganised sector held on Feb 28, 2001. Organised by FORCES, New Delhi.
19. Ramalingaswami, V., Johnson, U., and Rohde, J. 1996. The Asian Enigma: The
Progress of Nations. New York: UNICEF.
20. Sriram, R. 1994. Social Support Services for Women: A Delivery System, in K.
Cloud, et al, Capturing Complexity: an Interdisciplinary Look at Women, Households
and Development. New Delhi: Sage Publications.
21. Sriram, R. 1998. Women’s Empowerment and Child Care: the Interface, in
Swaminathan, M. (Ed.) The First Five Years: A Critical Perspective on Early
Childhood Care and Education in India. New Delhi: Sage Publications.
22. Swaminathan, M. 1985. Who Cares? A Study of Child-care facilities for low-income
Women in India. New Delhi: Centre for Women's Studies.
23. Swaminathan, M. 1991. Child care services for working parents in India,
International Labour Organisation (mimeo).
24. Swaminathan, M. 1993. Current Issues in Early Childhood Care and Education, in
Saraswathi, T.S. and Kaur, B. (Eds.) Human Development and Family Studies in
India: An Agenda for Research and Policy. New Delhi: Sage Publications.
25. Swaminathan, M. 1998. The First Five Years: A Critical Perspective on Early
Childhood Care and Education in India. New Delhi: Sage Publications.
36
ANNEXURE : Legislation related to creches
Name of Act
Min. no. of
workers
Act 30
Min. no. of
children
Age of eligible
children_____
Up to 6 years.
Authority to make
rules___________
A suitable room or
State Govt, shall
rooms for the use of make rules
children with
regarding location,
trained women in
construction,
charge
accommodation,
furniture and
equipment,
amenities and
facilities, milk and
refreshments, breast
feeding by mothers
etc.
Plantation
50
Labour
Act
1951 (d)&(w)
20
Up to 6 years
As above
State government
Mines act 1952
section 58
****
Up to 6 years
Room or rooms,
amenities and
supervision
Central government
Factories
1948
No min. number
specified
********
Provision
37
Name of Act
Provision
****
Age of eligible
children_____
Up to six years
20
****
Up to six years
20
****
Up to six years
Two rooms to be
provided for
children, one play
room and one
sleeping room
As above
Min. no. of
workers
50
Min. no. of
children
Contract Labour
(Regulation &
Abolition)
Act 1970.
Inter-State Migrant
Workers Act 1980
Beedi and Cigar
Workers
(Conditions of
Employment) Act
1966
Room or rooms and
trained in-charge
Authority to make
rules___________
State Govt.
Chief Labour
Commissioner
Central Govt.
As above
38
The Integrated Child Development Services
Ka vith a Krishnamoorthy
ICDS
CONTENTS
Page
1. Introduction
4
2. ICDS in India
4
5
6
7
8
12
13
14
14
15
Objectives of the scheme
The range of services
Modalities of operation
Coverage
Organisational set-up of ICDS (National)
Staffing
Financial outlays
Training
Monitoring and evaluation
3.
ICDS in Karnataka
The profile of projects and anganwadis in Karnataka
Expansion of the ICDS projects in Karnataka
District-wise profile of coverage
Staffing
Organisational structure
Financial outlays
Components of the ICDS programme
Health
Nutrition, growth monitoring and health education
Early childhood care and pre-school education
Infrastructure of the anganwadi centre
A profile of the anganwadi worker and helper
Training
Monitoring and evaluation
The role of the community
Role of NGOs in ICDS in Karnataka
16
17
18
19
20
21
22
23
23
26
31
34
36
38
42
44
45
4.
Key areas for advocacy
49
5.
Conclusion and summary
51
References
52
Annexure: The intervention of the Supreme Court on ICDS
53
2
ICDS
TABLES
Page
Table 1: ICDS services across age groups
7
Table 2: Approximate coverage (intended) in an ICDS project
8
Table 3: Staffing pattern, ICDS
13
Table 4: ICDS projects and centres in Karnataka
17
Table 5: Expansion of ICDS projects in Karnataka
18
Table 6: District-wise profile and coverage
19
Table 7: Staff position, 2003
22
Table 8: Allocation from Government of India
22
Table 9: State government outlays
23
Table 10: Immunisation service delivery and impact
24
FIGURES
Fig. 1: Coverage of ICDS scheme in India
9
Fig. 2: Number of ICDS projects area-wise
11
Fig. 3: Organisational set-up of ICDS (National)
12
Fig. 4: Organisational structure of the department at state level
21
BOXES
Box 1: Children of the urban poor- unreached by ICDS
10
Box 2: Impact of the ICDS nationally
16
Box 3: Community monitoring
43
3
ICDS
1. Introduction
The first few years of life have always been regarded as something special. The new-born
through a series of experiences grows to understand the world around her/him, attributing
meaning to all that s/he sees, hears, touches, feels. Traditional practices of child rearing have
placed a great importance on stimulation of the infant and young child through songs, stories
and games; practices that today find support by advances in medical science. In addition to
appropriate stimulation, an environment that promotes the health and well-being of the child
is of paramount importance.
The first six years represent the window period within which cognitive, language, physical,
social and emotional development is at its highest. At each of the sub-stages within this
period, the brain is primed for certain developmental tasks. Appropriate stimulation and
opportunities will lead to the child developing to her/his true and fullest potential. While it is
true that the brain's malleability allows for compensation to take place later (in the event of
the developmental prime time being inadequately availed of); it is also true that the best years
for inputs are the first six years.
The recognition that the first few years provide the foundation of each individual’s life has
led to initiatives across the world - by the government, private and voluntary agencies - to
meet the needs of the child under six years.
The Integrated Child Development Services (ICDS), operational in India since 1975
represents the largest State-driven initiative globally to address the needs of the child under
six years. The ICDS is the only government programme for children below 6 years that
offers an integrated package of services, catering to the related needs of health,
nutrition and education. It is also the only programme that addresses itself to children
living in poverty and holds the potential to compensate for a poor home environment.
Through this paper, an effort is made to assess the situation of the ICDS within Karnataka.
The first section looks at the origins, growth and impact of the ICDS nationally. The second
section analyses the performance of the ICDS in Karnataka; with a focus on the impact of
services. The next section looks at efforts by NGOs to support ICDS functioning. The
concluding section throws up issues for further discussion and areas for advocacy.
2. ICDS in India
The developmental needs of the young child first finds mention in national developmental
policy somewhere in the 1960s, a period when knowledge about the possible effects of
malnutrition on the growth of young children was coming to light. This awareness was
manifested programmatically through the introduction of the Supplementary Nutrition
Programme, under the Fourth Five Year Plan (1969-74).
Subsequent Plans laid great emphasis on child development with 48% of the Fifth Plan
(1974-79) and 59% of the Sixth Plan (1980-85) central sector outlay being spent on child
development programmes (Sharma, 1987). At this point in time, the perspective of welfare
underlined all interventions in child development.
4
ICDS
A shift in emphasis from welfare to development, at least in letter, came with the formulation
of the National Policy for Children, 1974. Its primary goal, to ‘provide adequate services for
children, both before and after birth and throughout the period of growth to ensure their full
physical, mental and social development’ led to the initiation of the ICDS on October 2nd,
1975. The idea of the ICDS Scheme was first presented at a Conference of the Indian
Association of Pre-school Education (I APE) in October 1972, by the Chief of the Department
of Nutrition and Family Welfare, Planning Commission of India. It is worth noting that the
Scheme did not initially include any component of pre-school education.
In 1972, the Ministry of Education also set up a study group for pre-school education, which
recommended that a comprehensive programme for the development of the pre-school child
be undertaken. The study group recommended an integrated approach interweaving health,
education and nutrition into the programme. The IAPE also submitted a memorandum to the
Planning Commission, exhorting it to include psycho-social development of children into the
programme.
Thus, the ICDS, when it was launched, sought to ‘promote the holistic development of
children under 6 years through the strengthening of the capacity of caregivers and
communities and improved access to basic services at the community level’ (NCAER, 2000).
In addition, the Scheme envisages effective convergence of inter-sectoral services such as
health, nutrition and pre-school education.
Launched as an experimental project in 33 blocks, the ICDS today covers 5652 projects
spread across 4553 rural, 759 tribal and 360 urban areas (www.indiabudget.nic.in; 2004).
2.1 Objectives of the scheme
As detailed in the official document brought out by the Department of Women and Child
Development, Government of India, the main objectives of the ICDS Scheme are as follows:
•
•
•
•
•
To improve the nutritional and health status of children in the age group 0-6 years
To lay the foundation for proper psychological, physical and social development of
the child
To reduce the incidence of mortality, morbidity, mal-nutrition and school dropout
To achieve effective co-ordination of policy and implementation amongst the various
departments to promote child development; and
To enhance the capability of the mother to look after the normal health and nutritional
needs of the child through proper nutrition and health education.
The national evaluation of the ICDS carried out by the National Institute for Public
Co-operation in Child Development (NIPPCD) in 1992, stresses the fact that the objectives
of the ICDS "are not limited to a mere delivery of services but emphasise the initiation of a
process aimed at bringing about social change in the life of the community”. Anecdotal
information from organisations working in the field as well as a scan of secondary research
reveal that this objective has rarely been in the consciousness of people implementing the
project, who continue to look at the ICDS as a package of services to be delivered.
5
ICDS
It is also worth noting that the essential temporary nature of the ICDS is underlined by the
fact that it is a Scheme, which could be withdrawn or pared down if there is no political will
to keep it running.
2.2 The range of services
While the focus of the ICDS has been promoting the wellbeing of children, the realisation
that the child’s health and nutritional status depends on the health of the mother, especially
during pregnancy and lactation; led to the inclusion of women in the reproductive age-group
within its ambit of services. The ICDS seeks to be a multi-sectoral programme “aiming at
convergence of services at the local community level for the young child, pregnant and
lactating mothers, and adolescent girls belonging to marginalised families and living in
disadvantaged areas including backward rural areas, tribal areas and urban slums”
(ICDS,GOI, 1995).
The package of the six services provided, as listed in the ICDS document of the Department
of Women and Child Development, Government of India, 1995, are as follows:
Health
• Immunisation
• Health check-up
• Referral services
Nutrition
• Supplementary Nutrition
• Nutrition and Health Education for women
• Growth Monitoring and promotion
Education
• Early Childhood Care and pre-school education to children in the ages of 3-6 years.
Convergence
•
Of other supportive services such as safe drinking water, environmental sanitation,
women’s empowerment programmes, non-formal education and adult literacy1.
These services are distributed across different age-groups as the table that follows shows.
1 While all these services have an implication on the child’s well-being, this paper docs not address this area;
both due to the paucity of data as well as the fact that the paper’s focus is on the services directly concerning the
child.
6
ICDS
Table 1: ICDS services across age groups
Parget
group
Services
offered
Children (6-12
months and 1-3
years)
Children
(3-6 years)
Women (15-45
years) esp.
pregnant and
lactating mothers
Adolescent girls
(11- 18 years)
Registration for
ante- and post
natal care
Vitamins, folic
acid and iron
supplement
Nutrition and
health education
Vit A and iron
supplement
Nutrition and
health
education
Self
development,
recreation and
skill
formation
Health check-up
Immunisation
Growth promotion
Supplementary feeding
Referral services
Vitamin and
iron supplement
•
•
Vitamin A and
iron supplement
Early childcare
and pre school
education
•
•
•
Source: ICDS, Ministry of I IRD, GO1, 1995
While the above range of services are listed on paper, on the ground, the focus of the ICDS is
the child under 6 years and pregnant and lactating mothers. NGOs working in areas where
ICDS anganwadis operate testify to the fact that programmes with adolescent girls are
conspicuous by their absence in the field.
It is pertinent to note that all of the above tasks are to be administered by one anganwadi
worker and one helper who are essentially seen as voluntary, part-time workers. The
workload and burden of responsibility seem well outside the scope of any two human beings,
however committed and well trained (J'or more details see page 33).
2.3 Modalities of operation
The Department of Women and Child Development in the Ministry of Human Resources
Development, Government of India, holds the administrative and financial responsibility for
the ICDS at the central level. While the cost of the feeding programme as well as additional
honoraria to anganwadi workers (if so decided) is met by the State Governments; the Central
Government funds the initial non-recurring expenditure as well as salaries and other
administrative costs.
7
ICDS
The Scheme being an integrated one, calls for coordination between different Ministries and
Departments, the chief being the Ministry of Health and Family Welfare. In addition, the
Ministry of Food and Civil Supplies, Department of Education, Ministry of Urban
Development and Ministry of Agriculture are also involved. Mechanisms for coordination
are set up at all levels but their effectiveness remains a question mark.
2.4 Coverage
The jurisdiction for one project is the Block. Within one project, there may be between
125-250 anganwadi centres (AWCs). Universalisation of the ICDS is said to have taken place
if each Block has an ICDS Project.
The services are provided through the anganwadi centre. One anganwadi centre covers a
population of 1000 in urban and rural areas and 700 in tribal areas. Each AWC is to cater to a
maximum of 80 children below six years (40 children below 3 years and 40 between three
and six years) and 20 women - pregnant and nursing mothers2 (16 women for SNP+ 4
referrals) and 2 adolescent girls. The actual number of beneficiaries who are eligible within a
population of 1000 in urban and rural areas and 700 in tribal areas is determined by a survey.
The table that follows, drawn from the GOI document on the ICDS gives an idea of the
approximate coverage in an ICDS project.
Table 2: Approximate coverage (intended) in an ICDS Project
Beneficiary
1
Children
below 6
years
0-6 years
Services
Rural/Urban project
Total
Intended
popln
reach
Supplementary 17,000 6,800
nutrition______
Immunisation
17,000
17,000
Health checkup ________
3-6 years
Non-formal,
8,000
4,000
pre-school Ed
2 Expectant
Supplementary 4,000
1,600
and nursing nutrition______
mothers
Health Check 4,000
4,000
up___________
Immunisation
2,400
2,400
against TT
3 Women
Health
and 20,000 20,000
(15-45 yrs.) Nutrition Ed
Source: DWCD, Ministry of HRD, GOI, ICDS, 1982
Coverage
Tribal project
Total Intended
popln reach
Coverage
40%
5,950
4,462
75%
5,950
5,950
100%
100%
100%
100%
50%
2.800
2,100
75%
40%
1,400
1,050
75%
100%
1,400
1,400
100%
100%
910
910
100%
100%
7,000
5,250
75%
' Earlier the norm was 32 children below 3 years, 36 children in the 3-6 age group and 10 mothers.
8
ICDS
These targets reflect the priorities of the ICDS programme - greater for immunisation
(100%) as against 40% for nutrition and 50% for pre-school education in rural and urban
areas and 75% each for nutrition and pre-school education in tribal areas. It is also pertinent
to note here that as per the NHFS II survey (UPS, 2000), the national coverage for
immunisation is only 42% though the ICDS has set for itself an aim of 100% coverage.
Figure 1: Coverage of ICDS scheme - government estimates
Coverage of ICDS scheme
i—Himachal
Chondigcih
Haryana
Prod«»h
Arvnochc*!
f
DoJN
■ ajotthan
FrtKJt»h
Novolond
Manipur
Oviarol
Modbyo Prod«ih
’—~~~
Da man
Oodra
NaBor Hartl
Mohvoaht'O
Wa»« »anflal
Tr.pv'a
Maghulo/o
Andhra
Pradath
Xo>na)aka
UiklhodwMp
(Indio)
.
Pond* harry
K»'olo
■ <-70%
■ 70 - 80%
80 - 90%
■ 90 - 100%
I ■
V
Source: DWCD, GO1 website, 2004
The map above, drawn from government data, shows full coverage (in that every Block has
an ICDS project) in the Southern states of Karnataka and Tamil Nadu; Orissa, a few of the
North-Eastern states, Himachal Pradesh, and surprisingly, Jammu and Kashmir. Andhra
Pradesh, Bihar, Uttar Pradesh and Assam represent the states with the lowest coverage.
A Report by the Ministry of HRD (2003), entitled Early Childhood Care and Education - An
Overview, states that the ICDS covers 3.44 crore children in the age group of 0-6 years in the
country, with a total coverage for children in the 3-6 age group of 1,87,59,510. With the total
0-6 population in the country being approximately 15.79 crores as per the 2001 Census,
ICDS actually covers only 22 percent of children below six years. However, we also need
to be aware that there may be children who access services such as health and pre-school
education through private and voluntary agencies, which is not reported. We would need to
see how many children less than six years have no access to services provided by voluntary
or private agencies to get an accurate idea of whether ICDS is reaching out to the uncovered
groups of children.
9
ICDS
BOX 1
Children of the urban poor - unreached by the ICDS
A study by the National Institute of Urban Affairs (1998) shows that only 8% of all ICDS
projects are located in urban areas, and that too, not always in the most needy areas. The
urban population of India constitutes 26% nationally, with no less than an estimated 20% of
the urban population (40% in the case of metropolitan cities) living in slums.
In the seven cities studied, there was an overall shortfall in terms of meeting the needs of the
urban slum population. The coverage varied from 25% of the children of the urban poor in
Kanpur, Patna and Bangalore to 50% in Ahmedabad and Amritsar to 75% in Trivandrum and
Nasik. Though some of these estimates relate only to the age group 3-6 i.e. for preschool
education, the low coverage is still a cause for concern.
It was also found that the services were not reaching all the poor within the slum. Most of the
children were excluded for a variety of reasons, ranging from concentration of certain ethnic
groups to mixed patterns of residence, non-availability of accommodation, unsuitable timings
etc. The general impression was that the most needy groups seemed to be the ones left out.
At the same time, however, even with limited coverage, there were some instances of
duplication of services, indicating the need for spatial mapping before programmes are
launched.
Source: Swaminathan, Mina, Process and Outcome Documentation of ECD in Urban
Disadvantaged Areas, National Institute of Urban Affairs 1998; Mimeo, quoted in Report of
the Committee on Early Childhood Education, Ministry of HRD, 2004.
Universalising ICDS
A move to universalise the programme was made in 1992, under the Eighth Five Year Plan
(1992-97), when 1346 more projects were initiated. By the end of 2001-02 it was proposed
that the ICDS expands to 5171 blocks implying a coverage of 90% by the end of the Ninth
Plan (1997-2002). This has however not been achieved as evident by figures from the
Department which state that as of Sept 2002; 4761 projects were operational
(www.indiabudget.nic.in). The most recent figures available from the DWCD GOI (2004)
website puts the total number of projects at 5652, implying complete universalisation.
These figures have to be read with caution. Universalisation simply means that every
Block has an ICDS project, which does not necessarily mean that all habitations are
covered (for more details in Karnataka, see page 16)
10
ICDS
Figure 2: ICDS projects
Number of ICDS Projects areawise
(On Universalisation)
Expansion of ICDS projects
6000
5614
5000
4661
4
Rural 4571
Urban 310
4000
3000
2000
Tribal 733
1000
Total 5614
0
□Rural
BUrban
33
[Hf
1975
1985
1995
1999
On Univerealisation
©Tribal
Source: DWCD website, GOI, 2004
Criteria for setting up an AWC
According to the GOI document on the ICDS, while selecting the location of a project,
preference is given to ‘those areas which are predominantly inhabited by the vulnerable and
weaker sections of society, that is Scheduled Castes and Tribes and low-income families
found in economically backward areas, drought-prone areas and areas in the development of
social services that requires strengthening’ (ICDS, DWCD, GOI, 1995).
The identification of beneficiaries is done through surveying the community and identifying
the families living below the poverty line. In order to enhance community participation,
efforts are being made to use mapping and other techniques for pre-project activities such as
selection of villages, identification of AWWs etc. (ICDS, DWCD, GOI, 1995).
The Committee on ECCE of the Ministry of HRD (2004) has called for a review of the
ICDS norms (laid down in 1974) for opening anganwadis. It recommends that for a
population of approximately 300 people and 20 (+/- 5) children of the related age group,
there should be one ECCE centre within walking distance from the home of the child.
It also recommends the provision of home-based ECCE facilities for smaller communities,
scattered populations, and tribal and hilly areas. This is a welcome move and needs to be
implemented immediately.
1I
ICDS
2.5 Figure 3: Organisational set-up of ICDS (National)
Ministry of Human Resource Development, Govt, of India
Director (Child Dev.)
Deputy Secretary (Trg.)
Department of Women and Child Development
_____________ STATE____________ t_________________________________
Dept, of Social Welfare/ Health/ Rural Dev./ Tribal Welfare/ Women & Child
Welfare/Dev
Director Nodal Dept.
Programme Officer
DISIRICT________ ▼__________________
District Welfare Officer / Programme Officer
_____________ BLOCK
Block Dev. Officer
______ SECTOR
Block Mukhya Sevika
Child Dev.
Project Officer
Medical Officer
Supervisor
Health Asstt. Female
VILLAGE
Auxiliary
Nurse
Midwife
Anganwadi
Worker
Adult
Education
Instructor
Anganwadi
Helper
Traditional
Birth
Attendant
Health
Guide
(Source: Sharma, 1987)
12
ICDS
ICDS is the responsibility of the Ministry of HRD, Government of India. In most states, it is
administered by the Department of Women and Child Development. At the district level, a
Programme Officer monitors and administers the programme. From the block level and
below, ICDS functionaries — the Child Development Project Officers (CDPOs), Supervisors,
anganwadi workers (AWW) and helpers - with the co-operation of staff of the health
department - Medical Officers, Health assistants, Auxiliary Nurse Midwifes (ANMs),
Traditional Birth Attendants (TBA) - and other development staff implement the ICDS.
2.6 Staffing
fable 3: Staff at each block (for one project), as stated in the ICDS, GOI document (1995)
Designation
CDPO
Number
Rationale
1
Persons
reporting
her/him
to
6
Supervisors
ACDPO
Responsibilities (adapted from
Sharma, 1987)
Administrative head at the Block
level responsible for
implementation and day-to-day
functioning
Same as above (for bigger
blocks: may or may not have)
Supervisor
6
1 for 17-25
AWWs
AWWs
125-150
125-150
AWCs in
one project
17-25
AWWs
Guidance to enable continuous
improvement
•
•
•
•
•
•
•
•
AW helpers
125-150
•
non-formal pre-school
education
organisation of the
supplementary nutrition
programme
imparting health and nutrition
education to women
educating parents through
home visits
eliciting community
participation and support
referrals to PHC for children
and mothers
basing with mahila mandals
and other community groups
and the primary school
maintaining prescribed
records and furnishing
monthly reports to the CDPO
Not listed anywhere
13
ICDS
While the responsibilities of the AW helper are not listed anywhere, it may be assumed that it
is to help the AWW in the fulfilment of her tasks. She may often take on roles such as
keeping children quiet, bringing children from and dropping them off at their homes, helping
prepare the supplementary nutrition etc.
The Medical Officers (MOs), the lady health visitors (LHVs) and female health workers from
nearby primary health centres (PHCs) and sub-centres form a team with Social
Welfare/DWCD functionaries to implement the health component of the ICDS
programme (Shanna, 1987).
2.7 Financial outlays
Alongside gradual expansion of the Scheme, there has also been a significant increase in the
Central Government's spending on implementation of the Scheme. As against the
expenditure of Rs. 1190.21 crores during 17 years, i.e. 1975-76 to 1991-92, the expenditure
during the five years of the Eighth Plan period (1992-97) was Rs. 2271.28 crores
representing 191% increase in just 5 years; which is in tune with the expansion of the project.
During the Ninth Plan period (1997-2002), a sum of Rs. 4960 crores was allocated (DWCD,
GOI website, 2004), a more than 100% increase in allocation.
The Budget estimate for the year 2002-03 was Rs. 163544.00 Lakhs while for the year 200304 it was Rs. 1657597.00 (DWCD, GOI, 2004)
The ICDS has also received external funding from the World Bank (WB) for the Tamil Nadu
Integrated Nutrition Project (1980-89); as well as ICDS Projects (922 projects) in Andhra
Pradesh, Orissa, Bihar, Madhya Pradesh, Uttar Pradesh, Tamil Nadu, Maharashtra, Rajasthan
and Kerala.
Under the Andhra Pradesh Economic Restructuring Project, WB funding to expand the ICDS
Scheme in 143 new blocks in Andhra Pradesh and to enrich quality of services in 108
existing ICDS blocks has also been committed. In addition, UNICEF has been providing
resources for essential supplies, and the World Food Programme and CARE have been
supporting the Supplementary Nutrition Programme (DWCD, GOI website, 2004).
2.8 Training
NIPCCD is the apex organisation for designing training programmes for ICDS functionaries.
Training for CDPOs and ACDPOs is imparted to ICDS functionaries by NIPCCD through its
three Regional Centres at Lucknow, Guwahati and Bangalore. Supervisors are trained in 18
Middle Level Training Centres and 300 Anganwadi Workers Training Centres. In addition,
the Central Technical Committee - Integrated Mother and Child Development also gives
training to medical and para-medical staff. NGOs have also been involved in training in the
areas of community participation, disability, pre-school education etc.
14
ICDS
Udisha - A move to revitalise the training component of the ICDS was undertaken through
the initiation of Udisha - a nation-wide World Bank-assisted training programme for ICDS
functionaries, launched in 1999. It consists of three major components - job training, other
trainings (innovative, area-specific training) and provision of Information, Education and
Communication material (IEC). Udisha envisages a spectrum of locally relevant training
interventions for achieving women and child development goals. It is being supported
nationally by an assistance of Rs. 600 crores by the World Bank for a time period of five
years, which ends in September, 2004 (www.indiabudget.nic.in, 2004).
Udisha seeks to redefine training of ICDS functionaries through a decentralised, participatory
approach. It aims at improving the communication skills of the functionaries, developing
their self-esteem, and introducing them to issues of empowering women. It also seeks to
revise the syllabus of training to make it more State-specific (DWCD, GOI, 1995;
www.indiabudget.nic.in, 2004).
A series of consultation were held over two years (along with N1PCCD and UNICEF) with
training institutes, trainers, community members etc. focusing on emerging programme
strategies, training needs assessment and methodologies, syllabus etc. A redefinition of
approaches towards training of child care functionaries and caregiver education was arrived
at, which stressed a holistic approach “reflected in the new child-centred curriculum that is
structured along the life cycle and development continuum of the child, pulling together
different sectoral interventions in a rights perspective” (Udisha - National ICDS training,
DWCD, GOI, 2000).
Probably for the first time in the history of the ICDS, Udisha looks at the Anganwadi
worker as the key functionary, worthy of the best possible inputs. It talks of empowering
the AWW, building her self-esteem and enabling her aspirations to be realised.
For regular monitoring and evaluation of the training component, State-level Training Task
Forces have been set up. The purpose of the Task Force is to integrate and coordinate all
aspects of the training and to recommend changes in curriculum, strategies and methodology.
2.9 Monitoring and evaluation
Monitoring is in-built in the ICDS programme with the Ministry of Human Resources
Development holding the overall responsibility. Monitoring is done through a central cell
established in the Department of Women and Child Development, which collects and
analyses the work reports. A national ICDS Management Information Systems (MIS)
working group facilitates the process of using the information to refine programme strategies.
State governments with more than three projects and Districts with more than five projects
also have MIS facilitating cells at the respective levels.
The MIS consists of the Monthly Progress Report which details information such as supplies,
staff in position, coverage of beneficiaries, percentage of severely and moderately
malnourished children etc.; and the Monthly Monitoring Report which relates to health staff
in position, supplies of medical and health items, birth rate, infant mortality rate etc.
15
ICDS
The reports are consolidated at the Central Technical Committee for Integrated Mother and
Child Development. The Central Technical Committee has also been carrying out research
on the health and nutrition components of the Scheme. A national evaluation was conducted
in 1992 by NIPCCD to assess the impact of the ICDS, the findings of which are summarised
in the box below.
BOX 2
Impact of the ICDS nationally
Immunisation - 49% of children and 46% of mothers immunised in ICDS areas as against
32% and 33% respectively in non-ICDS areas.
Infant Mortality Rate (IMR, 1990) - 71 for ICDS areas as against 80 (SRS estimates for
1989) for non-ICDS areas.
Pre-school education - 88% of children from ICDS areas enrolled into primary school as
against 60% from non-ICDS areas.
50% mothers in ICDS areas get their children medically examined as against 38% in NonICDS areas
A lower percentage of babies had low birth weight in ICDS areas compared to non-ICDS
areas.
Source: (ICDS, DWCD, GOI, 1995)
The mid-term evaluation of the World Bank supported ICDS projects in Andhra Pradesh also
found a positive impact of the ICDS on severe malnutrition and IMR. However, the gains
were not found to be entirely commensurate with investment due to problems of effective
targeting, implementation and coverage. The report drew attention to the fact that ICDS, even
after twenty years, covered less than half the target population and with far from satisfactory
services (World Bank, 1998-99 in Venita Kaul, in India Education Report, 2002).
3. ICDS in Karnataka
Prior to the ICDS being initiated, a Scheme called the Shishu Vihara was operational in some
parts of the State. This functioned under the aegis of the Block Development Officer and
aimed at providing nutrition and pre-school education to children.
ICDS was initiated in Karnataka in 1975 with a pilot project at T. Narsipur in Mysore
district, with 100 anganwadis. In 1993-93, ICDS was universalised in Karnataka, with each
of the 185 blocks in 27 districts having an ICDS project. Of the 185 projects, 166 are in rural
areas, 10 in urban areas and 9 in tribal areas.
16
ICDS
3.1 The profile of projects and anganvvadis in Karnataka
Table 4
Rural Urban
Tribal
ICDS Projects_______
9
Sanctioned__________ 166
10
Operational__________ 166
9
10
Anganwadi Centres
Sanctioned__________ 35,898 1,151
3,252
3,225
Functioning as on Feb. 35,898 1,151
2003_______________
Source: Dept of Women and Child Development, GOK website
Total
185
185
40,301
40,274
While, at the macro level there seems to be universalisation of the ICDS, in that every Block
has an ICDS project functioning; at the ground level, there are many communities not
served by an AWC (Anita Kaul, 2000 in Lakshmi Krishnamurthy et al, 2000). In all
probability, these are areas in remote rural and tribal areas which do not fulfil the population
criterion needed for initiating an AWC. Urban poor communities may also be left out since
they are considered ‘unauthorised’ settlements; not deserving of government services; the
provision of which, the government fears will give them some level of security. This implies
that children of socially and economically marginalised communities have little or no access
to health, nutrition and educational services. That it is the tribal areas in which AWCs fall
short of the target is borne by the fact that as against 3252 sanctioned projects, 3225 are
functioning as opposed to 100% functioning against sanctioned in both rural and urban areas
(refer Table above).
Of the 40,274 AWCs operational in Karnataka; 310 are run by an NGO Sumangali Seva
Ashram (see page 45); while the rest are run by the DWCD.
17
ICDS
3.2 Expansion of the ICDS projects in Karnataka
Table 5
SI.
No.
j__
2 ___
3 ___
4 ___
5 ___
6 ___
7 ___
8 ___
9 ___
10 __
11 __
12
13 __
14 __
15 __
16 __
17 __
18 __
19 __
Total
Year
1975- 76
1976- 77
1977- 78
1978- 79
1979- 80
1980- 81
1981- 82
1982- 83
1983- 84
1984- 85
1985- 86
1986- 87
1987- 88
1988- 89
1989- 90
1990- 91
1991- 92
1992- 93
1993- 94
State
Sector
2
7
5
1
15
30
Central
Sector
1
Total
4
3
3
19
18
1
2
7
9
4
3
34
18
8
8
8
8
14
28
6
6
18
19
155
14
28
6
6
18
19
185
The first project initiated in 1975-76 was supported entirely by the Centre. From 76-77 to
81-82 projects received support both from the State and the Centre. From 1982-83 onwards,
all projects have come under the Central sector. Growth in ICDS projects is determined by
the allocations made at the Central level, which may be a function of the resources made
available both through the Planning process as well as through external funding.
18
ICDS
3.3
Table 6: District-wise profile of coverage
Sr.
No
District
No. of
AWC
Total population
within project
I
Bagalkot
1,363
< 6 yrs
1,79,877
Women
32,735
1,355
2
1,192
1,49,298
19,603
1,192
1,890
1,20,809
22,390
1,890
4
Bangalore
(Urban)
Bangalore
(Rural)
Belgaum
3,773
4,67,791
80,252
3,773
5
Bellary
1,371
2,16,282
34,510
1,371
6
Bidar
1,151
1,83,518
34,969
1,151
7
Bijapur
1,300
2,03,157
37,559
1,292
8
Chmrjngr
1,085
86,600
15,720
1,085
9
Chikmglr
1,226
72,355
11.951
1,226
10
Chitrdurg
1,335
1,38,342
26,196
1,336
11
1,775
1,35,31 I
20,723
1,775
12
Dakshin
Kannada
Davngere
1,262
1,63,828
26,356
1,238
13
Dharwad
806
1,06,711
19,871
806
14
Gadag
835
1,05,243
19,915
836
15
Gulbarga
2,350
4,02,893
64.014
2,350
16
Hassan
1,602
1,16,216
19,308
1,602
17
Haveri
1,167
1,63,519
30,601
1,167
18
Kodagu
692
44,796
8,037
692
19
Kolar
2,360
1,76,173
34.603
2,360
20
Koppal
893
1,56,619
25,220
893
21
Mandya
1,655
1,54,603
24,987
1,656
22
Mysore
1,886
1,83,411
34,033
1,886
23
Raichur
1,306
1,84,336
36,795
1,306
24
Shimoga
1,323
1,09,434
19,210
1,323
25
Tumkur
2,337
1,79,592
32,464
2,337
26
Udupi
1.027
73,952
12,487
1,027
27
Uttar
Kannada
Total
1,201
82,189
13,448
1,201
40292
43,56955
7,57960
40124
3
AWCs giving
SNP for 21
days
No. ofSNP
beneficiaries
< 6 yrs
91,878
(51%)
68,573
(45.9%)
92,811
(76.8%)
1,67,588
(35.8%)
96,504
(44.6%)
91,493
(49.8%)
91,612
(45%)
61,869
(71.4%)
51,458
(71.1%)
95,390
(68%)
87,802
(64.8%)
92,065
(56.1%)
62,970
(59%)
69,350
(65.8%)
1,87,545
(46.5%)
70,91 I
(61%)
95,354
(58.3%)
30,610
(68.3%)
1,37,165
(77.8%)
68,563
(43.7%)
86,996
(56.2%)
1,06,838
(58.2%)
99,307
(53.8%)
65,868
(60.1%)
1,28,875
(71,7%)
50,394
(68.1%)
57,994
(70.5%)
25,08793
(57,5%)
Women
21.138
(64,5%)
14,028
(71.5%)
20,325
(90.7%)
50,369
(62.7%)
19,619
(56,8%)
18,060
(51.6%)
17,145
(45.6%)
10,240
(65.1%)
9,872
(82,6%)
19,805
(75.6%)
17,735
(85.5%)
14.265
(54,1%)
13,243
(66.6%)
11,863
(59,5%)
33,086
(51.6%)
16,772
(86.8%)
21,819
(71.3%)
7,273
(90,4%)
31,840
(92 %)
16,199
(64.2%)
18,553
(74,2%)
22,256
(65.3%)
21,428
(58.2%)
12,811
(66,6%)
28,012
(86,2%)
I 1,028
(88.3%)
9,441
(70.2%)
5,08734
(67,1%)
No. of PSE
beneficiaries
Boys
22,926
Girls
23,667
16,343
16,881
22,778
22,919
73,924
69,124
26,624
26,745
25,717
25,218
24,973
24,551
13,453
13,401
14,519
14,448
23,502
23,729
20,778
20,554
23,812
24,271
16,956
16,542
15,716
15,683
50,685
50,083
18,006
I 7,846
25,980
25,970
6,017
6,252
33,245
33.482
17,608
17,432
20,106
20,342
26,656
27,260
24,940
24,217
17,490
17,118
32,595
32,248
I 1,667
I 1,738
15,460
14,940
6,42476
6,36761
19
ICDS
The above table has been taken from the Reporting format II for the month of December
2003 used by the DWCD for monitoring the ICDS. This is taken as indicative of broad
trends and lends itself to the following analyses:
1. The State coverage for the Supplementary Nutrition Programme (SNP) for children in the
0-6 years age group is 57.5% and for pregnant and lactating mothers is 67.1%.
Considering that as much as Rs. 10566.02 lakhs is spent on the programme every year,
the coverage seems abysmal. However, it falls within the national norm of expected
coverage of 40% for the SNP. When seen District-wise, districts in North Karnataka fair
worse than those in coastal and South Karnataka as seen in the case of Belgaum (35.8%),
Bellary (44.6%), Bijapur (45%), Gulbarga (46.5%), Bidar (49.8%), Koppal (43.7%).
Bangalore Urban (49.5%) also shows less than 50% coverage which seems surprising but
may be explained by the fact that given the option of other private pre-school centres, the
numbers of children attending ICDS centres may be less.
2. Overall, the SNP for pregnant and lactating mothers seems to fare better than that for
children. Some districts show more than 90% coverage (Bangalore Rural. Kodagu,
Kolar). In general. Northern districts fare worse.
3. It is astonishing to note that as many as 168 AWCs do not supply supplementary nutrition
for 21 days. While it may be true only of this particular month and while any AWC that
falls short of even one day is included; it still raises cause for concern.
4. Data presented by the Department is in a form that often defies analysis. One wonders
whether this is just a lack of application or whether it is by design. While the figures of
children attending the pre-school education programme is given; the total population
under six years is not differentiated into 0-3 and 3-6 years, making any analysis of
coverage impossible.
3.4 Staffing
The ICDS functionaries come under the administrative control of the Department of Women
and Child Welfare. The Department is responsible for the recruitment, training and
supervision of all the functionaries.
20
ICDS
Figure 4: Organisational structure of the Department at state level
Director
_k__
Joint Director
(Programme,
Development
And Monitoring
Cell)
Joint Director
(Integrated
Child Development
Services)
Joint Director
(Administration)
Project Director
(Stree Shakti)
_________
Deputy Director
(Training)
Assistant
Director
(ICDS)
Assistant
Director
(Health)
Deputy Director
(Child Welfare)
Assistant
Director
(Monitoring)
Assistant
Director
(Child Welfare)
Programme Officer
Organisational structure at the district level
Deputy Director
Child Development Project Officer
I
Assistant Child
Development Project Officer
4
Supervisors
Anganwadi Workers
Anganwadi Helpers
21
ICDS
Table 7: Staff position as on March 31s', 2003
Sr. No.
Designation
Posts sanctioned
1
CDPO___________
ACDPQ_________
Supervisors______
Anganwadi workers
Anganwadi helpers
185
219
1875
40301
40301
2
3
4
5
Actual number in
place___________
171_____________
184_____________
1592____________
39785___________
40265
Posts vacant
14
35
283
516
36
Source: DWCD, GOK, 2004
It was in the category of Supervisors that a lag had existed which has been minimised with a
recent recruitment drive. 40% of supervisor posts have been reserved for AWWs which is a
welcome step. This will not only ensure career growth for AWWs, but their knowledge of
field realities will also help them perform this role better. The shortfall in AWWs may be
explained by the fact that some of them have been promoted as Supervisors.
3.5 Financial outlays
The following table summarises the financial outlays and expenditure for 2000-03.
Table 8: Allocation from the GOI
Rs. in Lakhs
Sr. No.
1
Scheme
ICDS
2
Udisha
Year
Expenditure
6655.20
7329.77
9860.08
213.43
189.07
196.64
2000-01
Total GIA
7466.18
7660.67
10541.29
433.72
270.29
239.22
3000.00
Balance
810.98
330.90
681.21
220.29
81.22
42.58
3000.00
2001-02
2002-03
4573.00
3778.95
2567.54
2892.44
2005.95
886.51
2000- 01
2001- 02
2002- 03
2000- 01
2001- 02
2002- 03
3
Pradhan
Mantri
Gramodaya
Yojana
(PMGY)
Source: DWCD, GOK, May 2004
The Central assistance for the ICDS went up in the year 02-03. This was due to an increase in
the honorarium of AWWs by Rs. 500 per month and that of helpers by Rs. 240 per month. In
addition, it was expected that the vacant posts of Supervisors would be filled (Supervisor
recruitment drive took place in 2003-04). The funds allocated under the PMGY are used for
the Supplementary Nutrition Programme.
22
ICDS
Under Udisha, the year 2000-01 saw a higher allocation, probably to take care of start-up
costs. However, the entire allocated outlay was not utilised. This is because grants are
received on the basis of the expenditure of the previous year. Department officials however
say this is a vicious cycle. Grants cannot be spent unless received and receipts are not
possible unless expenditure is shown!
Table 9: State government outlays
Year
SNP
2000- 01
2001- 02
2002- 03
2003- 2004
10908.60
I 1350.95
8455.15
10566.02
z\dditional
honorarium for
AWWs_______
1721.09_______
1778.48_______
1430.82_______
1461.23
Rs. in Lakhs
Total
12629.69
13129.43
9885.97
12027.25
Source: DWCD. GOK, 2004
The State Government funds the Supplementary Nutrition Programme (SNP) at the
anganwadi centres as well as an additional honorarium of about Rs. 450 for AWWs. The
Year 2002-03 saw a decrease in allocations for both SNP as well as additional honorarium
for AWWs. This is also the year in which the Central allocations were greater, due to the
increase in honorarium of AWWs; which also explains the decrease in State government
allocations for additional honorarium.
Though the ICDS programme sees a convergence of services of different departments, the
funding for the programme comes only from the DWCD. Other Ministries such as Health
contribute through health supplies, vaccines etc.
3.6 Components of the ICDS programme
The ICDS aims at the integrated delivery of health, nutrition and education for the wellbeing
of the child under 6 years. The AWC is the site for the delivery of services, and serves as the
converging point at the local level for services delivered by different departments; most
notably, Department of Women and Child Development and Health and Family Welfare.
3.6.1 Health
Health implies not just an absence of disease but a positive state of well-being. The ICDS
aims at enhancing the well-being of the child under six years and pregnant and lactating
mothers through a range of services. The intervention on health aims at:
• immunisation of children under six against the six killer childhood diseases, and of
pregnant women against tetanus
• reducing anaemia in both children and mothers through iron and folic acid supplements
• reducing night blindness through Vitamin A supplements
• deworming to enhance the nutritional status of the child and
• referrals to Primary Health Centres.
23
/CDS
The above services are carried out by the AWW with the support of the functionaries of the
Department of Health and Family Welfare.
Immunisation
The intent
Immunisation for children under six years is undertaken against the 6 vaccine preventable
diseases - diphtheria, whooping cough, tetanus, poliomyelitis, tuberculosis and measles. In
addition, pregnant women are given Tetanus Toxoid (T.T).
Table 10: Service delivery and impact
For Karnataka, the progress achieved under this programme for 2002-03 is as follows:
Target (in
actual
numbers)
For BCG, DPT,
Polio
and
Measles______
1026350
Achievement (in actual numbers)
BCG
DPT
Polio
Measles
994940
(96.94%)
982838
(95.76%)
782821
(76.27%)
928517
(90.47%)
Achievement
Target For T.T
10,29,521 (93.65%)
10,99,345
Source: Dept of Women and Child Development, GOK website, 2004
The above are percentages of the total child population below six years in the ICDS project
area and seem to indicate an impressive coverage.
For all immunisations, Karnataka is above the national average. Infant Mortality Rate in
ICDS areas has come down from 120/1000 in 1975 to 58/1000 in 2000 (Dept of Women and
Child Development, GOK website, 2004).
Comment
From a sample survey, the NCAER study (2000), reports that 70% of the children in
Karnataka are immunised against the six killer diseases. More recent reports however report
some disturbing trends. For instance, after being polio-free for the last few years, 35 cases of
polio were reported in Karnataka in 2004. The NFHS II study (2000), puts the immunisation
coverage as 60% of all children below six years. According to UNICEF between 1997 and
2000, the routine immunisation coverage fell for India fell from 60 to 40%.
(www.unicef.org/infobv country/india.html ).
Regional variations within Karnataka also need to be noted. Large-scale migration in North
Karnataka, for example, often means that children neither get immunised in Karnataka nor in
the neighbouring states to which they migrate.
24
ICDS
The high levels of coverage in immunisation against polio may be attributed to the Pulse
Polio campaign, which has secured high commitment from the political and administrative
machinery. Vaccines for the immunisation programme need to be kept under refrigeration.
Whether this is being followed strictly needs to be monitored. Activists have found cold
chain vaccines being kept without being refrigerated in District Offices.
Health check-up and referrals
The Intent
The Health check-up services aim at treatment of common childhood illnesses such as
diarrhoea, provision of iron and folic acid and Vitamin A supplements and deworming.
Health check-ups are to be held by Medical officers from nearby Primary Health Centres
once a quarter to monitor the ante-natal and post-natal care of mothers and the care of
severely mal-nourished children under six years of age and 'at risk' children such as those
born with congenital defects. Medicine kits are also provided to Anganwadi centres to render
primary health care.
In addition, severely malnourished children identified under Grade III and IV, pregnant
women and nursing mothers suffering from serious ailments are referred to nearby
Government Hospitals for specialised treatment. As of December, 2003, 8869 children
belonging to III Gr. and IV Grade were availing referral services (Dept of Women and Child
Development, GOK, 2004).
Service delivery and impact
The NCAER study (2000) reports that the coverage for antenatal services has been poor with
only 34% in urban and 48 % in rural areas being registered in the AWC. In a micro study
conducted by Karnataka FORCES (an advocacy network on behalf of the young,
underprivileged child) of 37 AWCs, it was found that iron and folic acid supplies have not
been replenished in some centres in Bangalore (Rural) (FORCES, 2003).
While many of the AWWs covered by the FORCES study said that they organised monthly
or quarterly health check-ups; most were vague about the details. In one AWC in Bangalore
(Rural), the doctor had not visited for three years!
Referral services translate, on the ground, to a slip of paper given by the AWW referring the
mother and child to a nearby PHC. While Department officials claim that AWWs follow-up
with the mothers; anecdotal testimony from the field reveal that no follow-up is maintained.
There is no record of follow up of whether mothers actually go the PHC and the nature of
treatment meted out.
Supplies of medicines and vaccines are not replenished adequately and when needed. This
has implications for the impact of the service.
25
ICDS
Disability
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995) clearly calls for:
• education of the public through the pre-schools, primary health centres, village level
workers and anganwadi workers
• screening all the children at least once in a year for the purpose of identifying ‘atrisk’ cases and
• taking measures for pre-natal, perinatal and post-natal care of mother and child.
The AWC and the PHC seem to be the ideal locations for the spirit in the above Act to be
translated on the ground.
Comment
While programmes of the ICDS such as timely immunisation are disability prevention
strategies; the potential for identifying and addressing early childhood disabilities, through
the ICDS and the public health care infrastructure does not seem to feature very strongly in
the ICDS programme.
In only 3 of the 37 AWCs covered in the FORCES study were children with disability seen,
suggesting that measures for inclusion need to be enhanced. The staff of only one centre had
received the Portage training (a tool for facilitating early diagnosis and intervention for
children with disabilities).
There have been some new initiatives such as the training of AWWs in selected districts in
early intervention for children with disabilities (undertaken by Seva in Action, based in
Bangalore) as well as the DWCD initiated Community-based Rehabilitation Network's
Portage training (under Udisha) that aims at early identification and early stimulation of
children with disabilities in 16 districts. These need to be strengthened. In addition, disability
prevention as well as appropriate remedial measures need to be seen as one of the goals of
the ICDS programme.
3.6.2 Nutrition, growth monitoring and health education
There is enough evidence to show that malnutrition has tremendous long-term impact on the
child's growth, limiting severely her capacities for learning. Nutritional supplements and
monitoring the growth of children through weight-for-age growth charts represent the efforts
of the ICDS programme to stem malnutrition amongst children below six years.
The intent
Growth is to be monitored by weighing children below three years once a month and those
above three years, once a quarter. Weight-for-age growth charts are to be maintained and a
community chart reflecting the nutritional status of all children registered in the AWC
displayed.
26
ICDS
This data seeks to help mothers and AWC staff to take corrective action, in terms of
additional nutrition, in case the child falls below the standard norms; thus preventing
malnutrition (ICDS, DWCD, GOI, 1995).
Nutritional supplements are provided to both children and pregnant and lactating mothers
with a view of filling the caloric gap between required nutritional intake and what is
available through regular intake of food.
The programme reaches out to around 30 lakh beneficiaries. Children in the age group of six
months to six years, pregnant women and nursing mothers and adolescent girls in the age
group of 11-18 years (in some districts) are provided supplementary nutrition each month.
Special attention is paid to children who are severely malnourished, who are given special
therapeutic (Amylase Rich Food) supplementary food, or double the ration.
According to the Department of Women and Child Development, GOK, (2004), differential
nutritional supplements are given through the programme, varying according to the age of
child and location of centre.
children in the 6 months to 3 years age group - Amylase Rich Food (ARF) is given 5
days in a week (100 gms. of which provide 13.5 gms. of protein and 380 calories of
energy) and egg on one day.
children in the 3-6 years age group - Energy food is given for 2 days, egg on one day and
rice-based local food for 3 days. Energy food is a mixture of wheat, bengalgram dal,
groundnut cake, soya, jaggery, vitamin premix, calcium with iron fortification. This has
to be mixed with lukewarm water and made into laddus.
pregnant women and nursing mothers - 1.5 kg. rice and 2.75 gms. of green gram are
given as take home food every week.
Milk bread is given to the beneficiaries of the two urban ICDS projects of Bangalore
city only. 2 slices of bread weighing 60 grams is provided to each beneficiary per day for
300 days in a year.
Food supplies come from different sources. Rice is sourced from the Ministry of Food and
Civil Supplies and oil from the Karnataka Oil Federation. 50% of the ARF is sourced from
Karnataka Agrocom Products and 50% from private suppliers, through tenders. The
remaining items are sourced from private suppliers through tenders.
Service delivery and impact
In popular perception, the ICDS is identified as a feeding programme, which is seen as the
most visible and tangible service. In fact, in many urban slums in Bangalore, the AWC is
called a ‘paal-roti’ (milk and bread) schools (MAYA, 2002). It is at feeding time that most
children turn up at the centre. At one AWC, though 22 children in the age group of 3-6 years
were enrolled, 44 children turned up at mealtime (FORCES, 2003).
27
ICDS
Comment
According to the NCAER (2000) study, in Karnataka, food is delivered to the centres 288 out
of the 300 prescribed days. In terms of coverage, supplementary nutrition was accessed by
an average of 62 children and 10 women per AWC, slightly lower than the national average
of 74 and 15 respectively. However, a report submitted to the Supreme Court by
Commissioners reviewing the performance of welfare schemes for the poor (in response to a
Public Interest Litigation filed by the People’s Union for Civil Liberties ) puts the national
coverage at a mere 16% of undernourished children (See Annexure on Page 48).
At the national level, there is some evidence of the positive impact of the nutrition
programme, with a significant reduction being brought about in malnutrition (N1PCCD,
1992). However other studies (Tara Gopaldas and Sunder Gujral quoted in Lakshmi
Krishnamurthy et al, 2001) show no significant difference in ICDS and non-ICDS areas
except in Tamil Nadu, where results could be attributed to the Tamil Nadu Nutrition
Programme which functioned with a concentrated focus on nutrition, in conjunction with an
efficient public health system (Lakshmi Krishnamurthy et al, 2001).
Growth monitoring
Maintenance of growth cards was reported by 75% of the AWCs in only 4 districts (NCAER,
2000). The authenticity of this data needs to be seen against the fact that the growth charts
are very complex making it difficult for AWWs with limited training to fill them. Though
AWWs are aware of the necessity of maintaining various records, the growth chart neither
figures as being amongst one of the more important from the point of view of monitoring the
growth of the child, nor is its link with nutrition recognised.
While only 13 of the 37 AWCs observed by the FORCES micro-level study had weighing
machines, 33 of them said they weighed children regularly. This is one more instance of the
AWW probably simply filling up the registers for fear of being pulled up by her superiors for
not doing her job. Often AWWs say that superstitious beliefs of parents do not allow the
child to be weighed for fear that the child may become thin. In addition, though the growth
charts showed most children as being normal in weight; the observation of children in the
Centre was to the contrary (FORCES, 2003).
Malnutrition
Across Karnataka, about 64% of children were reported to be moderately malnourished. In
71% of the ICDS Blocks, between 50-75% of children were severely malnourished (NCAER,
2000). Gulbarga and Bellary have the most number of children in the severely malnourished
category followed by Belgaum, Koppal and Raichur.
As per data from the DWCD, as of Dec, 2003; 32% of the children in the 0-6 years age group
are under grade I and II (moderate) malnutrition and 0.24% are severely malnourished.
28
/CDS
Comment
If in spite of such an impressive (on paper) web of services, periodic reports of child deaths
due to malnutrition still come in; the question arises whether these initiatives have an impact
on the overall nutritional status of the child.
It is important to note that the chances of mortality are highest in the severely malnourished
category. The low figures for severely malnourished children need not indicate a low
occurrence of severe malnutrition given that many infants who are severely malnourished
die, and that many infant deaths go unrecorded. Unless this data is seen with data on infant
deaths (which may also be underreported), it is difficult to assume that there are very few
children who are severely malnourished.
It is also noteworthy that AWWs are inadequately trained and have very little clarity on the
different levels of malnutrition. According to an activist, in a training programme, AWWs
(who had earlier received training from NIPCCD) reportedly mentioned Grade I and II
(moderate malnutrition) as children doing reasonably well and needing no intervention.
Children in Grade III and IV (severe malnutrition) were seen as faring badly. That the
moderately malnourished children require immediate attention, given that they run the risk of
moving into the severely malnourished category even with a small infection; was something
that the AWWs had missed.
Malnutrition is monitored by weighing and weight-for-age charts, which as we have seen
earlier are not being maintained rigorously. The authenticity of data recorded under such
circumstances then becomes suspect.
The ICDS solution of doubling the ration or giving special nutritional supplements to
malnourished children does not always work in an environment where food may be scarce.
The AWW cannot turn away children, nor can she give extra food to those who may need it
more. In addition, food and especially rations may be taken home to be shared with other
siblings and sometimes adults.
The poor quality of food is the most oft-repeated complaint from the recipients, with reports
of worms found in the food ((FORCES, 2003). The NCAER study states that the poor quality
of nutrition impacts the functioning of AWCs adversely in 40% of rural AWCs especially in
Bidar, Kolar, Mandya and Mysore districts.
Inadequate supplies, siphoning off of the supplies, transport problems in delivery are also
pressing issues in the implementation of the Supplementary Nutrition Programme.
29
ICDS
Nutrition and health education
The intent
With the aim of creating awareness about good health and nutrition to women in the age
group of 15-44 years with a focus on expectant and nursing mothers; trained Supervisors,
Anganwadi Workers, ANMs and LHVs jointly conduct nutrition and health education
sessions. Home visits are also undertaken. The content of the sessions include child care, care
of pregnant women and nursing mothers, diet needs, immunisation, supplementary nutrition
for children, sanitation, hygiene, cleanliness etc. (Dept of Women and Child Development,
website, GOK, 2004).
Service delivery and impact
The NCAER study (2000), states that 70% of mothers have been advised with regards to
their and their children’s diets, a majority of mothers seem to be aware of the basic aspects of
child feeding; 70% of mothers breastfed their babies on the day the child was born;
breastfeeding was normally carried out for 15 months and was on demand.
Comment
These findings however need to be viewed with caution. Various traditional harmful
practices still continue. For e.g. in most parts of Karnataka, colostrum is rejected and not
given to the infant. Practices for introduction of semi-solids also vary. In some cases, largely
in lower-income groups, supplementary foods are introduced too early. Due to compulsions
of the mother going to work, the infant may be given supplementary foods as early as three to
four months. Often, this may be just biscuits and tea, inappropriate nutritionally for such a
young infant. Though ragi kanji is a common weaning food, it may be prepared under
unhygienic conditions putting the infant at risk. Infants also need to be fed frequently,
something which a working mother may not have time for and which an older sibling may
not be able to do effectively.
There is also evidence that supplementary foods may be introduced too late. Introduction of
semi-solids before 8 months is culturally unacceptable in many parts of Karnataka (Lakshmi
Krishnamurthy et al, 2001).
The NCAER study also acknowledges that the effectiveness of the NHE sessions is not clear.
Response to campaigns through the audio-visual programmes and attendance at mothers'
meetings has been poor. This is substantiated by field observations which record that this is
one of the weakest components of the ICDS programme (Lakshmi Krishnamurthy et al,
2001). The fact that the AWW is not adequately trained and has little knowledge about the
very issues on which she is expected to educate, compounds the matter. In addition, unless
the NHE messages are contextualised within the realities of the mothers and made relevant, it
is unlikely that these sessions will have any impact.
30
ICDS
The location of the AWC makes a difference to the frequency of the AWW-community
interaction. In cases where the AWC is in the centre of the community, more interaction is
possible. The dynamics of caste and community underline home visits with access or the
lack of, being determined by the AWW’s caste; thus notable reducing coverage and impact.
Recommendations
•
•
•
•
•
•
•
•
Deworming every 6 months and giving Vitamin A and iron in tablet or liquid form
everyday in the AWC may be tried.
Early identification and appropriate treatment of childhood disability, through
community-based programmes, is crucial.
Training on why growth monitoring is important and its impact on the nutritional
status of the child need to be strengthened.
Weighing the child and growth monitoring is crucial. Parents need to be educated on
their importance and their co-operation sought.
The AWC must be open throughout the day and a hot cooked meal, along the lines of
the primary school meal programme be designed. In addition, the supplementary
nutrition component can look at snacks that are packed with nutrition but not very
time-consuming to prepare, thus freeing the AWW for other tasks with the children.
For example, seasonal fruits, groundnut and other kinds of chikki, sprouts hhel, as
well as energy foods may be given.
Regular replenishment of medical supplies and the medical kit is essential.
The NHE sessions can be more effective if they are linked to the local context and
possibilities of practice are clearly shown; rather than the focus on ideal messages,
which may be difficult to practice.
The AWC should be located in a central place so that all members of the community
have access.
3.6.4 Early childhood care and pre-school education
Advances in neuro-science demonstrate the critical importance of appropriate stimulation to
the child under 6 years, the period of rapid brain growth. Though corrective actions may be
possible at later stages; the brain is at its most malleable at this age. Studies across the world
also show that pre-school education has a remarkably positive impact on school enrolment,
retention and learning achievement.
The intent
The ICDS programme is meant to offer pre-school education for three hours to children in
the age group of 3-6 years in the anganwadi centres through an integrated approach. The pre
school education component also seeks to provide a better linkage between primary schools
and the anganwadi centres. The programme seeks to promote child-centred play-way
activities, built on local culture and practices that promote the child’s social, emotional,
cognitive, physical and aesthetic development (ICDS, DWCD, GOI, 1995).
31
ICDS
Service delivery and impact
There seems to be an across-the board acknowledgement that AWCs do help break children
and families into the culture of schooling, making it easier for the child to adjust to school.
Children are used to the routine of going to school, engaging in structured activities and
interacting with other children (FORCES, 2003).
Acknowledging the significance of pre-school education for universalising elementary
education, efforts have been made by the District Primary Education Programme (DPEP) to
strengthen the pre-school component in the ICDS. Supplementary training and appropriate
material have been provided with an aim of impacting the quality of pre school education
within the ICDS. In addition, new centres were set up, adjacent to primary schools, in areas
w'here ICDS was not operational. Efforts were also made to improving the ICDS-primary
school linkage by encouraging AWCs to extend their timings to synchronise with the primary
school, enabling older siblings especially girls to attend school (Venita Kaul in India
Education Report, 2002).
Coverage
About 90 children' in the coverage area of each AWC (population of 1000 people) would be
children in the age group of 3-6 years, making them eligible for pre-school education. Of
children eligible for PSE, more than 60% (about 54 children) have been enrolled in rural
AWCs, with a marginally less number in urban AWCs (NCAER, 2000).
However, field observations state that there are usually only about 20 children in the AWC,
including 1-3 year olds who may have come with their older siblings (Lakshmi
Krishnamurthy et al, 2001). Numbers of children may increase around the meal-time,
reinforcing the perception that the AWC is largely seen as a feeding centre.
Field experiences of MAYA, an NGO, working on ECCE issues and educational reform,
supports the observation that coverage of pre-school education is limited. In some of the lowincome areas in Bangalore where MAYA works, there are 22 AWCs to meet the educational
needs of 5000 pre-schoolers, an alarming 200 children per AWC. The coverage for PSE
through the ICDS centre is thus quite limited.
Content
The DWCD along with UNICEF and other groups has developed an ‘activity bank’,
comprising a collection of 100 stories, songs, creative activities and games for the overall
development of the child. An integrated approach of 42 themes has been developed with one
theme being taught each week. The Department of State Education, Research and Training
(DSERT) has developed an activity-based, thematic approach to PSE called ‘Chilli Pilli’ and
trained 2100 AWWs in 10 Janshala Blocks (educationally backward blocks identified by the
Department of Education) in using it. The manual seems developmentally appropriate and
very colourful; but its use has not expanded to the whole State.
' About 9% of a population of 1000 (the coverage area of an AWC) would be children in the 3-6 age group.
32
ICDS
Field observations however suggest that the PSE component is not being fully put to practice.
In 22 of the 37 centres visited in the course of the FORCES (2003) study of 37 AWCs, field
workers observed no educational activity going on. Often, AWWs were involved in
completing records while children just sat around.
In terms of the content of PSE, parental pressure and the AWW’s own comfort levels ensure
that where there is any educational activity going on, it is largely group activities such as
songs and stories and the teaching of the 3 Rs. While AWWs have been trained in activityoriented teaching and have educational material at their disposal; these are rarely used. For
one, they may be worried about being hauled up for material being ‘spoilt’; there being no
funds for much required replacement due to usage. Very often, the AWW spends her own
money on making teaching aids.
The FORCES study reports that toys available at the Centres were far from adequate.
Materials are supplied on a one-time basis and not used everyday, or used under strict
supervision. Charts are hung much above the eye-level of children. While there seem to be
monthly and yearly plans, AWWs question their usefulness to their context.
Achievement
According to the NCAER study (2000), only 40% of children are able to describe the
activities of the PSE; with it being an abysmally low 15% in the rural areas of Bijapur and
Hassan.
Comment
PSE is not being given its rightful due within the ICDS. While there have been pockets
where with highly motivated AWWs and good support from supervisors and CDPOs, there
has been some impact (eg. Mandya, Dharwad); in general the picture is dismal.
The AWW is overburdened with many tasks and the requirements of the feeding programme
often take up a lot of her time. In addition, parental expectation that children be taught
reading and writing and not just songs and games makes it difficult for directions at the
macro level (ofjoyful, activity-based learning) being implemented at the micro level.
The experience of the DPEP- supported AWCs (with extended timings) is a mixed one. In
areas such as Mandya, where training and other inputs were also received from CRY,
UNICEF etc. the impact has been very encouraging, with higher levels of enrolment,
retention and achievement. This however has not taken place across all DPEP districts. Also,
there seems to be very little ownership of this component in the ICDS, leading to questions
of its sustainability (Venita Kaul in India Education Report, 2002). The issue of poor quality
in the PSE component have also been raised by national-level studies (Upadhaya et al, 1998,
Kaul et al, 1998 in Venita Kaul in India Education Report, 2002).
33
ICDS
In spite of its lacklustre performance, it has been acknowledged by policy-makers, ICDS
functionaries, researchers as well as field practitioners in Early Childhood Education that the
ICDS does enable higher ‘school readiness’, creating a culture of schooling in the community
and instilling a habit of going to school in children. Evaluations have indicated that the DPEP
model for ECCE (adjacent to primary school), was more effective than the AWC in
providing a stimulating environment to children and a feeling of bonding with the school
(Venita Kaul in India Education Report, 2002).
The ICDS has the potential to play an extremely critical role in the national quest for
universalising elementary education, by enabling a strong foundation for later academic
achievement. Higher political and administrative commitment is required to enable the
realisation of this potential.
Recommendations
•
•
•
•
The timings of the ICDS need to be extended and wherever possible, AWCs
converted into full-day Anganwadi-cum-creches. An additional PSE teacher may be
appointed whose tasks will be solely that of PSE. Additional resources may be
secured from the Department of Education funds, especially the Sarva Shiksha
Abhiyan programme; given that there is ample evidence to prove that pre-school
education ensures better enrolment, retention and academic achievement. In addition,
if younger children are kept in a full-day Centre, older siblings especially girls are
freed from sibling care and can attend school themselves.
The importance of pre-school education in the child’s overall development should be
made more explicit to ICDS functionaries down the line as well as to parents and the
larger community. This will enable the PSE component secure its rightful place in the
programme.
Wherever possible, the AWC should be located in or close to the Lower Primary
School.
Educational materials need to be replenished regularly. Their use rather than their
being maintained in their pristine form, should be the indicator for assessing the
performance of the AWW.
3.7 Infrastructure of the anganwadi centre
In comparison with the rest of the country, the overall picture of the infrastructure of the
ICDS programme in Karnataka looks good, though there is a need for improvement in many
areas.
Anganwadis were located within one kilometre in 92% of the villages in Karnataka. Such
access was of a lower order in Chikmagalur (64%) and surprisingly 100% in Bijapur, Bellary
and Mandya (Public Affairs Centre, 2002).
60% of the urban and 50% of the rural AWCs are centrally located. 2 in 3 AWCs have
enough space with rural AWCs being better off; the space constraints in an urban slum being
a barrier to having the required space for activities (NCAER, 2000).
34
/CDS
Ownership of physical space
Of the 40,274 AWCs functioning in the state, only 22,304 centres (55%) have their own
buildings (DWCD, GOK website, 2004). In other cases, they may function from temples,
Panchayat buildings, buildings of charitable institutions etc.
This may have implications on access - children of religious minorities or from Dalit
communities would not be able to avail of ICDS services, if it functions from a temple. In
one AWC in Bangalore that is run in a temple, the local community docs not allow the AWW
to enter the temple when she has her periods, resulting in the AWC being shut four-five days
in a month. Similarly, functioning from institutions owned by other people might mean
irregularity in functioning, dependence on the institution’s policies, an unsafe and
undesirable environment for children etc.
For instance, field observations report that in 24 out of 37 AWCs visited in Bangalore city,
cigarette butts were seen lying around. Investigators were also told that the place was used
for drinking by men (FORCES, 2003).
Some AWCs function from homes with activities like cooking being simultaneously carried
out and the risk of accidents looms large. Storage space for materials may also be limited
(FORCES, 2003). In some cases, 2-3 AWCs functions from the same place (Sriramapuram
AWC quoted in FORCES, 2003 and Bhangi Colony, Mysore Road quoted in MAYA, 2003).
In such scenarios, AWWs may work out shift systems and absent themselves more
frequently.
The Department is aiming at constructing buildings for all the AWCs running in makeshift
places. A budget provision of Rs. 11 crores for construction of 835 Anganwadi buildings
during 2002-03 has been made by the Government of Karnataka. In addition, other
developmental schemes such as the Employment Assurance Scheme, schemes of the Malnad
Area Development Board, Hyderabad Karnataka Development Board as well as loans from
NABARD are being used. This needs to be given priority.
Water, toilet and play facilities
Water facilities are available in more than 70% of urban AWCs while only 50% of rural
AWCs have piped water, with a few having access to handpumps and tubewells. In more
than 75% of the AWCs, awareness on safe measures of water storage is prevalent.
Toilet facilities are abysmal. 90% of AWCs do not have a toilet (NCAER, 2000). The
FORCES study (2003) corroborates this by reporting that in 25 of the 37 AWCs, there were
no toilets with four of the rest being non-functional.
AWCs in urban areas are marked by the lack of open play spaces for children, located as they
may be alongside roads, in small rooms leading out to narrow, often unhygienic lanes etc.
(FORCES, 2003).
35
ICDS
Comment
While the macro picture may not look as grave as in other parts of the country; the micro
picture does reduce the quality of service offered. The lack of infrastructure like water and
toilets is but a reflection of the larger failure of development in a region (most urban slums
and areas in rural North Karnataka would not have access to water and toilet facilities); yet,
provision of quality Anganwadi services require that serious attention be paid to ensure these
basic services.
Recommendations
•
•
•
•
The efforts of the Department to ensure that the AWC functions from its own
premises need to be strengthened. Support from the private sector as well as local
charitable institutions may be taken for ensuring that all AWCs have their own
buildings as well as supply of water and toilets. This becomes more crucial if the
timings of the AWC are to be extended.
The AWC should be located in the centre of the community and as far as possible in
or close to the Lower Primary School.
Norms for the maintenance and upkeep of the AWC should be laid down and
stringently monitored. Leaking roofs, pitted floors etc. need to be immediately
repaired. Local resources in the form of labour can be accessed, voluntarily, for these
minor jobs.
Cooking space should be in a separate room with adequate ventilation.
3.8 A profile of the anganwadi worker and helper
The ICDS by design requires the AWW to be a member of the local community so that she is
better accepted and will have more effective ways of communicating with the beneficiaries.
Her involvement is seen as voluntary by the government, which probably provides the
justification for the fact that she is paid less than the legal minimum wage (Lakshmi
Krishnamurthy et al, 2001). As of June, 2004, an AWW is paid Rs. 1450 per month, of which
Rs. 1000 comes from the central Budget and Rs. 450 is the contribution of the Government
of Karnataka. Helpers are paid Rs. 700 per month.
Most AWWs in Karnataka are within the age group of 30-40 years, with the urban AWWs
being slightly older and married. Helpers would be slightly older and 20% of them are single
women (Lakshmi Krishnamurthy et al, 2001).
That a lot of communities where AWCs are located would be educationally backward
communities may have a bearing on the fact that less than 50% have secured education
upto matriculation and above; though the minimum qualification is matriculation. In 7
districts less than 25% of the AWWs were educated till matriculation. While it is true that
motivation and an aptitude for the job may be more important than the formal educational
qualifications, there also seems to be a co-relation between better performing ICDS districts
and educational qualification of AWWs (NCAER, 2001). Helpers are most often illiterate,
and yet, in many cases may be running the centre when the AWW has other tasks.
36
ICDS
The AW helper escorts children to and from the AWC, collects fuel, minds the children and
looks after the children and the centre when the AWW is away (Lakshmi Krishnamurthy et
al, 2001). Whether she is equipped to do this, in terms of training support to her, is unclear.
40% of AWWs and 60% of helpers live within the community with the rest usually being
within walking distance ((Lakshmi Krishnamurthy et al, 2001). In the FORCES study of
Bangalore Urban and Rural, a majority of the AWWs observed stay outside the village or
urban community; increasing the likelihood of their absenteeism and irregularity. In 16 of
the 37 centres visited for the FORCES study, the AWCs were managed by helpers who
tend to be from the same village or urban community. This is a shocking reality, given
that helpers are not trained to manage the centre at all and may often have their own chores to
attend to.
AWWs and helpers have been unionised and belong to different unions. One of the unions the Karnataka State Anganwadis Workers and Assistants Federation is pressing for a hike in
the salaries of the AWWs to Rs. 2450 per month and that of the helper to Rs. 1200 per month
(Deccan Herald, June 8, 2004).
Comment
More than 90% of the AWWs have received pre-service training but in-service training
seems to have received less attention. Many AWWs have not received any training for as
many as twenty years; with some not having received even the pre-service training
(observations by MYRADA and Samuha 2004). The complete lack of new ideas and a spirit
of freshness as well as opportunities for growth for AWWs, in such a situation, can well be
imagined. Refresher trainings are required on a more regular basis to keep the AWW
motivated and provide a sense of professional growth.
In addition, the training, while equipping the AWWs with certain knowledge and skills, has
not adequately addressed the important area of how to deal with the socio-economic and
political realities of the community; of which she herself is a part. Field observations also
underline the fact that the AWW requires training that will enhance her self-esteem, social
and communication skills and her analytical ability (Lakshmi Krishnamurthy et al, 2001).
Caste represents an important factor in selection and posting of AWWs and has implications
on who cooks the food (if the AWW is of a lower caste, either upper caste children will not
eat there or the community will ensure an upper caste woman cooks the food) as well as her
access to households. While the AWW is seen as a voluntary worker by the government,
most AWWs will state that they are in the job because they need the money; it is seen as a
job ((Lakshmi Krishnamurthy et al, 2001).
The AWW represents the welfare face of the State to the local community, often, in many
rural and tribal areas, the only face of the State. This leads her to be burdened with many
tasks that do not fall into her job profile at all. These include being drawn upon for census
duties, election duties, etc. In some urban low-income areas in Bangalore city, they have
even been asked to sort out problems with electricity meters!
37
1CDS
She is also now required to form Stree Shakti groups, help them maintain individual and
bank records, accompany them to the bank etc. Her work load includes filling in various
records, the most recent additions being birth and death registers; in addition to about 22
registers associated with the ICDS programme. She also has to get signatures of a local
eminent person who is supposed to vouch for the fact that she has conducted Nutrition and
Health education classes. Often, running after people to get their signatures, takes up her
time. It is also another instance of the total distrust placed in the AWW.
In addition, in many areas, the children speak different languages, with the AWW and helper
not necessarily being fluent in all. The use of any one single language handicaps those who
speak different languages (FORCES, 2003).
Subcontracting of work has also been observed as stated in the FORCES study. In one AWC,
the helper works as a house maid and has asked a woman who is a TB patient to take on her
role. She often spits on the floor, a potentially contagious activity. In another AWC, the
AWW pays Rs. 25 to a blind man to teach the children. In yet another AWC, helpers take
care of the children; both are illiterate and one is a deaf-mute (FORCES, 2003).
Recommendations
•
•
•
•
•
•
•
It is important to list all the tasks that are essential to the functioning of the AWC and
ensure that the AWW is held accountable for only these tasks. It would help to
realistically see what a person considered a ‘voluntary’ worker can do in four hours
time and ensure that the quantum of work is commensurate with it.
Changing the mindset of supervisors to not just criticise or boss over but positively
support the AWW would be important.
To break the isolation of the AWW, fora such as the Cluster Resource Centres can be
used where the AWW meets colleagues and is exposed to new ideas, methods etc.
While record-keeping is an important function, it may be worthwhile to look at less
time-consuming ways of ensuring that it is undertaken efficiently.
The remuneration of the AWW has to be commensurate with the job she performs.
The plea that she is but a voluntary worker, can no longer hold good.
The AWW and helper could be from different castes and language groups, to ensure
that all children are attended to.
More attention needs to be paid to the training of helpers which has been almost
completely neglected.
3.9 Training
Training is seen as a key component of the ICDS programme. NIPCCD is the apex body for
the training of ICDS functionaries and is concerned with the planning, coordination,
monitoring, training of ICDS functionaries, formulation of training strategies, development
and updating of training methodologies, aids, curriculum and materials and training of State
and district level officials, CDPOs and trainers (ICDS, DWCD,GO1, 1995).
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ICDS
Training of CDPOs/ ACDPOs
The Southern regional centre of NIPCCD, located in Bangalore, offers a two-month job
training that seeks to familiarise CDPOs, on joining, with various aspects of the ICDS with a
focus on the administrative and organisational structures. Developing skills in project
management, monitoring and supervision of staff and service delivery is a key thrust.
Refresher courses of a week’s duration are held after CDPOs finish two years of service.
NIPCCD also trains staff of AWTCs and MLTCs.
Training of supervisors
I he Middle-level Training Centre located in Ujire, is responsible for the training of
supervisors. Three more MLTCs in Mangalore, Ankola and Dharwad have been sanctioned
and will soon become operational. The training of 65 days covers the different components
of the Scheme and aims at developing the requisite supervision and programme management
skills as well as skills of enabling continuous education of AWWs and facilitating
community participation. Refresher courses are held for Supervisors after they finish one and
a half years of service.
The recent recruitment of Supervisors has led to a back log of training. NGOs like the
Karnataka State Council for Child Welfare (KSCCW), an NGO have been requested to run
6-day induction programmes, as an initial orientation.
Training of anganwadi workers
24 Anganwadi Training Centres (AWTCs) spread all over the State impart training to AWWs
and helpers. 10 are run by the Karnataka State Council for Child Welfare, which also
oversees AWTCs run by other NGOs.
KSCCW runs AWTCs in Tumkur, Mysore, Davangere, Madikeri, Gulbarga, Bangalore,
Shimoga, Anekal, Kanakapura and Kadur. The KSCCW holds the responsibility for
administrative and content supervision. It conducts a quarterly 45-day residential Job
Training Course (JTC) for 35 new anganwadi workers, and a 15-day refresher course every
two years tor 50 working anganwadi workers. It also conducts an orientation course for
anganwadi helpers. Each centre has seven staff, three of whom are full-time teaching
instructors.
The pattern of training and the curriculum being followed is decided by the Department of
Women and Child Development. KSCCW influences the curriculum through its role as part
of the State Level Task Force on Training. It has autonomy in the choice of resource persons
as well as methodology of training. The DWCD draws up a training calendar and deputes
trainees.
39
/CDS
While initially the job training was a three month course; in 1995, in all the new ICDS
projects a sandwich-training approach was implemented. This consisted of an initial phase of
2 months classroom-training, followed by 4 months in the field, concluding with a onemonth training at the AWTC. This was thought to be better than the all-at-one-time 3-month
course. However, the high incidence of absenteeism and the turnover of trainees for each
phase, has led to this pattern of training being withdrawn.
Currently, what is operational in Karnataka for AWWs is a 52-day training. 25% of the
syllabus is developed at the State level to incorporate State-level realities.
In order to clear the backlog of training for AWWs, Karnataka had evolved a system of
district-level refresher training. A core team of trainers was formed at the district level,
initially in 4 districts - Bellary, Gulbarga, Dakshin Kannada and Shimoga. This was later
expanded to the whole state and was operational for two years.
In addition, training of health department functionaries through medical colleges also takes
place. Along with the Department of Health and Family Welfare Services, the DWCD
conducted a two-day training course for anganwadi workers and lady junior health assistants.
Under Udisha, new initiatives such as the Community-based Rehabilitation Portage (seeking
to identify and offer remedial support to children with disabilities) training, training of
mothers of malnourished children have been held. The backlog of training of Supervisors is
also being undertaken under Udisha.
Comment
Training seems to be highly content-driven with not enough attention being given to the
processes of training (Lakshmi Krishnamurthy et al, 2001). Separate training programmes
are offered to AWWs, Supervisors and CDPOs. While the focus of the training will have to
be different for the different functionaries, this compartmentalisation ensures that each never
really understands the others. In discussing what had made the training in the Tamil Nadu
ICDS programme more effective, a NIPCCD official pointed out that all functionaries from
the CDPO downwards had to ‘sing and dance’ - in other words, what was expected of the
AWW, was also taught to higher officials. This integration of certain parts of the curriculum
would go a long way in improving the effectiveness of training; as well as fostering a spirit
of partnership and team spirit amongst the different functionaries.
The training also needs to reflect the field realities that the AWW would have to face.
Managing community dynamics should be integral to the training.
The KSCCW feels that the current 52-day (in effect 45 working days) and the reduction of
Block placement days from 15 to 5 days (under the Udisha Scheme), is inadequate. Also, the
block placement module is placed right at the end of the training programme, with trainees
returning just a day before the course ends. This leaves very little time for debriefing and
discussing problems encountered in the field. In addition, the time allotted for Community
Participation is limited to 5 days as opposed to the earlier 15 days.
40
ICDS
The faculty at the AWTC does not have a good feel of the situation on the ground though
they do spend a few days in the field. Feedback from the field is thus completely lacking.
This component needs strengthening so that the training programmes can be made more
relevant (Lakshmi Krishnamurthy et al, 2001).
There is very little attention paid to the training of helpers, all of whom interact closely with
the children and many of whom become de facto AWWs in the absence of AWWs. While the
latter is not to be encouraged, the fact that they work so closely with the children as well as
have community interactions, warrants their being trained well.
According to the KSCCW, grants are not released in time leading to a lot of difficulties,
especially since trainees continue to be deputed for training programmes. In addition, since
the funds are now being released directly to the AWTC (as per the Udisha norms), KSCCW
has very little fiscal control though they are expected to provide administrative supervision.
The withdrawal of a Field Office (as per a GOI notification) has also meant difficulties in
discharging the role of supervision of the AWTC by KSSCW.
Recommendations
•
•
•
•
•
•
•
The process and methodology of training needs to be given as much attention as its
content.
Evaluation of the effectiveness of training programmes should be regularly held and
corrective actions taken to make it more effective.
Training must look at developing communication skills as well as building the selfesteem and confidence of the functionaries.
Training of AW helpers needs to be regularised.
Joint training programmes of AWWs, helpers, CDPOs and supervisors could be held
so that there is interaction amongst them and they understand each other’s
perspectives.
Training should be an ongoing process. Very often, other than the initial job training
given when a functionary joins service, there is very little opportunity for additional
inputs. The monthly meeting, though visualised as a space for providing ongoing
inputs, is used, in reality only for administrative purposes.
Faculty of AWTCs should visit the field more often to understand the contextual
realities within which the AWC functions as well as to get feedback from AWWs on
the training and its effectiveness.
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ICDS
3.10 Monitoring and Evaluation
Monitoring is largely done through records maintained in about 22 registers and the Monthly
Progress Report and the Monthly Monitoring Report. For the AWW, maintenance of
registers assumes gargantuan proportions, often bogging her down. Every service delivered
as well as stocks have to be accounted for. There are registers for each aspect of the
programme - attendance, food distribution, immunisation etc. In addition, birth and death
registers as also those pertaining to the Stree Shakti programme have been introduced.
The paramount importance given to the registers results in not only overburdening the AWW
but, since it is the only means of verification, leads to falsifications that need not always
reflect the realities in the AWC. It also reflects the complete lack of trust in the AWW and as
a monitoring system is self-defeating ((FORCES, 2003).
Coin nient
The paradigm within which supervision operates seems to be one of inspection and fault
finding. Positive reinforcement of what AWWs do well is rarely given. AWWs view
supervisors as ‘bosses’ whose ‘inspections' have to be feared. Supervision is geared to
finding fault and is neither supportive nor facilitative. The very sharp hierarchy followed
mitigates genuine team work and collaboration.
Monitoring also seems to follow a ‘flavour-of-the-montlf policy. Whatever has caught the
imagination of the administrative and political leadership may be monitored more closely
such as, currently, polio eradication and Stree Shakti.
There is no rigorous internal evaluation system nor is there any space for functionaries to sit
across hierarchies and discuss concerns. There have been many external evaluations, with
most offering similar recommendations. Yet, very few of the recommendations actually get
implemented, suggesting a resistance to change within the system.
As far back as 1987, a NIPCCD report authored by Adarsh Sharma ‘Monitoring the Social
Components of the ICDS- A pilot project' called for community monitoring, stating that “the
present system of monitoring addresses itself to the operation and process of delivery of
services and does not report on quality. The beneficiaries who could be the best judge of the
programme are not included in the monitoring system”. The potential of a Community-based
Monitoring system in ensuring more effective and efficient services is demonstrated through
a Pilot Project operational in four Blocks in North Karnataka (see box below).
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ICDS
BOX 3
Community Monitoring
An innovative project to enable and empower communities, especially women, to monitor
government services in health, education and nutrition, has been initiated by the Department
of Women and Child Development in collaboration with UNICEF and Samuha, an NGO.
The project is operational in two Blocks each of Raichur and Gulbarga districts. These areas
were chosen on the basis of their low performance on development indices such as literacy,
infrastructure, community awareness; high infant and maternal mortality, malnutrition etc.
Groups of women are formed, street- or cluster-wise in each village; each group having about
20 members. Members are trained in understanding government services and schemes
available. They are also helped to understand issues in health, education and nutrition and
areas of concern are identified as ‘red alert’ areas. They are then trained in filling up a
standard questionnaire that seeks to identify the nutritional, health and educational status of
people in their cluster.
Two representatives of each group are selected and form the Village Development and
Monitoring Committee (VDMC). The VDMC meets every 15 days and reviews the status
within their village. This information is consolidated at the Gram Panchayat level and shared
at a monthly meeting alongwith the Medical Officer and Primary Health Centre staff (health
care), ICDS Supervisors (health, nutrition and education), and Cluster Resource Persons
(education). Issues are raised and accountability sought from the concerned officials.
This process of community monitoring has had visible impact. The Anganwadi workers are
more regular; and people ask them questions if the AWCs are closed. Malnutrition is being
monitored more closely. Enrolment and retention in schools have improved.
The biggest impact has been in the change in the attitude of the communities from that
of the government doing them a favour by running a school or a PHC to that of one of
demanding accountability for efficient and effective services.
Recommendations
•
•
The paradigm of monitoring has to shift from one of ‘inspection from above’ to that
of support and facilitation to help the AW functionaries do a better job.
Stronger mechanisms of community monitoring need to be implemented. The Bal
Vikas Samitis4, community-level bodies that seek to enhance community
participation in the AWCs, need to be given more teeth and powers. In addition, they
also need to be trained in what the role expects of them.
1 The nomenclature applied to these community-level bodies by GOI is Bal Vikas Mahila Samiti. However, in
Karnataka they arc called Bal Vikas Samitis, to enable men also to be part of the body.
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ICDS
3.11 The role of the community
The limited view of the role communities can play is seen by the statements of the ICDS.
The ICDS talks of encouraging ‘community participation in its processes of implementation,
by utilising local resources’ and ‘improving the capabilities of parents to take care of the
child and thus to involve the community’.
Given this restricted understanding, it is not surprising that, in practice, community members
are involved in aspects such as contributing fuel, provisions, in some cases space, donating
money for buying toys, uniforms, utensils and furniture etc. for use in
Anganwadi centres (ICDS, GOK website, 2004).
Bal Vikas Samitis (BVS) with representation from women Panchayat members, NGOs and
ICDS functionaries have been formed. This is being seen as a body that would ensure
community monitoring of the programme. While there is no documented evidence of the
impact of this body; conversations with NGOs working in the field point to the role that the
BVS plays as mere token.
People from the local community may also be nominated/ elected/ selected/ co-opted as
members of the Bal Vikas Samitis without having a clue as to their role, and having little or
no power to change things. The boundaries for ‘participation’ have already been drawn by
the programme; nowhere is there space for communities articulating their vision for the
programme nor for monitoring that the programme delivers. For the community, the ICDS is
a government programme whose implementation is the sole responsibility of the AWW.
Against the backdrop of the efforts at decentralisation underway across the country; comes
the suggestion that managing and monitoring the functioning of the ICDS be devolved to
Panchayati Raj Institutions (PRIs), which are seen as representing the interests of the
communities. This is already operational in Kerala.
In Karnataka, the S M Krishna government had passed a Government Order (GO) in May,
2004, to bring the AWCs under the purview of the Gram Panchayat. The GO required the
AWWs to obtain permission from the Gram Panchayat for taking leave. It also required the
Gram Panchayat to certify their attendance. As may be expected, this move has been resisted
by the unions who are egging the new government to withdraw this Order.
While the GO is a positive move to enhance the accountability of AWWs, there is also data
(from West Bengal, for example), that Panchayats use this mechanism to harass AWWs.
It is true that devolution to local bodies will bring the administration of the programme closer
to the community. Yet, it is also to be borne in mind that PRls are not homogenous bodies
that protect the common interest but are ridden with caste, class and gender divides. Unless
the PRIs are empowered to bring about fundamental changes, this move will only mean an
administrative token of convenience and political exigency.
It may be more useful to develop community-owned local institutions, which have parents as
members and which are primarily constituted for monitoring the ICDS and its functionaries.
44
ICDS
Recommendations
•
•
Greater community ownership needs to be built into the system. Looking at the
community as mere figureheads, who ‘participate’ in ways the State thinks fit, is not
very effective in the long run. The community needs to feel that it is their anganwadi
where their children go to get a good start in life. Once this feeling is achieved, the
community themselves will contribute to ensure that the AWC functions effectively.
For this to happen, the ICDS functionaries will have to change their perception of the
community as members who will pool in resources to that of members who will
arrive at how they want the AWC to operate, and take responsibility to ensure its
effectiveness. A stronger training input on this aspect needs to be first ensured.
Stronger and more autonomous Bal Vikas Samitis need to be built, who along with
the Gram Panchayat can take responsibility for ensuring the effective functioning of
the AWC.
3.12 Role of NGOs in ICDS in Karnataka
Over the last decade and a half, one sees the shift in emphasis amongst NGOs from running
alternate pre-school and non-formal education programmes at the micro level to more macro
level interventions that seek to bring about systemic changes in the educational system. The
latter may include efforts to enhance the involvement of the community in educational
matters to interventions that aim at supporting State-level structures. Vis-a-vis the ICDS
programme, the efforts of NGOs such as Samuha, MYRADA, Seva in Action and
Association for People with Disabilities represent some of the initiatives that aim at
enhancing the effectiveness of the ICDS programme.
Another discernible trend, to be seen against the backdrop of a gradual withdrawal of
services by the State; comes the attempt to involve NGOs in the implementation of the ICDS,
in order to demonstrate innovations and possibilities. In Karnataka, Sumangali Seva Ashram,
based in Bangalore, has been running ICDS projects for the last seven years.
3.12.1 ICDS projects run by an NGO
Sumangali Seva Ashram runs 130 AWCs in the slums of North East Bangalore; covering
10000 beneficiaries from the slums of Koramangala, Bansaswadi, Ulsoor, D.J.Halli and
HAL.
The format of the programme is exactly that of the government-run ICDS. Supplementary
nutrition, health check-ups, immunisation and health education and pre-school education are
the key activities. Almost 100% of children from the AWC join regular school - whether
government or private.
The children are given supplementary nutrition of 300 calories per day. Malnourished
children are given twice the amount. Nutritional supplies given by the Department are often
delayed, forcing Sumangali Seva Ashram to invest in making their own supplements.
Awareness on low-cost community nutrition is regularly held.
45
ICDS
Health checkups are conducted every three months and the growth chart of the child is drawn
with records of the immunisation given. SSA also refers the child to other hospitals in case it
is required. Pregnant women and lactating mothers are also given the required medicines and
grains for six days of the week.
Staff are trained through the Department training programmes for ICDS functionaries and
also receive inputs from Sumangali Seva Ashram. While the supervisors and project officers
are trained by N1PCCD, SSA sends newly appointed anganwadi workers and helpers for
training at the Anganwadi Training Centre. In 2002, SSA ran a two-day refresher course for
130 pre-school teachers of the anganwadis; which was funded by the ICDS.
By its own admission and as per the observation of other NGOs working in the field, the
programme implemented by the Sumangali Seva Ashram functions much like its government
counterpart. Sumangali Seva Ashram bemoans the lack of autonomy to take any decisions
regarding the functioning of the ICDS. Every decision has to be mandated by the department
officials. In this light, it seems more like the project being sub- contracted to an NGO rather
than an experiment in innovation; with ultimate control still in the hands of the government.
Delays in disbursement of salaries as well as other grants (deficit of Rs. 61 lakhs, March
2004) is a key problem that Sumangali Seva Ashram experiences. The AWWs complain
about the lack ofjob security and other benefits for AWWs, Supervisors and CDPOs.
3.12.2 NGO Support to ICDS
Training support
Sainuha
Samuha is an NGO that works in four districts in Karnataka - Bangalore Urban, Uttara
Kannada, Koppal and Raichur. They ran balwadis for pre-school education for five years.
The issue of long-term sustainability of an NGO intervention resulted in Samuha closing the
balwadis and strengthening the government-run ICDS Scheme.
Samuha has trained ICDS functionaries of 62 AWCs in Raichur and Koppal. The training
programmes, held every two months, aim at changing the attitudes of AWWs, helping them
understand the critical role of pre-school education in children’s development. Training
programmes are held for both AWWs as well as helpers; the latter whom Samuha believes
have no real training at all and yet, interact so much with children. AWWs from half of the
centres and AW helpers from the other half attend the training programme on any given day,
so that the AWC is not closed. The next training programme sees the trainees being reversed.
The content of the training programme ranges from curriculum and methodology of teaching,
the manner in which children have to be handled, the importance of involving the community
etc. Particular importance is laid on changing the attitude of the AWW and helper towards
the children. In addition, efforts are also made to educate parents on the importance of ECCE
and the AWC as a space for ensuring appropriate inputs to the pre-school child.
46
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ICDS
Samuha has also been involved in upgrading the physical infrastructure of the AWCs through
wall painting, construction of extra space for play and other activities, making the interiors
more child-friendly etc. Samuha sees its long-term role as that of supporting the existing
structure and based on their experience, lobbying for appropriate changes in the programme.
Community Based Rehabilitation Network (CBR Network)
The Community Based Rehabilitation Network (CBR Network) facilitates the networking of
NGOs in the field of CBR and the education of persons with disabilities.
Alongwith the Department of Women and Child Development, CBR Network has embarked
on two projects: Udisha-Portage project on early identification of disability; and joyful
inclusion. The former involves the early identification, intervention and stimulation of
children with disabilities in the ICDS programme. CBR Network has trained 28 facilitators,
345 supervisors and 6878 anganwadi workers in 16 districts.
The joyful inclusion project involves the creation of an inclusive classroom. Using
individualised teaching methods, adapted curricula and tailor-made teaching aids and
materials, children with special needs are enabled to study along with other children in a
school nearest to them. Teachers are oriented to child-focused learning from pre-school to
primary level. CBR Network has trained 30 schoolteachers of three gram panchayats in
Chamrajnagar district as village resource persons and block resource persons.
Association for People with Disabilities (APD)
The Association for People with Disabilities works at the early detection, treatment and
rehabilitation of people with disabilities, in both the Bangalore urban area as well as rural
areas adjoining Bangalore. APD has been involved with the training of AWWs to enable
them to identify children with special needs and either support them through their own
intervention or refer them to specialised agencies. Training is not seen as a one-off
programme but more as an ongoing support process.
Seva in Action (SIA)
Seva in Action is an NGO working on disability issues, focusing on detection, treatment and
rehabilitation as well as training and advocacy.
SIA has been consistently involved with training AWWs in the early detection, assessment
and appropriate intervention for children with disabilities. The initial training programme
was carried out in Manvi Block in Raichur district in 1997. Out of a total of 250 AWWs, 223
were trained. The training focussed on making the AWWs aware of the issues facing the
child with disabilities, the signs to watch out for, how to assess the child and the appropriate
intervention. The Portage checklist model was translated into Kannada and used as an
assessment and intervention guide. The last day they did a door-to-door survey in which 100
children with disabilities were identified and appropriate referrals made.
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ICDS
This training programme has since been carried out regularly. Between 1999 and 2003 - 503
AWWs have been trained in early intervention through an intensive programme of seven
weeks. The training is held over 3 phases with a mix of classroom and field study.
Training is also held for PHC staff. Under the Integrated Education for Disabled Children
programme of the Government of India; resource teachers specialised in education for
children with special needs have been trained and appointed in AWCs and Government
schools.
Adopting and strengthening existing AWCs
AVAS
AVAS is a Bangalore-based NGO working on issues of urban poverty, slum development
and housing. The need for a comprehensive holistic approach to community development
resulted in the organisation initiating work on ECCD.
AVAS works at strengthening the existing ICDS centres and has adopted 13 ICDS centres
and 2 run by the KSCCW in the areas of Koramangala, Jayamahal, Bharatinagar,
Basavangudi, Malleswaram, Varthur and the Hosakerehalli slum of Bangalore; covering
between 750-1000 children in the 2-6 years age group.
AVAS’s role has been in ensuring that the ICDS centres provide quality care. It provides the
AWWs with supplementary income and has mobilised funds for building of community
centres (which are also used for meetings by the community). The centres have been
decorated to reflect a suitable child-friendly environment. Pre-school education through
creative activities and appropriate nutrition form the focus of the programme. AWWs have
also been trained by the Promise Foundation to help build their creativity.
AWWs also participate in the community meeting once a month and discuss issues of
women’s empowerment, health, environment etc.
MYRADA
MYRADA works with 200 AWCs in Mysore district. A Community Health Worker works at
the village level on health issues and supports the local AWW in health-related aspects of the
ICDS such as weighing children, growth monitoring etc.
In addition, MYRADA has contributed in upgrading the infrastructure of the AWCs by
mobilising resources from the Panchayats as well as the community. Resources for the
upgradation are shared between MYRADA (35%), the Taluk/ Zilla Panchayat (60%) and the
community (5%). Each AWC consists of a large open hall which functions as the teaching
learning space, a separate kitchen and a store room. MYRADA has helped enliven the space
to make it more exciting for children through wall painting, provision of play equipment etc.
48
ICDS
While the involvement of NGOs is heartening and needs to be encouraged, caution has to be
taken to ensure that the State does not get into sub-contracting what is legitimately its
responsibility to NGOs, under the garb of efficiency and effectiveness.
4. Key areas for advocacy
The provision of ECCE cannot be viewed as homogeneous across the country. A variety of
approaches and strategies - including but not limited to home-based as well as centre-based are required which take into account the needs of children in different cultural and socio
political contexts. There also needs to be a greater emphasis on meeting the needs of the
child under three years. It is a little distressing to note that the Terms of Reference of
Committee on ECCE of the Ministry of HRD, do not address the child under three years;
stating as its does “To look at the coverage of ECE facilities and to recommend the
requirement, including financial requirement for additional facilities so as to provide Early
Childhood Care and Education to all children in the age group of 3-6 years" (MHRD, 2004).
This being said, more specific recommendations include the following:
•
Enhancing coverage to ensure true universalisation - Ensuring that each and every
child under six years has access to quality health, educational and nutritional services
necessitates a range of approaches. The norm of one ECCE centre within walking
distance from the home of the child, for a population of approximately 300 people
and 20 (+/- 5) children of the related age group recommended by the Committee on
ECCE of the Ministry of HRD (2004), should be accepted and implemented
immediately. In addition, relocation of poorly-attended ICDS Centres to where there
is a real need will also help enhance coverage.
•
Extension of timings - Drawing from the precedent set in Kerala and Tamil Nadu;
the timings of the AWC need to be extended from being a four-hour programme to
being an eight-hour one. This will allow for more time for pre-school activities. Rest
for children can be woven into the programme so that it does not become
burdensome. It helps relieve older siblings especially girls from sibling care, thus
enabling their participation in school. It will also ensure that children of working
mothers are not left unattended for large parts of the day.
•
Initiation of Anganwadi-cum-creches- The National Policy on Education (NPE,
1986) and the Plan of Action for the NPE (1992) stipulate that 25% of anganwadis
need to be turned into Anganwadi-cum- creches. This policy directive needs to be
enforced with more commitment to enable children below 3 years to avail of the
services. This will also be an essential supportive service for working women.
49
ICDS
Location of AWC - Wherever possible, the AWC needs to be physically located in
the primary school. Where this is not possible, functionally there must be links
between the two. This will enable a co-ordination between the pre-school and primary
school education programmes ensuring continuity in the educational experience of
children. This will ensure that the AWW also gets support in her role as a pre-school
teacher. There can also be a convergence of the nutrition programmes.
•
Physical lipgradation - Ensuring that the AWC has its own premises needs to be
given priority. The AWC must have its own physical space with space for children’s
activity, play and rest. The interiors must be colourful and attractive for children in
the 0-6 year age group. Water and toilet facilities must be assured.
•
Additional worker for pre-school education - An additional worker who takes care
of pre-school education may be appointed. Funds may be sourced from the Sarva
Shiksha Abhiyan, schemes for Girl Child etc. There is enough evidence that pre
school education enhances the enrolment, retention and academic achievement of
children. Thus investing in pre-school education would help in ensuring elementary
education for all children: a responsibility the State has committed itself to.
•
Community ownership - Efforts must be made to create structures at the local level
that will enable the community to have a greater sense of ownership over the AWC.
The Bal Vikas Samitis need to be given more power (akin to that of the School
Development and Monitoring Committee for primary school). Members of the Bal
Vikas Samitis must be selected from parents whose children come to the AWC. They
also need to be trained on their roles and responsibilities.
•
Quality - There is overwhelming evidence ’that the quality of ECCE services
determines the outcome. It is imperative that measures to improve the quality of the
ICDS be undertaken, such that all the services produce the desired results. Quality
does not imply a one-time input of training or materials or infrastructure upgradation.
It needs to be seen as a process of continuous improvement capable of making
required changes as the external contexts change.
•
Support system for children with disabilities - We need support systems, which
AWWs can access for dealing with children with disabilities. Ninety percent of the
identification and supportive stimulation for children with disabilities can be managed
by a well-trained AWW. The Udisha-Portage training programme needs to be
implemented on a larger scale. An environment in the AWC and attitudinal shifts and
increased commitment in AWWs, which supports the implementation of this training
need to be given more attention. For children with more severe disabilities, it may be
good to set up a Resource Room within the Cluster Resource Centre, with the
necessary specialised equipment. Senior and committed AWWs could be trained as
specialised resource teachers at the cluster level, and they could support AWWs in
handling children with disabilities at the AWW level as well as work with children
with more severe disabilities.
50
ICDS
Given that the best prognosis for children with disabilities lie in early detection and
appropriate intervention in the first 6 years of life, the period of the most rapid brain
growth; it is imperative that attention be paid to this area.
•
Regional differences - Variations in the performance of the ICDS programme across
districts has been observed with districts in North Karnataka performing worse than
those from South Karnataka. There is a need to document and analyse these
differences. The ICDS will have to allow for regional variations in the programme to
suit local needs. Budgetary allocations and other investment such as training will
have to be geared towards helping districts performing badly to improve.
5. Conclusion and summary
Karnataka has achieved “universalisation” of the ICDS programme. With performance in
areas such as service delivery, infrastructure and training being average, a lot still needs to be
done. Priority must be given to strengthening the pre-school education programme, extending
timings, infrastructure upgradation and enhancing the role of the community. The potential
for early detection and intervention for childhood disabilities needs to be tapped more
vigorously. Training needs to be seen as an ongoing process and supervision as more
nurturing and supportive than currently exists.
As of May 2004, the government has reiterated its commitment to the ICDS and its
universalisation. While this is to be welcomed, it is also true that ‘universalisation’, as the
State defines it does not mean that every vulnerable child is reached. Stronger efforts will
have to be made to ensure that children below six years in tribal pockets, urban slums, hilly
areas etc. have access to health, education and nutritional services. It is only with greater and
more sustained political and administrative will and commitment that this can be achieved.
The road to ensuring that every child in Karnataka has access to health, education, play and
leisure, is a long one, requiring contribution from all sections of society - the community, the
government, the private sector as well as the voluntary sector. We hope that this report will
play its role in tabling the current issues in achieving this challenge and serve as a document
on which to base future actions.
51
ICDS
REFERENCES
1. A Study of Anganwadis in Karnataka undertaken in 2002; The Forum for Creche and
Childcare Services (FORCES); 2003.
2. A Report of the Millennium Survey of Public Services; Public Affairs Centre; 2002.
3. Annual Report, Karnataka State Council for Child Welfare; 2003.
4. Annual Report, Seva In Action; 2003.
5. Annual Report, Sumangali Seva Ashrama; 2003.
6. Chukkimane; Building on Community capacities of Early Childhood Care and Education;
Movement for Alternatives and Youth Awareness (MAYA); 2002.
7. Early Childhood Care and Education; Venita Kaul in India Education Report, edited by
Govinda R; NIEPA; 2002.
8. Early Childhood Development - Programmes in Karnataka; Lakshmi Krishnamurthy,
Vani Periodi and Asha Nambissan; 2001.
9. Integrated Child Development Services, Concurrent evaluation, Karnataka; National
Council for Applied Economic Research (NCAER); 2000.
10. Integrated Child Development Services; Department of Women and Child Development,
Ministry of Human Resources Development, Government of India; 1995
11. Monitoring Social Components of Integrated Child Development Services, A Pilot
Project; Sharma; National Institute of Public Cooperation and Child Development
(NIPPCD); 1987
12. National Family Health Survey (NFHS-2), 1998-99: India; International Institute for
Population Sciences and ORC Macro; 2000.
13. Report of the Committee on Early Childhood Education; Ministry of Human Resources
Development, Government of India; 2004.
14. Udisha - National ICDS training; Department of Women and Child Development,
Ministry of Human Resources Development, Government of India; 2000.
WEBSITES
1. http://disabilityindia.org ; 2004
2. www.indiabudget.nic.in; 2004
3. www.infochangeindia.org; 2004
4. www.geocities.com/righttofood/comrs/comrs_reports.html ; 2004
5. www.newindpress.com; April 22, 2004
6. http://www.kar.nic.in/dwcd ; 2004
7. http://wcd.nic.in; 2004
8. www.unicef.org/infoby country/india.html
52
ICDS
ANNEXURE I - The Intervention of the Supreme Court on ICDS
The Supreme Court has been taking extremely proactive and progressive stands on the
tardy implementation of the ICDS. In response to a Public Interest Litigation (PIL) filed
by the People’s Union for Civil Liberties (Writ Petition (Civil) no. 196 of 2001), the Court
has appointed Commissioners whose brief includes monitoring the implementation of the
Court in matters related to the performance of welfare schemes including the ICDS.
The following figures of coverage, performance and impact of the ICDS which are based
on official figures supplied by the government are alarming to say the least:
•
•
•
•
The ICDS has catered to only 16% of undernourished children all over India
Only 3.4 crore children are receiving the benefits of supplementary nutrition
under the ICDS. This is nowhere close to the number of children in this age-group
(15 crore), the number of malnourished (8.5 crore) or even those from families
below the poverty line (6 crore).
fhe percentage of adolescent girls being covered under the scheme is even less, as
the scheme has not even been made operational in existing anganwadis. The
coverage of settlements is not complete.
In around 14 lakh habitations, only 6.05 lakh have anganwadi centres. Also, states
have placed greater emphasis on the number of anganwadis rather than on the
quality of services they offer.
The performance in Kerala and Tamil Nadu seems slightly better with the Scheme
reaching 50 per cent of the children, whereas in the rest of the country, the average seems
to be below 25 per cent.
Reports of the Commissioners to the Court
The Commissioners submit periodic reports to the Supreme Court. The Third
Commissioners’ Report stresses that “the provision of Integrated Child Development
Scheme (ICDS) in every habitation, as directed by the Court, is not being properly
observed and taken seriously. The Government of India has been more interested in
expanding the ICDS programme than in ensuring that it achieves results. Furthermore,
ICDS should aim to give particular attention to children in the poorest families and
to reach children aged under three”.
The Fourth Report of the Commissioners points to the lack of attention given by most
States to the plight of children from 6-months to 2 years “with no satisfactory
arrangement in feeding this extremely vulnerable group. In this context, States should be
directed to comply with the directions calling for an Anganwadi to be available in each
habitation, and for the coverage of adolescent girls, pregnant and lactating women under
this programme. Moreover, there is a need to direct states to ensure that all slums are
within convenient reach of an Anganwadi and urban homeless children are also
covered”.
53
ICDS
The Court passed an order on November 28, 2003, stating that “every settlement should
have a disbursement centre (anganwadi), and that every child up to the age of six,
adolescent girl, pregnant woman, nursing mother and malnourished child should be
covered by the scheme”.
The DWCD response
In a meeting with the Commissioners, held in November 2003, the Department for
Women and Child development (DWCD) argued that it had “neither the resources nor the
mandate” to universalise the ICDS as directed by the Supreme Court. The programme
does not reach every settlement even within the sanctioned project area and is only
targeted at disadvantaged families. Given the constraints, the Department is interpreting
the Court’s orders “within the existing guidelines”.
Taking serious note of this argument, the Commissioners have recommended that the
Court issue a clarification that the term “settlement”, as used in the November 2003
order, pertains to a cluster of households within a village. The order must not be
interpreted by the DWCD as only including present centres.
The PIL, the Commissioners’ Reports and the Supreme Court orders represent major
victories in the struggle for ensuring food security and combating malnutrition among
children. They are also potent weapons that can be used to ensure compliance at the local
level and need to be more wisely disseminated and applied.
Sources: Indian Express, April 26, 2004
www.newindpress.com, April 22, 2004
http://www.infochangeindia.org/
http://www.geocities.com/righttofood/comrs/comrs_reports.html
54
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Early Childhood Education
Ka vith a Krisk n a m oo rthy
Preschool
CONTENTS
Page
1.
Introduction
4
2. What is Early Childhood Education?
4
3. The imperative of early childhood education
6
4. ECE in India - A historical perspective
9
5. An assessment of the status of ECE in Karnataka
14
5.1 Early Childhood Education undertaken by the Government
5.2 Pre-school Education undertaken by the voluntary sector
5.3 ECE in the private sector
14
20
25
6. Training in ECE
25
7. Issues in ECE
26
8. Directions for future advocacy
28
9. Conclusions
32
References
33
2
Preschool
TABLES
Page
Table 1: Coverage of ECE services in India
12
Table 2: Coverage through ICDS in Karnataka
14
FIGURES
Fig. 1: ECCE strategy under DPEP
17
BOXES
Box 1: Committee on ECCE
31
3
Preschool
1. Introduction
The importance of the first few years of life to future well-being has been acknowledged
the world over. The care and nurturance needed by the new-born and the infant have led
to a host of traditions that continue to be followed to this day. Most of these traditions
have their roots in an understanding of the criticality of this phase to an individual’s
optimal growth and development.
Education plays a critical role in helping a new-born slowly adapt to the world, and grow
to be a healthy member of society. Education is used here not in the narrow sense of
formal, institutionalised education, but to denote a process of learning that begins at birth
and continues throughout life. The new-born, learns - through every interaction, every
smile, and every touch. As s/he grows, s/he requires more and more stimulation that
enables her/ him to make sense of the world. While there is an intuitive understanding of
such processes ingrained within communities; the struggle for survival amongst people
living in poverty often does not allow them to be practiced.
At a macro level, formal education is seen as contributing to the human capital of the
nation; at a micro level, it holds the potential to transform individual lives. While a lot of
attention has been paid to evolving strategies for ensuring elementary education; very
little attention has been given to developing well-thought out programmes - including
home-based ones - for the education of children below six years.
This paper seeks to highlight the critical significance of Early Childhood Education
(ECE)1 or Pre-school Education (PSE) in the development of the child. It then looks at
the trends of ECE, since Independence, in India. A focus on the key milestones in the
development of ECE in Karnataka with a special focus on the governmental and
voluntary sector follows. The paper ends with identifying the current issues as well as
future directions in ECE.
2. What is early childhood education?
At its broadest and most general, early childhood education may be termed as all those
processes and activities that ensure that a child in the under 6 years age group receives
developmentally appropriate stimulation and nurturance, that fosters and enhances her/his
complete physical, cognitive, language, emotional, spiritual and social development. This
may range from stimulation provided at the home, as a natural part of child rearing to that
provided in more structured or institutional forms such as creches, pre-schools or
nurseries.
1 The terms Early Childhood Education (ECE) and Early Childhood Care and Education (ECCE) arc used
synonymously in this paper.
4
Preschool
ECE is seen as a component of Early Childhood Development; which refers to “a
comprehensive approach to policies and programmes for children from birth to eight
years of age, their parents and caregivers”. Its purpose is to promote the child’s total
development (UNICEF, 2001).
Early Childhood Education has been defined by M S Swaminathan Research Foundation
as “a term that describes a programme aimed at providing opportunities for the all-round
development of children between the ages of 2 and 6 years” (M S Swaminathan Research
Foundation, 2000).
The Committee on Early Childhood Education , Ministry of HRD, Government of India,
looks at ECE as ‘preparatory education prior to formal education, including experiential,
incidental and informal education, imparting primarily life skills’.
Making the child below three years visible
Often, ECE is seen as a programme or a set of activities that apply to all children below
six or eight years, when in fact, the needs of the child vary greatly within this broad band.
In addition, most programmes have actually concentrated on the child in the 3-6 years
age group; probably because it is a more manageable group as compared to those below
three years. It is distressing to see that even the Committee on ECE set up by the Ministry
of HRD, GOI; in its Terms of Reference looks at children in the 3-6 years age group and
does not make too much reference to infant stimulation.
For children below three years, ECE would refer to processes and activities that comprise
infant stimulation; including development in the areas of cognition and language, social
interaction, fine and gross motor coordination and emotional growth. This would need to
be addressed primarily by parents and other caregivers in a ‘way-of-life’ approach; which
is informal and part of normal child-rearing. The movement to enhance parenting skills
represents a step in the direction of ensuring that infants secure developmentally
appropriate and adequate stimulation. This approach needs to be integrated into care
giver practices within creches and other institutions for the child below three years.
For children from 3-6 years, ECE would be more structured. While following an informal
approach and without burdening the child; it would look at enhancing the child’s mental,
physical, social and emotional capacities through developmentally appropriate activities.
It would also aim at enhancing the child’s readiness for formal school.
2 This Committee was constituted by the Ministry of Human Resources Development to look at the
coverage of ECE facilities and to recommend the requirement, for additional facilities for Early Childhood
Care and Education to all children in the age group of 3-6 years. It submitted its report in January 2004.
5
Preschool
3. The imperative of early childhood education
Possibly the strongest argument for investing in ECE comes from the perspective of the
rights of the child. Every child has a basic, fundamental right to survival and
development; to the opportunities that will help her/him realise her/his potential to the
fullest. This means, amongst others, an adequate and safe standard of living, health care
and adequate nutrition, education, play and recreation.
In addition, evidence from the disciplines of child development, child psychology
neurosciences as well as studies on the impact of ECE clearly demonstrate the fact that
ECE is not a luxury but an absolute imperative, necessary to the cause of full human
development.
The importance of early stimulation
Recent advances in neuroscience establish that the first few years represent a rapid phase
of brain growth, unparalleled in the rest of a human being’s life. Appropriate stimulation
in this period is the key to later success - both academic and otherwise - in life. The rich
heritage of songs, stories, and games in traditional societies are but a means of providing
a rich and varied stimulating environment for the child to blossom in.
Research tells us that the effects of what happens - or does not happen - during the pre
natal period and the early years of life, last a lifetime (Shore, 1997 in UNICEF, 2001).
The timing of appropriate stimulation is critical. There are periods when the brain is
particularly open to new experiences. If these sensitive periods pass by without the brain
receiving the kind of stimulation for which it is primed, opportunities for various kinds of
learning are substantially reduced.
When children do not get the care they need during ‘developmental prime times’, or if
they experience starvation, neglect and abuse, brain development may be compromised.
While there continues to be a debate on what constitutes the critical period, (since the
brain is capable of malleability and reorganisation throughout life); there is a general
consensus that the best period for intervention is the first five years of life (Gunston et al.,
1992 in UNICEF, 2001).
In addition, the key ingredients of emotional intelligence - confidence, curiosity,
intentionality, self-control, relatedness, capacity to communicate and cooperativeness that determine how a child learns and relates in school and in life in general, depend on
the kind of early care s/he receives from parents, caregivers and pre-school teachers
(Daniel Coleman, 1995 in UNICEF, 2001).
6
Preschool
Impact of Pre-school education (PSE)
As evidence from the neurosciences show, the most critical period for brain development
is over by the time the child reaches school-going age i.e. 6 years. This has implications
on the child’s performance in school.
Micro-level observations (by NGOs engaged in ECE) as well as studies at both micro and
macro levels have proven beyond doubt that children who have had access to ECE are
more likely to enroll in school, show better retention and academic success. This
assumes importance given the large wastage from primary school.
Seventy per cent of children who had received ECE later enrolled in primary school, and
were better adjusted than those children who had not received ECE (Sunder Lal, 1981 in
M S Swaminathan Research Foundation, 2000).
The longitudinal study of the NCERT on the impact of ECE on Retention in Primary
Grades3 establishes the positive role of ECE in promoting cognitive and social skills and
improved participation and learning achievement in primary school. The impact is
evident not only in the initial years but right through primary school. It was also found
that only 31.8% of children with ECE dropped out of school in Grade IV, as opposed to
48.27% without ECE (Kaul et al, 1993).
The national evaluation of the Integrated Child Development Services (ICDS), India’s
largest early childhood intervention programme, found significant differences in children
who went to ICDS centres and those who did not, in terms of higher enrolment and
retention (NIPCCD, 1992). This is supported by micro-level research which establishes
that children who have attended an ICDS centre perform better than those who do not, in
the development of motor and language skills and psycho-social behaviour
(Anandalakshmy et al, 1986; Devadas, 1986; Mistry et al, 1988; Sood, 1987; Tarapore et
al, 1986; Bilquees, 1986 in M S Swaminathan Research Foundation, 2000). They also
performed better in tasks involving “listening comprehension, object vocabulary,
sequential thinking and time perception” (Khosla, 1985; Sahni, 1984 in M S
Swaminathan Research Foundation, 2000).
ECE brings about an improvement in various inter-related dimensions of child
development such as social, cognitive and emotional development (Adish, 1983;
Chaturvedi, 1985; Paranjpe et al. 1985; in M S Swaminathan Research Foundation,
2000).
' The study covered 31,843 children in eights states of India - Maharashtra. Karnataka, Rajasthan, Tamil
Nadu. Bihar, MP. UP and Goa
7
Preschool
While there are no studies to show long-term gains of ECE in India; the High/Scope
study in the US - a carefully controlled study of the ECE Perry pre-school project showed that children who had accessed the ECE programme, were at 27 years better
socially adjusted, showed more participation in community matters, and showed fewer
instances of involvement in crime (Larry et al, 1988; in M S Swaminathan Research
Foundation, 2000). While it is true that these outcomes may be a result of many factors;
one may assume that ECE played a vital role.
The importance of quality in ECE
There is also evidence to suggest that it is not the mere provision of ECE that is important
but that it is its quality that determines outcomes. A significant relationship between the
quality of ECE and the level of learning competencies was established by a study
conducted by the M S Swaminathan Research Foundation on ‘Understanding the
relationship between quality of ECE and learning competencies of children’.
Quality was measured using indicators such as:
•
•
•
•
•
Availability of infrastructure facilities for ECE - including toilet, water,
classroom space, storage space, cleanliness of surroundings etc.
Personal care given to children during routine activities; including grooming,
hand washing etc.
Availability of teaching and learning material, their display and accessibility to
children
Schedule of activities - language and reasoning experiences, fine and gross
perceptual-motor activities, creative and social development activities
Process involved in conducting the activities and opportunity given to children to
participate
The study also established that active learning involving perceptual and motor skills was
the main reason for children’s enhanced learning competency.
This is supported by another study carried out by NIPCCD that reasons that unless an
input is of good quality, children may not develop and demonstrate the competencies
intended to be promoted through ECE (NIPCCD, 1997).
Social and economic reasons
Good quality ECE could also lead to other spin-offs. Universalising ECE holds the
potential to reduce social disparities - of caste, class and gender. If younger siblings are
taken care of, older girls will be released to attend school, ensuring their own
advancement. ECE can enable a level playing field, making it possible for children from
disadvantaged and marginalised communities to fare better in elementary schooling. It
holds the potential to compensate for a poor home environment that provides limited
stimulation, which puts children from such homes at a disadvantage.
8
Preschool
The economic spin-offs would include better productivity as adults; cost savings in terms
of remedial education, health and rehabilitation services; and higher earnings for parents
and other caregivers who have more time to engage in economic activities.
ECE and Basic Education
ECE is the building block of basic education and needs to be seen as the cornerstone of
efforts to ensure Education for All. Recent world conferences testify to a growing
appreciation of the crucial importance of the child's earliest years, and the need to support
families and communities in their role as the child's most influential educator.
Given that the learning capacity and value orientations of children are largely determined
by the time the child reaches the age of formal schooling, efforts to ensure education for
all necessitate programmes that help enhance the child’s cognitive and psycho-social
development as well as help raise the life-skills of families and communities
(www.unescobkk.org).
There is enough documented evidence to show that well-conceived quality early
childhood programmes help meet the diverse needs of young children during the crucial
early years of life, enhance their readiness for schooling, have a positive and permanent
influence on later schooling achievement. In addition, countries that succeed in
mobilising local government, municipalities, communities and voluntary organisations in
the care and education of young children have been able to decentralise and innovate in
their educational systems (www.unescobkk.org).
4. ECE in India - a historical perspective
1953-1966: Onus on voluntary agencies
The setting up of the Central Social Welfare Board in 1953 represents the first step of
Independent India in addressing the concerns of the under six year old child. In 1960, the
CSWB set up a Committee to study problems related to children below six years of age.
The Committee recommended that the government encourage voluntary agencies to run
pre-school centres, with government support. It also emphasised the importance of
training and recommended that a cadre of adequately trained child welfare workers be
prepared.
Accordingly, the CSWB started a grants-in-aid programme for voluntary agencies that
would run centres for pre-school education. In both the First (1951-56) and Second
(1956-60) Five Year Plans, education for children upto six years was an important part of
programmes for the welfare of women and children. The Third Plan (1961-65) period
saw the growth in the CSWB supported pre-schools to 6000, but concern over their
quality was emerging and the care of the young child was still seen within the child
welfare paradigm. The Education Commission (1964-66), while recognising the
importance of pre-school education, continued to reiterate that it be left to voluntary
agencies.
9
Preschool
1968 onwards: The government recognises pre-school education
In 1968, the Committee for the Preparation of Programmes for children (Ganga Sharan
Sinha Committee) recommended, for the first time, that the government invest in
preschool education. The action taken on this was however limited (Kaul, in India
Education Report, 2000).
The Fourth Plan (1969-74) saw the introduction of the Scheme for Family and Child
Welfare, whose objective was to foster the all-round development of the pre-school child,
through comprehensive welfare services, and by strengthening the family to play its role
in the child’s development.
The Fifth Plan (1974-79) represents a breakthrough, at least in letter, from looking at
children’s issues through a perspective of welfare to a more development oriented one.
This is seen in the formulation of the National Policy for Children in 1974, and its
programmatic manifestation in what was to become one of the largest early childhood
development programme - the Integrated Child Development Services (ICDS).
The idea of the ICDS Scheme was first presented at a Conference of the Indian
Association of Pre-school Education (IAPE) in October 1972, by the Chief of the
Department of Nutrition and Family Welfare, Planning Commission of India. It is worth
noting that the ICDS did not initially include any component of pre-school education.
In 1972, the Ministry of Education set up a study group for pre-school education,
which recommended that a comprehensive programme for the development of the
preschool child be undertaken. The study group recommended an integrated approach
interweaving health, education and nutrition into the programme. The IAPE also
submitted a memorandum to the Planning Commission, exhorting it to include psycho
social development of children into the programme. Non-formal pre-school education
was thus introduced as a major component of the ICDS programme along with nutrition
and health.
An expert group on Early Childhood Education was constituted in 1980, which
looked into the problems of pre-school education, especially its quality. The Expert
Group suggested viable models for both the training of personnel as well as for providing
pre-school education to marginalised children in tribal, rural and urban areas. While
action taken on the recommendations was limited, a grants-in-aid Scheme for voluntary
agencies working in educationally backward states was initiated (Kaul, in India
Education Report, 2000).
1986 saw the formulation of India’s first-ever National Policy on Education, which
explicitly recognised the importance of early childhood care and education. ECCE was
viewed as a crucial input in the strategy of human resource development and took into
account the holistic nature of ECCE (see below).
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Preschool
Constitutional and policy directives pertaining to ECE
The Constitution of India
Article 45 (Directive Principles of State Policy) of the Indian Constitution directed the
State to provide free and compulsory education to all children up to the age of fourteen.
The framers of the Constitution wisely understood the imperative of providing what we
now call ECE for the holistic development of the young child.
This has however been diluted with the passage of the Ninety-third Amendment to the
Constitution that guarantees, as a fundamental right, the education for children from six
to fourteen years, through the introduction of Article 21A that reads “The State shall
provide free and compulsory education to all children of the age of six to fourteen years
in such manner as the State may, by law, determine.” As far as ECE goes, Article 45
(Directive Principles of State Policy) now reads “The State shall endeavour to provide
early childhood care and education for all children until they complete the age of six
years.” There is no binding, therefore, on the State to ensure that the child under six
years is provided with ECE.
National Policy on Education (NPE)
The National Policy on Education (NPE) adopted in 1986 views Early Childhood Care
and Education (ECCE) as a crucial input in the strategy of human resource development,
as a feeder and support programme for primary education, and as a support service for
working women. ECCE Policy Directions include the following:
5.1 The National Policy on Children specially emphasises investment in the
development of the young child, particularly children from sections of the population
in which first generation learners predominate.
5.2 Recognising the holistic nature of child development, viz., nutrition, health and
social, mental, physical, moral and emotional development. Early Childhood Care
and Education (ECCE) will receive high priority and be suitably integrated with
the Integrated Child Development Services programme, wherever possible. Day care
centres will be provided as a support service for universalisation of primary education,
to enable girls engaged in taking care of siblings to attend school, and as a support
service for working women belonging to poorer sections.
5.3 Programmes of ECCE will be child-oriented, focusing around play and the
individuality of the child. Formal methods and introduction of the 3 R’s will be
discouraged at this stage. The local community will be fully involved in these
programmes.
5.4 A full integration of childcare and pre-primary education will be brought
about, both as a feeder and a strengthening factor for primary education and for human
resource development in general. In continuation of this stage, the School Health
Programme will be strengthened.
Source: NPE, 19X6, The Report of the Committee on ECCE, Ministry of HRD, GOI, 2004
11
Preschool
Almost twenty years down the line, the above well-intentioned statements remain just
rhetoric. We still do not see any form of integration between ECE programmes and
primary school, except, in some cases, in the DPEP areas. ECE programmes, for the large
part, continue to represent a downward extension of primary education, with the teaching
of the 3 Rs assuming more importance than more developmentally appropriate
curriculum. The pre-school component of the Integrated Child Development Services is
one of the weakest in the overall programme (See Section 5.1)
The NPE envisaged the establishment of 2,50,000 centres by 1990 to cover all tribal
development blocks, urban slums and areas having a substantial SC population, and the
coverage of 70% children in the pre-school age by 2000. The Acharya Ramamurti
Committee set up in 1990, however, noted that only 15% of children in the age group of
3-6 years had received any pre-school education, and only 10% of children in the under 6
years age group any child care service (Kaul in India Education Report, 2000).
The Tenth Five Year Plan (2002-2007)
The Tenth Five Year Plan also talks of the State’s commitment to ECE, and seeks:
•
To reaffirm the commitment of the ‘Development of Children' with a special
focus on early childhood development, not only as the most desirable societal
investment for the country’s future, but as the right of every child to achieve
his/her full development potential.
•
To adopt a rights-based approach to the development of children, as being
advocated by the draft National Policy and Charter for Children (2002).
While the approach paper is meant to only draw up a broad framework; the above
statements again seem like just so much rhetoric, in which politically correct
pronouncements are being made. It remains to be seen how much of this is actually
translated in the ground and in what manner.
Table 1: Coverage of ECE Services in India (2002)
102,70,15,247
Total Population______________________
15,78,63,145
Total child population (under 6 years)_____
7,18,91,067
Estimated population in 2001 (3-6 years)
4,27,862
Number of ICDS centres________________
3,15,03,764
ICDS beneficiaries (under 6 years)________
1,66,55,533
Preschool education beneficiaries (3-6 years)
Source: The Indian Child: A Profile, Ministry of HRD, GOI, 2002
According to this table; in 2002, ICDS serves approximately 19% of children under 6
years. Preschool education is offered to 23% of the 3-6 years population in 2002; as
against the target of 70% coverage aimed for by year 2000. The contribution of
private preschools is minuscule and unrecorded.
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Preschool
The coverage is extremely low, compared to the targets set out by the Programme of
Action, 1992 (POA to the National Policy on Education, 1986). The POA targeted at
setting up 10 lakh ECCE centres in 1995, and another 20 lakh by 2000. But the actual
coverage in 2001 was only about 4.28 lakh centres. The NPE targets laid out by the
Department of Education were to be implemented by the Department of Women and
Child Development; and lack of convergence between them could be one reason for the
limited achievement (Ramamurti, 1990).
The Committee on ECCE, Ministry of HRD, GOI, recommends that ‘For a population of
approximately 300 people and 20 (+/- 5) children of the related age group', there be ‘one
ECCE centre within walking distance from the home of the child. The provision of
home-based ECCE facilities should be encouraged and experimented with for smaller
communities, scattered populations, and tribal and hilly areas’ (Ministry of HRD, GOI,
2004).
Trends in ECE
Three trends are visible from the 1970s. The first is that of a rapid growth of
programmes for children and an expansion in terms of coverage in the ICDS Scheme.
Swaminathan remarks that while the schemes, in design, did attempt to address
educational development of the child under six years; in practice, they often
degenerated into feeding programmes or custodial centres with little regard for
psycho-social development (Swaminathan, 1999).
The mushrooming of pre-school centres - variously called nurseries, kindergartens, play
schools, play homes - represents the second trend. These are privately-run, for-profit
enterprises; more often than not developmentally inappropriate, academically-oriented
programmes, representing a downward extension of the primary curriculum. There is no
regulatory mechanism for such centres, which flourish in both middle and lower-income
communities in urban and rural areas. They have become the role models for the
programme content in the government sector and typify the aspiration of many a parent
(Swaminathan, 1999; Kaul, in India Education Report, 2000). The lack of regulation has
meant that while there has been a lot of innovation and flexibility in some centres in the
private sector, the majority are of very low quality.
The third trend is the growth of the ‘third sector’- the voluntary development
organisations, whose focus lies in the empowerment of groups living in poverty and
their organisation to advocate their own cause. Their perspective and approach make
these organisations - also called non-government organisations (NGOs) - different from
those supported earlier by the CSWB. A variety of innovative approaches, albeit at small
scale, have been initiated in differing contexts, and hold the potential for replication.
These trends are visible in Karnataka too and the analysis of the approach, coverage and
efficacy of the governmental and voluntary sector in Karnataka is detailed in the
following section.
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Preschool
5. The status of early childhood education in Karnataka
ECE in Karnataka is carried out by the government - through the Department of Women
and Child Development’s ICDS programme as well as by local city corporations; by
voluntary agencies and the private sector. The private sector has not been considered
here, except in terms of broad observed trends, since there is very little documented
information.
5.1 Early Childhood Education undertaken by the government
Integrated Child Development Services (ICDS)
The ICDS programme offers pre-school education (PSE) for three hours to children in the
age group of 3-6 years in the anganwadi centres (AWC) through an integrated approach.
The pre-school education component seeks to provide a better linkage between primary
schools and the Anganwadi centers. The programme aims at promoting child-centred
play-way activities, built on local culture and practices that promote the child’s social,
emotional, cognitive, physical and aesthetic development (ICDS, GOI, 1995)
In popular perception as well as observations of organisations working in the field, the
AWC is largely seen as a feeding centre, indicating a lack of rigour and focus on the
educational component.
Targets and coverage
The provision of preschool education through the ICDS anganwadis is limited. In 1982,
ICDS set targets to provide preschool education to only 50% of 3-6 year olds in rural and
urban areas; and 75% of 3-6 year olds in tribal areas. (DWCD). The National Policy on
Education, 1986, aimed to provide pre-school education to 70% of 3-6 year olds by 2000.
Table 2: Coverage through ICDS in Karnataka (2002)
Number of AWCs providing services_____________
39,878
68,26,168
Total child population (under 6 years)____________
Supplementary Nutrition beneficiaries (under 6 years)
24,76,278
36,91,377
Estimated child population, (3-6 years),
(7% of total population, 2001)___________________
Preschool beneficiaries through ICDS_____________
12,85,812
Source: The Indian Child: A Profile, Ministry of HRD, GOI, 2002
Despite ICDS being “universalised” in Karnataka; we can estimate that only about 36 %
of 0-6 year olds are receiving services at anganwadis. About 34 % of 3-6 year olds are
receiving preschool education through ICDS. As we know, the number of marginalised
children requiring services is much more; and 34% falls far short of the targets set by the
NPE.
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Preschool
The number of children enrolled and the number attending an AWC and availing of
preschool education may also vary. Field observations state that there are sometimes only
20 children in the AWC, including 1-3 year olds who may have come with their older
siblings (Lakshmi Krishnamurthy et al, 2001). Numbers of children may increase around
meal-time, reinforcing the perception that the AWC is largely seen as a feeding centre.
Field experiences of MAYA, an NGO working on ECCE issues and educational reform,
supports the observation that coverage of pre-school education is limited. In one of the
low-income areas in Bangalore where MAYA works, there are 22 AWCs to meet the
educational needs of 5000 pre-schoolers, which would work out to 200 children attending
one AWC (MAYA, 2003). This is supported by the observations of the Paraspara Trust
that in Akkiappa Garden, a low-income colony in Bangalore North, a community of 445
families has no AWC.
Pedagogy, methodology and materials
The DWCD along with UNICEF and other groups has developed an ‘activity bank’,
comprising a collection of 100 stories, songs, creative activities and games for the overall
development of the child. An integrated approach of 42 themes has been developed
with one theme being taught each week.
The Department of State Education, Research and Training (DSERT) has developed an
activity-based, thematic approach to ECE called ‘Chilli Pilli’ and trained 2100 AWWs in
10 Janshala Blocks (educationally backward blocks identified by the Department of
Education) in using it. The manual seems developmentally appropriate and very
colourful; but its use has not expanded to the whole State. An annual allocation of Rs.
500 is made for replenishing teaching-learning material.
The reality on the ground, however suggests, that the intent within the ICDS is not being
effectively translated into practice. In 22 of the 37 centres visited in the course of a micro
study by FORCES, an advocacy network on behalf of the young, underprivileged child;
field workers observed no educational activity going on. Often, AWWs were involved in
completing records while children just sat around.
In spite of being trained in developmentally appropriate play-way methods of learning,
the AWW, either because of her own comfort levels or because of parental expectations,
prefers the teaching of the 3 Rs and group activities such as songs and stories. While
AWWs have educational material at their disposal; these are rarely used. For one, they
may be worried about being hauled up for material being ‘spoilt’; there being no funds
for much required replacement. In addition, the numbers of children may sometimes be
large and it is much easier to organise a group activity that does not require distributing
and collecting play materials.
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Preschool
Achievement
In terms of achievement, a study by the NCAER in 2000 found that only 40% of children
are able to describe the activities of the PSE; with it being an abysmally low 15% in the
rural areas of Bijapur and Hassan. While there have been pockets where with highly
motivated AWWs and good support from supervisors and CDPOs, there has been some
impact (eg. Mandya, Dharwad); in general the picture is dismal.
Comment
This being said, different studies have found that coming to an AWC before joining
school has helped introduce the culture of schooling to the child and its family. Children
get used to the structure of a school and its routine and learn to engage in structured
activities and interact with other children (FORCES, 2003). This has led to greater
enrolment; and since the child is used to the habit of school; it has led to greater retention.
In addition, care of younger siblings through the AWC has released older siblings from
the burden of child care, thus freeing them to attend school.
It has been acknowledged by policy makers, academics as well as field practitioners that
PSE has a very important role to play in enrolment, retention and later academic
achievement. The import of this however has not steeped into field practice, resulting in
poor quality PSE being delivered through the ICDS programme. Two recent studies
continue to raise concerns of quality in the ECE component of the ICDS (Upadhayay
et al, 1998; Kaul ct al, 1998) and have recommended a review of the existing
arrangements and provisions from a holistic ECCE perspective.
Given that the ICDS as a programme has reasonably large outreach, and is the only
programme at this scale; it is indeed unfortunate that its performance in pre-school
education is so lacklustre.
District Primary Education Programme (DPEP), 1993
The District Primary Education Programme (DPEP) initiated in 1993, and supported by
the World Bank and other bi- and multi-lateral agencies, aims at improving educational
performance at the primary and pre-primary stage, through a decentralised planning and
implementation approach.
16
Preschool
Fig.l: ECCE Strategy under DPEP
Coordination with ICDS
Opening ECCE centres in
non-ICDS areas
School readiness
Opening pre-primary classes in primary school
Recognising the significance of pre-school education for universalising elementary
education, efforts have been made by the DPEP to strengthen the pre-school component
within the ICDS programme. Supplementary training and appropriate material have been
provided with an aim of impacting the quality of pre-school education within the ICDS.
DPEP also supported the opening of ECCE centres in non-ICDS areas.
A DPEP innovation was the setting up of new pre-school education centres, adjacent
to primary schools, in areas where ICDS was not operational. Evaluations have
indicated that this DPEP model for ECE (adjacent to primary school), was more effective
than the AWC in providing a stimulating environment to children and a feeling of
bonding with the school (Venita Kaul in India Education Report, 2000).
Efforts were also made to improve the ICDS-primary school linkage by encouraging
AWCs to extend their timings to synchronise with the primary school, enabling older
siblings, especially girls, to attend school.
An effort to build programmatic linkages between the ICDS and the school was also
made through continuing the play-way method of learning in the lower primary school. A
component of school readiness was introduced in the lower grades of formal school since
almost 81% of children being enrolled had no prior school experience. (Venita Kaul in
India Education Report, 2000).
Comment
The experience of the DPEP-supported AWCs (with extended timings) is a mixed one. In
areas such as Mandya, where training and other inputs were also received from CRY,
UNICEF etc. the impact has been very encouraging, with higher levels of enrolment,
retention and achievement. This however has not taken place across all DPEP districts.
Also, there seems to be very little ownership of this component in the ICDS, leading to
questions of its sustainability (Venita Kaul in India Education Report, 2000).
17
Preschool
Sarva Shiksha Ablnyan, 2000
The gains of the DPEP are sought to be consolidated through a vertical expansion
through the national programme for Universal Elementary Education (UEE) -the Sarva
Shiksha Abhiyan. The Sarva Shiksha Abhiyan recognises the importance of pre-school
learning and early childhood care and its role in improving participation of children in
schools. It seeks to work through the Integrated Child Development Services for the
provision of ECCE.
A provision of up to Rs 15 lakhs per year in a district for any innovative intervention
including for Early Childhood Care and Education has been made under the SSA.
Provision of honoraria for pre-school teacher, training of Anganwadi Sevikas for Pre
school learning, activity materials, organising training programmes for community
leaders, and promoting convergence between the school system and the ECCE
arrangement are some of the activities that could be supported under the SSA.
(Department of Education, GOI website, 2004).
Further, under the National Programme for the Education of Girls at the Elementary
Level (NPEGEL), which forms a part of the SSA framework, provision has been made
for setting up of community-based child care centres in areas where such services
are not provided under ICDS (Ministry of HRD, 2004).
In Karnataka, as in other States, the SSA is supporting the initiation of AWCs, with
extended timings, in areas where there are none. The infrastructure developed under the
DPEP has now been transferred to the SSA. While funding support is provided by the
SSA, the administration and monitoring is left to the Department of Women and Child
Development, the agency that oversees the ICDS programme. The risk of mediocre pre
school education under the ICDS is of concern in this modality.
Though the national policy seems to indicate a commitment to ECCE; in Karnataka, 45
pre-school centres that were being run under the DPEP have been closed down
following a government order. This may have been done in keeping with the policy
directive of government engagement primarily for education of children above six years,
as evident through the 93rd Constitutional Amendment for free, quality education for all
children in the 6-14 years age group.
Given that the SSA is the major initiative of the Central Government in the area of
elementary education; its scope needs to be enlarged to include the coordination,
supervision of quality, and monitoring of all efforts for ECE. This could be incorporated
into and achieved through the District SSA Plans.
Bangalore Mahanagar Palike
The Bangalore Mahanagar Palike (BMP) runs 78 nursery schools, located mostly in lowincome areas of Bangalore, reaching about 2500 children. While the BMP also runs 11
primary schools, it is in only 3 schools that the pre-primary centres and the primary
school are linked.
18
Preschool
The syllabus followed is similar to that of the ICDS programme, and focuses on joyful
learning. The BMP claims almost 98% retention rate of children in the pre-school
centres. Mid-day meals are provided with partial support from ISKCON.
Teachers are appointed by the BMP, and the minimum qualification is that of X/XII pass
with a Nursery Teachers Training Certificate. Private institutions such as Hymanshu
Montessori teachers’ training centre and as well as the District Institute of Education and
Training (DIETs) have been involved in the in-service training of the teachers.
While in other cities like Mumbai, the Municipal Corporation alone runs primary
schools; in Bangalore, the BMP plays a very limited role with the State Government
taking the responsibility for running almost all primary schools. Whether provision of
primary education is the job of the Municipal Corporation in big cities is debatable.
What is a source of concern is that the BMP seems very ill-equipped to handle the task
of running even 78 nursery schools and 11 primary schools. The links with the State
Government’s Department of Education seem nebulous and the priority for this task non
existent. In the absence of a clear policy for ECCE, the attention given to the educational
needs of children in the under 6 years age group is markedly low.
Karnataka State Social Welfare Advisory Board
The KSSWAB runs creches as well as a Demonstration project for pre-school education.
The Demonstration project was initiated in 1964 and is fully funded by the
Government of India with the KSSWAB channelling funds and monitoring the centres.
18 balwadis were set up to provide recreation, basic education and nutrition to children
below six years. However, following the expansion of the ICDS, the demonstration
projects are not considered useful. The effort is on to shut these centres. This is possible
only when the appointed teachers reach superannuation or in the case of death! Thus,
today 11 centres are being run in Anckal taluk with about 25 children in each balwadi.
The PSE curriculum consists of teaching children songs, stories, concepts such as
colours, shapes etc. Though nutrition forms the major attraction for children to come to
the balwadi, the allotted sum of Rs. 1.05 p per child per day is inadequate. Children are
given ragi porridge, upma, fruit etc.
The balwadis operate in panchayat premises or the local government school. Teachers
need to have completed the Balsevika training prior to joining. Field officers monitor the
programme through monthly inspections to monitor cleanliness, quality of teaching etc.
The emergence of the ICDS and its outreach means that there is duplication within the
same communities. While there seems to be a marked lack of dynamism and interest
within the programme, the programme continues because it cannot be shut down.
19
Preschool
A comment on state responsibility for ECE
The importance of ECE finds mention in both the National Policy on Education and its
programmatic expression - the Sarva Shiksha Abhiyan. The strategy of the SSA to work
through the ICDS has its benefits and limitations. While it can capitalise on an already
existing network of anganwadis; it is also true that, as we have seen earlier in the paper,
the PSE component of the ICDS continues to be its weakest. Unless strong links are built
with the ICDS functionaries, this strategy will only end up in SSA providing resource
intensive inputs and becoming funders of additional anganwadis, which continue to
operate in the old way.
In addition, it is primarily the duty or responsibility of the government to ensure that all
children, including children below six years, have access to appropriate and quality
education. It is only the government which has the resources and the reach that cannot be
matched by any other agency; which makes it all the more imperative that the
government enters the pre-school education field in a more planned and conscious
manner; giving pre-school education the priority it deserves.
The quest for
universalising elementary education needs to begin with ensuring quality, universal
pre-school education.
5.2. Pre-school Education undertaken by the voluntary sector
The last couple of decades have seen a growth in the number of voluntary development
organisations, also called non-government organisations (NGOs). NGOs have been
playing a critical role in working directly at the field level to address issues of
marginalised communities, and using this knowledge to lobby for and advocate desired
policy changes.
In the field of ECE, NGOs have been involved in running pre-school centres for children
in the 3-6 age group, and sometimes creches for children below six years. These
programmes have largely been small-scale, limited to the areas of operation of the NGO
- often a few slums in urban areas, and a few villages in rural and tribal areas.
NGO programmes are generally more flexible and allow for more innovation than other
large-scale programmes permit. In this section, we will review the work of NGOs
involved in ECE in the city of Bangalore.
Some NGOs such as Akshara and MAYA run or help communities run ECE centres.
There are others such as Akshayam, The Promise Foundation and Sutradhar that provide
early learning materials or training to anganwadis and balwadis. There are also NGOs
that have a different approach; such as teaching parenting skills.
20
Preschool
Akshara Foundation
The Akshara Foundation is an NGO founded in 2000, and believes in private-public
partnership to attain its goal of Universal Primary Education for every child below eleven
years of age in Bangalore. This partnership involves the Government, the local
community, the corporate sector and individual partners. Akshara enjoys a good strategic
relationship with the government and has key functionaries of the Department of
Education on its Board.
The pre-school programme
Recognising the lack of government facilities for pre-school education and realising its
importance in the campaign for universalisation of primary education; Akshara
Foundation started a Balwadi or pre-school programme. The programme is directed
towards children in the age-group of 3-5 years and focuses on preparing children for
primary school. It also seeks to make education a priority for parents.
Akshara begins by identifying an Educational Block and delimits a School Zone within it.
The School Zone refers to an area of 1 kilometer around the school or 500 children
around the school. A survey of all children in the 3-5 age group is done in the School
Zone. A local community person is identified as a volunteer to teach children. More than
90% of volunteers are women.
Following a screening process, the volunteers, who are at least high school graduates, are
selected and trained for 4-5 days in child development, the pedagogy of teaching very
young children, community participation, and modalities of conducting classes.
Most of the centres are run in the volunteers’ home for 2 hrs a day. Each class has around
20 children who are taught using the play-way methodology. Once the child crosses the
age of five years, the volunteer assists the parents to enroll the child in formal school.
According to Akshara, 90% of the children enrolled in primary school have been
retained. In addition, observation indicates that children from the Akshara balwadis
perform better in school compared to children with no earlier school experience or even
children who attend the ICDS Anganawadi.
An honorarium of Rs.300 per month is paid to the teacher. In addition, she is also
allowed to charge fees from the children. In June 2003, a one-week comprehensive
training was provided to 46 balwadi volunteers who have been termed as ‘edupreneurs’.
These edupreneurs have been given an ECCE kit, and supported to set up balwadis in
their own communities. As on Sept, 2003; Akshara ran 321 pre-school centres for 4,968
children. 42,869 children have accessed pre-school education over the last three years.
Comment
Concerns of quality and sustainability loom large with the Akshara approach. By their
own admission, conditions are not often ideal - the volunteer may be cooking while
simultaneously ‘teaching’ children; the rooms may be dingy and lack ventilation. In
addition, whether a one-week training programme is sufficient to train teachers is
questionable.
21
Preschool
In terms of sustainability, the Akshara approach seeks to identify all 3-5 year old children
in a community and with inputs of pre-school education, enroll them into primary school
once they are five years of age. In any particular area (School Zone, of one kilometer
radius), it is assumed that this task will take about 2-3 years. Beyond this Akshara
believes that the community will have to take responsibility. While ultimately the most
sustainable model would be that of community ownership, this can happen only if there
are clear and conscious steps to build the institutional capacities within communities. The
Akshara team has yet to think through strategies for this.
MAYA
MAYA (Movement for Alternatives and Youth Awareness) is a development
organisation working on issues of child labour and elementary education refonn, through
the building of community-based institutions.
MAYA’s foray into ECCE began as a strategy for the elimination of child labour. Pre
school centres were initiated in response to the observation that older children stay at
home to look after younger siblings; or younger children accompany their parents and
older siblings to work, rather than going to school. MAYA analysed that exposure to pre
school had a positive impact on the schooling opportunities of children; in inculcating a
habit of learning and a culture of schooling.
Initially, in 96-97, MAYA ran the pre-schools. However, it soon became apparent that
unless the community took on more responsibility, the programme ran the risk of being
external to the community. This had implications not only on its sustainability, but also
went against MAYA’s core belief in building the community’s capacities to respond to
their issues. Mahila sanghas (women’s groups) were therefore facilitated to run the pre
school centres. Discussions are held to establish the need for a preschool, to find space
and teachers, to communicate with parents, and supervise the preschool.
The monthly fee of Rs. 25/- forms the honorarium of the teacher. Parents and teachers are
supported to create learning aids through locally available materials. Community groups
raise additional resources by approaching elected representatives and individuals in their
locality.
Training of teachers is on-going, including weekly theme-based planning sessions,
monthly meetings and refresher trainings. The approach is eclectic and informal, drawing
on Piaget, Gardner and Montessori, with mixed and ability grouping of children.
MAYA sees its role as building the institutional capacity of the co-operatives to run the
pre-schools, on the one hand; and of building the capacities of the teachers, on the other.
At the end of 2003, MAYA has facilitated 90 centres reaching out to 2200 children. In
MAYA’s working areas, around 70% of the children in the 2-6 years age group now have
access to an ECCE facility. Since initiation, about 430 children have been enrolled into
formal
school.
22
Preschool
Comment
The strength of the MAYA approach lies in its focus of building community-level
institutions for addressing ECCE. While this model seems to have achieved success at the
local level, it remains to be seen whether it can be replicated at scale.
MAYA is trying to find ways of ensuring that structures of community ownership
become part of the mainstream political structure. This will ensure that not only are
children's rights in the local area addressed, but also that, community institutions become
an important voice to articulate policy agendas.
Paraspara Trust
Paraspara Trust has been engaged with ECE in an attempt to prepare children to join
primary school and to prevent children from slipping into child labour. Paraspara is
currently running 14 balwadis with about 400 children in the 3-6 years age group
accessing the services. An attempt is being made to have communities run the balwadis.
The programme focuses on pre-school education. The curriculum consists of songs, play
activities, stories and pre-writing and reading skills. Paraspara trains teachers. Classes are
conducted in the teachers’ homes or in community halls or other spaces located by the
community. Each centre has about 30 children.
Paraspara has also worked with ICDS anganwadis in two areas -Vivekananda Block and
Subedraplaya, in extending the timings and enhancing pre-school education. However
this intervention has been withdrawn due to lack of funds.
Sutradhar
Sutradhar is an educational resource center involved with the design and dissemination of
early learning resources. One of their innovations is an “Early Learning Kit” developed to
promote the all-round development of children from 3-6 years. It includes threedimensional, sturdy, and pedagogically rich materials for young children to use,
complementing locally available material. In 2000, a thousand of these kits were tested in
government-run anganwadis across Karnataka, with the support of CRY. Anganwadi
workers and CDPOs were oriented on how to use the play materials. The project included
follow-up visits to understand the effectiveness of the material.
Network for Information on Parenting/ Community Health Cell
The Community Health Cell is engaged in action and research in community and public
health issues, in the low income areas of Bangalore.
In early 2002, CHC initiated a parent skill programme for the Balamandir Research
Foundation in Chennai, involving 13 local organisations, including MAYA and APSA.
The development of training and tools included a learning-to-play calendar, with follow
up programmes in the field.
23
Preschool
As a result of this programme, the Network for Information on Parenting was formed in
March 2003, to understand nutritional requirements, care and bonding, gender issues,
disability, pre- and ante-natal care, and female foeticide, among other issues. This
information, disseminated over several months, is now available in Kannada, Tamil and
English.
This effort represents a larger global movement of building and enhancing parenting
skills. Special attention is played to developing skills of parents and other caregivers so
that they are better able to respond appropriately and adequately to the child’s need for
stimulation, laying the foundation for the child’s all-round development. This is seen as
an intervention in enhancing the environment in which the child grows, helping her/ him
thrive and develop to her/ his full potential.
The Promise Foundation (TPF)
The Promise Foundation set up in 1987 provides services in the area of mental health,
education and potential realisation.
Recognising the need for early childhood
intervention for cognitive development, TPF has a two-level Stimulation Intervention
Programme (SIP) for children in the 3 to 6 years age group.
Promise Shishukendra is a preschool and demonstration centre catering to the needs of 30
children in a slum in Koramangala. The pre-school demonstrates TPF's methods for
early childhood care and stimulation. With the aim of laying strong foundations for later
formal learning, the preschool lays emphasis on literacy acquisition skills, balancing all
round stimulation with individualised school-readiness stimulation.
TPF conducts training programmes primarily for anganwadi workers, ECCE workers in
NGOs, and community-based organisations. The programmes range from monthly
sessions to modular inputs spanning 3 to 12 months. TPF specialises in training people
who work in the rural sector and urban slums. An early stimulation kit has been
developed that is given to every trainee.
Akshayam - Cognitively Oriented Programmes for Pre-School Children
Based on the Play House Nursery School experience (since 1966), and several
experiences from children in rural areas as well as children with special needs; Indira
Swaminathan of Akshayam evolved the Cognitively Oriented Programme for Pre-School
Children (COPPC). This has also been used with anganwadis run under the ICDS.
Initiated in 1985, COPPC training was given to 140 child workers, including nursery
teachers, Balasevikas, and anganwadi workers and trainers. The ripple effect of this
training has since extended to 60,000 anganwadi and balwadi workers, and over a lakh of
pre-school children.
24
Preschool
Comment on voluntary sector involvement
The voluntary sector has shown innovative experiments in ECE. The initiatives have
focused on building the preschool-primary school linkages, on supporting government
programmes for universalisation, and on strengthening community capacities to own and
run ECE programmes. While some organisations support the efforts of the government,
others work towards making the State institutions more accountable; still others focus on
building community institutional capacities.
The role of these initiatives in the larger canvas of ECE has been that of highlighting
issues that need to be addressed in the government sector. While these initiatives have not
been at scale, they do hold important lessons that can be assimilated in mainstream
initiatives.
5.3. ECE in the private sector
The last two decades has seen a mushrooming of privately-run ECE centers; variously
called play schools, play homes, nurseries, pre-nurseries etc. While they began as centres
catering to children of the upper income groups; today they exist in urban poor
communities and in rural areas as well. They are said to have contributed to decreasing
enrolment in government-run facilities, discredited as the latter are in popular perception.
The focus on English education and preparation for an English-medium primary school
seem to be the reason for their appeal.
One of the reasons it is difficult to make any analysis on this sector is that there is so little
data. We have no idea about their magnitude, as they are not registered. There is also no
uniform curriculum save for the fact that they represent a downward extension of the
syllabus of the first few years of primary school. Often, developmentally inappropriate
activities such as writing are introduced at ages as young as two and a half.
These initiatives are often staffed by untrained persons, leading to a fall in the quality of
the programme.
6. Training in ECE
ECE training takes place under the auspices of the government, voluntary as well as
private sectors.
Training by the government
A large part of the training undertaken by the government is geared towards preparing
functionaries for the different government schemes - primarily for the ICDS. A 52-day
training programme for Anganwadi workers, a 65-day training programme for
Supervisors and a 60-day training is held as soon as the functionaries are recruited.
Periodic refresher training programmes are also held.
25
Preschool
In addition, pre-service training is offered by the Department of Education that runs 6
Nursery teacher training institutes. The DSERT (the state body of the NCERT) prepares
the syllabus and curriculum for the course.
The District Institutes of Education and Training (DIETs) as well as the Block Resource
Centres (BRCs) established under the DPEP programme also have an ECE component in
their elementary education programme, which may be seen as an attempt to strengthen
the linkages between pre-school and primary school, at least in training.
According to the National Council for Teacher Education (NCTE); there are 68
recognised courses at the pre-primary level out of the total 2871 courses recognised for
all other levels. 12 of the pre-primary courses are in Karnataka.
The pre-primary courses nationally are approved for an intake of 3021 students only,
which is insignificant in relation not only to existing requirements, but also with
reference to future demand. In addition, there are courses run by the Rehabilitation
Council of India and by many NGO and other private systems that prepare human
resources for their own requirements, but these do not significantly add to the overall
pool of ECE workers (Ministry of HRD, GOI, 2004).
Training by NGOs
The Karnataka State Council for Child Welfare (KSCCW) runs an eleven-month course
(Bal Sevika Training) on preparing young girls - who have passed their matriculation—
as child care workers. 40 batches of child care workers have been trained by KSCCW.
Trainees study child development, pre-school education services, health, hygiene and
nutrition.
In addition, NGOs are also involved in providing specific inputs to government
programmes. For e.g. Seva in Action and Association for People with Disabilities (APD)
have been training Anganwadi workers on identification and rehabilitation of children
with disabilities. Pedagogic training on a small-scale has also been undertaken by NGOs
like Samuha and Paraspara.
7. Issues in ECE
The invisible child below three - the child below three years exists in almost all
policy documents and programme design. Interventions with this group have
however, largely focused on health and nutrition, two critical components of
growth. There is evidence that the child in this age group too requires educational
- cognitive and language - stimulation; which is not often addressed. The recent
efforts at developing parenting skills seem to be a movement in ensuring
appropriate stimulation for the child under three years, and needs to be
encouraged. Interventions focused on this age group need to look at alternative
strategies such as family-based care, in addition to centre-based care.
26
Preschool
Limited reach of services — Given that there is so much evidence of the critical
need for early stimulation for realising every child’s potential; it becomes
imperative that priority be given to ensuring universalisation of quality ECE
services. Currently only about 19% of children in the under 6 age group seem to
be accessing any kind of ECE (Venita Kaul, India Education Report, 2000).
•
Neglect of ECE by Department of Education - The ICDS as a programme
focuses, at least in design, on convergence of different departments. However, in
practice its primary focus is on health and nutrition. The role of the Department of
Education is minimal, if at all. A recognition of the crucial role of ECE in
enrolment, retention and later academic achievement necessitates that ECE be
taken more seriously in our quest for universal elementary education.
This assumes importance since the Department of Education’s strategy for ECE is
to work within the framework of the ICDS. Unless stronger links are built
between the two departments, the danger lies in the pre-school component of the
ICDS running in much the same mediocre manner.
•
Quality Concerns - There is evidence to state that not only is ECE important but
that it has to be of a certain quality to have an impact. Given this, more efforts are
needed to regulate and ensure certain minimum levels of quality especially in the
unregulated private ECE services, much of which have degenerated into ‘teaching
shops’. In the governmental sector, what is needed is more optimum utilisation of
resources to ensure quality services. Monitoring and supervision, including that
by the community, need to be strengthened.
•
Training - Much of ECE training is happening within the government sector and
is geared towards staffing government programmes. Though there are fairly strict
prescribed norms for in-service and refresher trainings; often, the reality is that
many functionaries have not undergone any training.
Teachers in the unregulated, privately-run ECE centres are not mandatorily
required to have any formal qualification, and this dilutes quality. There is a
great need for ensuring that training of a certain quality is provided.
There also seems to be a gap between the ‘ideal’ in terms of what is taught in
training schools and the ‘reality’ of what is practiced in ECCE centres. A classic
example is the stress on learning the 3 Rs in an anganwadi, while what is
supposed to be followed is an informal methodology. Bridging this gap and
making the programme more sensitive to field realities will enhance the quality of
the programme.
27
Preschool
•
Community alienation - Within communities exist a rich treasure of songs,
stories and games that fulfill the developmental needs of the very young child.
These need to be built upon. Imposition of a centrally formulated curriculum and
patterns of learning alienate the child and her/his family from what is culturally
acceptable. ECE then begins to be seen as a service external to that of the
community, making it impossible for the community to take any ownership.
•
Absence of linkages - ECE needs to be integrated with what follows in the
child’s life educationally viz. primary school. A shared understanding between
teachers in ECE centres and primary school needs to be developed. A document
that summarises where the child is developmentally may be introduced; one that
the ECE teacher gives a child prior to her/ his admission in primary school. The
two stages - ECE and primary - are also seen as distinct, especially in the
government-run programmes where they are administered by different
departments. This barrier may be broken through the upward extension of the
ECE curriculum by ‘focusing on themes/concepts, skills and competencies to be
developed in primary classes rather than lessons/syllabus to be completed’
(Ministry of HRD, Gol, 2004).
The Committee on ECE of the Ministry of HRD, GO1, also recommends locating
the ECCE centres near the primary school and synchronising the timing with the
primary school. Proper linkages between ECCE and primary education may also
be established through school readiness programmes and joint in-service training
of ECCE workers and teachers of early primary grades (Ministry of HRD, GOI,
2004).
8. Directions for future advocacy
•
Age-appropriate intervention - Given that the developmental needs of children
vary according to their age, it may be useful to disaggregate ECE services on the
basis of age. Thus a programme for children below three years will need to look
at a primarily home/family-based intervention and institutional options such as
creches that emphasise health and nutrition along with appropriate stimulation.
This could be handled as a convergent programme meeting health, nutrition and
early stimulation needs by a programme such as the anganwadi-cum-creche run
by the Department of Women and Child Development.
Enhancing parenting skills as well as skills of other caregivers (in institutional
settings such as orphanages, for instance) through parenting programmes that are
contextualised within the experience of parents and care-givers is critical. Such
programmes could address the fundamental question of how parents can meet the
developmental needs of the child appropriately.
28
Preschool
For the 3-6 year old child, it may be best to locate services within the primary
school. The DPEP experience shows that this is a far better model to meet the
educational needs - both present and future - of the child. This allows the child to
get into the habit of schooling at an appropriate stage. The presence of an older
sibling in the vicinity is reassuring both for the younger child as well as the older
sibling.
The programme for the 3-6 years old child can be further broken into two sub
stages - 3-4 and 4-6 to allow for differences in their capacities (Venita Kaul in
India Education Report, 2000).
The Sarva Shiksha Abhiyan - the GOTs universalising elementary education
programme - would seem to be the appropriate vehicle for this. It is also
important that not only is the pre-school centre located within or very close to the
primary school but that there is also an interlinkage between the curriculum and
teaching methodology. Rather than a downward extension of primary school
curriculum into the pre-school curriculum, it would be more effective to ensure a
bottom-up, process of integrating developmentally appropriate syllabus at the
lower primary classes.
In addition, given that a large majority of children coming into Std I have no prior
school experience, it may be worthwhile to introduce a school readiness
component in Std I. This may be integrated into the functioning of the Department
of Education.
•
Supportive interventions - Interventions such as nutrition and health form an
important component of any effective ECE programme. Research indicates that
short-term memory, alertness and capacity to process information, among other
processes, are adversely affected by nutritional and health deficits (Levinger,
1994 in Venita Kaul, India Education Report, 2000). A supplementary nutrition
programme can be organised along with the primary school meal programme.
While ICDS offers this support, privately-run pre-schools as well as those run by
voluntary agencies and other governmental agencies such as the DEEP and SSA
also need to incorporate health and nutritional support into their programmes.
•
Addressing quality concerns - Quality concerns abound both in the
governmental as well as the private and voluntary sector. Quality would imply
setting up mechanisms that allow for a continuous improvement based on
feedback from the end user. Within the government sector, this may involve
ensuring a better and more optimal utilisation of resources, better supervision and
monitoring, as well as substantive upgradation of the programme. Within the
private sector, there is an urgent need for registration so that accurate data about
such centres is made available. This can then form the basis for ensuring that all
ECE centres in the State follow certain standards.
29
Preschool
Preschool materials - While the government has allocations for preschool
materials, this money is often given to the Zilla Parishad to spend; and at that
level, the materials available may only be KG cardboard and thermocolc. Efforts
need to be made to scrutinise the process of purchasing materials; which is based
on inviting tenders, sometimes at the cost of quality; and promoting corruption.
Resources need to be available annually; so that play materials become a recurrent
rather than a one-time expenditure. This would be a true gesture of the state’s
commitment to improving the quality of preschool education.
•
Regulation of the private sector - As we have seen, the private sector caters to a
large number of children. Quality issues loom large in such centres, managed as
they are by largely untrained people. In the absence of some basic criteria,
including amongst others, space, training of teachers, appropriate teaching
learning material and methodology; what goes in the name of pre-school
education is potentially harmful. In Maharashtra, FORCES has taken up the task
of setting up a regulatory body to monitor the quality of pre-schools and offer
accreditation. As a first step, registration of all ECE centres within Karnataka
may be undertaken. However, care should also be taken to ensure that regulation
does not imply greater bureaucratisation; such that genuine innovation and
flexibility is thwarted.
•
Community ownership - The root of a lot of dissatisfaction and lack of impact
of developmental interventions may well lie in the fact that the communities for
whom they are meant are completely alienated from the design and delivery of the
intervention. A sense of ownership of communities can only emerge if ECE
interventions build on their own capacities. It is important that communities
articulate what they would like from an ECE service. While there can be a broad
framework which may be uniform, these community articulations would need to
determine the content and process of ECE, contextualising it within their own
traditions, while at the same time bringing in aspects from current thinking. This
will lead to a greater accountability of both the service providers as well as the
community in ensuring that quality ECE services are delivered.
Curriculum for ECCE - Developmentally appropriate curriculum needs to be
developed for ECE programmes. The idea is not to burden the child but introduce
pre-school concepts in a way that catches the imagination of the child and builds
on her/ his innate curiosity and desire to learn. The curriculum should allow for
activities that help in the overall development of the child including physical
motor development, language development, socio-emotional development,
cognitive development and development of aesthetic and creative expression.
The programme must be joyous and built on the child’s interest.
30
Preschool
BOX 1____________________________________________________________
The Committee on ECCE set up by the Ministry of HRD, GOI, in its Report
(2004) has come up with following recommendations, which are extremely
comprehensive:
•
•
•
•
•
•
•
Learning at this stage should be characterised by group activities, play
way techniques, language games, number games and activities directed to
promote socialisation and environmental awareness among children.
Children should be provided with ample opportunities for developing the
essential skills of identification, comparison, matching, naming, seriating,
drawing and counting without subjecting them to formal ways of learning
numbers etc.
The methods of ECCE have to emphasise the activities arising out of the
child's interest and not due to teacher initiatives. There has to be more
focus on free play activities rather than guided and controlled activities.
The basic approach to early childhood education has to be “learning by
doing” and “learning through exploration”. The play component is the
central theme for promoting quality early childhood education. Pretend
play, dolls' play, puppet play, playing with blocks, puzzles and variety of
local specific games are important ingredients of quality.
Child-to-child interaction and child-nature interaction should also be
promoted apart from organising activities helpful in developing positive
attitudes and habits for healthy social participation. Children should also
be encouraged to play with pets, recognise common birds, animals, plants
and means of transport and some celestial bodies such as the sun, moon
and stars.
The curriculum should lay emphasis on activities like stories, rhymes,
music, clay work, drawing and painting and other forms of play. Local
plays, games, cultural contents should be appropriately integrated into the
programme.
All ECCE programmes should identify and appropriately integrate
children with special needs.
Formal teaching of subjects, reading and writing must be clearly
prohibited.
31
Preschool
9. Summary and conclusions
The recognition that the first few years of a child’s life are most critical to her/ his
optimal development has led to a dramatic rise in the magnitude, nature and scope of
ECE programmes over the last two decades. ECE programmes are today being run by
government, private as well as voluntary agencies. While the trend of ensuring ECE to
the child below six years is to be welcomed; we also observe a great variation in the
quality of the programmes. The lack of regulation of the private and voluntary sector and
inadequate supervision and monitoring in government programmes has led to diluting the
potential of early childhood education.
It is imperative that age-appropriate programmes are developed to cater to the changing
developmental needs of young children. Particular attention needs to be paid to the child
under three years, for whom home-based and community-based programmes may be
most relevant. Programmes for children in the age group of 3-6 years need to be
integrated within the primary school system to allow for a smoother transition. There has
to be greater integration between ECE programmes and primary school in the areas of
curriculum, teaching methodologies and monitoring the development of the child.
The constitution of a Committee on ECCE by the Ministry of HRD, GOI speaks of the
commitment of the State to address ECE matters. The report of the Committee, submitted
in January 2004, represents a comprehensive study of existing facilities as well as makes
some far-reaching recommendations. These recommendations need to be implemented in
both letter and spirit.
32
Preschool
REFERENCES
1. A Study of Anganwadis in Karnataka undertaken in 2002; The Forum for Creche and
Childcare Services (FORCES); 2003
2. Annual Report, Karnataka State Social Welfare Advisory Board, 2002-03
3. Chukkimane; Building on Community capacities of Early Childhood Care and
Education; Movement for Alternatives and Youth Awareness (MAYA); 2002
4. Early Childhood Care and Education; Venita Kaul in India Education Report, edited
by Govinda R; NIEPA; 2002
5. Early Childhood Development - Programmes in Karnataka; Lakshmi Krishnamurty,
Vani Pcriodi and Asha Nambissan; 2001
6. Impact of ECE on retention in primary grades; A longitudinal Study; Venita Kaul et
al;NCERT; 1993
7. Integrated Child Development Services, Concurrent evaluation, Karnataka; National
Council for Applied Economic Research (NCAER); 2000
8. Integrated Child Development Services; Department of Women and Child
Development, Ministry of Human Resources Development, Government of India;
1995
9. Quality matters -Understanding the relationship between quality of early childhood
education and learning competencies of children; MS Swaminathan Research
Foundation; 2000
10. Report of the Committee on Early Childhood Education; Ministry of Human
Resources Development, Government of India; 2004
11. The First five Years - A Critical perspective on Early Childhood Care and Education
in India; edited by Mina Swaminathan; 1998
12. The State of the World’s Children 2001; UNICEF; 2001
WEBSITES
1. www.kar.nic.in/dwcd; 2004
2. wcd.nic.in; 2004
3. www.education.nic.in; 2004
4. www.unescobkk.org; 2004
33
■r
•/ 'MH*
i
«■
13?*^
.-’■i
■ ■ y
Health and nutritional status of the young child
Dr. Maya Mascarenhas
Health
CONTENTS
Page
1.
Introduction
4
2.
The child and the health care system
5
3.
Programmes and policies for the child in India
9
4.
Factors that impact child health
13
5.
Nutrition and child health
16
6.
Status of child health in India
19
7.
Status of child health in Karnataka
23
8.
Moving forward
27
9.
Conclusion
30
References
31
Annexure
33
2
Health
TABLES
Page
Table 1: Comparison of key child heath indicators
20
Table 2: Health indicators of Karnataka and Southern States
24
Table 3: District wise child health indicators
25
FIGURES
Fig 1: The Public Health System
6
Fig 2: Multiple factors related to malnutrition in India
19
Fig 3: Interstate variations in Childhood Mortality
21
Fig 4: Immunisation coverage in Karnataka
26
BOXES
Box 1: Key Indian Policies on Children
9
Box 2: Low Birth Weight
17
Box 3: Common Indicators used to measure status of child health
20
Box 4: Major causes of childhood
21
Box 5: Key suggestions
30
3
Health
1. Introduction
Every child has basic rights to health and health care. While India has made huge
technological advances and improved its health systems, too many infants and children
are still dying and many more do not develop to their full potential due to illness. What is
worse is that most of the known causes of death are preventable. Even though we have
the technical expertise to tackle these problems; most of our policies and programmes,
although appropriate, are not effectively implemented.
The average Indian child has a poor start to life. There are nearly 160 million children
under six years of age in India: making up a significant 12% of the total population. Poor
health at this age has an impact right through adulthood. In fact, almost two million
children die each year before reaching their first birthday. Childhood malnutrition has
long term effects on cognition and physical development. Preventable and treatable
illnesses such as diarrhoea cause many young children to die.
Various factors determine the status of child health in India. Amongst them, the key
factors are related to poverty, living conditions, and the mother’s health status during
pregnancy and childbirth. Children who are
more frequently ill, often from preventable
Did you know??
infectious disease; and those who are
malnourished, and more likely to
• 1 in 11 children in India die before
die of their illness; are from the
their 5th birthday.
very young and underprivileged
• 8 lakh children die due to diarrhoea
populations within developing countries.
each year
• One in two children is
Inequities are seen in both access and quality
malnourished.
of care. Each day, millions of parents seek health
• Every 3rd child is born with low
care for their sick children; taking them either to
birth weight
hospitals or primary health centres, pharmacists,
• Two thirds of children are anaemic
doctors, or traditional healers. Poor quality of
• Only 42% are fully immunised
treatment and advice, lack of basic diagnostic
• Only 20% get enough Vitamin A to
facilities, equipment and drugs are what they
prevent blindness
get in return.
• 60 million children live below the
India has made an attempt to improve the
poverty line
health and nutritional status of its children
through its vast public health system and
programmes such as the Integrated Child Development Scheme (ICDS) and the
Reproductive and Child Health Programme (RCH). Karnataka’s performance in health is
mediocre at best, and lower than its neighbours Tamil Nadu and Kerala in child health
and nutrition. Important intra-state variations exist: health indicators in some of the
northern districts are extremely low even compared to national figures, due to widespread
poverty.
4
Health
This paper attempts to understand the various factors that impact child health in general,
and the status of child health in Karnataka, in particular. This paper focuses on the young
child under six years of age. It looks at the health system, health programmes and
government policies, and indicators of child health.
The aim of this paper is to identify issues related to child health that need immediate
attention, as well as put forward suggestions and strategies that may facilitate better
health prospects for the young child in Karnataka.
2. The child and the health care system
India has a population well over the one billion mark, and 12% of this population is
below the age of six years. It also has one of the largest public health system
infrastructures in the world. It is important to understand the components of this system
and their potential for improving the health of the young child. There are three service
providers:
• government health services: publicly financed and managed curative and
preventive health services, in general free of cost to the consumer. This accounts
for about 18% of the overall health spending and 0.9% of the GDP.
• private health services: owned and managed by the private sector, their services
tend to be more expensive. This sector accounts for about 82% of the overall
health spending and 4.2% of the GDP.
• health services offered by the voluntary or non-profit sector: these do not
factor significantly in terms of overall health spending or GDP, but offer quality
care to the underprivileged.
2.1 The public health sector in India
Health care in rural areas is provided through the public health system and the ICDS. The
public health system has three levels of functioning:
Primary level of health care
The primary health centre (PHC) is considered the basic health unit. Though this
concept was mooted in 1946, it came into being after the Alma Ata declaration of 1978,
when India launched its “Health for All by 2000 AD” programme. The PHC was initiated
to provide integrated curative and preventive health care to rural India, with a focus on
prevention. The key principles of primary health care are equitable access to all
irrespective of their ability to pay; community participation through the Panchayati Raj
system; and inter-sectoral coordination between departments such as the ICDS, rural
development schemes, women and child development schemes, and the panchayats.
5
Health
Tertiary level
Specialist
hospitals
>
T
Secondary
level
Primary level
Some specialist services gynaecology, pediatrics,
surgery, operation
facilities, blood transfusion
and diagnostics
Community health
centre
■7
First referral unit
** Primary Health Centre
Sub centre
Has specialised doctors cardiologist, neurosurgeon
etc.
-►
Provides free outpatient,
delivery, basic lab. services,
drugs through doctor and
other trained paramedical
persons
Male andfemale health workers
look after population of5000
Mother and Child
Figure 1: The public health system
The PHC is to cater to a population of around 30,000. A medical doctor aided by about
45 centre and field staff implement programmes. The centre is supposed to offer out
patient services, normal delivery care, basic laboratory services, and supply of essential
drugs. It also monitors and implements national programmes, including the RCH and
ICDS.
The sub centre is a smaller unit that provides outreach. It is manned by two field
workers - the Health worker (female) or the Auxiliary Nurse Midwife (ANM), and the
Health worker (male). They cater to the primary health needs of a population of 5000.
The ANM is primarily in charge of maternal and child health, while the male health
worker monitors chronic diseases and environmental sanitation and hygiene.
In India there are almost 23,000 PHCs with around 26,000 doctors in place. In Karnataka
state, there are 1676 PHCs with 1944 doctors managing these centres (tenth five year
plan). There are 8,367 ANMs in Karnataka. According to the tenth five year plan, there is
an estimated surplus of doctors at PHCs in India and a surplus of PHCs in Karnataka.
6
Health
Services provided by the PHC for the mother and child
Besides the out-patient primary care provided at the PHC, several specific interventions
are provided for the mother and child. Some of the major ones are:
I.
Through the RCH program:
a. Essential antenatal care and postnatal care
b. Early diagnosis of high risk pregnancies and referral
c. Family Planning services
d. Normal delivery care
e. Care of the newborn
f. Immunisation services
g- Treatment and prevention of diarrhoea and pneumonia.
h. Micronutrient supplementation of iron and folic acid, and Vitamin A.
2.
Through the ICDS scheme (in collaboration with the primary health centre)
a. Immunisation
b. Health check-ups
c. Referral services
3.
Treatment of communicable diseases
Secondary and tertiary levels of care
At the secondary level, the community health centres are supposed to have facilities for
detailed investigations, conducting operations with specialist doctors on board, and
providing blood transfusions. One centre caters to a population of around 1,00,000. In the
rural areas, most of these hospitals exist at taluka headquarters. For the RCH program,
there is a special unit at the secondary level called the First Referral Unit. All referrals
related to problems of the pregnant mother and the newborn are made to this unit. This
unit is equipped to conduct operations, Caesarean deliveries, blood transfusions,
emergency newborn resuscitation etc.
The third level provides tertiary care through hospitals in district headquarters in urban
areas. At this level, major surgeries and super specialist care in areas such as cardiology,
urology, neurology etc. are supposed to be available. The fees collected are on the basis
of a sliding scale; and BPL card holders get virtually free services.
Problems with existing services
Even though there are many primary health centres, albeit unevenly spread, in reality
only 36% of these centres have a doctor coming on a regular basis. Public expenditure on
health accounts for only 18% of overall health spending, compared to 82 % in the private
sector. People perceive the public sector as inefficient and of poor quality. Besides, with
more than 45% of doctors being absent from the PHC at any given time, the rural public
would rather go to a private physician who is accessible, available and approachable in
their eyes.
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Health
The ANM is called upon to deliver community based health care from a sub centre that
does not meet basic facility and drug availability requirements in most places.
She has to travel long distances without appropriate transport facilities, and is given
targets to work with despite India adopting the “target free approach”.
A recent evaluation study conducted in three districts of Karnataka to understand how
rural people utilise the primary health centre and its sub centre services found that:
•
•
•
•
•
•
•
•
All sub centers were under-utilised
No monitoring for utilisation of various health care services
There was no dialogue with the community
Health worker was not trained to use or call for community
involvement
Free services were seen as poor services
Location ofcentre was not suitable to the community
Health worker did not stay at the institution due to security’ reasons
Institutions were in poor condition; no electricity, water and resources
for maintenance and drugs.
(Source: Evaluation of the PFI-MYRADA RCH training of trainers programme: Internal
document)
The task force on health instituted by the Government of Karnataka, under the
chairmanship of Dr.H. Sudarshan, conducted an in-depth study of the health system in
Karnataka. They found the situation appalling. Only about one-third of PHCs had
critical staff and supplies, or offered delivery services. There was widespread
corruption ? one of the doctors appointed as the PHC officer was getting a salary even
though he had moved to another country over six years ago!
Though Karnataka has made several modifications based on the recommendations of the
task force by appointing doctors on contract, and introducing monitoring systems, there is
a long way to go in making an impact on health indicators. There is some coordination
between field level workers such as the ANM and anganwadi worker at the village level,
but this is not reflected at the PHC level or higher.
In addition, the Panchayati Raj institutions of gram, taluk and zilla panchayats have
specific responsibilities to monitor and support programmes including RCH (73rd and 74th
Amendment, the latter known as the Nagarpalika Act for local governance in urban
areas). A recent meeting with the elected women representatives of the gram panchayat
members in Chitradurga district revealed that over 80% of these women were not aware
of their responsibilities in monitoring the RCH programme, or even of the budget
allocated towards implementing RCH programmes through the gram panchayat
(Mascarenhas et al, 2004).
8
Health
2.2 The private health sector in India
There are many types of private health providers? from individuals in clinics to nursing
homes, to large tertiary level “hi-tech” hospitals. In rural areas, more than 50% of the
people go to private doctors and more than 80% are willing to pay for services (Source:
World Bank). People perceive private doctors to be available when they need them and
willing to lend an ear. However, the quality of care provided by private doctors is often
suspect as is their medical qualifications. Some studies have pointed to higher user-fees,
and prescription of unnecessary medicines and procedures in private health services.
Paradoxically, especially in Karnataka, multi-specialised, corporate hospitals are
increasing which claim to offer quality health care in cities, although at expensive rates.
With support from the government, they even cater to persons living in other countries,
and encourage a new industry of medical tourism. Often, these hospitals do not honour
their commitments to reserve a proportion of their service use for the poor. Some tertiary
care hospitals have also been started by charities. Services are free, affordable, or have a
sliding scale based on income. Perceptions of these services tend to be better than
government services.
In this scenario, is it surprising that the state of our people’s health is so dismal? People
run form pillar to post trying to seek help, which is either too expensive or of very poor
quality, or too late. The poor and uneducated have no recourse but to go to unqualified
private doctors who are ready to give them “something for their problem”, regardless of
the appropriateness of the treatment or the ethics of health care.
3. Programmes and policies for the child in India: a historical overview
Box 1: Key Indian policies on children_______________________________________
• The Indian Constitution - directive and principles
• National Policy for Children 1974
• Integrated Child Development Scheme 1975
• National Health Policy, 1983/ revised 2002
• National Policy on Education 1986/revised 1992
• National Child Labour Policy 1987
• National Plan of Action for Children 1992
• India’s Ratification of UN Convention on the Rights of the Child 1992
• India’s Ratification of CEDAW (Convention on elimination of discrimination against
women)- 1993
• Infant Milk Substitutes, Feeding Bottles and Infant Foods Regulation and
Production and Distribution Act, 1992
• National Policy on Education, Program of Action 1992
• National Nutrition Policy 1993
• 73rd and 74th Constitutional Amendments for Local Self Governance 1994
• National Reproductive and Child Health Programme 1997
• National Population Policy 2000
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Health
Post-Independence, no specific programme or policy was spelt out with regard to the
health of the child. Constitutional principles determined health plans. The emphasis was
on reducing the population through family planning services, and the health of the mother
and child was largely neglected. The National Policy for Children in 1974 recognised the
child’s needs for the first time. The current programmes for child health are the
Integrated Child Development Scheme (ICDS) initiated in 1975, with a focus on
nutrition; and the Reproductive and Child Health Programme (RCH) of 1997. The RCH
builds on earlier maternal and child health programmes. A few important policies are
described below (more details are enclosed in the annexure).
1. National Policy for Children, 1974
The National Policy for Children reaffirmed the Constitutional provisions and declared
that "it shall be the policy of the State to provide adequate services to children, both
before and after birth and through the period of growth, to ensure their full physical,
mental and social development”. This would be done in a phased manner so that, within a
reasonable time, all children in the country enjoy optimum conditions for their balanced
growth.
2. The Integrated Child Development Services (ICDS) Scheme, 1975
Still regarded the most important scheme for children due to the extent of the population
it is meant to cover, the Integrated Child Development Services (ICDS) Scheme was
conceived as a delivery package of services for early childhood development. It aims to
improve the nutritional and health status of vulnerable groups that include pre-school
children under six years, and pregnant women and nursing mothers, through services that
include supplementary nutrition, pre-school education, health services and health
education. These are provided through the “anganwadi centre”. The main persons
involved in service delivery are the anganwadi worker and the helper. Some of the health
services, such as immunisation, are coordinated with the ANM.
3. National Plan of Action for Children, 1992
The National Plan of Action reiterated the promises made by the global fraternity at the
World Summit for Children, and set out a time frame for India’s Charter of Action for
women and children. Some of the specific plans put in place to ensure improved child
health included a reduction in the number of infant deaths and the prevalence of
malnutrition by the year 2000 AD.
10
Health
4. India’s Ratification of the UN Convention on the Rights of the Child, 1992
The Indian child is entitled to several rights as part of India’s ratification to the UN
Convention on Child Rights. Some of these are the right to survival, with a specific
emphasis on the female child right from female foeticide to the survival of the girl child,
the right to health to prevent childhood physical and mental illnesses, and the right to
nutrition through adequate supplementary nutrition and environmental hygiene to
prevent the contamination of food; for all families below the poverty line.
5. National Reproductive and Child Health Programme, 1997
The Reproductive and Child Health Programme (RCH) in India, which aims to address
the reproductive needs of men, women and children through their entire life cycle,
evolved from other separate vertical national programmes into the current integrated
approach.
India was the first country in the world to pioneer a national program in family planning,
with the objective of decreasing the growth rate by controlling family size. This was
revised when the government realised that there was little acceptance as families were not
assured of the survival of their children, and thus had more children in the hope that some
would survive beyond childhood. Later the focus shifted to improving the health of the
mother and child. This resulted in the Maternal and Child health Programme and the Safe
Motherhood and Child Survival Programme.
Currently, these interventions have been subsumed in the Reproductive and Child Health
Programme (RCH).
Family
Planning “
Programme
Programme
>
Maternal
Safe Motherhood
and Child
and Child Survival
Health Programme
Programme
Reproductive
>
and Child
Health
The RCH programme serves five different groups: mothers, children, eligible couples,
women with gynaecological related problems, and adolescents. There is a strong focus
on the quality of health and survival of the mother and young child. In contrast to other
programmes, the approach is democratic and based on community needs - at least on
paper.
The RCH programme is in its 7th year of operation. From the National Family Health
Survey
(NFHS - 1 and 2) data we can assess the health status of women and children, and the
impact of the RCH at ground level.
11
Health
6. National Population Policy, 2000
The Population Policy prescribes strategies towards achieving a stable fertility rate and
net reproduction rate. One section is devoted to the child. Acknowledging that infant
mortality is the most sensitive indicator of health, attention was devoted to various
measures that would ensure survival of the infant. These included focussing on the
neonate (less than 1 month old) with specialised care through super specialists. Another
area emphasised through this policy is immunisation for children.
7. National Health Policy, 2002
Reframed after almost 20 years, this policy has made very strong recommendations to
improving health for all in the country. Surprisingly there is no specific reference to
any child health indicators or programmes in this document. An oblique contribution
to reduced infant mortality is through the women’s health strategies portrayed in this
document, where special emphasis is laid on ensuring essential care to all pregnant
women.
Comments on policy and programme
ICDS
Growth monitoring and nutrition supplementation is the main activity of the anganwadi
staff. The high levels of malnutrition in children under six years are a sorry reminder that
these interventions are not carried out effectively.
While the ICDS scheme has a holistic approach at the field level, and involves the family
and community to a large extent, there are several drawbacks. The poorly paid,
overburdened anganwadi worker and helper cannot possibly fulfil their job requirement.
They also depend on the PHC to provide healthcare, checkups and immunisation, and the
PHC system itself is dysfunctional.
In Karnataka, even with “universalisation” of ICDS in all 27 districts, the same problems
surface. The anganwadi teachers do not have regular supplies of food or medicines to
fulfill the health and feeding programme objectives.
The National Population Policy
This spells out details for specialised care to reduce the high incidence of newborn
deaths. Most of these suggestions seem impractical in the rural context, when access to
basic primary health care itself is inadequate. How then will it be possible to expect
neonatologists and other specialised doctors to be available to the rural poor?
The Reproductive and Child Health Programme (RCH)
The RCH is the most comprehensive program for women and children. If implemented
correctly, one can guarantee the reduction of maternal and infant deaths. The often
quoted National Family Health Survey conducted in 1992-93 (NFHS-1) and again in
1998-99 (NFHS-2) made a detailed study of the impact of the RCH program.
12
Health
Its results have clearly established a lack of seriousness on the part of the State to deliver
primary health care to the most vulnerable groups - women and children. (NFHS-2 India
Report)
4. Factors that influence child health
a) Poverty
Simply put, there is a significant and direct correlation between poverty and ill health all
over the world, including India. Current health service delivery strategies do not reach
children most in need, especially the poor; because their
families lack the knowledge or financial resources to
A childfrom a poor family is
provide good nutrition; or because families do not
almostfour times more likely
have access to the solutions that can save lives.
to die in childhood than a
Governments and communities have not made
child in a better offgroup.
a sufficient and sustained commitment to the
rights, health and survival of children. Malnutrition is a fundamental problem among
children in the developing world. In 2000, malnutrition was associated with 60% of all
childhood deaths, mainly among the poor, (see pg 14)
b) Safe and supportive environment
A safe and supportive environment depends on both access to resources as well as good
behavioural practices. Access to safe drinking water and sanitation facilities are crucial.
Overcrowding and poor ventilation encourage respiratory infections. Good hygiene and
sanitation practices protect children from diarrhoea and other communicable diseases.
Good practices include hand-washing, proper water storage, defecation in designated
sites, burial of faeces, clearing faeces out of homes and compounds.
c) Availability of health care services
It is of little use creating awareness and raising the expectations of people if health care is
not accessible. For the poor, accessibility is limited by distance and time, availability of
doctors and drugs, and poor quality of care. Any programme to improve childhood
mortality and illness needs to address these issues.
d) Women’s health and nutritional status
Women in India are disadvantaged throughout their lives. A low birth weight female
baby may experience biological and social vulnerability. She is more susceptible to
illness and malnutrition. Due to a widespread culture of son preference, girls receive less
health care and education, and this makes them more vulnerable. Poor health in young
adulthood is further compounded by physiological demands of pregnancy. Poor women
have to resume work soon after delivery and are less likely to eat and rest adequately.
13
Health
More than one third of Indian women have a Body Mass Index1 of less than 18.5.
Anaemia is common throughout a woman’s life and poses a heightened risk during
childhood and again during childbearing.
The international standard for the minimum weight of a woman prior to pregnancy has
been lowered, and this is of concern. It has been lowered from 45 kgs to 38 kgs for no
apparent reason (UNICEF, 2003).
e) Maternal practices related to childbirth
These include antenatal care for screening, management and referral of potentially
complicated pregnancies, adequate nutrition for women before and during pregnancy and
lactation, the presence of a trained attendant at birth, and family planning. These
measures will result in healthier newborns; and concurrent family planning can improve
the mother’s health by increasing birth spacing and prevention of unwanted pregnancy.
The challenge is how to provide these to women who need them, especially poor women.
f) Exclusive breastfeeding
Breastfeeding to the exclusion of anything else for the first six months of life helps
mothers (because it temporary stops ovulation) as well as babies (reduces infant mortality
due to infectious disease and lowers risk of malnutrition caused by premature
complementary feeding).
Exclusive breastfeeding includes feeding colostrum (“milk” expressed in the first three
days after delivery), no pre-lacteal feeds, and no other liquids or foods in between. In
India, it is considered good to breastfeed; but only 37% of children under four months are
exclusively breastfed due to various factors. (NHFS-2).
g) Timely introduction of appropriate complementary foods
Appropriate complementary feeding is linked to child survival, especially between the
ages of six and 11 months. Many poor children are not introduced to semi solids and
solids at the correct age and with adequate frequency and dietary diversity. This is started
too late resulting in malnutrition.
Timely introduction requires feeding children nutritious foods of appropriate consistency,
and in sufficient quantity, beginning at the age of six months, the age at which breast
milk alone does not provide all the needed energy and nutrients.
Caregivers need to feed the child frequently (around three times a day for children who
are also breastfeeding, and five times a day for children who are not being breastfed),
encourage the child to eat, be responsive to the child’s needs during feeding, and give
separate servings to each child. The cost of fuel and lack of food and time make this
difficult for poor, working families.
1 Body Mass Index (BMI) is defined as weight (kg)/height2 (m) Normal: 18.5-25 (NFHS-2)
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Health
h) Correct home management of childhood illness
The mother or caregiver must be able to recognise an illness and respond either with
correct home treatment as in early diarrhoea; or by seeking care from a trained health
provider. Complete information about where to go, when to go and who to go to should
be made available to responsible persons in the community and all family members who
have small children in their homes. Women also need to be more empowered in decision
making to be able to respond appropriately.
An integrated and holistic approach to child health is important in the treatment of sick
children to prevent deaths. This implies considering the many factors that put children at
serious risk of disease as well as ensuring a combined treatment of major childhood
illnesses. Timely referral, involving parents in effective home based care, emphasising
the prevention of disease through immunisation, improved nutrition, and exclusive
breastfeeding are crucial to improving the health of our children.
i) Completion of a full course of immunisations
Increased immunisation coverage is linked to better child health. There is general
agreement in the public health community that increased coverage in recent decades has
led to substantial reductions in child death, to the near eradication of polio, and to major
reductions in the case of measles, diphtheria, and pertussis through the world. Better
immunisation coverage requires strengthening health care facilities and outreach services
with an emphasis on primary care. Ironically, programmes that target only one specific
disease often reduce the usage of other services. There is evidence to show that the Pulse
Polio programme has actually reduced immunisation coverage of other diseases. (Bhatia
et al, 2004).
j) Family and community practices and beliefs
Cultural beliefs and norms vary across communities and impact child survival, health and
development: these include practices of hygiene, childbirth and childrearing, feeding, the
distribution of food in the home, and the care of sick children.
In India, there are several beliefs related to the pregnant woman and small child. They
range from good to benign to harmful. Some of the harmful ones that should be actively
banned include feeding of castor oil to the newborn baby (which causes aspiration
leading to pneumonia); branding the child with a hot iron, and female infanticide.
Pregnant women have restricted quantities of food to avoid having a big baby; and
lactating women discard colostrum as it does not look like milk.
Harmful practices are widely prevalent in the south, including Karnataka. Several
practices adversely impact the girl child and need to be eliminated through awareness,
publicity, and legal threat.
15
Health
5. Nutrition and child health
Nutrition is the basis for health and well being. Nutritional disorders include protein
energy malnutrition and micronutrient deficiency, and result in:
•
•
•
•
•
Increase in mortality and a shortened life span
Illness
Poor physical growth, delayed motor development, and later problems in
reproductive health
Impaired cognition, poor school performance, diminished productivity
Disability
“...Nutrition is a cornerstone that affects and defines the health of all people, rich or
poor... Poverty, hunger and malnutrition stalk one another in a vicious circle,
compromising health and wreaking havoc on the socioeconomic development of whole
countries, entire continents...This is a travesty of justice, an abrogation of the most basic
human rights.” (Director-General, WHO)
About 50 % of children under 5 years of age are malnourished in our country. They
have sub-optimal vigour and stamina, poor neuromotor co-ordination, learning skills and
mental capabilities, and end up being adults with a reduced capacity to work and be
productive.
Protein Energy Malnutrition
Protein energy malnutrition is classified as mild, moderate and severe, depending on the
degree of under nutrition measured as weight for age. Even though there has been a
steady decline in the prevalence of severe malnutrition, the prevalence of mild and
moderate malnutrition is almost 50% in India. Various studies show that only 5% of
pre school children have normal body weights for age. Mild and moderate
malnutrition are likely to be associated with chronic illnesses, and even a simple bout of
viral illness can make a child slip from mild to moderate or even severe malnutrition.
In 2000, malnutrition was associated with 60% of all childhood deaths in India; and
in 1998, more than one-third of young children were stunted. Children in poor families
and communities are worse nourished, and more likely to be stunted, than children in
better-off settings. Furthermore, in most urban and rural locations the proportion of
malnourished children among scheduled castes and tribes is consistently higher than in
other groups.
2 A condition resulting from long-term inadequate intake of protein and energy that leads to wasting of
body tissues and increased susceptibility to infection.
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Health
BOX 2
LOW BIRTH WEIGHT (LBW): defined as birth weight less than 2500 grams
(WHO)
Low birth weight is due to a baby being born preterm or a full-term baby that is small for
its gestational age (SGA - Small for Gestational Age). SGA in term can be due to the
poor nutritional status of the mother, or because of a congential problem.
LBW is a risk factor for future health problems, such as malnutrition, recurrent infections
and impaired physical and mental development. Nearly 50% of neonatal deaths occur
among LBW babies. (NFHS-2)
In developed countries, new-borns with LBW are fewer, and approximately two-thirds of
LBW babies are pre-term. Out of an estimated 22 million low birth weight babies born
worldwide annually, India accounts for about 7-10 million. A third of all live births in
India are LBW. More than half of these are full term babies. Mothers under 20 years,
first time mothers, mothers shorter than 150 cm, and mothers weighing less than 45
kilograms deliver more LBW babies.
Micronutrient Deficiencies
The major micronutrient deficiencies are of iron, vitamin A and iodine. Nearly half of
the world’s micronutrient deficient people are found in India.
For example, of the 20-40 million children world-wide who are estimated to have at least
mild vitamin A deficiency (VAD), half reside in India. VAD causes an estimated 60,000
children in India to go blind each year. However, only around 20 % of children receive
at least one of the compulsory five doses of Vitamin A supposed to be given to children
between the ages of 6-36 months.
Iron deficiency anaemia (IDA) is the most pervasive of all nutritional deficiencies in
India, particularly affecting women, especially pregnant women, as well as infants, young
children, and adolescent girls. Children of 12 to 23 months have a high prevalence of
anaemia (78 percent, NFHS-2), perhaps due to the late initiation of weaning at this age,
coupled with poor nutritional supplementation. Rural children are more likely than
urban children to be anaemic. The poor nutritional status of mothers reflects on their
children, and suggests a poor family diet.
The prevalence of anaemia in pre-school and school children is alarmingly high; at
around 75% in the rural areas (NFHS-2). This is a critical issue, as iron deficiency
anaemia not only leads to illnesses; it also directly correlates with reduced cognitive
development.
17
Health
Hookworm infestation is a major cause of iron deficiency anaemia; second to an
inadequate intake of iron rich foods. This can be addressed by regular deworming and
footwear outside the home.
The RCH programme and the ICDS are to provide iron supplementation for children and
pregnant women. However, the percentage of children receiving iron and folic acid
supplementation is less than 8 %. under six years, actually.
The burden of iodine deficiency disorders (IDD) in India is of major proportions:
estimates attribute 90,000 stillbirths and neonatal deaths each year to iodine deficiency.
The three nutrition programs to combat micronutrient deficiencies (Vitamin A, iron and
iodine) have been in operation for over two decades through various national
programmes, and are currently integrated in the RCH programme. But these have had a
negligible impact due to systemic problems such as lack of co-ordination, shortage of
resources, inadequate and irregular supplies, lack of proper orientation and training of
functionaries, poor monitoring and supervision, poor community motivation and
education, and the continuing poverty of those most at risk.
ICDS and nutrition
The ICDS is meant to play an important role in combating early childhood malnutrition
in our country. But for the past 30 years, ICDS has been able to cater to only 16 per cent
of undernourished children. These alarming statistics tell us the real story: only 3.4 crore
children are getting the benefits of supplementary nutrition under ICDS. This is
nowhere close to the number of children in the age group (15 crores), the number of
malnourished children (8.5 crores) or even the numbers from families below the poverty
line (6 crores). (New India Press, April 26, 2004)
Causes of malnutrition
India is not deficient in food grains, and yet there is a problem of malnutrition beyond
mere nutrient deficiency. The dynamics of food production, distribution and purchasing
power; and health factors related to food utilisation are the underlying causes.
18
Health
FOOD PRODUCTION
Labour
Agricultural
Education
Land
Agricultural Water
skills
Technology
Health status Seeds
FOOD DISTRIBUTION
Economic
Cultural
Govt, policy
Social status
Number below poverty line
Food taboos
Low purchasing power
Child care
Transport, storage
Girl child
Urbanisation
Special interventions
Feeding programmes
Health programmes
MALNUTRITION
FOOD UTILISATION
Special needs: infants, pregnant
women
Malabsorption, Reduced intake
Chronic infections
Parasitic infestations
Figure 2: Multiple factors related to malnutrition in India
6. The status of child health in India
Improvements in child health include reduced infant mortality rate, access to drinking
water, and a significant increase in polio immunisation. However, the key problems of
child health are linked to poverty eg low birth weight babies. The major causes of infant
deaths such as diarrhoea, pneumonia, neonatal tetanus, and measles are aggravated by
malnutrition. Lack of drinking water, sanitation and poor personal hygiene increase
infections.
The health of a child is measured using several indices. Of these, the most sensitive
indicator is the infant mortality rate. Mortality estimates are actually underestimates; as
many infant deaths are not recorded and occur at home.
19
Health
BOX 3: Common health indicators
Perinatal mortality rate (PMR)
Neonatal mortality rate (NMR)
Infant mortality rate(IMR)
Under 5 mortality rate(USMR)
number of deaths between 28 weeks of gestation to 7 days
after birth per 1000 live births________________________
number of deaths below the age of 1 month per 1000 live
births___________________________________________
number of deaths below 1 year of age per 1000 live births
number of deaths below 5 years of age per 1000 live births
In contrast to other nations, India has a poor health record. The table shows where India
stands in comparison to populous countries such as China, or neighbors such as Sri
Lanka.
Table I: Key health indicators of developed and developing countries
India
USA
China
Sri Lanka
Total population (thousands)
10,25,096
2,91,038
12,94,867
18,910
Births per annum (thousands)
25,112
4228
1,88,857
312
Under-5 mortality rate
93
8
39
19
Infant mortality rate
67
7
31
17
Life expectancy at birth (years)
64
77
71
73
GN I per capita (US$)
460
35,060
940
840
Child mortality
The most widely used indicators are infant and under five mortality rates. In India,
neonatal deaths contribute to a large number of infant deaths, and are a significant
indicator. Since we do not have an established system to collect and analyse morbidity
(illness) data in India, we rely on mortality data to help draw up plans and programmes
for the child.
20
Health
BOX 4: Major causes of childhood mortality - medical and social
Medical causes_________
Still birth
Prematurity
Congenital defects
Asphyxia, birth injuries etc
Jaundice and septicemia
All of the above
Diarrhoea
Respiratory infections
Malnutrition
Anaemia
Other infections, accidents
Diarrhoea
Respiratory infections
Other infections
Malnutrition and anaemia
Period
Neonatal
mortality
1MR
U5MR
Social causes
_________________
Poverty
Age of mother: too young/old
Birth order more than 3
Spacing between children < 2 years
Delivery conducted by untrained person
All of the above
Poor weaning practices
Poor personal hygiene
Unsafe drinking water
Over crowding
AH of the above
One could infer that mortality rates could be reduced without waiting for economic
improvement; through increased access and utilisation of essential services. These
include reproductive health services, prenatal care, breast feeding, immunisation, home
based treatment of diarrhoea, and timely introduction of supplementary foods.
Figure 3: Interstate variations in childhood mortality (NFHS-2)
140
120
1-100
• n
80
60
40
20
0
x:
V)
<D
T)
S
E
05
cn
<
Q_
05
C
Z)
05
-C
CL
o
C
05
£
v>
05
ro
CtZ
05
C
05
05
ZE
05
05
CD
ro
c
05
CO
05
c
0
05
2•
205
-C
05
2
J2>
CL
n_
<
ZJ
TJ
05
z
05
H
IS
2Q
I
□ Neonatal
mortality
□ Infant
mortality
□ Under 5
mortality
21
Health
There are variations across the states, with Kerala doing well, and states like Uttar
Pradesh and Madhya Pradesh skewed in the opposite direction. Overall, the neonatal
mortality rate for India is around 40, while the infant and under 5 mortality rate stand at
68 and 95 respectively.
In 1998, about 2.5 million under-5-year-olds died in India, the highest total of any
country. In the mid 80s and early 90s, there was a rapid decrease in infant and childhood
mortality in accordance with the goals for 2000 AD. However, recent data indicate that
the decline in child mortality rates has slowed down since; even showing increasing
trends in some states, including Karnataka. (UNICEF report).
The most recent figures show that the infant mortality rate was 68 per 1000 live births
according to the Sample Registration System, Office of the Registrar General, India
(2000). This is the good news. The bad news is that we are talking about infant deaths
that could be largely avoided, and given India’s population, the number of infants that die
each year is enormous. Active intervention is required to ensure a reduction in infant
mortality. It is not that India does not have the health care or the nutritional knowledge to
address the problem. The problem is lack of awareness and accessibility, especially for
the rural population.
More money has to be put into health and education, and health services have to improve
at all levels and dimensions - infrastructure, training of personnel, availability of
medicines, availability of staff for longer hours in the day, better roads and transport for
remote areas, essential emergency services and referral mechanisms to those services. We
already have the infrastructure in place, but need to work at quality, efficiency and
accountability.
Childhood morbidity
Morbidity is a measure of the burden of illness.
Acute Respiratory Infections are a major hazard for the young child, particularly
children between 6 months to 3 years. The government has provided the antibiotic
cotrimaxazole to trained field nurses for ARI. Unfortunately, families may not refer the
child who has fever, cough and rapid breathing to a medical facility in time. It was found
that less than 15 % of families with children who had ARI received antibiotic treatment
(NFHS-2).
Diarrhoea is a major hazard for children under five years, particularly between 6 tol 1
months (NFHS-2). To control diarrhoea and for child survival, a decade ago the
government launched an Oral Rehydration Therapy (ORT) programme. The community
was educated about dehydration and ORT. Unfortunately, only 9 districts (out of more
than 600) in the whole country reported over 50 % use of ORT for diarrhoea of children
below 5 years.
22
Health
Pediatric AIDS is emerging as a serious public health concern in India. Out of the
55,764 identified AIDS cases in India in 2003; 2,112 are children. Children get AIDS
through contaminated blood and transmission from an infected pregnant woman to her
baby. In India, National AIDS Control Organisation (NACO) is a key player in AIDS
control. Blood is tested at blood banks, and pregnant mothers who are HIV positive can
receive anti-retroviral treatment. In Karnataka, there are 40 PPCTCs (Prevention of
Parent to Child Transmission Centres) in 27 districts that offer treatment free of charge.
This treatment reduces the transmission of the HIV virus to the baby by more than half.
Vaccine preventable diseases and immunisation coverage services
All children of one year should receive 1 dose of BCG, 3 doses each of oral polio and
DPT and 1 dose of measles. This is defined as complete primary immunisation. Analysis
of the vaccine-specific data shows that complete immunisation coverage of children in
India is 42%. NFHS-2 data puts vaccine coverage at 85 percent for BCG, 75 percent for
three doses of the DPT vaccine, 78 percent for three doses of the polio vaccine and 67
percent for measles. These figures are believed to be higher than the field reality.
Recently, there have been spates of polio outbreaks in the north-western part of
Karnataka. After being polio-free for two years, the outbreak was particularly worrisome
for the global eradication effort. Despite the adequate supply of quality vaccines,
immunisation was not reaching enough children, especially in rural areas. This was
largely due to a lack of mobilisation, poor supervision, insufficient community
involvement, and a lack of consistent vaccination delivered by teams going door-to-door.
It is events like these that require us to review our programmes and policies and
concentrate on the issues that require attention such as community involvement and
monitoring of programmes.
7. Status of child health in Karnataka
Karnataka indicators are listed below. While they are better than the national average,
most of the indicators are far below neighbouring states of Kerala and Tamil Nadu.
Kerala has outstanding performance indicators in comparison to its neighbours. In fact,
Kerala is considered to be on par with most developed countries in its health indicators.
Tamil Nadu is a close second, thanks to their strong drive towards implementing primary
health care. They have succeeded particularly in the area of deliveries being conducted by
trained persons and immunisation coverage. In contrast, both Karnataka and Andhra
Pradesh are far behind.
23
Health
I able 2: Health Indicators of Karnataka and the southern states in relation to India
Parameter
Karnataka
Tamil Nadu
Andhra Pr
Kerala
India
IMR
51
48.2
65.8
16.3
67.6
U5MR
70
63.3
85.5
18.8
94.9
Age at marriage
< 18 yrs.
46.3%
25%
64.3%
17%
50%
Institutional
deliveries
51%
79.3%
49.8 %
93%
33.6%
Trained delivery
attendant
59%
83.8%
65.2%
94%
42.3%
Immunisation
coverage
60%
88.8%
58.7%
79.7%
42%
Prevalence of
anemia in age 635 months
70.6%
69%
72.3%
43.9%
74.3%
Underweight
33.6%
36.7%
37.7%
26.9%
47%
Stunted3
44%
29.4%
38.6%
21.9%
45.5%
Wasted4
20%
19.9%
9%
11.1%
15.5%
Source: NFHS-2 Survey
There is a significantly high prevalence of malnutrition. Of particular concern is the
incidence of stunting, which is reflective of a chronic malnutrition process. This is in
spite of the fact that a food supplementation program of ICDS covers all these states.
A district wise break up of the important indicators shows a wide disparity with districts
like Bangalore Urban and Dakshin Kannada being better off than districts like Bidar,
Bellary and Bijapur. These results are also reflected in specific antenatal care services.
' Low height for age
4 Low weight for height
24
Health
Table 3: District wise break up of key child health indicators
District
Age at
marriage
<18yrs
Bangalore___ 4839.2
37.5
Bangalore Rural 1673.2
57.1
Belgaum______ 3583.6
76.3
Bellary_______ 1890.1
76.1
Bidar________
1255.8
90.8
Bijapur_______ 2928
87.1
Chikmagalur
1017.3
35.8
Chitradurga
2180.4
66.5
D. Kannada
2694.3
26.9
Dharwad______ 3503.2
67.6
Gulbarga______ 2582.2
82.4
Hassan_______ 1569.7
52______
Kodagu_______ 488.5
28.8
Kolar________ 2216.9
74.3
Mandya______
1644.4
76.7
Mysore_______ 3165
65.1
Raichur_______ 2309.9
82.8
Shimoga______ 1909.7
44______
Tumkur_______ 2305.8
68.2
U. Kannada
1220.3
31.8
KARNATAKA 44977.2
62.9
(Source: RCH-RHS Survey - 98-99)
Population
(lakhs)
Infant
mortality
rate____
50_______
50_______
50 _____
79_____
66 _____
75_____
55
51 _____
29
74
59_____
61_____
41_____
56 _____
67 _____
57 _____
59_____
69_____
64_____
49_____
53
Under
5 MR
67
67
69
119
85
88
75
104
46
95
86
78
66
100
84
89
80
88
102
69
90
%of
Institution
Deliveries
89.3
48.9
40.8
27.5
11.4
22.2
53.7
37.5
77.0
39.8
12.7
45.6
76.0
36.1
48.8
51.4
11.9
45.0
41.1
72.2
41.8
Infant mortality is very high in the districts of Bellary, Bijapur and Dharwad, while under
five mortality is highest in Bellary, followed by Chitradurga, Tumkur and Kolar. More
than 80% of the women are married below 18 years in the northern districts of
Bidar, Gulbarga and Raichur; and these same districts show a very low (<13%)
prevalence of institutional deliveries.
Morbidity status in Karnataka
In Karnataka, the prevalence of diarrhoea in children below 5 years was around 18.9 %,
varying from 31.5 % in Kolar to 6.5% in Dakshina Kannada. However, only 6.7 % of the
children in Kolar who had diarrhoea received ORS compared to 11 % of the children in
Dakshin Kannada. The prevalence of ARI was around 17.7 % overall in the state with
variations as large as 60% in Kodagu to 4.1 % in Gulbarga. Approximately 10,000
preschool children go blind every year due to severe vitamin A deficiency (NFIIS-2).
25
Health
Malnutrition and micronutritent deficiencies
44% children below three have some form of malnutrition. The Vitamin A prophylaxis
programme is to supplement all children between the age of 9 months and 3 years with 5
doses of Vitamin A at 6 monthly intervals. In Karnataka, around 52 % of children did
not receive even one dose of Vitamin A.
The number of children who received iron supplementation is equally low. With anaemia
prevalence at around 75 % in the pre school age group, this programme deserves serious
attention. Only 5.6 % of children received any form of iron. Even the urban district
of Bangalore showed coverage of 4.5 %.
The Government of Karnataka is in the process of formulating a State Nutrition Policy
to emphasise the need for reduction of malnutrition of all types; including micronutrient
malnutrition among children, adolescent girls and women of child bearing age. The main
aim is to reinforce an intersectoral approach to reduce severe and moderate malnutrition
among children under five years, micronutrient deficiencies, and low birth weight babies.
It addresses chronic energy deficiency among children, nutrition in tribal groups, and the
participation of NGOs in nutrition programmes.
A State Plan of Action for children (2003-2010) has been formulated for child health,
maternal health and other health care services. The plan addresses protein energy
malnutrition, micronutrient malnutrition, maternal and fetal malnutrition, diet etc. A
coordination committee is in place to review the state plan of action, and it will also
coordinate and monitor the implementation of the state nutrition policy.
Vaccine preventable diseases and immunisation coverage
One of the major goals for 2000 AD was universal immunisation for all children below 1
year of age. From the results of the R.CH- RHS survey, we see that about 72 % of infants
received the complete primary schedule of vaccines (BCG, 3 doses of DPT, 3 doses of
oral polio and measles. Around 6 % of infants did not receive any vaccine at all.
T
[-jlron suppl.
Vitamin A
^Complete course
^Measles
OPV3
„DPT3
4=
I..........1-
0
10
20
— I---------130
40
50
j
I
J-—
60
70
80
□
90
BCO----------------
100
Fig. 4: Coverage of major immunisations and supplementations to children below 5 years in
Karnataka
26
Health
8. Moving forward
There is no doubt that the situation of child health in India, and Karnataka in particular, is
depressing. Some of the challenges we face are:
1. A slow rate of decrease in infant mortality and under five mortality in the last few
years.
2. Falling immunisation coverage in the recent past, despite intense efforts.
3.
Poor maternal health: India’s maternal mortality ratio (number of women dying due
to pregnancy related causes) at around 540 deaths per 100,000 live births, is one of
the highest in the world. This has a direct bearing on the health of the infant and
child. In fact, there is not even a direct measure for maternal mortality, these are
extrapolated figures.
4. Continued discrimination towards girls; with the child sex ratio falling sharply from
945 females per 1,000 males to 927 per 1,000.
5. More than fifty per cent of children under six years of age are malnourished, the
proportion of low birth weight babies remains high, and about 75 per cent of children
are anaemic.
Karnataka has made efforts to understand
and improve the health status of women and
children. Following the recommendations of the
Health Task force and the National Health Policy,
Karnataka has developed a document highlighting
its Vision for the year 2020 (see Annexure)
The goals include improving indicators
such as infant and child mortality, etc.
The government is in the process of developing
a planning document for the RCH -2 programme
with World Bank assistance to address the vision
objectives.
What the Government should do
to address the health needs ofpoor
children.
Make a strong political commitment
to strengthen and expand efforts for
the reduction of infant and child
mortality, and malnutrition.
Improve health outcomes of poor
children by increasing availability of
resources to health centres on a
regular basis.
Strategies to move forward
In order to achieve the vision 2020 of Karnataka,
it is important that relevant strategies be put in place.
One of the main strategies would be to prioritise
activities based on performance across the state.
Low performing districts will require additional
inputs and monitoring in order for them to
“catch up”.
Strive for high quality ofservices with
interventions that are effective and
sustainable.
Review and support efforts and factors
that determine the health of the poor
child.
27
Health
A. Enhancing service coverage, making health care more accessible and affordable
This is the key to improving child health. It is the State’s responsibility to strengthen
existing health systems (e.g. by improving the availability of drugs, monitoring and
surveillance). The World Bank has a special financial envelope to provide additional
assistance to seven backward districts in Northern Karnataka (RCH Consultant, GOK)
The essential elements of child health and nutrition services (e.g. immunisation
programmes and micronutrient supplementation) need to be promoted. We also need to
integrate approaches to clinical management of acute respiratory infections, malnutrition,
diarrhoea and other major causes of childhood illness with schemes such as the RCH
program and the ICDS.
B. Improving health care delivery in terms of quality of health care
•
•
•
Improving referral services (including obstetric emergencies)
Reducing neonatal and infant mortality by implementing essential care of the
newborn, early detection of illnesses and combating malnutrition.
Ail components of the RCH and ICDS package should be implemented, without
compromising on any elements.
C. Tackling malnutrition from the level of food production to treatment for the
stunted and wasted child
Malnutrition has been identified as the most significant factor that impacts childhood
deaths and illnesses. It is critical that policy makers review the existing nutrition
supplementation through the ICDS; and the micronutrient supplementation through the
RCH program to reverse the appalling situation of malnutrition and anaemia in children.
D. Convergence between ICDS and RCH Programme
There is a large amount of overlap in the child health components of the RCH
programme and the ICDS scheme. Better coordination at the field level would improve
both access and utilisation of services by the community and the child. This would reduce
the burden on both the field workers, who spend much of their time collecting and
reporting similar data.
E. Promote community participation in prevention and treatment of illnesses
On one hand, the State is responsible for the “supply” of health services. It is also
important to focus on creating a “demand” for these services; this can only be done by the
involvement of the community. One of the primary reasons for the failure of several of
the programmes listed is due to poor monitoring and a lack of accountability.
28
Health
This can be remedied to some extent by people assuming a greater voice and
responsibility in order to access health services for themselves and their children. The
gram panchayat has been empowered to monitor and govern several of the services
provided to the pregnant mother and child, including essential antenatal care, universal
immunisation etc. There should be widespread publicity and training of the panchayat
and community members for them to understand and assume their responsibilities as
local monitors of national programmes. When the community is an equal partner in
planning, implementation and evaluation, such programmes will eventually lead to
behaviour change that is sustainable.
Several NGOs in Karnataka have self help groups (SHG) that have formed village
health committees made up of SHG members, anganwadi teacher, gram panchayat
member, ANM and others to monitor the essential services for a pregnant woman and
child. In Chamrajnagar taluka, MYRADA has promoted this as a “credit plus” activity.
Samuha, an NGO in Raichur, has special committees to monitor the health and
education of young children.
Local community groups, self help groups and community based organisations can make
an impact if they are made more aware of their rights to health, and the rights of their
children to health and education.
F. Encouraging public private partnerships for improved quality of healthcare
services
The private sector, which accounts for more than half the total spending on health, can be
recognised and trained to provide and support child health interventions. Privatisation
alone cannot be a strategy. The potential of making profit from the poor is much less that
of the middle and upper classes, and so the private sector lacks the incentive to provide
quality services to poorer populations and rural areas. The partnership between the
Government of Karnataka and private health care providers in instituting a health
insurance scheme for the rural poor is an example of newer forms of private-public
partnership.
G. Periodic review and revision of programmes and policies
Some revisions need to be made based on field practicalities. For example, in the ICDS
scheme, growth monitoring is conducted by monthly weighing. It has long been proven
that there is no need for such frequent weighing. The frequency can be brought down to
once a quarter, thus reducing the burden on the anganwadi worker.
In another instance, a recent Supreme Court order in response to a PIL has demanded the
implementation of the feeding program through ICDS in India. This was after an
assessment that showed states such as Bihar had not even initiated the supplementary
feeding program.
29
Health
9. Conclusion
A world fit for children is one in which all children get a good start in life and where
minimum standards of health and education are met. It is a world in which all children
have the opportunity to develop their individual capacities in a safe and supportive
environment. Children are one third of our population and all of our future.
Improving child survival remains a major development task in India. Future child health
policies should build on past lessons from child health programmes, sustain the
achievements that have already been made, enhance quality and efficiency, and address
specific gaps in infant health and nutrition.
Malnutrition during childhood impacts child development and raises the risk of morbidity
and mortality in later years of life. There is an urgent need to combat this crisis by
addressing all factors associated with poor nutrition, right from food production to
equitable distribution to adequate food intake.
It is also important to have a better understanding of the main determinants of the health
and nutrition cycle for children, in order to develop more effective strategies for child
survival, health and development. The challenges over the years will be to jointly address
the most important determinants and gaps in the cycle with affordable, cost-effective and
culturally appropriate interventions. Actively addressing and minimising barriers to
access through structural changes, with an awareness program alongside, should prove
both efficient and effective. Some key suggestions:
BOX 5: Key suggestions
1. Enhancing service coverage, making health care more accessible, available and
affordable
2. Improving health care delivery in terms of quality of health care
3. Implementation of all the components of the currently existing programmes such as
the ICDS and R.CH programme; and emphasising simple preventive measures such as
essential antenatal care, routine immunisation, and micronutrient supplementation.
4. Improving sanitation and drinking water services
5. Promoting community participation in prevention and treatment of childhood
illnesses
6. Promoting community participation in the planning, implementation and monitoring
of all programmes; so as to ensure ownership as well as quality
7. Tackling malnutrition head on, from food production to the stunted and wasted child.
8. A special focus on the child under 3 years, due to the links between nutrition, health
and cognition
9. A special focus on the girl child, to ensure her needs of nutrition, health and
education
30
Health
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Policies and Regulations.
3. International Institute for Population Sciences (UPS) and ORC Macro. 2000.
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4. UPS. 2000. National Family Health Survey 1998-1999 (NFHS-2), Karnataka:
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5. UPS. 2001.: Reproductive and Child Health Project: Rapid Household Survey 1998-99
6. Karnataka. 1999. Human Development in Karnataka 1999: Planning Department,
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8. K Sheela. Nutrition scenario in Karnataka, a state in southern India Asia Pacific
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9. Kulkarni MN; Pattabhi YN. Evaluation of effectiveness of ICDS in 7 anganwadi
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10. Lopez, Alan D. 2000. Reducing child mortality; Bulletin of the World Health
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11. Mariam Claeson, et al. 2000. Reducing child mortality in India in the new
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12. Mascarenhas et al. 2004. Maternal Health Care and Local Self Governance in
Karnataka: A situation Analysis. A CBPS working paper (not published).
13. Mosley WH, Chen LC. An analytic framework for the study of child survival in
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14. National Health Policy 2002: A draft report.
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15. New India Press.com: Despite SC order, Centre, states failed undernourished kids;
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NFI Archives. 1995.
18. Singh M. Role of micronutrients for physical growth and mental development. Indian
Journal of Paediatrics 2004. 71:59-62.
19. Tullu MS, Kamat JR. Paediatrics in India. Journal of Postgraduate Medicine. 2000.
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20. UNICEF. The State of the World’s Children, 2004. New York: Oxford University
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23. VHAI. 1992. The State of India’s Health. Ed; Alok Mukhopadhay.
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32
Health
Annexure
The government of Karnataka has developed a vision for Karnataka based on the
recommendations of the Karnataka Health Task Force which conducted a detailed
investigation of the health system and services in the state.
Some of the
recommendations of the task force that have been incorporated into the Kartnataka
Vision document are:
1. Infant Mortality Rate
The Infant Mortality Rate in 2020 will come down to less than 25 from the present
figure of 51 (in 2001). Proactive measures will need to be taken not only to prevent
stagnation of the figures, but to remedy the worsening of IMR occurring over the past
5 years in 10 districts. The process will include the availability of the second birth
attendant, recommended by the Task Force for Health and Family Welfare. She will
look after the newborn, ensuring spontaneous breathing and preventing hypothermia
and other problems, thus reducing neonatal deaths, an important component of infant
mortality. Improved birth weight as a result of better nutrition of the mother starting
from adolescent period and avoiding infection are other factors helping in the
reduction of infant mortality. Better quality and complete coverage of antenatal care,
access to emerging obstetric care, implementation of the universal immunisation
programme, health promotion including nutrition, education of mothers and families
and a focus on caring for infants are all part of the intervention required to achieve
lower IM Rs.
2. Under - Five Mortality Rate
There will be reduction in the under - 5 mortality from 69.4 (1994-98) to 40-45. The
child will be healthier if certain measures are taken: commencement of breastfeeding
immediately after the birth of the child (benefiting from the goodness of colostrum);
exclusive breast feeding for the first 6 months; better universal immunization
coverage (with a good cold chain system) including immunization against measles;
better nutrition with weaning (supplementary) food from 6 months (food being given
free to the poor), child care and psychosocial stimulation. This will be achieved
through working collaboration between anganwadis of the ICDS scheme and primary
health centres / subcentres.
3. Crude Birth Rate and Crude Death Rate
Both the indices will have fallen. The Crude Birth Rate will come down to 14 in 2020
from 21 in 2001; the Crude Death Rate to 7.0 from 8.0. The Total Fertility Rate will
go down to 1.6; the Couple Protection Rate go upto 75%. Population stabilization will
be in sight. We need to achieve this with gender equity, guarding against sex selection
practices unfavourable to girls.
4. Nutrition
The percentage and absolute numbers of severely and moderately undernourished
children will be significantly reduced, as a result of better nutrition awareness and
action. Mid-term goals stated in the health policy document will be improved by a
further 50% by 2020.
33
Health
5. Immunisation
There are many goals for 2020. There should be better coverage of children under the
Universal Immunisation Programme. Paralytic polio should be eradicated, and the
number of vaccine preventable diseases is reduced There is need for dependable
refrigeration system. By 2020, this basic preventive health strategy will have
universal coverage with good quality.
Vision Document for Karnataka 2020: the goals
2001____________ Source / Year
Indicators________
Infant Mortality Rate
58 / 1000 live births SRS 1999
Under-5 Mortality Rate
69 / 1000 live births
NFHS-2
Crude Birth Rate
22.3 /1000
population______
7.7/1000
population______
195 / 1,00,000 live
births__________
61.7 years
SRS 1999
1996-2001
2020_______
25 / 1000 live
births______
35 / 1000 live
births______
13/ 1000
population
6.5/ 1000
population
90/ 1,00,000
live births
70.0 years
65.4 years
1996-2001
75.0 years
2.13
51.1
NFHS-2
NFHS-2
1.6
75
59.2
NFHS
35%
1994
10%
86.3
2000
100
59.7
2000
70%
60
NFHS-2
90
70.6%
NFHS-2
40.0%
Crude Death Rate
Maternal Mortality Rate
Male
Life
Expectancy at
Female
Birth_______
Total Fertility Rate
Percentage of
Institutional Deliveries
Percentage of safe
deliveries____________
Newborns with Low
Birth Weight_________
Percentage of mothers
who received ANC____
Percentage of eligible
couples protected______
Percentage of children
fully immunised______
Anaemia among
children (6 - 35 months)
Severe
under
nutrition
Nutritional Moderate
under
Status of
children
nutrition
Mild under
nutrition
Normal
SRS 1999
SRS 1998
2
95
6.2%
2.0%
45.4%
25.0%
Gomez, 1996
39.0%
43.0%
9.4%
30%
34
Health
Sex (Gender) ratio
Sex (Gender) ratio, 0-6
years______________
Indicators__________
Infant Mortality Rate
964FZ 1000M
949F / 1000M
Under -5 Mortality Rate
69 / 1000 live births NFHS-2
Crude Birth Rate
22.3 Z 1000
population______
7.7 Z 1000
population______
195 Z 1,00,000 live
births
Male
61.7 years
SRS 1999
1996-2001
2020_______
25 Z 1000 live
births______
35 Z 1000 live
births______
13 Z 1000
population
6.5 Z 1000
population
90 Z 1,00,000
live births
70.0 years
Female 65.4 years
1996-2001
75.0 years
51.1
NFHS-2
NFHS-2
1.6
75
59.2
35%
86.3
NFHS-2
1994
2000
>95
10%
100
59.7
2000
70%
60
NFHS-2
90
70.6%
NFHS-2
40.0%
Crude Death Rate
Maternal Mortality Rate
Life Expectancy at Birth
2001 census
2001 census
2001____________ Source
58 Z 1000 live births SRS 1999
Total Fertility Rate____________
Percentage of Institutional
Deliveries___________________
Percentage of safe deliveries
Newborns with Low Birth Weight
Percentage of mothers who
received ANC________________
Percentage of eligible couples
protected____________________
Percentage of children fully
immunised__________________
Anaemia among children (6 - 35
months)
Severe under
nutrition_________
Nutritional
Moderate under
Status of
nutrition_________
children
Mild under nutrition
Normal__________
Sex (Gender) ratio
Sex (Gender) ratio, 0-6 years
2.13
SRS 1999
SRS 1998
6.2%
45.4%
39.0%
9.4%
964F /
1000M
949F /
1000M
975FZ 1000M
970FZ 1000M
2.0%
Gomez, 1996
25.0%
2001 census
43.0%
30%________
975F/ 1000M
2001 census
970F / 1000M
35
St
IBI
Disability and the young child
Padma Sastry
Disability
CONTENTS
Page
1. A historical overview
4
2. National and international policies and acts
5
3. The all India scenario: estimates of disability and causes
8
3.1 The NSSO surveys
9
3.2 Causes of disability
10
4. Government schemes for intervention and prevention of disability
13
5. The situation in Karnataka
14
6. Summary of issues: the young child with disability
25
7. Concluding thoughts
27
References
28
Annexure
31
2
Disability
TABLES
Page
Table 1: Disabled persons by sex and type (all India)
9
Table 2: Disabled persons for the age group
0-4 and 5-9 years, by type of disability
9
Table 3: Disability-specific data
10
Table 4a: Causes of visual disability
10
Table 4b: Causes of hearing disability
11
Table 4c: Causes of speech disability
11
Table 4d: Causes of locomotor disability
12
Table 4e: Causes of mental retardation
12
Table 5: Disabled persons by gender
15
Table 6: Children with disabilities
15
Table 7: Training of anganwadi supervisors and workers
20
Table 8: Training of health personnel
22
BOXES
Box 1: ICDS services
18
Box 2: Objectives of the training programme
21
3
Disability
1. Introduction: historical overview
Since time immemorial, the elimination of the disabled has been a common and widely
accepted practice in many cultures, from east to west. Plato and Aristotle approved of this
practice; in the belief that “nothing imperfect or maimed should be brought up”. In the
Indian scriptures, the theory of Karma prevailed. In the medieval ages the notion of the
goodwill of man and the responsibility of the strong to protect the weak gained currency.
St. Jerome urged "'one should be eye to the blind, arms to the weak and feet to the lame".
Hospital fraternities were set up to care for the physically disabled. With the decline of
the power of the church, the care of the disabled became the state’s responsibility.
Buddhism and Jainism promoted a positive social attitude towards the disabled. In the
reign of Chandragupta Maurya, vocational rehabilitation workshops were established for
the physically disabled.
Though efforts for the rehabilitation of persons with disabilities have evolved over time;
reflecting a progressive response to persons with disability, the medical perspective
dominated well into the 70’s. The medical model saw disability as a personal issue; and
the negative effects of impairment as something to be cured. The focus was to help such
persons adapt to the community using aids and appliances, education and training.
Institutional care, promoted both by the state and by the NGOs, was the predominant
paternalistic approach, promoting an attitude of dependence. Cases of a community
approach to rehabilitation were far and few.
Following this period, discourse at different forums resulted in a paradigm shift in
viewing disability. A social approach emerged that saw disability as a form of
discrimination, and social justice as central to providing the disabled with equal benefits
in society.
Over the last decade; there has been a move away from the medical, welfare, and social
model to enabling the rights of disabled persons, providing them with equal
opportunities in all spheres, and enhancing the engagement of civil society in the
“inclusion” of the disabled. Several countries including India have enacted Disability
Rights Acts. The Persons with Disability Act, 1995, seeks to empower disabled persons
so that they can be part of mainstream society. It is now also accepted that the
environment and context in which the disabled person lives must also change.
What disables a person most is the attitude of his/her family, friends and society.
Parents of disabled children today are encouraged to seek early identification and support
without fearing rejection and alienation in society.
The NSSO survey 2000 reveals that 55 percent of the disabled in India are illiterate. If
persons with disability are encouraged to develop a positive self-image; it could change
the larger attitude towards disability. A key to this process would be to enable the
disabled to see their abilities.
This paper seeks to explore what it means to encounter “disability” within the context of
the young child.
4
Disability
2. Policies and acts for children and disability
Policies and acts related to disabled persons have become significant only over the last
decade. They have emerged in response to a better understanding of disability; as well as
consistent advocacy efforts.
A brief historical account of the declarations and policies for the disabled is presented
below: from the constitution of India that framed the “care of the disabled” in broad
terms; to the Persons with Disability Act, 1995, that speaks of the rights of the disabled.
2.1 I he Constitution
The Constitution of India states that the “state shall within the limits of its economic
capacity and development make effective provision for securing the right to work, to
education, and public assistance in cases of unemployment, old age, sickness and
disablement and in other cases of undeserved want.”
The Directive Principles of State Policy include the following:
The rights of children to be protected against exploitation
To opportunities for healthy development, consonant with freedom and dignity
To free and compulsory education
To promote educational and economic interests of weaker sections
To protect them from social injustice
The responsibility of the state to raise the level of nutrition and standard of living
To improve public health
It follows that these benefits should be available to all children; including those with
disability.
2.2 International declarations
India is a signatory to several international declarations: United Nations Rights of the
Child, United Nations Standard Rules on the Equalisation of Opportunities, the Jomtien
Declaration on Education for all, the Salamanca Statement and Framework for Action,
and the Biwako Framework for Action Towards a Barrier-free and Rights-based Society
for persons with disabilities. It is also a signatory to the World Declaration (September
1990) in the Survival, Protection and Development of Children; and the Plan of Action
for implementing it.
Following the World Summit, India began formulating a National Plan of Action to put
into practice the promises made to the global community; by setting out national,
quantifiable goals to be achieved by the year 2000. In this context, the government
brought out the revised National Plan of Action for Children in 1992; and recently drew
up the National Charter for Children, 2003.
5
Disability
2.3 The National Plan of Action for Children, 1992
The National Plan of Action for Children, 1992, identifies quantifiable targets in terms of
major as well as supporting sectoral goals. Some of its goals are:
•
Eradication of poliomyelitis by the year 2000 A.D.
•
Achieve and maintain immunisation coverage at a level of 100 per cent of infants.
•
To assist children affected by one or more disabilities, with no access to proper
rehabilitative services, and especially to lift the status of those most marginalised.
2.4 The National Policy on Education, 1992
Initially formulated in 1986 and revised in 1992, The National Policy on Education
recommends the Integrated Education for the Disabled. Although this policy refers to
children above 6 years of age, it brought in a new concept that is now being extended to
the under 6 years age group. The outcome of this policy was the formation of State
Resource Groups for special needs education; and a cadre of trained teachers. Some states
have included Integrated Education as a component in the teacher-training curriculum.
2.5 Sarva Shiksha Abhiyan (SSA), 2000
Sarva Shiksha Abhiyan is a programme initiated by the Department of Education to
provide universal quality elementary education for children from 6-14 years. Integrated
education is seen as one way to meet this objective of “universalisation”. SSA
emphasises the prevention and early identification of disability; and calls for functional
and formal assessment of identified children. Removal of architectural barriers, teacher
training and provision of aids and appliances are also to be implemented. Rs. 1200 per
child, per year, for the integration of disabled children in regular schools can be accessed.
2.6 The National Charter for Children, 2003
The State and community recognise that all children with disabilities must be helped to
lead a full life with dignity and respect. All measures will be undertaken to ensure that
children with disabilities are integrated into mainstream society and actively participate
in all lifestyles.
•
•
•
The State and community shall provide for their education, training, healthcare,
rehabilitation and recreation in a manner that will contribute to their overall growth
and development.
The State and community shall launch preventive programmes against disabilities and
early detection of disabilities to ensure that families with disabled children receive
adequate support and assistance in bringing up their children.
The State shall encourage research and development in the field of prevention,
treatment, and rehabilitation of various forms of disabilities.
6
Disability
2.7 National Commission for Disabilities, 2003
The National Commission for persons with disabilities was set up in 2003; and one
believes that it will ensure the convergence required to meet the needs of persons with
disability.
Its purpose is to recommend programmes for the elimination of inequalities in status; and
to ensure facilities and opportunities for the disabled by providing appropriate education
and vocational training.
2.8 The Disability Acts
•
•
•
•
National Trust Act, 1999, aims to take total care by appointing guardians to
persons with autism, cerebral palsy, mental retardation and multiple disabilities so
that care is provided throughout their life.
The Mental Health Act, 1987, pertains to provisions for the mentally ill.
Rehabilitation Council of India Act, 1992, is responsible for standardising and
regulating training programmes for various categories of professionals.
The Persons with Disabilities (Equal Opportunities, Protection of rights and full
participation) Act, 1995, places responsibility on the centre and state to provide
equal opportunities for citizens to participate in society.
2.8.1 The Persons with Disability Act, 1995
The Persons with Disabilities (Equal Opportunities, Protection of rights and full
participation) Act, 1995, has been a major milestone in the history of the disability
movement in India. Some of its features that are relevant to children include:
a) Prevention and early detection of disability (Sec. 25)
b) Free education for every child with disability, in an appropriate environment, till the
age of eighteen years. (Sec. 26 a)
c) Schemes and programmes for non-formal education (Sec. 27)
d) Reservation of 3 per cent seats for admission to all government educational institutions
(Sec. 39)
e) Non-discrimination in transport, on the road, and in the built environment, so that
persons with disabilities can go to any place without any hindrance (Sec. 44-46)
f) Special opportunities to overcome any kind of discrimination being faced, e.g.
preference in allotment of land to disabled persons for housing, business, special
schools, research centres, recreation centres and factories (Sec. 43)
g) Generic and specialised services for rehabilitation (Sec. 66)
h) Appointment of a Commissioner in every State, to look into complaints relating to
deprivation of rights of Persons with disability (PWD). (Sec. 62)
7
Disability
3. The all-India scenario: estimates of disability and causes
The estimations of persons with disability vary a great deal. For policy formulation and
the provision of services; it is vital that reliable estimates of incidence and prevalence of
various disabilities are made, in line with accepted definitions of the different categories
of disabilities. However, disability is not a well-defined condition, and there are many
conceptual difficulties in articulation. It is also difficult to enumerate the number of
disabled children due to the social stigma attached to disability, and parents’ feeling of
guilt that make them less than forthcoming in sharing information. “It is important to
recognise that the available statistics in India are not very reliable; and more “hard data”
is required before more accurate conclusions can be drawn.” (Director, Mobility India)
Data on disability has been gathered through the census and the National Sample Survey
Organisation (NSSO). In the 1981 census, the enumeration of the disabled was taken up
for the first time, as 1981 was declared as the “International year of disabled persons” by
the United Nations. This was followed by another enumeration of disabled persons along
with the population census in 2001.
The NSSO has been periodically collecting information on disability through large-scale
socio-economic samples.
3.1 The National Sample Survey Organisation (NSSO) estimates
The NSSO carried out the third survey (NSSO 58th round) on the disabled in 2002, at the
request of the Ministry of Social Justice and Empowerment, Government of India, a
nodal ministry for the disabled. Along with details of physical and mental disabilities; the
socio-economic characteristics of disabled persons such as their age, literacy, vocational
training, employment, and cause of disability were collected. This survey estimated the
number of disabled as 18.53 million, comprising 1.8 percent of the total population.
The NSSO Survey 1991, however, estimated the percentage at 5% (2% physical and 3%
mental), more in keeping with WHO/UNDP international figures. This conservative
estimate would put the total number of disabled at 50 million in India. International
estimates vary from 5-10% as they also include learning disability as a category.
National Centre for Advocacy Studies (NCAS) is a social change resource centre,
working for human rights, social justice and accountable governance. NCAS estimates
that 1 in every 10 children is either born with or acquires a disability by the first
year of life. (Ref: “The Disabled Child’’). Despite reservation for persons with disability
by the government being at 3%; there are still so many unemployed disabled persons;
thereby suggesting that the NSSO survey, 2002 estimate of 1.8% is low. (Perscon:
Alternate Law Forum)
The details of the NSSO, 2002 survey presented below reflect an estimate of the number
of disabled persons in India by type of disability, by age, by gender, and causes (tables 1
to 4e).
8
Disability
fable 1: Number of disabled persons per 1,00,000 by sex and type (all India)
Type of
Disability
Mental
retardation
Mental illness
Blindness
Low vision
Hearing
disability
Speech______
Locomotor
Any disability
Rural
Urban
All
Male Female Average Male Female Average Male
Female Average
113
69
92
118 81
100
115
72
94
128
191
76
319
91
230
95
301
110
210
86
310
105 71
116 166
46 62
234 238
89
140
54
236
122
171
68
296
86
214
87
285
105
192
77
291
242 176
1274 804
2118 1556
210
1046
1846
221 151
1058 730
1670 1311
187
901
1499
237
1217
2000
169
785
1493
204
1008
1755
411 —
Source: NSSO 58"' Round
We see that locomotor disability has the highest incidence followed by hearing, speech
and visual disability.
Table 2: Number of disabled persons per 100,000 population; for children up to 4
and 5-9 years, by type of disability
Age group/ disability
Up to 4 years
5-9 years
Rural
Urban
Rural
Urban
Mental retardation
59
75
115
153
Mental illness
12
16
32
35
Blindness
32
30
48
73
Hearing
55
55
172
142
Speech
129
132
297
285
Hearing and speech
86
86
209
215
Locomotor
334
291
716
557
More than one disability
523
487
1167
1015
This table reflects the distribution of type of disability in the age group 0-4 and 5-9 years.
The age group of children under 6 years is not reported. Locomotor and speech
disability are seen to be the two most prevalent disabilities in the young child.
9
Disability
Table 3: Disability-specific data, NSSO, 58th round, 2002
This table provides an overview of the percentage distribution of type of disability.
Rural
Urban
Loco
motor
52%
55%
Mental
retardatn
4%
4%
Mental
illness
5%
5%
Blindness
10%
8%
Low
vision
4%
3%
Hearing
Impaired
10%
9%
Speech
5%
4%
Multiple
Disability
10%
12%
3.2 Causes of disability as per the NSSO survey, 2002
Several factors predispose Indian children to disability. The key factors include:
malnutrition or other nutritional deficiencies, communicable diseases, early childhood
infections like encephalitis or meningitis, poor sanitation, consanguinous marriage, lack
of immunisation, early motherhood, and of course, head injuries and accidents (Tali,
“Seen, hut not heard”, 2002)
Physical disabilities due to polio constitute the largest cause, followed by
communication and visual disabilities. (M.J. Thomas and Maya Thomas: An overview).
The findings reported under the NSSO, 58th round, 2002 are summarised in the
following tables 4a to 4e. The reporting is per thousand persons with a particular
disability.
Table 4a: Causes of visual disability
Urban
Causes of Disability_____________ Rural
1___
Sore eyes during first month of life
3 ___
8
6_
Sore eyes after one month_________
8
Severe diarrhoea before 6 years of age 7___
212
196
Cataract________________________
80__
Glaucoma______________________ 52__
40
Corneal opacity__________________ 21 __
164
170
Other eye diseases_______________
36__
Smallpox_______________________ 47__
2___
Burns_________________________
4 __
47__
Injuries other than burns___________ 38
49__
22
__
Medical/surgical intervention_______
200
Old age________________________ 250
74
70__
Other reasons___________________
89__
90
Not known_____________________
1000
1000
Total
Diarrhoea-related visual disability is found to be a preventable causal factor for the
under 6 year old child.
10
Disability
Table 4b: Causes of hearing disability
Causes_________________
German measles/rubella____
Noise induced hearing loss
Ear discharge_____________
Other illnesses____________
Bums___________________
Injury other than bums_____
Medical/surgical intervention
Old age_________________
Other reasons____________
Not known_______________
Total
Rural
6___
17__
165
229
2___
£7_
14__
254
77__
183
1000
Urban
8___
31___
132
221__
2___
59__
22___
295
99__
128
1000
Table 4c: Causes of speech disability
Causes_________________ Rural Urban
Hearing Impairment_______ 9____ 1___
Voice disorder___________ 90
£7__
Cleft palate______________ 15___ 21___
Paralysis________________ 239
250
Mental illness/retardation
79
100
Other illness_____________ 222
243
Burns___________________ 5____ 5___
Injury other than burns_____ 46___ 62___
Medical/surgical intervention 20___ 44__
Old age_________________ ]4___ 10___
isons____________________ 68___ 68___
Not known_______________ 148
102
Total 1000
1000
1000
For about 31 per cent, the cause is old age. For a large number, the reasons are unknown.
Ear discharge appears to be an important cause, applicable to young children.
11
Disability
Table 4d: Causes of locomotor disability
Cause____________________
Cerebral Palsy_____________
Polio_____________________
Leprosy cured_____________
Leprosy not cured__________
Stroke____________________
Arthritis__________________
Cardio-respiratory diseases
Cancer___________________
Tuberculosis______________
Other illnesses_____________
Burns____________________
Injury other than burns______
Medical/surgical intervention
Old age___________________
Other reasons_____________
Not known________________
Total
Rural
24__
295
8___
17__
66__
29__
3_
3
3___
120
20__
256
20__
35__
46
47__
1000
Urban
23___
270
29___
8____
82___
35___
3____
2
3____
120
18___
271__
26___
3]
31__
1000
Polio is the main and preventable disability.
Table 4e: Causes of mental retardation
Causes_____________________
Pregnancy and birth related
Serious illness during childhood
Head injury in childhood______
Heredity____________________
Other reasons________________
Not known__________________
Total
Source: NSSO 58lh Round
Rural
29__
393
85__
20__
201
250
1000
Urban
30___
460
128
33___
163
184
1000
The principle cause of mental retardation was cited as “illness during childhood” (42%)
followed by injury in childhood (10%). Cases of mental retardation due to “pregnancy
and birth related factors” were 3%. In 25% cases, respondents were not aware of the
probable cause of retardation.
There is a direct link between disability, poverty, and poor health care in the
community. Poverty implies living in unsanitary surroundings with a lack of waste
disposal treatment, and unsafe drinking water: the breeding ground for many infectious
diseases. If childhood diseases go undetected and treated due to poor health care services,
they can result in disability.
12
Disability
Poverty also implies food deprivation; leading to malnutrition of children and poor
nutrition of pregnant and nursing mothers. Poor nutrition, frequent pregnancies, and poor
quality of peri-natal care work in tandem and contribute significantly to disability.
There are some inter and intra state variations with regard to the prevalance of disability.
The national average of physical disability is 19/1000 as per the NSSO 47,h round, 1991.
A few states that have a higher prevalence rate than the national average are: Andhra
Pradesh (24.98/1000), Himachal Pradesh (28.70/1000), Karnataka (21.31/1000), Madhya
Pradesh (27/1000), Orissa (23.06/1000), Punjab (29.36/1000) and Tamil Nadu
(23.72/1000). In Kerala and Gujarat; night blindness, and impairments related to visual,
auditory, vocal and locomotor are low; whereas in Bihar and West Bengal they are high
in children between under 4 years.
The advocacy internet estimates that 1 in every 10 children is either born with or acquires
a disability by the first year of life. This suggests that significant measures need to be
taken for both identification as well as prevention and rehabilitation of persons with
disability. However, the advocacy internet reports that 97 percent of disabled children
in developing countries are without any form of rehabilitation; and 98 percent
without any education.
4. Government schemes for prevention and rehabilitation
The Ministry of Welfare, reconstituted as the Ministry of Social Justice and
Empowerment, is responsible for the disability sector in India. It looks after the welfare,
social justice and empowerment of disadvantaged and marginalised sections of society
viz: scheduled castes, minority, backward classes, persons with disabilities, aged persons,
street children and victims of drug abuse!
“The basic objective of the policies, programs, laws and institutions of the Indian welfare
system is to bring the target groups into the mainstream of development by making them
self-reliant” {http://socialjustice.nic.in/about/welcome.htm )
The Ministry identifies
seven disabilities:
In 1947, India had a total of 32 schools for the blind, 30
for the deaf, and 3 for people with mental retardation. In
2004, there are around 2,500 special schools.
Orthopaedically Handicapped
Visually Impaired
Hearing Impaired
Mentally Retarded
Multiple Handicapped
Leprosy cured handicapped
Mental Illness
In 1970, there were only two teacher training
institutes, both leading to a diploma in special
education. Today there are 37 centres offering such
diploma courses; and about 12 universities offering a
B.Ed. degree in special education.
13
Disability
The ministry has set up 11 District Rehabilitation Centres across the country, one of
them being in Mysore; to provide comprehensive rehabilitation to people in the rural
areas. The services include prevention, provision of aids and appliances, therapeutic
services; job placement and vocational training.
There are four Regional Rehabilitation Centres (RRTCs) in Chennai, Lucknow,
Mumbai and Cuttack, to provide training and human resources for rehabilitation services.
While these programmes are very well intentioned, most of them, invariably, remain
notional in character. Their outreach and accessibility in remote and rural areas
remain negligible. As a result, while comprehensive rehabilitation services are provided
in few urban agglomerates, a large part of the country, especially the rural areas, remain
unserviced. (Disability India. Journal).
Since a large number of disabilities are preventable, the guidelines of the National Health
Policy promote prevention. However, these appear to be limited to immunisation and
programmes for the prevention of blindness and leprosy.
As part of its rehabilitation schemes, the ministry offers the Scheme of assistance to
disabled persons for aids/appliances (ADIP scheme). Under this scheme, aids and
appliances that cost less than Rs.6000 can be availed of by people whose income is less
than Rs.8000 per month. Apart from different societies, charitable trusts, district rural
development agencies, and other bodies authorised by the ministry; this scheme can be
availed of at the District Rehabilitation centres, viz Mysore for Karnataka.
Apex level institutes located in different parts of the country develop the human
resources required to provide services to the disabled. Each of these institutes works in a
different field of disability. These institutes run specialised courses to train professionals
in the different areas of disability; and are at the forefront of their respective specialties:
The National Institute for the Mentally Handicapped, Secunderabad
The National Institute for the Visually Handicapped, Dehra Dun
The Ali Yavar Jung National Institute for the Hearing Handicapped, Mumbai
The National Institute for the Orthopaedically Handicapped, Kolkata
The National Institute for Rehabilitation Training and Research, Cuttack
Institute for the Physically Handicapped, New Delhi
5. The situation in Karnataka
Karnataka is the eighth largest state in India; both in geographical area and population.
According to the 2001 census, Karnataka has a population of 5,27,33,958; of which
68,26,168 are below 6 years. The percentage of children below 6 years is 12.94 per cent.
With regard to disability, Karnataka has been in the forefront of efforts. It was the
second state, after Andhra Pradesh, to set up the Directorate of Welfare of the Disabled as
an independent department, in August 1988. The Directorate aims to bring persons with
disability into the mainstream of society.
14
Disability
Karnataka is also the first state to have conducted a survey on disability in 1991-92.
(Source for Tables 5-6: Survey of persons with disability in Karnataka, 1991-92)
Table 5: Disabled persons by gender
No. of persons with disabilities
Male
2,04,520
Female
1,44,023
Total
3,48,543
Table 6: Children below 6 years with disabilities
District
Orthopdc
Impaired
Bangalore
1223
Bang (U)
1431
Belgaum
1945
Bellary
2538
Bidar_____ 778
Bijapur
2330
Chikmaglur 598
Chitradurga 1286
4013
Dharwad
D Kannada 836
Gulbarga
2863
Hassan
616
164
Kodagu
Kolar_____ 1212
Mandy a
665
Mysore
1418
Raichur
3599
Shimoga
1630
Tumkur
1600
U. Kannada 484
Total
31229
Visual
Impaird
Hearing
Impaird
Mental Ret/
Mental
illness_____
Leprosy
Cured
Multi
disabled
212
188
118
311
85
173
99
208
427
78
353
109
22
203
90
344
323
355
259
263
351
121
325
193
196
622
289
487
145
51__
294
231
433
418
285
398
101
5817
297______
245______
260______
227
60_______
238______
158______
155
460______
222
355______
161______
57_______
196______
171______
208______
329______
317______
319______
108______
4543
37
21
7
26
10
15
10
8_
92
4
64
5
0
12
3
6
29
35
2
2
388
103
0__
13
178
243
41__
3805
J_
3__
39
23
29
261
68
145
79
0__
61
60
25
119
88
34
12
1183
The prevalence and type of disability in the state is in keeping with the national trend (see
Table 2). It is also worth noting that so-called developed districts such as Dharwad and
Bangalore too appear to have a relatively high number of disabled children. Due to the
reasons cited earlier; these figures also appear to under-report the actual prevalence of
disability (for example, there are many special schools in Bangalore city that work with
children with multiple disability, recorded here as nil). It is also hoped that further
enumerations will draw a distinction between mental retardation and mental illness.
15
Disability
5.1 State administration
The state government has constituted a State Co-ordination Committee and a
Commissioner for persons with disabilities as per the provisions of the Act. A deputy
director, assistant director and a gazetted manager assist the Director of the Directorate of
Welfare of the Disabled. The staff of the Directorate including the ministerial staff is
mainly on deputation from other departments such as the Department of Women and
Child Development. At the district level, the District Disabled Welfare Officers are the
implementing officers.
5.2 Schemes and services for the disabled
Although the state has several schemes for the disabled, there are no special schemes for
children beloyv 6 years.
Monthly financial assistance to disabled persons
The Department of Welfare of the Disabled provides a maintenance allowance of Rs. 125
per month to disabled persons below the poverty line. Disabled persons whose family
income is less than Rs.6000 per annum and who have more than 40 per cent disability are
entitled to get this allowance. Tahsildars of the concerned taluk are the sanctioning
authorities. At present the state dispenses this allowance to around 3,00,000 persons with
various types of disability.
Until last year, this allowance was open to any person who was eligible, including
children. Now, only persons over 16 years are eligible for this allowance.
Aids and Appliances to disabled persons
Under its rehabilitation schemes, the state provides aids and appliances such as tricycles,
hearing aids, Braille watches etc to disabled persons whose family income is less than
Rs. 11,000 per annum in rural areas and Rs.24,000 per annum in urban areas.
The challenges posed in getting a medical certificate or income certificate to access the
monthly pension, scholarship, assistive devices and other schemes is a deterrent to
accessing the service; and results in the poor utilisation of these benefits.
One way of ensuring the inclusion of persons with disabilities as one of the service
groups and enhancing access to resources at different levels might be by involving
persons with disability at the Gram Panchyat, Taluk and District level.
16
Disability
Identity card for disabled persons
The state issues identity cards to all categories of persons with more than 40 per cent
disability; based on the disability certificate issued by government hospitals. Around
2,50,000 cards have been issued so far. This card entitles the disabled person to avail of
any benefits offered by the government.
These cards are issued by the Directorate of Welfare of the Disabled in Bangalore; or by
Child Development Programme Officers (CDPOs) of the ICDS; District Disabled
Welfare Officers at the district; or the State Referral Centres.
Of all the schemes offered, the monthly disability pension takes up roughly 80 per cent
of the budget; and is clearly not earmarked for children. Educational scholarships,
assistance for self-employment, grants-in-aid to NGOs and CBR programmes take up a
substantial part of the rest of the budget. Other initiatives such as prevention, early
identification and intervention get only a small allocation.
To initiate and sustain new programmes towards bringing a qualitative change in the lives
of persons with disabilities, especially the poor in rural areas; the reach of the disability
welfare department at the district and taluk levels must be strengthened. A convergence
and better utilisation of development schemes is called for.
National Programme for Rehabilitation of Persons with Disability (NPRPD)
The NPRPD is a programme of the Ministry of Social Justice and Empowerment. In
Karnataka, it is being implemented in all the talukas of three districts of the state Tumkur, Bellary, and Mysore. The project aims at providing a comprehensive
rehabilitation service under one roof; such as aids and appliances, counselling by
specialists, and corrective surgery. A State referral Centre has been set up at the Sanjay
Gandhi Accident and Research Institute in Bangalore.
The service, follow up and repairs of appliances for persons with disabilities is not
available across the state. For example, to undergo an audiometry test and get fitted with
a hearing aid, a person in Koppal district of Karnataka has to travel all the way south 500
kms to Mysore.
Schools
The Department inns four residential schools for the visually impaired and four schools
for the hearing impaired.
The schools for the hearing impaired are located in Mysore, Belgaum, Bellary and
Gulbarga. While the one in Mysore runs from Class 1-10, the remaining three are from
pre-primary to Class 7.
The schools for the visually impaired are located in Mysore, Hubli, Gulbarga and
Davangere; and except for one, all have classes from Std 1-10.
17
Disability
5.3 Integrated Child Development Scheme (ICDS)
While the Department of Welfare of the Disabled concentrates on the rehabilitation and
welfare of the disabled, the onus of prevention, early identification and intervention is
with the Department of Women and Child Development (DWCD) through its ICDS
programme.
The Integrated Child Development Scheme (ICDS) has been “universalised” in
Karnataka. It is a comprehensive child development program. The ICDS aims to
improve the nutritional and health status of children below 6 years, to serve pregnant and
lactating mothers; and enhance the mother’s capability to look after the nutritional needs
of the child through health and nutrition education. It offers a package of six services:
BOX 1: ICDS services
I. Supplementary Nutrition: Children less than six years, pregnant and lactating
mothers receive this supplement. Severely malnourished children receive double
quantities.
2. Immunisation: Children receive immunizations to prevent diphtheria, tetanus,
whooping cough, tuberculosis, polio and measles. Pregnant women receive tetanus
toxoid.
3. Health Checkup: Antenatal care of pregnant women; post-natal care of
nursing mothers; and care of children less than six years of age.
4. Referral Services: Referral services for both mothers and children to PHC,
sub-centres, District or Referral Hospitals.
5. Nutrition and Health Education: Nutrition and Health Education is provided to
women between the ages of 15 and 45.
6. Preschool Education: Children of 3-6 years of age are provided with non-formal
pre-school education in an anganwadi in each village or locality.
The focal point of the ICDS is the anganwadi center. One anganwadi is set up for a
population of every 1000. The centre works from 9.30-1.30 pm when children, 3-6 years,
are given non-formal preschool education and supplementary nutrition.
Therefore, the anganwadi centre is the first institution that a potentially disabled or
disabled child encounters. This provides an ideal opportunity for early identification and
appropriate stimulation and intervention. However, it has been found that the ICDS has
“failed to focus on prevention and early identification of disability, and
concomitantly, on interventions that could minimise the impact of impairments.
This is a glaring omission, considering that the ICDS targets children in the under 6
years age group’’. (Tali: “Breaking Barriers: Physically challenged children ’’)
18
Disability
Though an awareness module on disabilities has been included in the job training course
which every anganwadi worker goes through, children with disabilities are not included
by design (italics added) in the anganwadi centres. (CBR network, South Asia). A study
undertaken by Karnataka FORCES in 2002 shows that in the 40 anganwadis observed in
Bangalore (urban and rural); children with disabilities were seen in only three centres.
5.4 Prevention, early detection and intervention initiatives in Karnataka
With the aim of early identification and intervention, the state has implemented two
programmes: in Manvi taluk of Raichur district and H.D Kote taluk of Mysore district.
This programme has been implemented with the help of CBR Network, an NGO; and
NIMHANS (National Institute of Mental Health and Neuro Sciences).
CBR Network conducted a pilot programme on the implementation of the Portage
package in Manvi taluk of Raichur district. With a population of 2,00,000; Manvi was an
underdeveloped area with the highest incidence of disabilities. CBR network trained a
range of functionaries, from grass-root workers to government functionaries and
members of the local self-government. Children with special needs were identified and
integrated to pre-schools; and many received medical rehabilitation.
Portage is an internationally accepted American approach to early intervention. It
promotes a package of interventions that apply an inclusive approach; are simple to
use; demystify concepts of disability; are precise; and any mother with basic literacy
skills can learn to use it.
The CBR network adapted Portage to Indian conditions, and field-tested this model in
Manvi. After positive feedback, this package was later implemented in all the 27 districts
of the state.
In order to make this effective and sustainable, the Department of Women and Child
Development undertook training programmes for its anganwadi supervisors and workers.
The table illustrates the coverage.
19
Disability
Table 7: Training of anganwadi supervisors and workers
Posts filled as of May 2004
Udisha-Portage
programme-For Total number of Anganwadi Supervisors:
early detection of disability________ 1728_______________________________
U d i sha- Portage
p rogram me- For Total number of Anganwadi Workers:
early detection of disability
39690
Training coverage as of March 2004
Udisha-Portage
programme-For 16 districts
early detection of disability
(First phase in Mysore, Chamrajnagar,
Raichur, Koppal and Bangalore).________
2
Udisha-Portage
programme-For 7676 trained anganwadi workers
early detection of disability________
3
Udisha-Portage
programme-For 1093 trained anganwadi supervisors
early detection of disability________
4
Udisha-Portage
programme-For 11 districts - training in progress
early detection of disability________
5
Udisha-Portage
programme-For 54 trained facilitators in talukas (Two
early detection of disability________ facilitators in each district are trained).
Source: Department of Women and Child Development, 2004
1
The training methodology involved an orientation to members of the Zilla or Taluk
Panchayats, community leaders, officials of health, education, agriculture and other
related departments. Two facilitators from each district were identified; one from an
NGO, and the other a government functionary such as a District Disabled officer or an
officer from the DWCD. The facilitators then attended a 15-day training programme at
Bangalore. By this methodology, a permanent human resource team was available in
each district to carry out new and ongoing training. The NGO representative would be
the person providing continuity; as compared to the government representative who
would be subject to transfers.
20
Disability
BOX 2: Objectives of the training programme
The objectives of the training programme were:
•
To enable anganwadi workers and mothers to understand the underlying principles of
Early Childhood Care and Development
•
To enable anganwadi workers to facilitate a stimulating environment to ensure that the
child receives appropriate support during the fundamental developmental period
•
To enable Anganwadi workers to identify developmental delays and disabilities in the
0-5 years period; and extend support to mothers to train the children using the residual
potential to the optimum extent
•
To train supervisors as resource persons; and to train anganwadi workers to use the
Indian portage guide for planning and intervention
•
To reach out to all the disabled children in rural/tribal and urban impoverished areas
(Source: DWCD)
In 2001-2, NIMHANS worked in H.D. Kote taluk of Mysore district. The project aimed
at setting up a network of personnel in three sectors - ICDS, Health and Education - in
an integrated manner through the training of anganwadi workers, health workers, doctors
and teachers.
NIMHANS conducted four multiple disability camps and provided
medical and psychosocial rehabilitation.
5.5 Training of Primary Health Care functionaries
In keeping with the spirit of the PWD Act, Chapter IV (d), to provide training to the staff
of the Primary Health Centers (PHCs), the RCI (Rehabilitation Council of India)
launched the National Programme for Orientation of Medical Officers for disability
management in 1999. Karnataka was the first state in India to take up this
programme for all doctors of the primary health centers as well as orthopedic
surgeons; towards important aspects of disability prevention, early identification,
intervention and management. The Institute of Speech and Hearing in Mysore was
entrusted with the task of conducting the programme
(see Table 8)
21
Disability
Table 8: Training of health personnel
Place_____________
Institute of Speech
and Hearing,
Mysore___________
Institute of Speech
National Orientation Programme on 97 Orthopaedic
Surgeons
and Hearing,
Disability Management
Mysore____________
Source: The information is based on pers.comm. with the Asst. Commissioner of
Disabilities and http://rehabcouncil.nic.in/home.html
Activity________________________
National Orientation Programme on
Disability Management
Personnel/coverage
1600 PHC Doctors
5.6 Evolution and role of NGOs
Traditionally, NGOs working in mainstream development activities such as poverty
alleviation, education and health have not attended to persons with disabilities. The
general perspective was that working with persons with disabilities required special skills
and was best left to specialists. At the most, NGOs met the needs of persons with
disabilities through the distribution of out-sized wheelchairs, tricycles or hearing aids at
public functions.
Some NGOs began to provided institutional care. It was often parents of disabled
children who founded these institutions. Persons with disabilities became dependent on
the institution, and lost contact with their family. The State on its part could not manage
to deliver services and programmes on its own, and once again relied on voluntary
organisations to fill the gap.
The NGO sector has played a very important role; not only in providing services to
persons with disability, but also in mobilising people to fight for the rights of the
disabled. There are more than 3000 voluntary organisations in the country actively
involved in ensuring a life of dignity and equality for differently-abled children (Tali:
Breaking barriers). The only disadvantage is that most of the NGOs are located in urban
areas catering to the needs there; while a large percentage of the disabled population
requires rehabilitation in rural areas.
In 22 districts of Karnataka, through centrally sponsored schemes, there are 81 aided
NGOs that work with the disabled.
The department offers up to 100 percent grants-in-aid to voluntary organisations to pay
for the salaries of teaching staff; 50% for non-teaching staff; and maintenance charges.
Of the 34 institutions aided by the government in Karnataka working for different
types of disabilities; 27 of them are schools for children 6 years and above; and the rest
are training centres for technical, mobility and vocational skills. There appear to be no
separate grants-in-aid schemes for services for children under 6 years.
22
Disability
5.7 Community based rehabilitation (CBR) and its approaches
The community based approach became a reality when institutions were no longer in a
position to provide services for all the disabled. Initially this approach focussed on
rehabilitation of persons with disabilities within their own community. Again, the
emphasis was more on providing medical services to persons with disabilities such as
referrals, corrective surgeries, and provision of aids and appliances. However, this
approach over the years did not result in any change in the status or quality of life of the
disabled persons; despite their having accessed rehabilitation services.
Soon it became evident that not only were the medical and rehabilitative needs of the
disabled necessary; but one would also need to address their social needs. This could be
ensured by including persons with disability in mainstream education, or equipping them
with vocations for their livelihood; both measures would ensure social visibility. This
became a more holistic form of rehabilitation.
The current rights based approach in community-based rehabilitation believes in
facilitating groups of persons with disability to demand their rights, access schemes
of the government, and generate income for themselves as a group.
In a large developing country like ours, there are numerous gaps left by the government
both in terms of reach and in terms of access to quality service. Various NGOs working
for the disabled have filled in the gaps by providing required services.
An intervention for Dastagir..
Dastagir is a 9 year old child with cerebral palsy who looks
like a 3 year-old. He was born at home after a full-term
pregnancy. When he did not cry immediately on birth, the
doctor told his parents that he would be severely disabled. As
he was growing, his limbs were not strong, he could not move
around and could not speak. For the next six years, he
remained at home with no intervention. When Mobility India
began its CBR programme in the area three years ago, he was
identified and put on a rehabilitation programme. Today, he
is able to stand with support; calls out a few words and can
recognise objects that are placed in front of him.
23
Disability
Kartik rediscovered..
Kartik is two and a half years old and cannot hear. When his developmental
milestones were delayed, his parents thought that he was slow to catch up. It was
only when he did not speak or show signs of communication even after he was a
year and a half that they began to be concerned. It was then that an NGO with its
CBR programme intervened and advised testing. The tests proved that he was
profoundly deaf. He was advised to wear a behind-the-ear hearing aid that the
NGO provided. Besides that, they ensured that he enrolled in a special school
where he will begin therapy for two hours a day.
5.8 Groups working on issues of disability
Association of Persons with disabilities (APD), Lingarajpuram, Bangalore
APD runs an integrated school, community based rehabilitation services in rural and
urban areas, provision of assistive devices.
Mobility India, .IP Nagar, Bangalore
A rehabilitation, research and training centre, and community based rehabilitation - to
enhance mobility of persons with disabilities and ensuring access to relevant
rehabilitation services for persons with disabilities in rural and urban areas.
National Association for the Blind, Jeevan Bhima Nagar, Bangalore
Has an integrated education programme and community based rehabilitation programme
for visually impaired children in urban and rural areas. Mobility and vocations skills are
offered to persons with visual impairment.
Shree Ramana Maharishi Academy for the Blind
School for visually impaired children, training programme for community workers, and
community based rehabilitation in rural areas.
Spastics Society of Karnataka, Indira Nagar Bangalore
Focus on people with cerebral palsy, community-based rehabilitation, school for children
with cerebral palsy, development delays, neuro-muscular disorders and slow-learners.
Dr. S. R. Chandrashekar Institute of Speech and Hearing, Hennur Road, Bangalore
Provides assessment and therapy for speech, language, hearing and learning disorders at
its center; and in their urban and rural camps.
RV Integrated School for Hearing Impaired, Lalbagh West Gate, Bangalore
Integrated school and services to help children develop speech and language skills
through early intervention.
24
Disability
Action of Disability and Development, Banashankari, Bangalore
ADD India work with organisations in rural areas, in organising disabled persons groups
to advocate for their rights and inclusion.
Karnataka Parents Association for Mentally Retarded Citizens (KPAMRC),
Bangalore
An association of parents of children with disabilities, with members from across the
state working as a support group and in conducting training programmes.
Seva-In-Action (SIA), Koramangala, Bangalore
Community Based Rehabilitation programmes; and working in the areas of inclusive
education in collaboration with the government.
CBR Network (South Asia), Banashankari, Bangalore
Community Based Rehabilitation, conducting training in inclusive education; and early
identification and intervention of disabilities.
Bangalore Children’s Hospital, Bangalore
Specialises in caring for children; runs the Jagruthi school for children with special
needs; has a child development centre providing early intervention to infants and toddlers
with development delays.
National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore
A teaching hospital that offers comprehensive evaluation for children with development,
emotional, behavioural, academic and psychotic disorders.
6. Summary of issues: the young child with disability
The fact that the first six years of a child’s life are crucial for his/her development is well
known universally. Most of the child’s development takes place during this period;
including group socialisation, learning, and physical development. The following are a
few issues that affect the disabled child in particular.
a. Poverty is a central issue that needs a specialised focus; as it is the root cause for
disability. Malnutrition and limited access to health care as a result of poverty will
continue to be a key underlying problem. Lack of safe water, sanitation, and poor
personal hygiene contribute to ill health; leading in some cases to disability.
b. Immunisation coverage: Of all the disabilities, the orthopaedically handicapped are in
significant numbers. The National Policy for Children mentions the eradication of
poliomyelitis, but in Karnataka the task force found the coverage of immunisation in the
range of 60-80 percent. The government Pulse polio programme yielded a two-year polio
free period; but the recent detection of nine new cases in north Karnataka has raised
alarm bells again.
25
Disability
c. The ICDS programme has the widest reach to service this age group. In Karnataka
there are more than 40,000 anganwadis; across all 27 districts. The ICDS docs not have
any special early identification program apart from the training given to anganwadi
workers.
Early intervention and stimulation are necessary to avoid secondary
disabilities.
d. The workload of the anganwadi workers makes implementation of the Udisha
Portage a less than feasible option. Since the anganwadi worker works at the grassroot
level, she is required to participate in several other government programmes; limiting her
time for child-related activities.
e. Not all anganwadi centres are accessible to the disabled or barrier free; hence, they
prevent a disabled child from coming; even though he or she may be willing.
f. Most disabled children are discouraged by parents and siblings to perform life skills on
their own, which makes them dependent. A shift in cultural perception is required by all
caregivers; and society in general; to bring the disabled into the mainstream.
g. Lack of awareness and the challenges posed in getting a medical certificate or
income certificate to access the monthly pension, scholarship, assistive devices and other
schemes is reflected in the poor utilisation of the schemes; and is a deterrent to access the
schemes.
h. Since the District Rehabilitation Center and the Primary Health Care (PHC) systems
work independently, there is a lack of coordination. The PHC functionaries too are not
adequately equipped to provide inputs on rehabilitation. Therefore, early identification
does not get the required attention.
i. The allocation of resources for prevention, identification and early intervention is
limited. Much of the budget goes towards paying pensions, scholarships, providing aids
and appliances, maintaining institutions for the care of people with disability, and in the
running of special schools.
j. The services for persons with disabilities are unevenly spread across the state.
k. In places where NGOs implement a CBR programme; early intervention and
stimulation takes place (see boxes) and disabled children attend anganwadis.
26
Disability
7. Concluding thoughts
It is imperative that reliable estimates of the incidence and prevalence of various
disabilities are available in accordance with accepted definitions of various categories of
disability.
With the strengthening of preventive measures and coordinated efforts, the rate of
disability ought to reduce. Paradoxically; new modes of living, a dramatic increase in
accidents at home and outside (on agricultural farms and in industrial units); the misuse
and abuse of drugs and other chemicals; failure of health services to significantly reduce
the mortality of mothers and new-born children; and a host of other factors are only
adding to the prevalence. Poverty too is the root cause for disability, and unless this issue
is addressed head on, all health or social interventions will have a cosmetic affect.
The allocation for early detection and prevention is inadequate. The Primary Health
Centre does not coordinate with the District Rehabilitation Centres, and is also woefully
under-staffed to respond to local needs.
Government schemes are also underutilised, due to a lack of information as well the
difficulties experienced in availing of them. The process of early identification and
intervention are more effectively done by NGOs due to their presence in the field.
Therefore, some resources could be directly routed through them.
The new trend for enabling the rights and dignity of disabled people can be addressed by
planning and implementing a range of services aimed at making them independent in all
respects. These services could cover all aspects of an individual’s life from before birth to
death; from health to education; leisure to employment; housing to transport etc.
The future challenge is to focus on a “zero rejection” in the provision of suitable services
for children of all age range and severity levels. There is a need to carry out sustained
awareness-raising campaigns on all the dimensions of disability.
The convention on the rights of the child upholds the right to life and development. But
society neglects its disabled children in every way: from a denial of the right to life, to be
born, to survive, to receive equal opportunities.
Looking back, we have made some strides in the field, considering the socio-economic,
linguistic, religious and cultural variations in our country. Looking ahead, we realise that
a lot more needs to be done if all persons with disabilities are to be given equal
opportunities and access.
27
Disability
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15. Raymond,L., 2001. Understanding disability from a south Indian perspective.
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Disability
16. Report of the project on evolving community based models of delivery of services
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17. Thomas, M. J., and Thomas, M., 2002, An Overview of Disability Issues in South
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WEBSITES
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4. Department of Women and Child Development, Ministry of Human Resources
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District Bijnor, Child Development Project Office http://bijnor.nic.in/cdpo.htm
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29
Disability
11. Rao, Indumathi. Equity to women with disabilities in India.
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BROCHUR.HTM
30
Disability
ANNEXURE : Early Childhood Care and Education (ECCE)
(Extracted from “Documentation of Good Practices in Special Needs and Inclusive
Education In India” prepared by CBR NETWORK (South Asia) for UNICEF
It is now globally recognized that systematic provision of ECCE helps in the
development of children in a variety of ways such as group socialization, inculcation of
health habits, stimulation of creative learning process and enhanced scope for overall
personality development. In the poorer sections of the society, ECCE is essential for
countering the physical, intellectual, and emotional deprivation of the child. ECCE is also
a support for universalisation of elementary education and it also indirectly influences
enrollment and retention of girls in primary schools by providing substitute care facilities
for younger siblings.
At present, Integrated Child Development Services (ICDS) is the most widespread ECCE
provision. Besides, there are preschools, balwadis and so on under the Central Social
Welfare Board, in addition to some state government schemes and private efforts. Efforts
have to be made to achieve greater convergence of ECCE programs implemented by
various government departments as well as voluntary agencies by involving urban local
bodies and gram Panchayat. Further, ECCE will be promoted as a holistic input for
fostering health, psychosocial, nutritional and educational development of the child
(MHRD 2002). The role of ICDS in early identification, early stimulation, pre school
preparation of children with disabilities etc. is not yet fully explored. Only the Women
and Child Development department in Karnataka through the project titled “Udisha
Portage” implement one such initiative of large-scale inclusion of children with special
needs. 1
There are a number of projects initiated in India for early identification and intervention.
UNICEF in India has supported such initiatives in different States. These projects were
implemented both in urban impoverished and rural areas. The major implementing
organizations in these programs have been NGOs such as Spastics Societies, CBR
Network, Samadhan, etc. The strategy of these projects was to train families, especially
mothers, in early childhood care and education using the locally available resources.
Within these projects there were efforts to include children with disabilities into ICDS,
however, there are not many projects initiated and supported by the State Govts,
promoting a horizontal inclusion of children with special needs in the ICDS program. The
only state which has taken a major initiative is the (Women and child development Dept.)
Karnataka State which is promoting horizontal inclusion by training all its 40,000
Anganwadi workers in 27 districts to use Indian Portage. This certainly is an initiative by
the State Govt, which has replicability value. There is a tremendous need to promote an
active policy of inclusion in pre-schools managed by private organizations. India has a
very large number of such pre-schools and day-care centers run by private organizations
and which are not funded by the Govt. Therefore it becomes important to develop
mechanisms to ensure these pre-schools also fulfill their social responsibility by opening
their schools to all children including children with disabilities. Having said this there is
also an urgent need to develop tools for early identification using inclusive principles
1 Udisha Portage is the largest inclusive education program initiated by the Government of Karnataka in India. This is a
World Bank supported program and is implemented with technical support from CBR NETWORK.
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Disability
rather than looking at disabilities. Early childhood care and education will be possible
only when there are strong linkages with the primary healthcare system. At present
experiments such as DRC (District Rehabilitation Center), which worked separately from
primary health care has not achieved much in ECCE. This is mainly due to lack of
knowledge and skills available in the personnel of primary healthcare on ECCE. At
present, in the curriculum of the medical, nursing, health workers training program, as
well as primary health care personnel training program we do not see a component on
early identification and intervention of children with disabilities. Such a component needs
to be incorporated into the training program. The curriculum should go beyond mere
awareness building and lead to development of practical skills. For eg. By including
functional assessment and Indian portage in these training programs as a compulsory
component, these personnel will have necessary skills to guide the families.
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