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Frame work for
C R Y’s
Health Policy Development
EMERGING FROM CASE STUDY OF ITS GRASSROOT INVOLVEMENTS
and IN THE LARGER CONTEXT OF THE CHILD IN INDIA
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MANI KALLIATH mbbs. mph
Frame work for
C R Y’s
Health Policy Development:
EMERGING FROM CASE STUDY OF ITS GRASSROOT
INVOLVEMENTS AND LARGER CONTEXT OF THE CHILD IN INDIA
By
MANI KALLIATH mbbs, mph
August 2002
Copyright
Published by
Year of Publishing
CONTENTS
I
Introduction
1
II
Methodology
4
III
The context - Internal Environment
6
IV
V
a.
CRY Organization
b.
Partner Performance
Context - External Environment
a.
Child health situation
b.
Policies and programs
c.
Civil Society Responses
Prelude to the Recommendations
a.
Observations from the micro situation
b.
Critical issues
c.
Pointing at need for intervention
23
69
VI
Recommendations
85
VII
Impact Indicators
94
VIII
Conclusion
References
98
100
ANNEXURES
Annexure 1 : Six Partner Case Studies
102
Annexure 2 : Case Studies of Innovative Child Health Program
140
Annexure 3 : Supporting Documents
148
Annexure 4 : Field Study
155
ACKNOWLEDGEMENTS
This report is the result of the idea conceived by Ms. Shefali Sunderlal, the
earlier Director Development Support CRY and made possible by the Trustees
of CRY sanctioning this Study. This task was ably pursued and supported by
Ms. Ila Hukku, the present Director, Development Support.
The author of this report is Dr. Mani Kalliath, Public Health Specialist, and
the findings, interpretations and conclusions expressed have been made by
the author. The author was supported by Dr.David Antony, Public Health
Specialist, in carrying out part of the field study and by Mr. Shaju Joseph,
Social Scientist, who not only provided editorial support, but also developed
the note on 'Civil Society Responses'.
The Program Support Unit (PSU) of the CRY team facilitated the field study.
The author is grateful to Mr. Subhasis, Mr. Atin, Mr. Vasu and Mr.John as
well as the regional team members, Mr.Singh, Mr.Manav, Ms.Sangamitra,
Ms.Soha, Mr.Sotto and also the team of the partner programs studied. The
author acknowledges the enthusiastic support received from the PSU team,
during the planning meeting, the field visits and during the review meeting
in May 2002 which brought out specific suggestions.
Dr. CM Francis, Medical Educationist and Public Health Specialist, guided the
study at the conception stage, and gave valuable support through specific
feedback and suggestions to the first draft. Dr. Abhay Bang,
'SEARCH'
Gadchiroli, gave valuable feedback and suggestions to the first draft.
The
author
acknowledges
numerous
resource
persons
especially,
Dr. Rajnikant Arole of Jamkhed and Dr. Vandana Prasad of FORCES, for their
written feedback to questionaire on 'child health priorities', Dr. Suneeta
Prajwala, Ms. Gayathri Ramachandran IAS (former Secretary,DWCD, AP), Dr.
Vijayaraghavan Associate Directoi NIN, Prof. Babu Mathew, National Law
School, Ms.Sudha Murali UNICEF for the time made available on this subject.
Ms. Lakshmi, Documentation Officer CRY was very resourceful in getting
relevant documents and Mr. Satish provided able assistance in typing,
making the layout and cover page.
Last but not the least the author wishes to thank his wife Ms.Cecily, who
through her support and encouragement made it possible to complete this
report through the long process involved.
I.
INTRODUCTION
CRY network is going to be in existence for almost 25 years, working on developmental
issues of children.
Over this period, the scenario of issues affecting children and their quality of life has
undergone vast changes, mostly for the worse. During this two and a hnlf decades the
understanding of development has also undergone paradigm changes. Social sector
perspectives have moved from charity orientation to development orientation and from there
further to empowerment orientation.
Starting with small beginning and intense passion in its child focussed partnerships, the
CRY family has expanded into a large network and as a resource support organisation. The
CRY has moved into “Third Generation" NGO resource group by Korten's nomenclature
whose primary role is “to address societal concerns in a substantive way” (Shaping Policy :
Do NGOs Matter ?, Aseez Mehdi Khan, PRIA, 1997). During these two and a half decades,
some of this shift of priority and role may have taken place proactively, by design. More
likely much of the change may have been reactive, in response to the needs and pressures
from the grass roots partnership.
It appears to the outside observer, a watershed in the maturing of CRY into a third
generation NGO network /resource support organisation started about 5 years ago. During
these five years, CRY has consciously moved from relief and development oriented
approach to a ‘rights’ oriented (empowerment oriented approach). This has resulted in CRY
investing for and being a prime mover for the campaign for universal education rights of the
child. This process has built in (internalised) new collective learning in the areas of rights
oriented perspective, strategies, skills and tools.
CRY’s focus and emphasis over these years have been primarily on education sector.
Though health interventions have been part of CRY involvement, these have happened
because of needs raised by partners.
The health sector interventions seem to be sporadic and adhoc and it is not clear how
effective they have been. Nor have there been much internal documentation reflecting on
evolution of policy and strategies in the health sector. It makes the observer conclude health
sector intervention did not result from conscious and planned steps.
Now with the organization better established in its perspective and strategies regarding a
rights oriented approach in the education sector, it .is time to do the same in the health
sector.
-1 -
Purpose of this assignment
The purpose can be summarised as the following:
To prepare the CRY organization and partnership network to develop long term systematic
involvement in child health issues.
Towards this purpose the assignment would help to develop a long term perspective and
understanding of strategies at different level of the network and open the way for
appreciating the capacities, systems and resources required.
It would also help in identifying immediate activities to be carried out
Terms of Reference (TOR)
The objective of the Study
To develop recommendations for CRY’s future health sector thrusts from a child rights point
of view, both for grass root involvement through CRY partners and for Policy Advocacy
efforts at the national and state levels
To suggest Child Health issues to be addressed
The strategic paper on health issues would have to address the following categories of
issues:
Generic issues, many of which have also been identified by health activists as “child
ealth campaign” issues :
Poverty, food, under-nutrition and malnutrition
Mother health and effect on child health
Lack of basic systems for care (of the child)
Stresses on family caring system
Issues in weaning and supplementary feeding
Promotion of micro-nutrients versus lack of food
Malnutrition in older children
Access to quality primary health care.
Withdrawal of state from basic services (including health)
Inadequacies in comprehensive policies and schemes for the child
Health issues of an inappropriate schooling system
Inadequate budgetary allocation for child health
Special issues affecting specific sections of children:
Violence against children (including sexual abuse)
Deprivation of the girl child.
Street children and child labor
Female foeticide
Children affected by AIDS
Children with disabilities
-2-
To analyse primary and secondary data to identify issues specific to children of age :
■
0 to 2 years
■
2 to 6 years
■
6 to 14 years
Study Process
•
Analysis of relevant government policy and program review documents to arrive at
likely child health impact:
■
■
■
In the context of child rights milestones
Controversial issues and gaps
Steps towards correction
•
Scanning of child health related documents that are likely to influence governmental
policies in the future.
Studying the experiences and priorities of voluntary sector
Interacting and observing experiences of 2 or 3 experts, promoting child health from
a “Rights
I
angle” to identify key program and policy interventions
Field visit of five CRY partners from the three regions of Mumbai, Chennai and
Calcutta and interacting with concerned program support team, to identify priorities for
CRY’s interventions.
Expected outcome
A referenced document that suggests directions and modifications in reference to
government policies and program affecting child health in India.
Guidance for developing CRY’s health sector policies, approaches and interventions, both
for micro level policy advocacy and for direction action through micro level partnership.
Significance of the Document
This document can become a blue print for CRY’s planning process in the health
sector. It brings together current data on child health issues both from micro level
observations of issues confronting CRY partners and from macro level data available
from secondary sources. It analyses strengths and limitations of public health
policies and programs for child health combining the insights of health activists and
researcher’s own perceptions gained over two decades involvement. It puts together
an overview of civil society responses regarding child health and the opportunities
inherent in that. It summarises key concerns and issues of child health keeping the
larger perspective of determinants. It suggests strategies within a “Rights oriented
Approach” of participatory decentralised interventions, wherein it also tries to locate
CRY’s own possible roles. This document also spells out specific recommendations
that CRY could take up keeping in mind CRY organisation and networks perceived
strengths and limitations.
-3-
II.
METHODOLOGY
The TOR identified the following types of information to be collected.
■ Analysis of primary and secondary data specific to age categories of children
■ Field data from CRY partners.
■ Experiences of 2 - 3 experts on child health rights.
■ Experiences of CRY program support team
■ Generic and special issues affecting children health.
■ Policy and program review documents
■ Experiences of voluntary sector.
Micro level study
A PSU meeting with the consultant was held to plan the study which decided to study
2 different regions of CRY Network namely North and East. One NGO from
Karnataka was also included totalling six projects. In addition it was decided to
interact with resource groups and eminent persons involved in public health to gather
perspectives on key issues for child health. Based on their feedback the key issues
to be focussed in the study were identified. Many of these issues were incorporated
into the micro-study questionnaire.
Study teams decided to use a case study method using 3 levels of interactions with
each project.
1. Studying available written information on the programe.
2. Directly interacting with the key staff members of the organization
3. Focus group discussion with sample groups from the community of intervention.
The concerned regional offices sent the internal monitoring report by CRY of each
organization being studied. It was informed to the study team that the NGOs own
reports were not available.
Tools
Two types of questionnaire were developed for data gathering from the field. A
questionnaire having questions pertaining to nine different areas were sent, 2 weeks
prior to the visit to the NGO partners in order for them to be prepared with relevant
data. (This step was to prove to be ineffective subsequently as the questionnaire in
English was poorly understood and responded to by the NGO partners). A more
detailed format with nine sub areas for information gathering was developed after the
first NGO visit to be used as a guide by the investigators, while interacting with the
different levels of functionaries and intervention community. The information
emerging was entered into the formats during or immediately after the focus group
discussion (these formats are appended under Annexure IV).
Justification
The study team adopted these tools for the following reasons.
1 Baseline data regarding health status of the area or project output indicators were not
available (not being collected)
-4-
2. During the short visit to each project (less than two days) focus group discussions
with different stake- holders was thought to be most appropriate method of gathering
qualitative information which would provide a deeper understanding of the ground
situation.
The sampling of the focus group was decided by the project holder based on the criteria
suggested that is to include different categories of stake holders - women's group,
prople’s organization, Panchayat members etc. In each location a member of the
regional PSU of CRY and a key functionary of the NGO accompanied the researchers.
CRY PSU team based on the variations in partnership involvement and type of issues
taken up for intervention determined the location of projects visited.
The data collected was collated and interpreted by the study team based on the
qualitative impressions gained. (This was necessitated, as the data recording method by
the two members of the team were not identical).
The presentation of the field study data is made in three different manner:
A “case study" of each institution is included in the annexure, the SWOT analysis is
presented in a tabular form “Partner Performance” and a summary of the findings is
included as “Observations from the Micro Situation”.
Two model programs were visited to identify best practices at programmatic and policy
levels ie ‘SEARCH Gadchiroli’ and ‘ICDS program of MediCiti Hospital’. A description of
the relevant program is attached in Annexure, drawing conclusions for child health.
The study team interacted at depth with the members of the regional PSU team including
CRY Fellows, to identify perspectives, capacities and issues identified by them. The
outcome lead to recommendations made under ‘CRY organization related’.
The macro literature study
Several sources of literature was referred to develop the macro-perspective. These
included national policy documents related to health, national program documents
from government and UNICEF, national health survey outcomes, critiques of policy
and programs by national networks or resource bodies. Also accessed were web
sites and published information from national level NGOs, networking forums and
political parties concerning public health and child health. Digesting this vast
literature also lead to defining the chapterisation of the study and identifying key
recommendation to CRY. Accordingly the chapterisation and recommendations have
been modified in the final report.
-5-
III.
A CRITIQUE OF INTERNAL CONTEXT
Context / Premises / Background of the Recommendations To CRY
The recommendations, which we make to the CRY, that constitute the main theme of this
document emanate from the critique of the situation - child survival and development. The
critique is dealt with at two levels, viz. internal and external.
The organization of CRY and the performance of its partners constitute the internal
context. The problem of child survival and development and responses of various groups
or sectors (like government, civil society, NGOs, political parties, private sector and so on)
in the form of policies, legislation and programmes comprise the external context. A
critique of developments at these two levels, brings to light certain key issues in the area
of child survival and development, from which emerge our recommendations.
CRY organisation, policies and programmes
(This is extracted from the internal document “CRY,a View of the Organization”)
CRY is a young network working on the issues of the child. Started in 1979 with a
shared capital of Rs. 50 and working from a kitchen table, it has grown into a national
network of 300 ground level partnership and impacting on about 9 lakh children. Their
objective is to be a facilitator through the partnerships at the ground level and their
macro level initiatives, to positively influence the lives of children in the country. CRY
raises its resources primarily from around one lakh individual donors. The other sources
of include sale of products, about 100 corporate donors and resources raised from
outside the country. Hence CRY has the added opportunity of influencing public opinion
on behalf of the deprived child through its donor-related network.
CRY’s program include development support, communications, youth wing resource
generation (which activities constitute the face of CRY to the world) as well as human
resource development, finance and information technology. Development support is the
key program impacting on the life situation of the child and is carried out through 6 levels
of partnerships. These are the following: fellowship program for individuals, support to
implementing organisations, support to resource organisation, partnerships with nodal
agencies, alliances and with the government. CRY supports resource organization that
has expertise to enhance the quality of small initiatives. This is done through
development of innovative models, teaching methods, materials and training programs.
Similarly CRY is involved with nodal agencies which can offer both financial and nonfinancial inputs to smaller initiatives in the same geographical region.
Alliances are promoted on an issue-based angle both between CRY partners and other
NGOs. In several states such state level alliances exists. At the national level CRY is
part of alliances such as Campaign Against Child Labour’, ‘National Alliance for the
Fundanemental Rights to Education, ECPAT etc. Over the next 3 years CRY aims to
enable a convergence of these issue- based alliances, towards the formation of a
-6-
national child right alliances. CRY is also partnering government through experimental
projects, which are meant to be developed as ‘models' for replication.
These different levels of partnerships help in magnifying the outcomes, as well as
making effective outcomes in relation to the situation of the child.
CRY’s Focus Areas in Development
CRY undertook a comprehensive programme evaluation in 1995-96, which covered all
partners and took over a year to complete. Three key decisions that emerged from this
process were the holistic focus on child rights, role expansion to organization building (in
the realm of non-financial support) and a proactive role in influencing the national
agenda for children.
This evaluation also validated CRY’s belief in the importance of education in a child's life.
It also pointed out the gaps in understanding of health-related issues and the need to
intervene in the area of preventive and promotive health. Given the gaps in
understanding, it was decided to further research the issues of health before identifying a
relevant and effective approach. However, in the area of education CRY’s experience
and perspective enabled it to formulate a coherent intervention strategy for immediate
implementation. Five years later in the year 2000, CRY find that the focus on education
has yielded enormous learning and has put CRY in a position to influence related
agendas at the micro levels.
In the absence of a national CRY policy on health, regions have worked with their
partners based on their own skills and perspectives and regional expertise. However,
CRY moved away from supporting nutrition programs for children to supporting
community health initiatives focussed on mother and child health. Traditional systems of
medicine have also been supported through some projects. CRY pro-actively supported
initiatives on the issue of child labor and disability in different parts of the country by
building strong linkages between these issues and education focus. CRY also supported
a few initiatives working with issues such as child sexual abuse, institutionalization of
children and adoption, in order to understand these issues further.
Concerted efforts have been made in the past four years to move from a child relief
perspective to child rights perspective. The importance of the child's right to participation
has also been understood by CRY and explored in its own work and that of its partners
STRENGTHS OF CRY
As an institution
CRY is an independent Indian organisation working for Indian children. CRY’s agenda is
not determined by political will or donor ideology.
Strong belief in the power of collective action which has been demonstrated in 2 different
ways. In 21 years, CRY has reached out to over 1,00,000 individuals and organisations
that have pledged their support to children. On the other hand, CRY has supported over
-7-
300 child development initiatives and has disbursed Rs.43.40 crores to reach out to over
9,00,000 children.
A strong, committed Board of Trustees: CRY's Board of Trustees are professionally
qualified people, with a varied experience. The role of the trustees extends from ensuring
adherence to policy, to questioning and supporting actions taken. The Board of Trustees
sanctions each and every one of the initiatives supported by CRY.
People: Over the years, CRY has managed to attract and retain professionally qualified
people who are committed to working for children.
Clear articulation of mission statement: While there always has been internal clarity of
the vision of CRY, largely due to the conviction of the founder, the articulation of the
mission statement has enabled external clarity and the ability to take a leap forward.
Accountability and transparency are the tenets on which CRY stands. This is reflected in
the fact that CRY is the first non-governmental organisation to publish its annual results.
Philosophy of partnership: This is a philosophy that CRY believes in and is implemented
in all its relationships from project holders, donors and well wishers. Programme
planning, monitoring and evaluation is done on a participatory basis. There is no "donor
donee" relationship with any of the institutions CRY is working with, be it through raising
resources or disbursing them.
Action oriented ideology -"What I can do, I must do" a simple statement made by the
founder is a driving force within the organisation.
Ability to evolve as a learning organization: The commitment and perseverance of the
individuals who joined hands with the founder have guided the evolution of CRY as an
organization. CRY has always responded to the needs of the external environment and
internal infrastructural limitations by proactively restructuring the way it works.
As a development support organisation
Support to small, struggling organizations with a focus on vulnerable children and
women: CRY has recognized the value added to the development sector through the
innovations of new, small organizations working in the field and their need for
sustainability and guidance.
A strong Development Support Team consisting of professionally qualified people to
provide extensive support to the initiatives selected.
A proactive approach of working in partnership for monitoring and evaluating the
supported initiatives.
A thorough process for selection and appraisal of initiatives to be supported.
-8-
J
Development of a financial risk management module, assisted by a team of chartered
accountants.
In-depth assessment of non-fmancial needs of partners with respect to training needs,
capacity building, information and material requirements.
As a resource raiser
Unique application of fund raising as a strategy to sensitize, motivate and create
opportunities for people to take responsibility for the situation of deprived children in
India.
Provision of a simple, affordable way to involve ordinary people who feel they are not in
a position to make a sizeable difference to the situation faced by children.
Providing an opportunity to each and every person to participate in this movement for
child rights within the context of their own lives.
Use of "products for a cause" as an effective strategy for raising resources and creating
awareness.
Creating opportunities for artists, photographers, designers, and printers to contribute
professional services.
Recognised the importance of events as opportunities to reinforce credibility, enhance
image, increase awareness levels, create media excitement and raise resources. Events
are another illustration of our belief in the power of collective action.
As a networking organisation:
As a result of its belief in the power of collective action, CRY has recognized the value of
networking amongst organizations as a platform to learn and share from a variety of
experiences.
CRY has promoted the setting up of partner alliances on a geographical basis with the
objective of putting forth issues and organizing collective action for change.
CRY is a part of the Campaign against Child Labour, ECPAT, Donor Agency Network,
and the National Alliance for the Fundamental Right to Education.
CRY has recognized the importance of formation of networks and strategic alliances to
influence policy to make an impact at the national level on issues affecting the child.
-9-
WHO
CHILD
I
i STATE
PUBLIC
1 > IN INDIA
> OVERSEAS
CRY - THE BUSINESS MODEL
HOW
THROUGH
> DIRECT ACTION WITH > FELLOWS
CHILDREN
> PROJECTS
> COMMUNITY
> RESOURCE
MOBILISATION
ORGANIZATIONS
> POLICY
> NODAL AGENCIES
IMPLEMENTATION
WHAT
RIGHTS TO
> SURVIVAL
> DEVELOPMENT
> PROTECTION
> PARTICIPATION
> POLICY
>
FORMULATION
I
IMPLEMENTATION
>
> LEGAL REFORM
> AWARENESS
>
> SENSITISATION
i > ACTION
>
>
- 11 -
PARTNERSHIPS WITH
GOVERNMENT
ADVOCACY
> ALLIANCES
> THINKTANKS
> MEDIA
FINANCIAL
&
MATERIAL SUPPORT
VOLUNTEERISM
ADVOCACY
> INDIVIDUALS
> ORGANIZATIONS
> PRIVILEGED
YOUTH
> MEDIA
CRY’S ROLE
FINANCIAL SUPPORT
> CAPACITY BUILDING
> ORGANISATION BUILDING
> PROGRAM DEVELOPMENT
> TRAINING
PERSPECTIVE BUILDING
> CHILD RIGHTS
> ACCOUNTABILITY
MODEL BUILDING
DEVELOPMENT
SECTOR
STANDARDS
> FINANCIAL SUPPORT
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> LINKAGES
CRY: Critical Review of Micro Level Situation and Partner Performance
An over view of the micro level reality in which CRY partnership with other NGOs
operates is given first. The details of the same situation are given as annexure under
the title ‘Perceptions from Micro Situation’. A summary statement of the findings of a
SWOT analysis of partner agencies of CRY follows this brief description in the
following pages.
>
ii
- 12-
*•
SL.
No.
Areas Examined
T-
Major health problems
2.
Health Care:
AN OVERVIEW OF MICRO LEVEL CRY PARTNERSHIP
Prevailing Situation
Initiatives Launched
Remarks
Malnutrition in all age groups,
Malaria,
ARI,
Measles,
Whooping cough, TB, Arthritis
and Pneumonia
is
not
Promoted herbal medicines, The approach
comprehensive
and
the
village clinics and moving
thrust is on curitive care
through vaids and RMPs
Natal, ante and post natal
TBAs and elderly ladies are
the care-takers; the coverage of
TBAs below 50% and trained
TBAs are less than 50%; PHC
not catering to this need;
In some places TBAs were The communities do not
trained and engaged ; a have any idea of neonatal
cadre of village health problems and death; this
workers created; awareness vital area is not seriously
dealt with
building made
Care of the under-two
No facility exists; pulse polio Village clinics; feeble efforts No data on the issue;
was the only intervention; to activate PHCs; village Not very seriously and
systematically dealt with
indigenous practitioners and health workers
RMPs only resort
Care of the 3-6 year old
No facility except near 25% There a few creches and
coverage of ICDS; these are centres;
not fully functional too; elder
female sibling or elderly women
! are care-takers
' Care of the 6-14 year old
No facility at all.
Disability Programme
No facility existing in the public
A
health sector
I
- 13-
Adolescents
girls
group
started in one program.
specialized
programme
CBR activity is done only in
specialized programmes. It
SL.
No.
Prevailing Situation
Initiatives Launched
Remarks
is not yet integrated by
other NGOs.
A very serious problem of all
age groups; ICDS and PHC
coverage very poor
The coverage is below 40 %;
still protected water is not
guaranteed;
(disability) initiated comm
unity based rehabilitation
(CBR)._________________
Awareness building; in one
place
kitchen
garden
promoted
Initiated efforts for more
coverage; in some places
water
awareness
on
protection effected
Very little efforts in this
direction
Areas Examined
3.
Nutrition
4.
Safe water
5.
Sanitation
6.
Housing
Children under stress
This problem has not been
tackled effectively
No
long-term
and
sustainable
measures
adopted.
Community
mobilisation
Very poor sanitation; very few
towards this end was not
toilets; no arrangement for
attempted at
disposal of wastes
Nothing
has
seriously
been
Community sanitation and
Not much information collected
improving inhabitability of
done
on this
dwelling places could be
addressed by community
mobilisation
Child labour and differentially Two partners having special Not seriously integrated into
abled, are the common issues focus on these issues the operations.
initiated
a few set of
identified.
activities
Sources: 1.Focus group discussions
2.Studies of five partner agencies
A summary of the findings of SWOT analysis of five partner agencies of the CRY.
(For the detailed report of the review of these agencies, see the Annexure 1)
-14-
1
SL
No.
Partn*r
Agency
iT~ cws
T
Strength
Weakness
Opportunities
Threat
Remarks
I.The forum of VOP
which can develop a
health
perspective
towards
leveraging
public
health
infrastructure
responding to peoples
health priorities;
leadership belong to the
local feudal elite structuie;
Perspective building,
capacity
building
and
building
up
2.Non-existent
Government
interface;
2.Interventions
with
RMPs
through
the
people's
movement
(VOP)
for
rational
services;
2.They may not side with
issues of the poor. Hence,
there is a threat of
sabotaging the process;
3.Promotion of herbal
medicine as a relevant
effective and potentially
sustainable
intervention;
3.Weak vision and
low commitment of
the
project
leadership;
3.The excellent and
rational
Ayurvedic
doctor
as
local
resource.
3.The spread of RMPs
who
are
in-ational
in
treatment and pricing of
their services ;
4.A
collective
democratically
functioning core team
of dedicated individuals
with wider perspective;
4.The
health
of 4. Chances for critical
in collaboration in health
in sector
programmes
public health areas is particularly
towards
weak.
ensuring accountability
of
the
local
functionaries.
4.Denegrating
the
rich
herbal traditions and cause
the eroding of their status; j
1.Programmes
have
gone beyond service
delivery
and
have
managed to organise
the
community
for
peoples
action
for
basic rights;
2.Working
structures
with
of
governments;
1.Training
for
the
various functionaries
and
community
leaders
not need
based;
capacity
team
perspective and
- 15-
collaboration
and
linkages
are
the
major areas of thrust
for this organisation.
SL.
No.
S.Credibility
government
Opportunities
Weakness
Strength
Partner
Agency
with
Threat
Remarks
5.The central person
in the health care
team is weak in
bureaucracy;
perspective,
knowledge
and
networking skills.
6.A TBA as the central
person in the health
2.
GSS
care team
1.Promotion of herbal
medicines as a local
appropriate
and
potentially sustainable
response to the health
needs of the people;
2.Experience
of
peoples
mobilisation
and
asserting
demanding
and
basic
i needs
public
and
1.Negligible
interventions
health sector
in
(only
t.The
people’s
organisation into which
health dimension can
around 5% of total
budget);
be built into ;
2. Low
of
2.The
involvement of
poor
morcha
into the self
the
government
levf
capacity and
vision
of
leadership;
would make it possible
for leveraging of better
implementation
i accountability;
system
government
health
of
primary
care
programmes;
L
! 3.Creditability of project
holder and team with
3.No
secondline
leadership;
— 16-
3.The school clinics
The perspective and
capacity
building,
lobbying and linkage
with
government,
proper utilisation of
school clinics and
consolidation
of
people’s
organisation are the
requirement.
SL.
No.
Partner
Strength
Weakness
Opportunities
Threat
Remarks
Agency
the people;
4.
A
team
of
enthusiastic dedicated
person;
3.
MONF
5.
The organization
has a good reach in
around 200 villages.
1.A team of purely
professional staff.
Personnel with the right
attitude,
motivation
and
enthusiasm.
2.A successful and
replicable project;
4.
PKK
tendency
the
project
institutionalisation
4.The
1 .A few part
temporary
of
to
time
^nd
project
based
associates and staff
with
too
many
commitments
and
hence stretched out
in terms of time
allotment.
a
This
can
be j
developed
as
a
model
and
a
resource
support ■
one
2.MON Foundation can
be a resource support
organisation for Child
Mental Health.
I.The experience and
expertise arising from
26 years in the field;
1. Focus totally
disability;
2.Committed
2.No
and
I.The result of this
action research also
should
be
made
available to the other
partners;
7-
on
structured
1 .Evolving
organisation;
2.The excellent rapport
relationship
problems in the adolescent
and teenage groups of
disabled children
Interpersonal
SL.
No.
Partner
Agency
Strength
Weakness
Opportunities
motivated
project
holder and the core
members of the
Staff;
development
and
delegation in terms of
second
line
leadership;
of the organization at
least with concerned
Ministry of the GOI
S.Skilled
technically
S.Absence of good
systematic database
of
available
resources
both
governmental
and
otherwise
and
trained
manpower;
4. Technical support in
terms
of
latest
equipment such as
computerised
audiology aids;
5.
SSDC
1.
Simple
curative
healthcare is
being
made accessible in
remote villages;
1.Undue
emphasis
on curative care;
1.Village
cadres;
2.Most of the promotive
and preventive health
care is done indirectly
at the level of the
village communities;
2.The
belief
of
villager
that
safe
deliveries are those
done in institutions or
Hospitals;
2.Community
structures
collectives;
- 18-
level
health
and
Threat
Remarks
SL.
No.
Partner |
Strength
Agency
I 3.Self-reliant
Weakness
and
sustainable
interventions;
6
APD
3.Poor concept
antenatal care;
Opportunities
of
4.Committed and are
active project holders:
4.No two-way second
contact
care
or
referral services ;
5.Vision and mission
to empower the people
are shared by all the
staff at various levels
5.Poor linkages with
government;
Poor communication
skills;
6.Very good response
from
the
target
communities ;
6. Low
This
specialized
community
based
health program with
disability focus has
addressed
the
preventive
promotive
curative
and
rehabilitative aspects of
disability well.
The
strategic
planning efforts of
ADD Rural need to
improve.
There
appears to be come
unclarity on evolving
directions
of
the
program i.e. whether
to develop further in
level
linkages
government
3.Willingness
community
contribute
Threat
Remarks
of
to
of
with
community
based
disability work or into
an integrated health
and
development
- 19^—————
The APD team works
in close collaborations
with the ICDS centre
and the sub centre
ANMs in the area of
Changing
occupational
patterns of the area is
exposing
working
adolescent
girls
to
occupational
health
pregnancy
promoting
hazards associated
sericulture.
care
and
immu
nizations. Though they
are
not
directly
providing
these
services
to
the
community,
however
the facilitation of the
with
SL.
No.
Partner
Agency
Strength
Weakness
program.
Opportunities
village
based
government cadre has
produced good results.
They have had good Some of the present Orienting the local level
results especially in the priorities
of
the functionaries of the
direct
involvement program need to be government system on
areas of disability work reevaluated, such as disability
issues
is
as per the outcomes the appropriateness generating
results.
already brought out. of adopting certain The primary teachers
This can be enhanced villages and validity given orientation are
further with a dimension of continuance of screening the students
on mental disability.
nutrition
supple for disabilities.
mentation activities.
Good rapport has been
built
up
with
the
community especially
as an outcome of the
direct
involvement.
This has enabled them
to
mobilize
the
community to take up
some responsibility in
the children’s health
and education,
This
needs
to
be
strengthened further.
No work is being
done in the area of
mental
disability.
This group is ideally
placed to take up this
dimension, given the
necessary supports.
-20-
Threat
Similarity
interacting
and
motivating
the
health professionals at
the district level, is
resulting
in
better
functioning
of
the
orthopaedic
referral
system at the district
level.
Government
promoting
women’s sangha’s in an
adhoc manner through
anganwadi workers could
bring about division among
women’s
organizations
between beneficiaries and
those deemed benefits.
Remarks
SL.
No.
Partner
Agency
Strength
Weakness
government
interface
has- been
strengthened. Both the
support given by the
program, to community
level
government
program
and
the
dialogue entered into
with
government
Program lacks good
quality
education
material for health
education
of
the
community groups.
The
functionaries
have
contributed to this.
organization
inherited
a
positive
image of strong values,
The
from the swamiji who
donated the property.
This image has been
maintained.
There is a positive staff
culture of openness
transparency
and
accountability to each
other. Accordingly the
plans are made and
There
is
no
intervention with the
community
based
health providers such
as dais, herbalists
and RMPs.
This
sector has important
contributions to make
in sustainability of the
program.
The program’s ability
in mobilizing grass
root communities and
empowering them for
political action is a
weak area. This is
~21 -
Opportunities
The
early
efforts
Threat
at
larger networking and
mobilising
people’s
groups on children’s
issues, will
opportunities
building
confidence.
promote
in
people’s
Remarks
SL.
No.
Partner
Agency
Strength
Weakness
reviewed by the group
themselves.
also
reflected
in
related activities such
as
mobilizing
panchayat
bodies,
and
issue
based
networking at a wider
level in support of
local health needs.
The organization has
invested
in
staff
capacity building so
much so that some of
the staff is becoming
local resource persons.
There is need for a
competent core team
in health.
Such a
core team need to
have
a
minimum
required training in
health, atleast three
months training in
community
health
program
manage
ment in a good field
based facility.
-22-
Opportunities
Threat
Remarks
IV
A CRITIQUE OF EXTERNAL CONTEXT
We shall present a critical evaluation of the problem situation related to child survival and
development, namely indicates of child health care, child health and physical environment,
child under dress, problems affecting child welfare.
We will also examine policies,
legislation, programmes of government agencies, responses of civil society organisations,
positions of leading political parties and interventions of private sector.
CHILD HEALTH PROBLEM SITUATION
The child health related situation in the country though snowing minimal improvement over
the years shows that the various programs have hardly made a dent on the problem
situation or the underlying causes. We will examine at some detail the priority indicators
related to child health : namely physical health indicators (infant and child mortality, maternal
mortality, malnutrition
communicable diseases), child health supportive physical
environment (Water, sanitation and housing), child under stress and risk (working children,
sexual abuse and child prostitution, disabled child, juvenile delinquency, children
infected/affected by HIV, female foeticide) and problems affecting child welfare (deteriorating
child care systems, deterioration of women’s livelihood security and community level food
security). I believe these indicators capture the health aspects of the ‘child survival and
protection needs’.
CHILD HEALTH CARE INDICATORS1
Infanf Mortality
Infant mortality rate at national level has declined from 110 per 1,000 live births in
1981 to 71 per 1,000 live births in 1997. However, wide disparities persist. IMP
varies from 12 in Kerala to 96 in Orissa (a level higher than that of Bangladesh or
Nepal). Mortality rates among socio-economic classes show wide variation. Children
of literate rural mothers have much lower IMP i.e. 64 vs. 89 for illiterate mothers
(NFHS, 1998). The IMP and the child mortality amongst Scheduled Castes and
Scheduled Tribes are 22% and 45% respectively higher than the national average at
the same point of time. The IMP is 83-84 and child mortality 39-46 for the SCs and
STs against the national figures of 76-61 IMP and 29-22 child mortality. The IMP for
children of families with high standard of living is 43 whereas for those from low
standard of living is twice high as 89.
The rate of decline of infant and child mortality has also slowed in recent years.
Infant mortality overall has remained close to its present level of 71 per 1,000 live
births since 1993. There has been no decline in urban IMP during the same period.
1
The following topics infant mortality, maternal mortality, malnutrition, access to safe water
sanitation and housing have been extrated from ‘A Programme for Children and Women in
India, Plan of Operations 1999 - 2002, GOI with UNICEF’. The author has contributed in the
above topics only the paraphrasing and emphasis whenever it appear.
-23-
Moreover, age-specific child mortality (between the ages of 1- 4) at 24 per 1000 live
births has been declining at a slower rate since 1981 - three points per year between
1981 and 1986, two points between 1986 and 1991, and 1.5 points between 1991
and 1993. This slowing of momentum on child survival is a cause of growing
concern at a time when other conditions are becoming increasingly favourable
particularly with the spread of literacy and improved communications.
Deaths in infancy are not spread out evenly throughout the first year. In 1992, 66%
of infant deaths were neonatal deaths. This concentration of deaths in the first month
of life underscores the importance of the peri - and neonatal period for urgent policy
attention. Whereas mortality differentials between boys and girls in the first year of
life are small at the national level, with greater desegregation of data, it has been
found that girls continue to face higher risks of mortality. Mortality among girls is
20% higher than that among boys throughout childhood. One of the largest such
differentials in developing countries, this reflects the unequal treatment that girls
receive, especially in caring practices and health - seeking behaviour.
Much of this mortality is attributable to underlying malnutrition. The fact that nearly
one third of babies born are low birth weight itself is a reflection of poor condition of
women’s nutrition. Some 80% of women are anaemic and as many as 58% reduce,
rather than inciease, their food intake during pregnancy.
Another reason for infant mortality is the incidence of vaccine - preventable
diseases. The national EPI programme has helped to reduce the deaths caused by
illness from vaccine - preventable diseases. Immunisation coverage, however,
remains low in many districts, with as many as 30% of children not receiving any
vaccinations at all. Deaths from measles, pertussis and diphtheria are now as much
as 80% less than pre - immunisation levels. There has been success in bringing
down the incidence of neonatal tetanus which has fallen from 20 to 10 per thousand
live births in the last 5-8 years. However, there is still a large disparity between
states in reported TT coverage. Multi-indicator cluster surveys indicate that only 43%
of pregnant women had received full TT immunisation in Rajasthan, while 92% had
received such immunisation in Tamil Nadu.
Infections of the lower respiratory system continue to account for 15 - 28% of infant
deaths, with twenty per cent of children suffering from acute respiratory infections
receiving no treatment at all.
Deaths due to diarrhoea have been declining, although only 43% of mothers in India
(in 1993) knew about ORS, and only 26% reported having ever used it. These figures
point at the difficulties the primary health care system has faced in responding to
illnesses that cannot be predicted, and to the need for care to be available at all
times. It is here that preventive activities but repeatedly fall short of responding to
the needs of urgent ‘unscheduled’ care. As a consequence, families often turn to an
unregulated private sector for curative care.
-24-
The key issues o. serious concern emerging from the foregoing analysis are: overall
slowing of momentum in child survival, the predominance of neonatal death in infant
mortality, social background and sex still remaining as strongest variables for infant
mortality, and malnutrition, low coverage of immunisation and infections that can
either be easily preventable or be controlled without much difficulty are the causes for
infant mortality
Maternal Mortality
The maternal mortality rate estimated to be between 437 - 570 per 100.000 live
births remains unacceptably high. Close to 125,000 women die from pregnancy or
pregnancy-related causes every year. A study of NFHS (GOI 95) revealed that about
42.4 percent women in rural areas did not get any antenatal care, with wide state-wise
variations. Among these 15% were provided care at home by the health worker and
cr.ly 48% received two tetanus injections and folic acid. Only 16 per cent had
institutional deliveries. Of those who delivered at home (84%) only 40% were
assisted by dais (both trained and untrained). Community studies in tribal areas show
that almost half of the women dying of maternal case die at home and another 10 15% die on the way to hospital
Many of these deaths occur in young women. It may be noted that most of these
deaths are preventable, through appropriate service provision.
However if the causes of death of women are analysed one finds that child birth and
pregnancy related deaths accounted only for 2.9% of total deaths of females (Modal
Registration Scheme quoted in, ‘A Public Health Perspective, Imrana Quadeer,
Anubhav Feb 99’) The main cause even in child bearing group (15-44 age group)
are the communicable diseases which has more than double the proportion of deaths
from maternity causes. Other priority causes include anemia and malnutrition.
Hence public health program for women/ mothers need to prioritize the main causes
of mortality rather than exclusively focus on reproductive health alone. It needs to be
recognized that general illnesses of mothers also contribute to maternal mortality.
Hence the main program addressing women’s health, the reproductive and child
health program (RCH) need to be looked at critically.
The examination and analysis of data on maternal mortality brings to light the
following issues. The precise levels of maternal mortality are not known which itself is
a comment on the low political priority given to women’s health. The fact that most of
the maternal mortality cases are preventable points at a prevailing major service gap
for women in management of obstetric emergency. The major program focussing on
women’s health, the RCH, has a selective focus and doesn’t cover all the priority
causes of women’s mortality and morbidity.
Malnutrition
Fifty three per cent of under-five children in India are malnourished and this
accounts for the one-third of the world’s children who suffer from malnutrition. The
-254
rate of decline in malnutrition remains strikingly low, at no more than one per cent per
year.
Over 50 per cent of young children, adolescent girls and women in the reproductive
age group suffer from nutritional anaemia. Only 10 per cent of children can be
classified as normal. Nearly, 90 per cent of children had low weight for age and 45-50
per cent is classified into moderate and severe category. There is a wide difference
between high income and low income categories with only 10-15 per cent of high
income category children showing moderate malnutrition (NNMB, 1984; NIN, ICMR,
Hyderabad). 88 per cent of pregnant women were anaemic.
Vitamin A deficiency among pre school children is estimated at 1.1 per cent (NNMB,
1994). The NIN estimates that 56 per cent of pre-school children and 50 per cent of
expected mothers suffer from iron deficiency. It is estimated that iodine deficiency
accounted for 90000 still birth and neonatal death annually. Nutritional blindness
affects over seven million children in India annually. Some amount of progress has
recently been achieved in salt iodination (86 per cent) throughout the country. Still
considerable number of newborns and school children remains vulnerable to iodine
deficiency disorders (1DD). However, progress in tackling anaemia and vitamin A
deficiency has been far from being satisfactory.
Sub-clinical Vitamin A deficiency in pregnant women and children increases
morbidity and mortality. Iodine deficiency disorders (IDD) in expectant mothers can
result in mental retardation in their infants while iron deficiency in infancy and early
childhood period delays psychomotor development and impairs cognitive
development.
Nutritional status especially of the youngest child during the first three years of life,
has significant implications for physical and cognitive development just as the psycho
- social stimulation and the child-parent interaction has. Neglect of children in this
age group has serious implications in terms of overall development, readiness for
schooling and learning capacity.
Such high levels of malnutrition persist despite the major investment of human and
financial resources by the State in child development programmes. The Integrated
Child Development Services (ICDS) programme, launched in 1975, has become in
the largest effort in history to improve nutrition and child development and now
operates in over 400,000 of the country's 600,000 villages. However, the expansion
and continued strengthening of infrastructure support to ICDS Aganwadi Centres
(AWCs) to meet the goals for children represents a continuing challenge, especially
in unreached areas.
The “invisibility" of malnutrition has much to do with its neglect. Low birth weight is
the best single indicator of the risk malnutrition. Therefore, the only means of
assessing the degree of malnutrition is by measuring weight against child’s age. Yet
growth monitoring is neither widespread nor focused on the very young child. Low
-26-
birth weight is also emerging as a major cause of chronic illnesses later in life, as well
as a factor in mental retardation. Close to 33 percent of all infants born in India are
of low birth weight - a level that has hardly fallen in the last two decades.
Low birth weight reflects an inter-generational transmission of malnutrition. Girls are
married young, thus enduring early pregnancies and childbirth before they attain
physical and mental maturity. While differences in nutritional status between boys
and girls are not visible in macro - level data, the care - seeking and care-providing
behaviour of families continue to discriminate against the girl child. A first daughter is
often given care comparable to a son, but second or third girl children are particularly
vulnerable to malnutrition and higher child mortality.
Malnutrition is not necessarily an outcome of low incomes, it could be an outcome of
infectior s, and illnesses as well as inadequate or inappropriate feeding and caring
practices. Caring practices include not only care of children, but care of women as
well. Care of women and girls is as important as care provided by women. Girls and
women in India find themselves in a particularly disadvantageous position in the
extended family, with excessive demands on their time and energies to meet
household needs. They are also vulnerable to violence and abuse and poor care
within the family. Promoting gender equality, particularly shared parenting and care
responsibilities are crucial for preventing malr trition
Environmental stress and geographical remoteness present special difficulties in
realising nutrition rights for children and women. Nutritional security is severely
compromised at certain times of the year because of adverse weather conditions and
poor land productivity. These have an even more profound effect on people
belonging to the Scheduled Castes and Scheduled Tribes due to their inadequate
household resources and lack of access to social services. Concerted efforts are
required to address the nutritional needs of these under-served communities.
The spread of HIV/AIDS in India poses a special threat to the nutritional wellbeing of
the child.
Insufficient attention has been paid to the child’s growth during the critical period
between 4 and 24 months when malnutrition sets h. and peaks. This period is critical
for mental development. Recent data reveals, for instance, that only one-third of
children are given complementary foods between the ages of 6-9 months, when
breastfeeding needs to be supplemented with regular consumption of semi-solid or
mushy foods. Low level of awareness among families and service providers about
proper feeding practices directly contributes to the problem.
Better education for girls, improving the knowledge of mothers and adolescent girls,
and better care of girls and women, especially during pregnancy, are vital conditions
for improving the health and nutritional status of both women and children. These
pre-birth and socio-cultural factors have not so far been well addressed within
child development and nutrition programming in India.
-27-
The right of all women to be informed and counselled on appropriate infant and
young child feeding practices needs to be recognised. This is even more crucial for
the most marginalised and disadvantaged groups. Similarly, the choice of feeding
practices by an HIV positive women should be an informed one
The review of nutritional situation in our country reveals quite a lot of information
pertinent to policies and programme. Even now the rate of malnutrition among
children in India is very high. Still the growth monitoring is not properly done. Low
weight at birth, the best single indicator of malnutrition reflects both economic and
socio-cultural factors of malnutrition. Low weight at birth in general is intergenerational transmission of malnutrition. Factors like social segregation; remoteness
and so on act as additional factors in the case of SCs and STs. In the case of the
other sections of the poor, feeding and caring practices and neglect of or inadequate
care during the early years of childhood are important factors. Mothers affected by
HIA/AIDS constitute another factor for low nutrition. It is unfortunate to observe that
our policies and programmes do not address these socio-cultural factors of nutrition.
Communicable Diseases
Overview of Communicable Diseases (CD)
Our country is witnessing an upsurge in communicable diseases causing millions to
be sick and lakhs to be dying annually. Communicable diseases are caused by
microorganisms, which can spread from one infected individual to another through
varied mechanisms. The major communicable diseases (according to their severity
and extent in chidren) are: Malaria, Tuberculosis, HIV/AIDS, Leprosy, Diarrhoeal
diseases, Upper Respiratory Illnesses, Filaria, Viral Encephalitis and Kala Azar, to
name but a few.
Diarrhoeal diseases or faeco-oral diseases is an important category of ‘food, water
and soil borne dieases’. The important ones in this category are, amoebiasis,
giardiasis, gastro-enteritis, bacillary dysentry, cholera, typhoid hepatitis Aand E, and
poliomyelitis. Fifty percent of infant deaths are attributed to diarrhoeal diseases. An
estimated 1.5million under-five deaths occur in India every year, due to water related
diseases (Report of the Task Force on Health and Family Welfare Karnataka, 2001).
Acute Respiratory infection in children are responsible for 25 to 35% of deaths
among children below five years of age (Report of Independent Commission of
Health in India, Control of Communicable Diseases 1997).
Though Tuberculosis primarily is a decease of adults, TB in children is a serious
problem. Good estimates are not available due to the difficulty in diagnosing
pediatric age group Tuberculosis. About 3 lakh children become orphans due to TB
annually.
-28-
Malaria causes serious medical complications and death for mothers in pregnancy
(upto 10% of pregnant women). It can blight the development of the child before and
after birth and also cause deaths (spontaneous abortions upto 60% pregnancies). In
highly endemic areas frequent infection helps communities to buildup natural
immunity to malaria, though at an enormous cost in sickness and loss of life in early
childhood.
Women loose some of their acquired immunity to Malaria during pregnancy
especially during first pregnancy, exposing them to life threatening anaemia and
miscarriage. It also results in delivery of under-wieght babies the “small baby
syndrome” (Risks in motherhood, David Payne, World Health, May - June 1998).
Japanese Encephyalitis is a viral disease causing brain fever, transmitted by
mosquitoes. It is highly prevalent in southern and eastern parts of the country.
Reported JE cases in India have been around 4000 in epidemic years. It affects
mostly children between 2 to 15 years. It is major concern because of the high
mortality rate of 20 to 40% (Manual on JE, IIHFW, Hyderabad 2001).
There has been an increase of old communicable diseases as well as emergence of
new ones in epidemic proportions. We find in India some communicable disease
occur across the country, whereas : me others though prevalent in large numbers,
are restricted to specific regions.
Communicable diseases can be grouped according to their mechanism of spread,
(as the interventions are also aimed at tackling the mechanisms). They are classified
in order of spread as :
Persons to person transmission eg. Tuberculosis, AIDS, Leprosy
Food, water and soil borne eg. Diarrhoea, Hepatitis A, Hook Worm
Infestations
Insect or vector borne eg. Malaria, Dengue, Japanese (Viral) Encephalitis
Animal borne eg. Rabies
The Role of Public Health Sector In CD Control:
efforts
Weakness of public health
Historically India's public health system has not fared well in controlling
communicable diseases. This is partly to be explained by the reality that the role of
the health system in combating public health problems (such as communicable
diseases) is limited. Interventions of other sectors aimed at the root causes of
diseases such as provision of: safe water, environmental sanitation, security of food
and nutrition and healthy life styles are equally important, if not of prime importance.
Public health strategies adopted, are believed to have been short sighted and
blighted with many faults such as: being centralised (with no space for decentralised
planning), techno-bureaucrat driven (with no community participation), technology
oriented (overlooking the socio-environmental dynamics).
-29-
Compounding the problem further, it is believed by many public health experts that
there has been a breakdown in the public health system in the recent decade. The
quality and motivation of public health professionals, the functioning of public health
institutions and laboratories, the effectiveness of the surveillance system, as well as
the relevance and effectiveness of the public health policies and programmes, have
all believed to have deteriorated.
Lessons from major C D Control Programs
We will look deeper into three nationally priority diseases namely Tuberculosis,
Malaria and HIV/AIDS, to learn urgent lessons.
(a)
Tuberculosis
It is believed that the tuberculosis epidemic in the country is over 3 centuries old.
Present situation (given below) has not appreciably improved from what it was at the
time of independence.
Active disease
Infectious stage (sputum positive)
New patients per year
Annual Deaths
15 million (about 20 out
of 1000 persons)
3.5 million (one fourth of
all cases)
2.3 million
0.5 million (number one
killer amongst infectious
diseases)
Tuberculosis was recognised as a national priority from the time of independence.
Based on a path breaking research done in the country, the National Tuberculosis
Programme (NTP) was initiated in 1962. The study found that TB patients were
bothered by their disease and sought help early from care givers (but usually turned
away by care giving with only cough medicines). The programme was integrated into
the Primary Health Services so as to be accessible to the dispersed population. The
basic unit of the programme is the District TB Programme (DTP), which functions
through the Peripheral Health Institutions (PHIs) which are primarily the PHCs and
some NGO/Private institutions. The case identification, treatment and follow up are
to be done at the PHIs and DTPs provide capacity building, coordination and
monitoring. The multi drug regime of treatment based on daily dosage schedule
(given free of charge) has been revised over the years.
In 1997 with World Bank loan of 440 million dollars, the Revised National TB Control
Programme (RNTCP) was started, which would cover 1/3 all districts. Incorporated
into the policy guidelines are specific roles for NGOs and other Civil Society groups
(5 types of TB control activity NGOs could take up).
-30-
Critique of the policy and programme for TB control ( Whatever Happened to
Health for All by 2000 AD’, The National Coordination Committee of Jan Swasthya
Sabha, May 2000)
The NTP or DTP though based on sound research, for its effectiveness is
dependent on the public health system (mostly primary health care system).
However the PHC system has failed in the country and along with that the TB
programme has also failed.
• The public health sector is only the first contact for chest symptomatic patients in
less than 50% cases (recent data shows less than 30%) hence the number of cases
diagnosed was low.
•
The treatment completion (case holding) of those started on treatment has been
poor in the long course treatment (about 30%) and even in the short course
chemotherapy (SCC) regime only about 60%.
•
The programme has been beset with problems resulting from lack of political
and bureaucratic will - exemplified by the lack of regular and assured supply of drugs
and other diagnostics.
The basis for the new RNTCP policy and programmes are being contested for the
following reasons:
■
There is not enough evidence to show the effectiveness of the treatment regime
introduced (intermittent regime).
■
The Directly Observed Treatment Strategy (DOTS) in practice (at the level of the
peripheral health care workers) may result in many patients being left out of
treatment, if the staff feels they will not be regular. The principle of DOTS is
questioned, as impractical to implement.
■
The high cost of the drug regime, puts question on the sustainability of the
programme, in situations where external loans are not available for the same.
The key lessons we learn from the failures are:
o
Public sector must ensure minimum resources - infrastructure, human power
and drugs.
o
Need for promoting community pressure and partnership for TB Control (through
locally elected representatives) so that public health sector will be responsive and
accessible.
o
Involving the private health sector into the control programme in a systematic
manner.
o
Need for asserting people's right to conditions that promote health (as TB is
directly related to poverty).
(b) Malaria
The National Malaria Eradication programme was initiated in 1957 as a vertical
programme on a war footing. In every block malaria workers were appointed for both
- 31 -
spraying DDT and to detect outbreaks early, supervised by a hierarchy of officials.
The programme was based on the strategy of vector control through spraying DDT
and chloroquine treatment for those affected with malaria.
By early 60s there was drastic reduction of malaria cases and deaths. However by
early 70s the epidemic started rising again when a 'Modified Plan of Operation' was
put into action. Other modification of strategy has been introduced in the 90s such
as 'High Risk Areas Plan'. This time round there was no appreciable improvement in
the problem and besides more malaria is being caused by Plasmodium Falciparum.
Falciparum infection is more severe and resistant to drugs. Now malaria control is
felt to be unattainable and the name changed to 'National Anti Malaria Program.
The present estimate of Malaria is about 20 - 30 million rcases per year(based on
other sources of information) whereas government data- shows
------- ; ten times lower
figures!
Critique of the Programme (Whatever Happened to health for All by 2000 AD)
As a vertical programme, it has three basic limitations, which was bound to cause
failure in the long run.
•
Programme is technology centric (relying on DDT and drugs) but not
recognizing the social and environmental factors contributing to the problem.
•
Programme is fragmented - using only limited options, whereas a wide
variety of options based on local needs, needs to be utilized.
•
Programme is administration driven with no community participation.
Most of the measures required for success need community involvement (such as
ensuring personal protection, clearing breeding sites etc)
Learning
The key lessons we learn from the failures are:
°
Need for implementing localized plans based on
local needs and hence making funds available for the same.
°
Need for institutionalized
participation of community (such as panchayat's role)
arrangements
for
°
Importance of adequate surveillance mechanism
(with input from the community, private health sector, and state health sector) at the
district level.
°
Required resources must be made available
through state health department (for personal protection, environmental
management, pesticide spraying, and drug treatment) as well as through ensuring
required public health infrastructure.
-32-
J
(C)
HIV/AIDS
Overview of the prdblem (‘Strategic Plan of AP State AIDS Control Program’,
APSACS.2001)
In India HIV/AIDS epidemic is now a decade and a half old. Within this short period it
has emerged as one of the most serious public health problem in the country. It is
estimated that 3.7 million Indians are HIV positive. Though presently this figure is
less than 1% of adult population, it is expected to reach 5% of the population by 2005
(40 million).
The available surveillance data clearly indicates that HIV is prevalent in almost all
parts of the country. In the recent years it has spread from urban to rural areas and
from individual practicing risk behavior to the general population. Studies indicate
that more and more women attending antenatal clinics are testing HIV positive
thereby increasihg the risk of prenatal transmission.
About 75 per cent of the infections occur from the sexual route (both heterosexual
and homosexual) about 8 per cent through blood transfusion, another 8% through
injecting drug use. About 89% of the reported ca^es are occurring in sexually active
and econor ically productive age group of 18 - 40 years. One in every 4 cases
reported is a woman.
Root causes of the problem
•
Rural poverty and urban migration, with resultant stressed
life situations, breakdown of traditional values and support structures.
•
Cultural taboo on sexuality, resulting in ignorance and
unhealthy sexual attitudes and practices.
•
Sex-worker profession being illegal (not monitored and
supported in health parameters), leading to spread of Sexually Transmitted Diseases
(STDs) and HIV infections to the clients.
•
Prevalence of significant levels of STDs and Reproductive
Tract Infections (RTIs) and insufficient resources for management of these problems
in the health system.
Draft National AIDS Control Policy (‘Draft National AIDS Control Policy’, NACO 2001)
The general features of the policy are:
•
Prevention of further spread of the disease by
awareness generation among people at large and specially among high risk behavior
groups and making available to them tools for protecting themselves.
•
Efforts towards control of STDs and RTIs.
•
.
To enable individuals and families affected by
HIV/AIDS to manage the problems with their family and community support.
-33-
•
Improving services for the care of People Living
With AIDS (PLWA) both in hospitals and at home.
•
Strengthening and capacity building of the health
care system, for surveillance, diagnosis, management, blood safety, attitudinal
change etc.
The policy is being implemented through state level agencies set up for the purpose,
which in turn operate through the District Leprosy Control setup. There is emphasis
on partnership with NGOS in several areas of implementation namely:
Consultation at the policy making level
In awareness generation, provisioning of counseling
facilities, intervention projects among high-risk behavior groups.
•
hospice (terminal) care.
Provision of medical facilities, home based care and
Capacity building of NGOs to take up newer
responsibilities.
Critique
The program is in its infancy stage and as such it is too early to make a learned
critique. However one can anticipate that, the weaknesses of the public health
system (already
effectiveness.
discussed),
will
affect
the
AIDS
Control
Programmme's
There is an undue reliance on technology (condoms) as a preventive measure,
though the cultural and environmental setting of the problem is very clear.
Government programs would find addressing them difficult.
As yet HIV/AIDS care is not integrated into the public health system, besides there
exist, fear and bias even among health functionaries, which make them refuse care
to the affected.
As yet the private health sector including the Indian Systems of Medicine (ISM) are
not integrated into the overall plan. This will lead to failure in containment of
transmission as well as exploitations by unscrupulous elements.
Though policy documents refer to involvement of the community the past record of
government initiatives suggests, it is unlikely to succeed. However community based
strategies, support structures and awareness campaign is a crucial element (as a
root cause is embedded in the socio-cultural environment).
CHILD HEALTH SUPPORTIVE PHYSICAL ENVIRONMENT (Sanitation, Hygiene
and Water Supply)
-34-
Denied access to required quantity and quality water, grossly inadi juate sanitation
facilities and poor personal hygiene practices are major contributors to ill health
especially of children.
In the 80s decade the policy attention on safe water, promised the possibility of
universal access to protected water. However the outcomes have belied that hope.
Unhygienic practices and contaminated water cause diarrhoea and ill health that
account for nearly 400,000 child deaths annually. The lack of sanitation is a
significant contributory factor in malnutrition, which impairs the growth of more than
58 million children. Over 70% of the health problems faced by children in primary
schools are caused by inadequate hygiene.
Access to safe water
India has made significant progress during the last three decades in provisioning of
rural water supply. The government has adopted a coverage norm of one safe
source supplying 40 litres per capita per day, for a population of 250 within a distance
of 1,600 metre in the plains or 100 metre elevation in the hills. The Rajiv Gandhi
Water Mission took up provision of safe drinking water to 100 per cent habitations in
the 80s with support from UNICEF. It relied mostly on borewells for extracting
ground water, to be supplied through hand pumps or overhead tanks. Though
almost complete coverage was claimed, on a disaggregated analysis it was seen that
a third of hamlets were not covered.
After launching new schemes further to
address the sections not reached by the earlier ones, more coverage has been
claimed.
As per the official estimate, In 1996 about 86 per cent - 85 % urban and 86 % rural of the population had access to safe drinking water.
The 14% of the population that remains without access to safe water represent in
numerical terms a substantial population, many of whom reside in tribal or remote
geographical areas. Statistical coverage does not always guarantee effective access
to all social groups, especially those living in India’s many hamlets, often composed
of Scheduled Castes and Scheduled Tribes.
Access to water sources by itself does not assure protected water. An NCAE country
wide sample study puts unprotected water usage at 52%. Of the protected water
sources 17% is piped water, 18% is from hand pumps and 13% from sources such
as open wells.
The challenges currently faced by our country in the case of drinking water can be
summarised as given below:
• Problems of water quality are becoming increasingly acute. Borewells, long
promoted as safe sources of water, are found to be faecally polluted as a result of
poor well construction and insanitary well surroundings
At least 10% of the
- 35 -
population has higher levels of fluoride, arsenic, iron or salinity in their sources of
drinking water.
• The limitations of centralized, sectoral and technology oriented approach has had
its limitations. Sustainability of the very technologies used to rapidly and cost
effectively provide access to safe water to millions of households is under threat from
falling water tables, caused by over-exploitation of groundwater for irrigation and
industry.
The fresh water situation is increasingly threatened by indiscriminate
pollution of surface as well as ground water.
• Even the available water sources are not accessible equally. Various socio
political factors intervene in accessibility to water sources. The public water supplies
that as per official estimates provide water are often irregular or out of order for long
periods. (A recent Government study revealed for instance, that 23% of hand
pumps, 14% of mini - piped schemes and 44% of larger piped water supply schemes
were not functioning due to breakdown and poor maintenance.) These could be
related to poor community ownership of and maintenance water source, and poor
community monitoring of quality. Coupled with these are problems of transparency in
governance.
• Under the influence of new economic policy, government is inclined to privatise
the service of supply of drinking water. There is much apprehension on the cost
increase for the poor that it will entail.
The poor access to drinking water by a household directly affects the child’s right to
survival and development. The failure to assure safe water and clean environment
affects the fulfillment of other rights also. For instance, the absence of separate, safe
and clean toilets deters parents from sending their daughters to school and denies
many girls the right to basic education (give data and source). Non availability of
potable water nearer to the dwelling places imposes a heavy burden of drudgery on
women and young girls as they are forced to walk long distances to obtain safe water
for household use. This perceived duty of girls within the family to fetch water, and
perform other household chores also contributes to the denial of education for girls.
Sanitation
In 1996, about 26% of households had access to proper sanitation - up from 23% in
1991 The national rates for access to sanitation increased in the year 1999 to 29%
(urban 70% and rural 25%). This is a deplorably low figure. More over the access to
sanitation facilities is uneven. The urban figure, however, disguises the fact that
millions of families in the poorest urban settlements, many of which are unauthorized,
face insanitary conditions that are life threatening to children.
Communities
belonging to scheduled castes and scheduled tribes stand out as the most
disadvantaged groups in terms of enjoying equal access to environmental sanitation
also as we found in the case of safe drinking water.
Another overlooked area in the case of sanitation is the facilities for disposal of solid
and liquid wastes. This needs special attention and emphasis by the government by
allocating adequate funds.
-36-
>
The continued neglect of the environment in urban slums poses one of the greatest
threats to progress on reducing infant and child mortality and improving nutritional
status of children living in such disadvantaged areas. Almost a third of households in
urban slums do not have access to any kind of toilet. Drainage and garbage disposal
systems are often overwhelmed or absent. Public latrines poorly designed and
maintained, become themselves major centres of infection and often deter use by
women and children.
On the other hand we find that the demand for latrine facilities is high from certain
sections (especially from educated women given the decreasing scrub cover). This is
inspite of the government experiences of poor utilization of funds.
One could identify a lot of reasons for poor achievement or underperformance in this
sector
• Though planners have given consistent emphasis to sanitation in plan documents,
the budgeting for this item has been low.
• There is a narrow focus on the choice of technology. Wide variety of technology
options based on local situations and local resources need to be made available,
which could lead to sustainable usage. Successful experience of Sulabh Souchalaya
is an example.
• There is a general lack of demand for toilets, and indifference on the part of
families and communities for a safe environment for their children and for
themselves.
Community needs to be active participants in raising demands for services (based on
felt needs) and in planning and paying for services (according to their capability) as
opposed to being passive recipients. High prevalence of non utilization or under
utilization especially of sanitation facilities when socio-cultural factors have not been
considered in the plan, is observed
• Quality of service and its monitoring is another gap. Built in mechanisms for
monitoring the safety and usability of sanitary facilities, changing in conditions of
water availability is required.
Housing
There is immense shortage of housing needs estimated at a shortfall of 23 million.
The outlay for housing has progressively decreased from 2.5% in the II plan to 1.47%in the VIII plan. The plan outlay centrally is routed through the Indira Awas Yojana
(IAY) and at the state levels through the minimum needs programme. Trend is of
increasing investment of private sector in housing, which tends to increase the
prices.
Given the large investments required a more feasible approach to the problems to
provide land rights and facilities like credit and support for upgrading. The poor
themsekes will build their houses. This is equally true in the urban areas where the
-37-
>
poor have through prolonged struggles managed to win legal rights to plots, however
environmentally degraded they were and created them into suitable housing.
‘However the new economic policies tend to aggravate the problem through
accelerated unemployment, rising prices and cut back on state subsidised basic
services and facilities. Policy trends are supporting the market forces such as
repealing of the urban land ceiling act, and large-scale demolitions of slums for
procuring valuable lands for business interests, The vision of social housing has
been lost and housing is no longer considered an instrument for bringing about
redistributive justice’ Jai Sen, Convenor, NCHR.
A child’s right to secure environment begins with assured access to safe water and
clean surroundings both vital for healthy growth of the child. The assurance of such
a right depends critically upon public provisioning by the state, the behavioural
patterns of parents in the family and outside the home, and upon the level of
information communities have on are the benefits of hygiene and environmental
sanitation. Social discrimination and exclusion can deny the right to use public water
sources and sanitation facilities by communities like SCs and STs even if all the
above conditions are fulfilled.
Several factors thus constrain fulfillment of the child’s right to safe drinking water and
a clean environment. Some of them are with in the control of the household and the
community, others beyond the control. A major factor however has been attitudinal
and behavioural change that has been slow to come about. A child’s most
immediate environment is the family and the home, where hygiene practices, such as
hand washing, toilet use and the safe handling of drinking water are critical.
Behavioural changes become fundamental to alter such practices.
Outside the
home, the child's environment widens to include the community, where safe water
sources, waste management and drainage are crucial. Public provisioning has been
underperforming in these areas. The issues include adequacy in financial outlays,
access and quality of services, the relevance of technology choices, community
participation and sustainable usage. Beyond the habitation, the management of land,
forest and water has a direct bearing on the living conditions of the communities
depending on these resources. Very little public action has been mobilized for
preventing environmental deterioration and its impact on water table replenishment
and sustainability.
THE CHILD UNDER STRESS AND RISK
In the situation of growing economic disparities, 1break down of family support
systems and changing values especially of consumerism
-- 1 In a patriarchal class and
caste ridden society, the child is under stresses and risks to physical and mental
health.
Working children and bonded child labour.
-38-
J
The country has a large number of children forced into adult roks of earning a
livelihood. According to the 43rd round of the National Sample Survey (1987), the
number of working children was estimated to be 17 million. The present figure is
estimated to be around 20 million. The International Labour Organization (ILO)
figures for year 2000 is given below:
State
Child Labour in India_______
Number
Andhra Pradesh
(Girls outnumber boys 51.5 to 48.5)
Uttar Pradesh__________________
Madhya Pradesh_______________
Maharashtra________________ __
Karnataka_____________________
Bihar
____
1.66
Percent
14.7
(92% rural)
1.41_______
1.35_______
1.06_______
0.97_______
0.94
12.5
12.0
9.5
8.7
8.3
(International Labor Organisation -AP Project on Child Labor)
This is a result of the increasing poverty, break down of family caring systems and
other manifestations of the economic policy changes. Being in forced child labor
invariably damages their growth and development and violates their basic rights. The
children are scarred fc life, by hampered growth, occupational diseases and having
remained unschooled while their peers move ahead. These are handicaps that rob
them of their full potential.
Legal Provisions, Policies and Programmes
The constitution contains provisions for protection of children from work that is
beyond their capacity, or involves long hours of work interfering with their education,
recreation, rest and overall physical and mental development. Protection is also
available under various industrial acts labour laws enacted from time to time.
The Supreme Court in its land mark judgement delivered on 10 December 1996 in M
C Mehta Case (M C Mehta Vs State of Tamil Nadu and others 1996 (B) SCC 756)
gave a major fillip and encouragement to the efforts of various agencies working on
child labor.
The Supreme Court directed among other things, to conduct a detailed survey of
child labor in the entire country. According to the judgement, on completion of the
survey an amount of Rs. 20,000 per child should be collected from those who have
employed child labour in hazardous occupations and processes, to be used as
corpus for a Child Labour Rehabilitation cum Welfare Fund to be set up at the district
level. States should also ensure alternative employment to one able bodied adult
member of the family of the child who was withdrawn from the work or alternatively
contribute Rs 5,00o per child to the said fund. The child would be ensured
education in the formal school, and the employer should be prosecuted for violating
the prov.sions of the child labour act.
-39-
If the identified children were working in a non-hazardous job, the child should be
imparted education at the cost of the employer and the Government should ensure
that the child does not work for more than 4 to 6 hours.
Features of Government Policy on Child Labour (2000)
•
Universal Elementary Education by 2005 as the main tools.
•
Time bound Programmes to end child labour.
•
Shift of child labour subject to Education Department from WD & CW and
labour departments.
•
Provision of Schools, teachers etc., for child labourers by the government
through DPEP.
•
DPEP emerging as a main player to end child labour.
Most of the efforts towards the elimination of child labor thus far has been focussed
only on the rehabilitation of the child by attempting to get the child into an educational
or vocational stream using a variety of rather good and innovative strategies.
However there has been little effort to look at and focus on the families of the children
and provide to the families all such inputs which could bring about a strong
commitment in the parents against child labour and towards the continuation of their
child’s education. This would also mean bringing about an improvement in the
economic situation of the families.
A fall in incomes and simultaneous increase in family expenditures can at times
make it difficult for parents or families of children to sustain rehabilitation efforts. But
so far, most of efforts for rehabilitation of children have focused only on the child,
attempting to get the child into an educational or vocational stream. Such as
integrated girl child rehabilitation program of Women’s Cooperative Finance
Corporation, “Back to School Program" of Social Welfare Department or Non Formal
Education scheme of ministry of Human Resource Development. There has been
little effort to look at the families of the children whose ncomes decrease when the
child stops working and expenditures increase when the children are enrolled into
schools. There has been no effort to provide additional assistance to improve the
economic situation of such families (Which could be one amongst the primary causes
of child labour) so that they are able to cope with the drop in incomes when the
children stop working and join schools.
A comprehensive approach should also converge health inputs, both in the area of
awareness generation and also in terms of curative care and health promotional
aspects, for the families at risk, who are likely to send children into forced labor.
Simultaneously health of children in hazardous occupations needs to be closely
monitored and attended to using the legal instruments available.
Child Prostitution
Though reliable estimates are not available micro level studies show that about 15%
of all women in sex trade are children. The most comprehensive study by Govt, of
-40-
I
India suggests atleasi 28000 children a.e in prostitution in the 6 metropolises alone.
India Today in 1990 quoted a figure of 500000 minors in prostitution (“Child
Prostitution: The Ultimate Abuse" report of National Consultation on Child Prostitution
1995 UNICEF, New Delhi).
The contributing circumstances are utter rural poverty, illiteracy, dysfunctional
families and the affected children themselves being illiterate. About 20% of child
prostitutes are thought to come from the traditional systems of temple prostitution
“Jogini or Devadasi”. This system is also contributed to by the impoverishment of the
lower caste groups (schedule castes). Exploiting these circumstances are networks
of traffickers operating from the impoverished areas with direct linkage to the brothels
in the metros. They dupe the family and the child through various inducements.
Another factor that has suddenly increased this exploitation is the recent increase in
‘sex tourism’ and India becoming increasingly a center for global sex tourism.
Children in sex trade are exposed to various dangers. These dangers include
physical and emotional violence, greater danger of being infected with STDs and HIV
infection due to the immature development of their genital systems and the deep
emotional trauma which leaves a permanent scar in their psyche. Some thinkers
assert that it is the ultimate denial of the rights of the child, transforming his/her entire
life; (DR John Rhode, UNICEF Representative)
Policy and Provisions
The solution to this problem of tragic proportions is difficult and complicated,
requiring collaborative efforts from wide sections of the society and government the
existing response of the state is very weak and inadequate.
The National Policy for Children, 1974 states that “Children shall be protected against
neglect, cruelty and exploitation”. The National Decadal Plan of Action for the Girl
Child (1991 - 2000 AD) recognises the rights of the girl child to protection from
exploitation, assault and physical abuse.
The Supreme Court of India in a “Public Interest Litigation” in 1990 on the subject of
child prostitution had directed that the central and state governments should set up
Advisory Committees to suggest measures to be taken in eradicating child
prostitution.
However existing law related to the offense are riddled with loopholes. The lawenforces (police) are insensitive to the sociologica' and human problem, and often
end up abetting the offenders and penalizing the victims.
The rescue work of children so trapped is dangerous for NCOS alone to handle as
underworld Mafia’s are involved. In addition a comprehensive mechanism for rescue
does not exist as of now. Rehabilitation of the vulnerable or rescued children
requires sensitive approach, both due to the social stigma and the psychological
-41 -
scarring. The children’s institutions such as the remand homes are least suitable for
this.
Targeting of the vulnerable families for preventive work is a Herculean task, given the
wide- spread rural poverty and illiteracy. Compounding all these inadequacies in the
response, is the negative impact of globalization. Globalisation is increasing rural
poverty and feminisation of poverty as well as increasing the market demand for child
prostitution through global sex tourism. The legal statutes alone are not adequate to
tackle this menace.
The Disabled Child
It is estimated that 10 per cent of the population worldwide is disabled. The
extrapolation that 35 million Indian children are disabled is considered conservative
by many. Most Indian children are disabled because of poverty and its correlates.
Protein malnutrition, Iodine deficiency and Vitamin A deficiency are the major causes
of mental retardation and blindness. Based on the type of disability, it is estimated
that of the orthopaedically handicapped, locomotion disability is the most prevalent in
the 0 - 14 age group with at least 2.4% incidence. The most significant causes are
poliomyelitis, cerebral palsy, paralysis, arthritis and amputations. 5 - 7% children
suffer from signs of Vitamin A deficiency with an estimated 60,000 children becoming
blind each year; an estimated 6.6 million children are mentally retarded and 2.2
million afflicted with cretinism resulting from iodine deficiency. Developmental delays
and mental handicaps are the most under reported of all disabilities. The National
Sample Survey of 1991 estimated that in the 0-14 age group, the incidence of
hearing handicap is 1.4%. Of the 4 million leprosy affected persons one fifth are
estimated to be children and about 15 to 20% cases are with deformities. The
available statistics on the incidence of various disabilities are limited and believed to
understate the scale of the problem due to tendencies of families failing to recognise
or acknowledge disabilities especially communication and mental disabilities. Lack of
early detection and treatment leads, in most cases, to major and stressful secondary
handicaps of physical function, intellectual handicap and social and emotional
behavioural problems. The vast majority of disabled children lead lives singularly
lacking in stimulation; they know no difference between childhood maturity and old
age.
Health services for the Disabled
This situation is further exacerbated by the lack of basic services.
Very little care is available at the three levels of prevention (Primary, Secondary,
Tertiary) in the field of disability.
In the chapters concerned with nutrition we see that Vitamin A deficiency, Iodine
deficiency and protein malnutrition among children have not seen effective
interventions (primary prevention). On the contrary the situation could deteriorate
given the compromised food and nutrition security of the household. These are
important contributory factors of disability. (Polio-eradication program however has
-42-
i
been one of the successful programs, we are proudly moving into the eradication
stage).
A similar bleak situation is seen regarding early treatment of causative diseases,
early detection of disabilities and appropriate medical rehabilitation (secondary and
tertiary prevention). Skilled personals are not available at a countrywide level in the
public health system. Even the PHC doctors are not adequately trained and skilled in
rehabilitation aspects. The few services that exist are mostly in cities and accessed
mainly by the middle and upper classes. Rehabilitation strategies focus largely on
literacy and academic goals. The few assistive devices produced are suited to the
aspirations of financially well off urban Indians. An estimated 98 percent of rural and
95 per cent of urban disabled children have no access to services.
The recent deaths from five of 29 inmates of a hostel for mentally ill at Erwadi,
Ramanathapuram, has brought to attention the pitiable lack of resources for the
mentally ill. It is stated that 80% of the districts in the country don’t even have a
trained psychiatrist, let alone mental hospitals! (‘Shocking Neglect of Rights of
Disabled Persons’, Javed Abidi PUCL Bulletin Dec 2001)
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act 1995, is a comprehensive lec. slation. It came to be passed with
the concerted and sustained advocacy efforts of groups working on disability issues.
The act defines disability to mean the following seven areas:
1. Blindness
2. Low vision
/
3.
4.
5.
6.
7.
Leprosy
Learning impairment
Loco motor disabilities
Mental retardation
Mental illness
The Act has established the responsibility of society to make adjustment for disabled
people. It has opened many doors to disabled children and adults. However the
implementation of the Act so far has been very tardy. Critics attribute it to the
following reasons:
• Though a mechanism has been put into place through the Act, implementation
blocks, are systems pervasive.
•
Lack of political will, financial support and excessive beaurocracy.
•
Lack of awareness among government departments about the act.
•
No monitoring mechanisms for the implementation of the Act
•
Lack of awareness among the disabled people about the act.
•
Lack of strong Advocacy groups to pressurize policy makers and implementers.
-43-
Juvenile Delinquents
Over the years, the process of social development in India not only led to changes in
the family structure and values, but has also resulted in an increase in social
problems like destitution and juvenile delinquency.
The government of India has introduced various pieces of legislation and
programmes to minimise these social problems. A well-planned juvenile system
comprising of Juvenile Welfare Boards, Juvenile Courts, Observation Homes,
Juvenile Homes, Special Homes and After-care Organisations is in operation.
With a view to provide a uniform pattern of justice to juveniles throughout the country,
Juvenile Justice Act 1986 came into force in 1987. The Act has brought a change in
the upper age limit of juveniles (from the earlier age limit of 21 years for both males
and females) to 16 years for males and 18 years for females. The Act provides for
the care, protection, treatment, development and rehabilitation of neglected and
delinquent juveniles and lays down a uniform legal framework to ensure that no child
under any circumstances is lodged in jail or kept in police lock-up. The Act provides
for a different approach in the processing of the neglected juveniles vis-a-vis the
delinquents. While neglected children are produced before Juvenile Welfare Board,
the delinquents are dealt with by the Juvenile Courts.
HIV Infected and Affected Children
At 1% of HIV prevalence among pregnant women in India it is estimated that there
are annually 1.3 lakh HIV positive pregnancies and about 33% of the children born
will be HIV positive (Dr Deepti Dingaonkar, paper presented at National NGO Meet
on HIV/AIDS, May 2002, thane) Besides the positive children, a large number of
children become affected as HIV orphans.
The basic needs of children who have been orphaned by AIDS are the same as
needs of all children. A unique aspect of HIV/AIDS is the stigma and fear and
isolation that acc-.mpany it and the possibility of rejection and prejudice. Infected
and affected HIV O'-phans become dependent on the wider community to care for
them. Other family members surviving such as grand parents are hardly in a position
to care for them as majority are from poor socio economic background.
Hence issues of caring, schooling and psycho social support of these children
become important societal concerns given the lack of programs and resources made
available for abac-! >’ied children.
Medical management
issues are complicated though effective and relatively
economic prevens/e measures are now available (such as Nevarapine and AZT
prophylaxis,
planned ceasarian delivery and cessation of breast feeding).
Considering the ow resource set up in the country the above mentioned
interventions are i ' ^ely to be implemented universally.
-44-
I
This is iispite of the fact that AIDS control program is picking up well in the country,
given the considerable international attention on this issue. Government efforts all
never the world has not borne good results, without the catalyst role played by civil
society groups.
Female Foeticide
Female foeticide and infanticide is one growing issue linked to the patriarchal value
of male preference but exacerbated both by the new technologies introduced, as well
as by the pressures built up to reduce the number of children. According to non
governmental organizations, over 2 million female feticides are reported every year. It
is just the tip of the iceberg (Dr. V.C.Patel, IMA,Reuters New Delhi, November 12,
1999).
1991 census counted 927 females to every 1000 males in the Indian population. It
showed conclusively a declining sex-ratio trend starting from the beginning of the
century. Today in a population of one billion, males out number females by an
estimated 48 million or there is a case of between 32 - 48 million missing females.
There is a danger that as coercive measures to impose a two-child norm continue
such as reduced maternity benefits, debarring from elective offices etc, the female
feticide will worsen
Many Indian communities are known to practice female infanticide.
In recent
decades misuse of prenatal diagnostic techniques to determine sex of foetus even in
the first trimester has become common. This followed by sex selective abortion.
Given the patriarchal value systems of the Indian society, there is a deep-rooted ‘son
preference’ in the society. The female has a lower siatus and is discriminated against
in most sections of the society.
Under pressure from ‘rights activists’ groups, the central government brought out the
Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act 1994.
The Act, which required individual ratification by state assemblies, bans the use of
pre-natal diagnostic technologies for sex determination and provides for a three-year
imprisonment and a fine of Rs. 10000 for offenders. However it has been difficult to
implement. An estimate puts the number of ultra sound clinics in India at 20,000 and
the number of registered ones at a mere one percent (Sabu Georne, quoted in
‘Demographic Danger Signals’, Frontline Feb 4, 2000.)
There are loop-holes in the Act such as it does not provide for action on the basis of
complaint by a third party i.e. other than the doctor who undertakes the procedure
and the pregnant woman. The Indian Medical Association (IMA) has acknowledged
that doctors are responsible in some measure for continuing practice of female
feticide.
During the ‘Decade of the Girl Child’ (1990 - 2000) central and state governments
introduced various schemes aimed at enhancing the status of the girl child. These
- 45 -
include the ‘Cradle Baby Scheme’ of Tamil Nadu, “Apni Beti, Apna Dhan’ scheme of
Haryana, under which small benefit is made available to the mother and to the girl on
reaching 18 years, ‘Girl Child Protection Scheme’ for income poor families, involving
monitory benefits to the family. However they have hac \ittle impact.
Since 1998 a campaign against this practice has been initiated by civil society groups
“Campaign Against Sex Selective Abortion” (CASSA). CASSA is pressuring
appropriate authority to implement PNDA focusing on the aspect medical ethics by
medical profession.
OTHER PROBLEMS AFFECTING CHILD WELFARE
Deterioration childcare systems
Child care that is best accomplished in the home environment is increasingly affected
as women spend more time away from home. On an average most women spend 7
hours working outside the house and 4 hours working inside the house making a
workload of 11 - 12 hours daily. Most of them start working one month after the child
is born. This leaves them little time to attend the young children who require much
attention. The statutory maternity leave and such benefits are available only to the
7% of women in the organized sector. Even in their cases, the leave does not cover
the 4 — 6 months of recommended breast feeding period. The remaining percentage
of women in the unorganized sector are able to spend only little time in child care and
hence child care is left to older siblings especially girl children and in conditions with
no adult supervision - which could be both unhealthy and dangerous. This also
affects the development in terms of schooling of children who become caretakers.
Study shows that only 30% of women exclusively breast feed in the period 0-3
months, when breast milk is the most protective and nutritious food; weaning food is
introduced late 9-12 months by 60% of women (‘Women in the informal sector’,
Indu Pathak and Pushpa Patnaik, NIUA 91).
Deterioration of women’s livelihood security
As a direct outcome of the process of liberalisation, privatization and globalization the
livelihood security and food security of the society especially the women and children
are adversely affected. There is an increasing trend of casualisation of women’s jobs
accomplished by inappropriate and inferior working conditions including lack of
maternity benefits and childcare (Jayanti Bhosh, Macro Economic rends and female
employment in gender and employment Pg 348) There is a significant decline of
female wage earners in the rural labour market from 42% in 74 - 75 to 30% in 93 94 ( ‘Womens Workers in Agriculture’, Jeemol Unni, in Gender and Employment in
India, 1999, Delhi)
The increasing urbanisation and urban poverty trends, is resulting in a large segment
of urban poor women in below poverty line wages and having to work over time.
-46-
Women are increasingly employed in conditions of cheap labour as domestic
workers, construction labourers etc. There is a lack of appropriate legislation and
social benefits for the unorganized sector - and this sector is increasing. As brought
out in a later chapter this phenomenon drastically affects women’s ability to care for
the young children. The time available for care taking is cut into as well as the
additional but critical resources that women bring into the family budget is reduced.
The state’s response in this larger scenario has b en totally inadequate. The state in
fact has been cutting down poverty alleviation and employment schemes.
Food Security
The food security of women and children in low-income groups is badly affected.
The daily deficiency of food of pregnant women in low-income groups is 500 calories,
requiring additionally one fifth more quantity of food. This is reflected in the high
incidence of low birth weight babies - 52% among severely undernourished women
and 42% among moderately undernourished and 37% among mildly undernourished.
(‘Empowering Women’, Rajammai P Das, in Proceedings of the Nutrition Society of
India, 1995.)
The food security of the poor is affected in several ways. Agricultural production at
the national level has shown a downward trend, the average gro\ h registered being
3.4 in 80 - 81 and 1.4 in 90-91. The pulses and coarse cereals which are the food
of tne poor have come down by - 1.3 and - 0.7 respectively (J P Singh and Alok
Darsh, Agriculture in Alternate Economic Survey 91 - 98) as the cash crop cultivation
increases. At the same time another trend is the reduction of subsidy to the farm
sector resulting in 75% increase in prices for the4 public distribution system (PDS).
The coverage of PDS has come down from 15.3 % in 51 to 9.1 % in 1995.
Cultural factors especially relating to rearing foods and weaning practices also
contribute to malnutrition. The market has a major influence in misinforming the poor
mother leading to her introducing costlier but inadequate breast milk substitute or
weaning food substitutes. Within the patriarchal system of the society, the girl
children get most neglected i.e. get least amount of food and caring. Starting from
infancy... this gender-biased discrimination continues during adolescence where they
become further prone to anaemia due to menstruation and inadequate awareness of
nutrition requirements. Early marriages and early motherhood continues the chronic
malnutrition and poor health.
Recently much research has been done on the role of micronutrients’ deficiencies in
the health of children. This has led to high pressure marketing of micronutrients by
large drug companies confusing and misinforming the poor, into buying costly tonics.
The fact remains that if children ate sufficient food there would be no question of
deficiencies.
-47-
SUMMARY NOTE
The foregoing discussion brought to light the following key issues in the area of child
survival and development. Slowing of momentum of child survival reflected in
slowing of decline in !MR, sexual discrimination in childcare leading to increased
mortality rate of girl children, poor coverage of immunisation resulting in infant and
maternal mortality, epidemic of HIV/AIDS, serious nutritional deficiency status,
breakdown of child care systems, poor sanitation and housing, inadequate access to
protected water and existence of a considerable number of children under various
stresses.
The policies of programmes of CRY should address to these key issues. While
decision on policies and programmes are being finalised, an understanding of the
national level official policies, official programmes and responses of various civil
society groups to the above problem situation is important on two grounds. The first,
the magnitude of the problem is so huge that the efforts of the CRY alone are not
sufficient to deal with the situation. The second, in the globalised environment, new
paradigm of partnership of different stakeholders is emerging as a new strategy.
Therefore, the policies and programmes of CRY must be able to provide space for
these considerations. Hence, a review of policies and programmes of governments in
the area of child survival and development, responses of NGOs, political parties, civil
society bodies and other stakeholders of child development are made. The
recommendations we make to CRY take into account these responses too.
NATIONAL POLICY ENVIRONMENT AFFECTING CHILD HEALTH
India’s commitment to universal health care started from the time of independence.
The Shore committee report, which was independent India’s charter on health begins
with the opening statement ‘No Citizen should be denied an adequate quality of
health care, merely because of his or her inability to pay for it.
The Alma Ata Declaration
India as a signatory to Alma Ata Declaration committed herself to health for all by
2000,Alma Ata declaration recognised that health is a fundamental human right and
that the attainment of the highest possible level of health requires the action of many
other social and economic sectors in addition to the health sector.
The agenda stated among other things a complex set of strategies to improve
people’s livelihood and their quality of life and affirmed the state’s responsibility in
people’s health. The priorities of ‘Health for All by 2000’ was captured in the National
health Policy that was passed in 1983
The National Health Policy -1983
Some of the significant features of this policy were:
■
Large-scale transfer of knowledge and skills, to village based volunteers
■
Sanitary cum epidemiological stations, dispersed through out the country.
■
Emphasis on Primary Health Care (PHC)
■
Community Participation
-48-
J
Services to be available Free of cost
Secondary and tertiary care provision in support
Promote Privatization in health sector
Medical education
It, under emphasized Indian Systems of Medicine.
The policy had by and large been well thought through. It recognized that the
majority of Indians the need was for a well-dispersed and accessible primary health
care. The secondary and tertiary care structures were to function in support of
primary nealth care. Given the preponderance of poverty related diseases and that
they can be prevented by appropriate measures, the thrust of health policy 83 is
logical and scientific. Though chromic diseases and disease of affluence were also
becoming widely prevalent, the emphasis was on dealing with these also at the
primary health care level.
In retrospect ‘Health for All’ was not given a chance to succeed, as it was made a
vertical programme and a selective one at that without people’s participation. But
more importantly the World Bank that became increasingly influential in determining
India’s health policies had other agendas.
The World Bank’s Influence on Health Policy
Increasing influence of World Bank on Country’s health policy became evident from
the early 90’s, as the Bank’s investments in health sector grew. The bank has
funded through loans several health sector projects both at the central and state
levels into which are built in bank” policy directions.
The Bank, document Investing in Health’ 1993, calls for focussing on a small set of
public interventions that would be judged by the technocrats to be cost effective in
improving health indices for the minimum expense. In other areas private sector is to
be encouraged in the provision of services. The World Banks idea of health care as
a ‘safety net’ further interprets state supported intervention limited to a very select
role. These are Family Planning, Women and ChildCare, Nutrition, TB and Sexually
Transmitted Diseases. Within these areas the focus was further narrowed during
implementation. In other areas of health sector bank policy holds that private sector
will respond to the needs. This has translated into tertiary and secondary care
facilities increasingly being privatized even primary health care is being contracted
out (where suitable parties are found). Another policy component is for the public
sector to levy ‘user charges’ for their services that the consumer is likely to value,
namely curative care. Recently responding to lobbying by affected groups, user
charges in health sector is being removed by the bank.
Concomitantly other international trade related policies are also having their influence
on Health Sector Policies. The WTO provisions of TRIPS (Trade Related intellectual
Property Rights) are going to have a negative impact on the self reliant
pharmaocfutical sector, which had contributed to lower drug prices in India. The
-49-
progressive patent law passed by parliament 1970 will get changed under TRIPS
resulting in domination by Multinational Drug Companies.
In the present policy scenario the outcome of bank influence is that the state
withdraws from its institutional responsibility of ensuring health, and move into
‘regulatory roles’ in health. The assumption that ‘for- profit private sector’ will meet
the needs of the people in areas vacated by the state is ill founded. The poor are not
able to pay even a minimum amount of the exorbitant charge of private sector, and
hence will not be able to access their services.
The worst affected in such a
situation are the women and the children of the marginalized communities. The
prioritization of state services purely on the basis of cost-effectiveness, results in
local needs of people in health not being meet. This is already a problem of
centralized health planning which becomes further accentuated.
National Health Policy 2002
Significant features are:
•
Increased expenditure in health to 6% of GDP and 33% of it from public health
investments. Present central government outlay to state health financing to increase
from 15% to 25% over the next eight years.
•
Increased emphasis to primary health care with a funding ratio 55% - 35 - 10
(Primary- secondary - Tertiary). Funds to be utilized for upgradation of facilities and
increasing the number of facilities (to meet existing gaps). Essential drugs to the
primary health care infra structure to be supplied directly from central funds.
Charging of ‘user fees’ in secondary and tertiary establishment based on user’s
capacity to pay.
•
Increasing the manpower in public health and the reach of health manpower in
under served areas - capacitating licentiates in Allopathy, Practitioners of Indian
systems and paramedical workers of Allopathy, to practice clinical work in specified
under- served areas.
•
Increasing the number of specialists in family medicine and public health.
•
Medical grants commission to oversee even geographic spread of government
medical colleges.
•
Emphasis on control of prioritized communicable diseases - TB, Malaria,
Blindness Control and HIV/AIDS.
•
Specified roles and specific budgeting for involvement of NGOs in disease
control.
•
Decentralization of implementation through autonomous state level and district
level committee in which health department will have monitoring role primarily.
•
Emphasis on a national disease surveillance network on priority diseases
through local, district and state level mechanism, strengthened with information
technology
Health activists,-^^have welcomed some of the provisions of this new policy, are
critical of the general thrust and orientation of the document, which they feel, has
-50r
been too much influenced by the World Bank policies and of the Industrial
lohby(fredback from *he constituents of People’s Health Movement).
•
The Policy document does not come out as advancement on the past
experiences of health sector. It demonstrates a patchwork character and has
significant omissions.
•
Policy document in its analysis does not analyse the failure of the Health For
ALL (HFA) commitment and build upon it. Hence a mere renewed commitment in a
policy document to primary health care is unlikely to translate into results.
•
Some of the basic factors that resulted in the failure are outlined below. They
include lack of decentralization and investing control in the local bodies, lack of
strengthening local level planning based on local needs, problems in convergence of
health related public interventions. Policy is significantly silent on these aspects.
Similarly the excessive influence of drug companies and techno- beurocrats on policy
process- another factor for failure is not scrutinized.
•
The charging of user fees in the public facilities at the secondary and tertiary
level care without foolproof systems for identifying the poorest, experience has
shown excludes the poorest.
•
Policy support for the continuing withdrawal of the state from health provision
-esporsi’-'lities by ‘leaving implementation to autonomous committees’ has ominous
implication for the weaker sections as fhe autonomous committee need not be
accountable bodies in the same sense as ihe state is.
•
Two important areas standing out by its absence are mention on issues of child
health and issues of nutrition.
•
There is evidence of ill conceived commercialization in health sector, with the
policy encouraging through fiscal incentives earning ‘foreign exchange’ from service
seekers from overseas.
National Population Policy 2000
The immediate objectives of the NPP 2000 is to address the unmet needs of
contraception, health care infrastructure and health personnel and to provide
integrated service delivery for basic reproductive and child health care. The medium
term objective is to bring the Total Fertility Rate (TFR) to replacement levels by 2010,
through vigorous implementation of inter-sectoral operational strategies. The long
term objective is to achieve stable population by 2045, at a level consistent with the
requirements of sustainable economic growth, social development and environmental
protection
In pursuance of these objectives, several national socio- demographic goals to be
achieved in each case by 2010 are formulated. <n order to achieve these goals
twelve (12) strategic themes have been identified, which include:
• Decentralized planning and program implementation.
• Convergence of service delivery at the village level.
• Empowering women for improved health and nutrition
• Child health and survival
• Meet the unmet needs for family welfare services
-51 -
-ill.
•
Attention to Under served population
The National Population Policy and the new Reproductive and Child Health (RCH)
programme reflect certain shortsighted visions. Though the policy has moved away
from a target driven approach and recognizes importance of addressing all the issues
concerning reproductive health, there are several problems in the policy directions.
The entire approach is still contraceptive centred, and fails to recognize the
relationship of population to poverty and under development. It equates reproductive
health to maternal care and fertility control, wh
inadequately addressing
determinants like sexuality, cultural values, infertility services and reproductive tract
infections. They seek to introduce hazardous injectible contraceptives. Assumes that
privatization of certain services will provide a better outreach and make it more
consumer friendly. Though targets are removed a number of disincentives are
introduced for two-child norm, which will discriminate against the poor.
i
The Convention on the Right of the Child (and evolving policy environment for the
child )
The Government of India (GOI) had identified the need for a special policy for the
betterment of the children as early as in 1974. The National Policy for children was
initiated by the GOI in the year 1974. This policy had spelt out the various areas
including health of the child, which needs to be worked upon.
It was in 1992, that the GOI ratified the Convention on the Rights of the Child (CRC)
In,the same year the GOI formulated the National Plan of Action for children in the
context of cooperation. The health highlights of this Plan as put in the clause 2.7 had
four mam priorities, the reduction of the Infant Mortality Rate, the Underfive Mortality
Rate and the Maternal Mortality Rate as well as bringing down the number of Low
Birth Weight children.
The Convention on the
p Right
• of the Child (1992) and the National Plan of Action for
Children, are progressive-----documents.
I‘
However
given the proven gap between policy
and implementation in the country, concerted advocacy will be required to make
gains.
NATIONAL PROGRAMME SITUATION
The Public Health Services
Access to and utilisation of quality health services is t
one of the most important
determinants of child health. During the last 45 years a number of government health
institutions have been established in the rural areas.
Although the country's primary health
care system has expanded considerably,
access to such services is still limited on account of many social and geographical
barriers.
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I
The orgam. lion and functions of country's public health services are detailed below
(The Independent Commission on Health in India, Health For the Millions, Nov - Dec
1907v
Sub-centre level: As per current norms, one sub-centre (SC) has to be provided for a
general population of 5,000 persons, and for a population of 3,000 persons in tribal
and difficult areas. The standard staff in SC is one male and one female health
worker, and one female attendant.
Primary Health Centre : As per current norms, one primary health centre (PHC) has
to be provided for every 30,000 population, in general, and 20,000 population in tribal
and difficult areas. Six SCs fall within this population base. Apart from rendering
services, the other important functions of the PHC are supportive and supervisory in
nature. It has to cater to all the SCs and villages within its jurisdiction. The PHCs
were established to serve as a focal point, through which integrated curative,
preventive and promotive health care could be delivered to the entire population of a
defined geographical area.
A Community Health Centre (CHC): one for about a population of 1,00,000 persons.
It was expected to provide public health expertise, epidemiological services, training,
mjn.x .ng and evaluation, continuing education and to be the first level referral for
specialist medical treatment - including diagnosis, special investigations,
consultation, special treatment and surgery.
The CHC was to be headed by a Public Health Officer. Other specialists were to be
a general physician, general surgeon, obstetrician and gynecologist and pediatrician.
Many taluk or tehsil hospitals and even PHCs have just been redesignated.
Presently in most states, the Chief Medical Officer (CMO) is at the top leadership
position, however, most of them only look after the hospitals and are interested in
clinical work. Public health is responsibility of a Dy. CMO, most of who are not
formally trained, either in public health or in management. Various national health
programmes like malaria eradication, tuberculosis control, leprosy eradication and
family welfare programmes, are managed by respective programme officers, without
any co-ordination or communication.
HEALTH INFRASTRUCTURE AND MANPOWER - COVERAGl AND
GAPS
Population
No. existing
No. needed
% vacant or
Covered
& in
of 100%
uncovered
position
coverage
(for 2002
population)
Sub Center
5000
136818
23190
14.91%
PHC
30000
22991
4212
16.25%
CHC
“3776“
100000
2712
58?2W
- 53 -
ANM
MPWM
LHV
Doctor
5000
5000
30000
30000
133567
”72869
19364
"24648
27501
64860
4224
“1531
5.12%
"16.39%
13.76%
-15.11%
Source : Bulletin of Rural Health Statistics in India : June 1998, Rural Health
Division. DGHS, MOHFW, GOI.
Applying current norms it is estimated that the shortfall in the number of
SCs/PHCs/CHCs is of the order of 16 percent. However this shortage is as high as
58% when disaggregated to CHCs only. This shortfall is not a national average as
several states have adequate or excess requirements.
Public Health Investments and the quality of services
Public Health Investment as a percentage of GDP declined from 1.3 per cent in 1990
to 0.9 per cent, in 1999. Central budgetary allocation for health has remained at 1.3
percent of the budget, whereas the state allocation have declined from 7% to 5.5%.
The current annual per capita expenditure is only Rs. 160.
Given this low priority for health the reach and quality of public health services have
been poor. It is estimated that less than 20 percent of the population seeks OPD
services and less than 45 percent awails of the facilities for in-door treatment in
public hospitals.
The access and quality of services in the public health system continue to remain
poor.
Public Health Critiques point out that due to the following policy and
programmatic gaps the system is allowed to fail.
There is inadequate funding for the infrastructure, inadequate staffing and very
little essential supplies. As mentioned earlier the state funding has been declining in
real terms.
The costs of drugs have been rising as a result of the deregulation of drugs
brought about by the new drug policy.
•
The centralized system has a fragmented approach to planning. The criteria for
program planning is determined by cost effectiveness and hence several needed
services of the community are dropped out.
■ The priority and emphasis in monitoring remains on a few programs namely
family planning, immunization and TB. Hence most of the national preventive
programs remain on paper as the capacity for implementing is not built up and their
progress not monitored.
A referral system is not built up inspite of policy priority for ‘community health
center’ for one lakh population. Con- committantly and indirectly private sector
provisioning of secondary care is encouraged which cannot be accessed by the poor.
Strongly Emerging Private sector
-54-
J
Several recent studies ha
pointed out that 70 - 90% of all curative health care in
India io delivered by the private sector. People who go to the private health
practitioners, however, often do so because they have no other option. It is perhaps
true that the private practitioners offer services that are more easily available at
regular hours, more personalized treatment, a beJer supply of medicines, and offer
continuity. But this does not mean that the quality of care is assured. The price paid
for health through the private sector can be very high, often putting a poor family into
debt and threatening an already precarious income flow. The private health care has
shown to be on many occasions, irrational and unscientific too.
The poorest 10% of the population still depend on the government health facilities,
however inadequate they may be. (study of sevapuri, Independent commission on
health in India, P 304). The real issue is that the government primary health care
centre and the sub-centre offer little by way of good quality or regular care to the
community. Unless the sub-centres begin to function well, there is little that can be
done to prevent the poor from being exploited by private practitioners.
Child care
Integrated Child Development Services (ICDS)
The ICDS programme was initiated in 1975 with the following objectives:
• To improve the health and nutrition status of children 0-6 years by providing
supplementary food and by coordinating with the state health departments to ensure
delivery of required health inputs;
• To provide conditions necessary for pre-school children’s psychological and
social development through early stimulation and education;
•
To provide pregnant and lactating women with food supplements;
• To enhance the mother’s ability to provide proper child care through health and
nutrition education;
• To achieve effective coordination of policy and implementation among the various
departments to promote child development.
In practice most beneficiaries of supplementary feeding are not selected through
nutritional screening.
Over the last two decades the ICDS coverage has
progressively increased. As of 1996, there are 4,200 ICDS blocks with 5,92,571
ancai.z dis in the country; the number of beneficiaries rose from 5.7 million children
and 1.2 million mothers in 1985 to 18.5 million children and 3.7 million mothers in
1996.
Nutrition Foundation of India (NFI) and National Institute of Public Cooperation and
Child Development (NIPCCD) had conducted evaluation of ICDS. The following
reasons for lack of improvement in nutritional status in ICDS areas were identified:
• Inadequate coverage of children below three years of age who are at greatest
risk of malnutrition;
- 55 -
• Irregularity of food deliveries to anganwadis and hence irregular feeding and
inadequate rations;
• Poor nutrition education for mothers and communities) to improve feeding
practices at home;
• Inadequate training of workers in nutrition, growth monitoring and communication;
• Poor supervision
• Poor co-ordination and linkage with health workers.
• Lack of community ownership and participation.
Crdche Services:
In 1975, the Department of Women and Child Development started the scheme of
Creche / Day Care Centres for children of working and ailing mothers. The scheme
was to provide daycare services for children (upto 5 years of age) of mainly casual,
migrant, agricultural and construction labourers, whose total monthly income does
not exceed Rs. 1,800 per month. The children of these women who are sick or
incapacitated due to sickness or suffering from communicable diseases are also
covered under the scheme. The services include supplementary nutrition, health
check-up, immunisation etc. The Central Social Welfare Board and two other
national level voluntary organisations implement the programme. During the year
1995 - 96, 12,470 creche units provided services to about 30,00,000 children.
Government estimates that 12 lakh crdches are required to cover all needy children.
But only 14,000 crdches are run by the government. A study of crdche services in
India done by NIPPCD highlights a number of issues.
> only 70% of children enrolled were under one year age
>
the average space provided per child was 3-6 square feet
>
almost all centres had a dearth of play material,
> 73% of the centres did not have toilet facilities for the children
the childcare worker was grossly underpaid.
With most women being working mothers, universal day care facilities and social
security for caring for children is a minimum social obligation.
In pursuance of the commitment at the Cairo P( ulation and Development
Conference, the Family Welfare Program has been changed to RCH. The RCH
program articulation includes ‘Target free approach in Family Planning’, integrating at
the community level components of the programs- Family Welfare, Child Survival and
Safe Motherhood, and Prevention and Management of Reproductive Tract and
Sexually Transmitted Diseases. The activities are to be client centered, demand
driven and provide services with quality assurance. Male participation is to be
promoted. The spectrum of services have been enlarged and to be ‘available- from
adolescent age through reproductive period.
-56-
In its aims and objectives RCH has sevt .il problems. These include concentrating
on indiwidual rather uian community health, a contraceptive focused approach rather
than a holistic approach, assume that privatisation of services will make it consumer
friendly, and that problems are related to efficiency rather than need for greater
public investments and does not promote appropriate values in respect to sexuality.
Programme Of Cooperation: UNICEF - GOI: 1999 - 2002:
The GOI in close collaboration with the UNICEF has formulated a Programme for
Children and Women in India between 1 January 1999 and 31 December 2002. This
programme is to be seen in the context of the CRC, the World Summit for Children,
the World Declaration on the survival, Protection and Development of Children in the
1990s and the Convention on the Elimination of All forms of Discrimination Against
Women (CEDAW).
The areas of intervention were identified as the improvement of Child’s environs
(Sanitation, Hygiene & Water Supply); Reproductive and Child Health; Primary
Education; Childhood Development & Nutrition; & Child Protection: Advocacy &
Information for CRC
Four important area of strategy was identified as the Country wide ones: 1. Strengthening Partnerships, Cooperation & Alliances.
2. Promoting Decentralized Community Management or local governance.
3. Enhancing Women’s capabilities.
4. Ensuring convergence of basic social services. Convergent Community Action for
Capacity Building.
• To contribute to the fulfillment of the rights of the least-served children in deprived
rural communities by ensuring adoption of appropriate community processes.
• To strengthen the capacity of government to respond to community plans and
achieve convergence of services for the child.
• To promote sustained action through better awareness and capacity of all
500,000 women representatives of panchayaths.
• To develop and implement monitoring systems, which can be employed by the
community to track the situation of children and women and generate, appropriate
action in at least one-third of all villages.
To n 3 :ure progres : of this Programme, three complex goals were chosen as they
depict the overall programme effectiveness. These three are:
1.
Reduction in the incidence of Low Birth Weight (LBW) children.
2.
Reduction in the Maternal Mortality Rate (MMR).
3.
Elimination of Child Labour.
Health Goals
The following health goals were chosen in the Programme of cooperation:
• Reduction of the IMR to < 50/1000Live Births.
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•
Reduction of MMR from 437 to 300/ 10O.OOOLBs.
•
Other supportive goals to further the above two.
Nutrition
• Reduction of the 1990 levels in Severe and Moderate malnutrition among
Underfive children by atleast 50% by 2002.
Water and Sanitation
•
Universal access of Safe Drinking Water by 2002.
•
Improvement in access to sanitation from the present level of 30% to at least
50% by the year 2002.
Critical Areas for NGO Intervention
• The programme strategy has envisaged an Intersectoral Facilitatory Team of
functionaries (IFT). There is to be a nominee or representative of local voluntary
organisations in the IFT.
• Through the CCA strategy also, voluntary agencies are to be involved at different
levels.
• At the levels of blocks, districts, States and the center, the CCA support and
steering groups will be formed with a range of functionaries. In all these support or
steering groups, NGO representatives are present.
• The Programme for Cooperation has recognized the role of voluntary
organizations in helping to raise the status of women and in participatory
development through a wide spectrum of successful projects for social change.
The CCA strategy seeks the active involvement of the voluntary sector at different
levels in partnerships with the GOI & UNICEF.
CIVIL SOCIETY RESPONSES
NGO Sector Child Concerns
Campaign Against Child Labour (CACL)
The Campaign for Child Labour (CACL) is a network of 5400 organisations and
individuals sensitised towards the issue of child rights and child labour. Organisations
that are active in child rights and human rights, research bodies, women’s groups,
trade unions, academic institutions, media agencies, corporate houses, student
volunteers and eminent citizens constitute the campaign. The CACL has today been
spread over in 12 states, viz. Maharashtra, Andhra Pradesh, Tamil Nadu, Karnataka,
Gujarat, Bihar, Orissa, Goa, Uttar Pradesh, Rajasthan, West Bengal and Madhya
Pradesh. It has State Secretariats in Andhra Pradesh Gujarat, Bihar, Karnataka,
Kerala, Orissa, Maharashtra and Tamil Nadu. The state co-ordination groups initiate
processes of CACL, seeking to strengthen state/district/taluk and grassroots
networking. The Executive Committee of the CACL is comprised of the state
convenors and nominated experts. The Central Secretariat administers co-ordination
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J
ind networking at the national level. Besides it has a National Coordination
Committee and an Advisory Committee to provide directions and guidance in its
operations.
The CACL defines child labor as "a phenomenon which includes children below 14
years, prematurely leading adult lives, working with or without wages, under
conditions damaging to their physical, mental, social, emotional and spiritual
development, denying them their basic rights to education, health and development".
(Campaign Against Child Labour)
The Campaign is against all manifestations of child labor, in any occupation or
processes in all sectors of work including the formal, informal, organized,
unorganized, with or without wages, within or outside the family. Therefore, it holds
that all forms of employment of children are hazardous ones.
The objectives of the Campaign are the following
•
Create awareness on the eradication of child labour;
• Make education up to the age of 14 years a Fundamental Right and ensure free,
compulsory and quality education till the age of 14 years.
• Highlight violations provisions of child labour laws and provide justice through fact
finding and litigation;
• Lobby for the review of policies and legislation on child rights, child labour and
education;
• Put forth successful strategies and alternatives for rehabilitation of working
children;
•
Facilitate field research to feed into the programme strategy of the CACL
• Popularise the UN Convention and the various Conventions of the ILO pertaining
to chik' abour.
The major campaigns undertaken by the CACL in the recent past are given below.
•
Litigation (both PIL an Judicial) on various acts governing child labour
•
National Convention of child labourers.
•
First alternate country report on child labour submitted to the UNCRC
•
Postcard Campaign to make Education a Fundamental Right.
•
Critical analysis of the rehabilitation scheme and mainstreaming in NCLP
•
Petition of cases of child rights violation to the NHRC and obtain justice
•
•
The first state level Commission on Child Labour instituted in Bihar
83rd Amendment Bill.
National Alliance For Right To Education (NAFRE)
The NAFRE came into existence in 1998 with the common goal of realizing
education as a Fundamental Right of every child. Aga Khan Foundation, Bodh, CRY,
MV Foundation, National Foundation of India, National Law School University of
India, PRATHAM, Save Alliance, UNICEF and Vikramsh^a joined hands for this
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common cause, and are united on a broad understanding that it must be realized
with a sense of urgency. The NAFRE today is a national coalition of 2,400 education
centric grass root voluntary organizations and thousands of individuals from all
sections of society working together to make education a reality for every Indian
child. The Alliance has now its presence in 14 States in India. The 14 states are:
Andhra Pradesh, Delhi, Gujarat, Jharkhand, Karnataka, Kerala, Madhya Pradesh,
Maharastra, Orissa, Rajasthan, Tamilnadu, Uttarancb ' Uttar Pradesh and West
Bengal.
The NAFRE works with the following objectives. Act as a platform to strengthen
micro level initiatives towards universalising education. Act as a critical link that
transfers the learnings from the grassroots to the macro level to facilitate assessment
/ strengthening / reforming of various policies on education. Work with all levels of the
Legislature, Bureaucracy, Media, and Corporates in pursuit of bringing NAFRE’s
holistic dimension to education. Monitor and promote the status of education while
simultaneously catalysing replicable models.
NAFRE is concerned about the 63 million children who are still out of school. It feels
that there has been a lack of political commitment in making Universal Elementary
Education (UEE) a reality and that the entire approach to UEE should be from a
humane perspective.
Currently, the NAFRE is working towards incorporating certain positive changes in
the 83rd Constitutional Amendment Bill, a bill that aims to make education a
fundamental right for every child in India.
Quality education to all and
decentralisation of education are the two other important concerns for the NAFRE.
Therefore, the NAFRE works for, along with Universalisation of Education, the
systemic changes in education system that is relevant to each and every individual
and community in every corner of the country. It implies the need for developing a
system of education for the masses based on equity, excellence and relevance within
the framework of affordability and the question of balancing the indigenous
knowledge base of a marginalised community in a globalised economy.
The NAFRE has adopted four strategic measures to achieve its objectives. These
strategic measures are:
Coalescing the national groundswell demand for UEE
Displaying the national ground swell demand
Developing national opinion towards UEE and
Showcasing workable models on ground that energize the government system
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The Disability India Network
There are many Non Government Organizations working in the sphere of providing
facilities and services for persons with disabilities, yet there is no comprehensive
data available for the ready reference of professionals and parents seeking access to
this information. The Disability India Network provides countrywide support and
services to disabled children, their parents and organisations. It creates a Register of
Services that could be made available to all - Nationally and Internationally - via the
Internet. Thus, organizations would have the benefit of being accessible to those who
require their services within the country, and additionally, have the advantage of
being visible to the world outside. Organisations already on the web, with their web
sites, will have the supplementary convenience of a link, enhancing their site
visibility.
More than 400 organisations have so far become part of the growing database and
each one of them has been given a free page to list their contact details and
specialties. Pediatricians and other child specialists will be standing by to assist
parents with their queries, Access Centres are proposed to be opened in various
parts of the country to help parents access the site and retrieve relevant information
without having to go from pillar to post.
Campaign Against Female Foeticide
Female feticide is one extreme manifestation of violence against women. Female
fetuses are selectively aborted after pre natal sex determination, thus avoiding the
birth of girls. In India where female infanticide has existed for centuries, now female
feticide has joined the fray and is increasing each day. The campaign against female
feticide is minimum two-decade-old. An earlier and successful case is the Forum
Against Sex Determination and Sex Pre-selection (FASDP) in Maharashtra. The
result of its campaign has been the Maharashtra Regulation of Use of Prenatal
Diagnostic Techniques Act, 1988.
The enactment of legislation by the government of India in 1994 is the result of a
national level campaign. The enactment of this legislation became instrumental for
the National Human Rights Commission (NHRC) to intervene in the situation and to
direct the Medical Council of India to take action against medical practitioners found
abusing prenatal diagnostic techniques.
The Indian Medical As ociation (IMA), The UNICEF, the National Commission for
Women, the People’s Union for Civil Liberty (PUCL) the People’s Health Assembly
(PHA) and the Department of Women and Child Development jointly and separately
started the campaign against female feticide. The given below are the positions taken
by these organisation in this
The Indian Medical Association (IMA) decided in 1999 to join government and non
governmental organizations in their fight against female feticide and sex
determination tests. "The IMA has declared that no medical professionals would
involve themselves in this heinous crime directly or indirectly," said IMA honorary
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general secretary Dr Perm Aggarwal. He added the association had informed its
members that doctors testing fetuses for gender faced possible expulsion from the
medical profession. In 1994, Indian law ruled that informing parents of the sex of their
unborn child was illegal, but Aggarwal says the practice is nonetheless widespread.
In this context, the IMA decided to fight against this practice.
The PHA has suggested the following measures as campaign against female
Feticide. The structures necessary for the implementation of the 1994 law have to be
created at the district level. Volunteers have to be actively mobilized to monitor the
registration and the functioning of the sex-determination clinics in different districts.
Effective alliances with ethical Doctors have to be made from the local levels. Test
cases have to be filed against the violators. And also important is that we have to
preserve with the media to highlight obstacles in the implementation of the Act. The
consciousness of our society has to be raised against this crime. Simultaneously we
have to get involved in actions to ensure that the public at large becomes supportive
of this campaign. Lobbying with political parties to put this issue on their agenda is
imperative.
NGO Resource Groups Involving In Child Health Programmes
A brief description of the activities of a few major national NGOs has been presented
x
below.
CARE-lndia
Cooperative for Assistance and Relief Everywhere (CARE)- India is the Indian
chapter of CARE, an international relief and development organization. CARE began
operations more than 50 years ago to help survivors of World War II. It was
established by 22 charities to send CARE Packages of food, clothing, medicine and
other relief supplies to people in Europe and Asia after the war. Now CARE exists to
affirm the dignity and worth of individuals and families in some of the poorest
communities of the world, in over 69 countries.
An “India where vulnerable people realise their aspirations for a better life in a better
community is the vision of CARE . Therefore, CARE . >rks for the enhancement of
the capabilities of vulnerable people, especially women and children, to enable them
to control their lives better. CARE has identified its role as a “catalyst and innovator in
relief and development, valued by all, striving for excellence”.
CARE commenced its activities in India in 1950 and currently it has its operations in
eleven states in the country - Andhra Pradesh, Chhatisgarh, Delhi, Gujarat,
Jharkhand, Madhya Pradesh, Maharastra, Orissa, Rajasthan, Uttar Pradesh and
West Bengal. Over seven million individuals in nearly 100,000 villages in these states
are covered by the operations of CARE now. It undertakes the task of sustainable
development. It has multi-sector approach and addresses significant problems in the
areas of nutrition and health, population, small economic activity development, girl's
primary education, urban development, agriculture and natural resources and tribal
empowerment. Besides, it provides emergency relief, often food, medical supplies
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and so on. The immediate goal for CARE in such coi :itions is to save lives. The
Central and State Governments, non-governmental organisations (NGOs) and
community-based organisations (CBOs) are the project participants of CARE.
The main focus of the operations of CARE in India over the years has primarily been
food. Until a decade and half ago, the primary thrust of the activities of CARE was
provision of food to vulnerable groups, especially children in the age group of 6 to 11
years.
Christian Children’s Fund (CCF)
The CCF is an UK based body working for the welfare of the children. The CCF was
formed more than 60 years ago to help the children devastated by war. Later it
extended its operations to other parts of the globe. Currently, the CCF is supporting
more than 2.5 million children in over 30 countries.
The CCF believes that all children have the right to experience life witn as much joy
and hope as humanly possible.
The objective of the CCF is to further the good of the children who are in need, their
families and communities. It proposes to create an environment of hope and respect
for needy children of all cultures and beliefs in which they have opportunities to
achieve tneir full potential, and provides practical tools for positive change to
children, families and communities
The major thrust areas of operations for the CCF are safe water, nutritious food,
medical care and an education for children.
Save the Children Fund (SCF)
Save the Children Fund (SCF) is an UK based body working to create a better world
for children. It works in 70 countries helping children in the most impoverished
communities of the world. The SCF is a part of the International Save the Children
Alliance, which aims to be a truly international movement for children.
The SCF believes that all children have a right to a happy, healthy and secure start in
life. Its vision mission statement reflects this belief. "In a world which continues to
ueny children their basic human rights, we champion the right of all children to a
happy, healthy and secure childhood" (Save the Children's Vision, Mission, Values
Statement, 1997)
The SCF is committed to narrowing the gap between real life situation of children and
the ideal situation hoped for them. It supports practical projects that involve children
and their families in improving their day-to-day lives. Emergency relief and preventive
work to help children, their families and communities to be self-sufficient are also
taken up alongside long-term development. Another important activity is the lobbying
for changes that will benefit all children, including future generations.
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The SCF has had a firm commitment to making children's rights a reality. All of Save
the Children's work is now centred on its commitment to making a reality of children's
rights.
Plan International India
is an international humanitarian, child-focused
development organisation working with families and their communities to meet the
needs of children around the world. Non-political, and with no religious affiliations,
Plan International aims to build a better world for children, now and in the future.
Plan
International
Plan envisages a world where all children realise their full potential. It endeavours to
crate societies that respect rights and dignity of people. It proposes to achieve the
above by enabling deprived children, their families and their communities to meet
their basic needs and to increase their ability to participate in and benefit from their
societies; fostering relationships to increase understanding and unity among people
of different cultures; and promoting the rights and interests of the children.
Plan works in five domains or critical and interrelated areas that produce long-lasting
impact on a child’s life. These domains are growing up healthy, learning, habitat,
livelihood and building up relationships.
Plan works 45 developing countries throughout the world. The operations of Plan
commenced in India in 1979. It operates in India through 14 NGO partners and 29
programme units in 13 states.
It influences opinions and issues at every level, from local community policy to the
agendas of governments and international coalitions. And it affects the daily lives of
countless ordinary people, from the children helped to the sponsors who give their
support.
World Vision of India
World Vision is an international Christian relief and development organisation. It
serves the poorest of the poor, without discriminating against caste, religion, region
or gender. The focus of the operations of World Vision is on children because World
Vision believes that they are the hope of the future. According to World Vision, the
best way to ensure the total well being of children is to work through their families
and communities. . World Vision seeks to help communities become more selfreliant. This means helping people to be able to take care of themselves and their
families. Thus by helping families nurture their children, communities are helped to
build their future. World Vision extends support in the form of child sponsorship and it
reaches out to children through families and by involving communities. The
assistance provided by regular sponsorship payments saves lives and improves the
quality of life for many children
World Vision provides hostel facilities, food, education, and health care to children
with special needs. The target group includes children affected by polio, children
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whose hearing is impaired, mentally challenged children and tribal children. Besides,
the issues of street children, child labour, children of commercial sex workers or
those ;kely to be d.^.vn into the profession, children with special needs. AIDS victims
and children in especially difficult circumstances are addressed.
When disasters strike, World Vision responds immediately to provide relief and
rehabilitation and remains in the area till the survivors are back on their feet.
World Vision strives to change a culture of poverty and despair to one of hope and
opportunity, by building a nation that does not tolerate poverty.
World Vision began its work in India, at Calcutta in 1962. It was registered under the
Tamil Nadu Societies Act in March 1976 as World Vision of India, with its National
Office in Chennai (Tamil Nadu). The activities of World Vision India cover 1.5-lakh
children through 28 projects in 24 states and almost 100 districts. It has 105 Area
Development Programmes (ADPs) and 13 Community Development Projects. It
works through the community to ensure a development process that will be sustained
and continued even after World Vision withdraws from the area.
Private Sector And Child Health
The Indian Academy of Pediatrics
The Indian Academy of Pediatrics was formed 1963 by amalgamating the
Association of Pediatricians in India and the Indian Pediatric Society. Today, the IAP
has around 14,000 members with 140 branches that work for the furtherance of the
objectives of the IAP and work independently as per lAP's constitution. The IAP has
13 subspecialty chapters and 4 working groups. Besides, various issue based sub
committees appointed by the Executive Board function from time to time.
The Indian Academy of Pediatrics is committed to the improvement of the health and
well being of all children. The Academy dedicates its efforts and resources for this
purpose. The members of the Academy are committed to achieve the optimum
growth, development and health in the physical, emotional, mental, social and
spiritual realms of all children irrespective of diversities of their backgrounds. The
following are the major areas of activities of the IAP
Advocacy for children: Serve as advocates for the legitimate causes of children, their
growth, development, health, emotional nurture, opportunities, rights, equity and
justice. cerve as co. .petent and responsible source of information relevant to the
health and well being of children, to other organizations, the public and the
governments.
Professional education and improvement: Provide and promote ethical and
professional standards among the members and provide and promote education and
training for the improvement of the knowledge, attitude and skills of members in
pediatrics in its widest sense.
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Research: Provide leadership, guidance and support for research in its broadest
sense, relevant to the health and well being of children.
Support for pediatricians: Provide a forum for promoting the role and opportunities of
pediatricians as the best equipped professionals for the care of sick children and to
maintain the health and well being of all children. Remain as the spokesmedium of
appropriate training of medical and related supportive professionals involved in the
care of children in different settings.
Membership service: Provide services benefits and recognition to assist and support
the members for meeting the needs and challenges inherent in pursuing our mission.
Education of parents and the public: Design and conduct programs and efforts for the
education of parents, the public and policy makers on their role in the promotion of
health and well being of children at home, in school and in other situations.
Political Agenda
This section examines the positions taken by the major national parties on health in
general and child health in particular. The different positions of the national parties
are examined separately
The Bharatheeya Janatha Party (BJP)
The position of the BJP on various issues are well articulated in its Election Manifest
(1998) and the common agenda of the National Democratic Alliance (NDA) the ruling
coalition led by the BJP
The agenda for governance put forth by the NDA commits itself to “efforts to ensure
that potable drinking water is available to all villages”(ltem 15, Agenda of
Governance) and to pay due attention to the “age old and traditional methods of
water utilisation, in both rural and urban areas"(Bid). A similar commitment has been
made by the NDA in the case of education. This is very significant in the case of
children. The agenda says," We are committed to a total eradication of illiteracy. We
will implement the constitutional provision of making primary education free and
compulsory up to Sth standard”(ltem 16 of the Agenda). The most remarkable item in
the agenda is the one dealing with children. “ We will present a National Charter for
Children. Our aim is to ensure that no child remains illiterate, hungry, or lacks
medical care. We will take measures to eliminate child labour”(Bid item)
The Charter for Children developed by the BJP reflects these commitments. The
Charter upholds the belief that every child is born and has the right to be happy and
that all children have the right to food, shelter and clothes; they have the right to
education. The Charter has been formulated in the context of the UNCRC. The
manifesto makes it very clear that the BJP is committed to implement the UNCRC in
both letter and spirit. Then the BJP pledges to protect Children's rights (I) to the
highest attainable standard of health care; (ii) to be registered immediately after birth;
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(iii) to protection from all forms of sexual exploitation and sexual abuse; (iv) right l
play; (v) right to education; and (vi) right to shelter.
The manifesto then discusses the question of child labour. It commits itself to total
abolition of child labour and proposes to amend the present Child Labour (Prohibition
and Regulation) Act to remove the distinction between hazardous and nonhazardous processes. It identified the following as effective measures to abolish child
labour. Regular and persistent inspections by labour departments at the Centre and
in the States; special annual campaigns to detect child employment; identity cards
which will be mandatory for all young workers; welfare benefits, especially social
assistance to poor families, aimed at ensuring a minimum income and thus removing
the need to rely on their children's labour; and free and compulsory primary
education.
The Communist Party of India (Marxist) (CRIM)
The CPI (M) endeavours to achieve People's Democracy as a step towards the goal
of a socialist society. The immediate target in this regard is to replace “the present
bourgmis-landlord State by a State of people's democracy". (The programme of the
CPIM adopted at the Seventh Party Congress of the Communist Party of India held
at Calcutta, October 31 to November 7, 1964 and updated by the Special Conference
of the Communist Party of India (Mar :st) held at Thiruvananthapuram, October 2023, 2000) The programme of the CPlM then moves on to spell out the tasks of a
People’s Democratic government, that is the government the CPI (M) proposes to
install immediately, if voted to power as a strategic measure.
The CPI (M) document spells out 35 tasks or programmes as the document terms it,
for a People’s Democratic government under the leadership of the party. Only two
among these pertain to children and health. They are: (i) “Public educational system
shall be developed to provide comprehensive and scientific education at all levels.
Free and compulsory education up to the secondary stage and the secular character
of education shall be guaranteed. Higher education and vocational education will be
modernised and updated. Development of science and technology will be promoted
through a whole range of R&D institutions. A comprehensive sports policy to foster
sports activities shall be adopted”(item 6.3.xvi of Peoples’ Democracy and its
Programme) and (ii) a wide network of health, medical and maternity services shall
bo established free of cost; nurseries and creches for children; rest-homes and
recreation centres for working people and old-age pension shall be guaranteed. The
People's Democratic Government will promote a non-coercive population policy to
create awareness for family planning among both men and women (item 6.3.xvii of
Peoples’ Democracy and its Programme).
The Communist Party of India (CPI)
The Communist Party of India (CPI) has made references to education and health in
its draft programme. The draft party document speaks about education thus. “Urgent
steps for universal elementary education as also scientific and technological
education, secular in content and form without which it is foolish to think of a
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modern, developed India competing with other developed countries”(Struggle for An
alternative path, Draft political resolution for the 18th Congress of the CPI. Emphasis
found in the original text). It assures “ a comprehensive health and education
programme; mobilizing tens of thousands of health workers and teachers for the job;
measures to ensure potable drinking water facilities in every locality” in the area of
health. (Struggle for An alternative path, Draft political resolution for the 18th
Congress of the CPI. Emphasis found in the original text).
The Communist Party of India (Marxist Leninist)- CPI (ML)
The CPIML Liberation has made certain commitments in the areas of education and
health. It pledges to strive for “effecting a modem democratic cultural transformation
o^ the whole society, ensuring universal education and basic health-care for the
people, abolition of a sorts of social, economic and sexual exploitation of women and
ensuring their equal status and rights in all affairs of life, eradication of caste
oppression, protection of the rights of dalits and adivasis and helping all weaker
sections of the society to catch up in the race of social progress".
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J
V
PRELUDE TO RECOMMENDATIONS TO CRY
Perceptions from Micro Situation
The perception from ground situation supports the perspectives obtained nationally, though
a regional variation is quite marked. The trends obtained from focus group discussion
among the field staff and community group in the Kumaon sub region of the Eastern UP
can be cited as example. The summary of the same is given below. The situation presented
below is the worst one because the UP was the state with least infrastructure and facilities
among the three states studied.
Health Care
Antenatal, Natal And Postnatal Care.
There is hardly any care provided through the PHC systems. The only care available
is through traditional dais of whom 60% were untrained and through elder women
within ule family. Bui tneir knowledge on neonatal care is not adequate. As a result,
there continues to be neonatal mortality from tetanus and other neonatal infections in
the region.
Under Two Health Care
The only service available from the PHC systems at the village level was for polio
mass campaign (pulse polio). People had to fend for themselves otherwise and
significantly curative care was being provided by local vaids and indigenous
practitioners.
Three To Six And Six To Fourteen Health Care.
On an average below 25% of the villages had ICDS centres. These centres were
running at below par efficiency even in the area of nutrition supplementation, which is
the only service provided in these centres. There was no school health programme
existing for the elder children. The primary schools were rarely functional, there were
no mid day meal programme or school health check-up organised from the health
services. For the same reason there were no government programmes for the
handicapped children or adolescent girls or for that matter for any of the children at
Nsk.
*
Health Supportive Interventions
Malnutrition was stated as one of the four major health problems, others being Acute
Respiratory Infections (ARI), Malaria and Diarrhoea of younger children of the area.
However, as mentioned above, nutritional interventions are of limited consequence.
The people perceived the changing food patterns (due to unavailability of traditional
coarser grains) as deteriorating the health situation. The PDS, which is expected to
provide minimum, required quantity of food grains to the poor is not properly
functioning. In one situation where information on the functioning of PDS was
available, it took protracted struggle with the active support of the NGO facilitator to
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obtain ration cards for majority of BPL families. One can assume that a large number
of BPL families are excluded from the PDS systems.
WATER .As also evident from national situation there 3 some improvement in the
access of villages to borewell water. On an average 50% of the villages had round
the year access to bore-well water. However, contamination of the water was an
issue as there was no system for monitoring water quality.
SANITATION. Latrines and disposal mechanisms for liquid and solid wastes are
practically non existent. Though there was a special scheme for public toilets for
Ambedkar villages, it was not functional.
Situation in Other States.
The micro level situation was better in all respects in West Bengal. The care of the
underfives and immunisation cover, as well as accessible curative care services (at
least in terms of private health care) were better. More number of NGOs in general
are functioning in the eastern region and so the general awareness level of the
people are also higher. People’s groups, in particular Self-Help Groups of women are
slowly being empowered there. In Karnataka the public infrastructure was generally
present, however services rendered to the community were inadequate.
Critical Issues of Child Health
In the previous chapter, dealing with the external environment we had a fairly detailed
discussion on the situation of child health under various sub headings. We have also
seen from a critical angle the state policies, legislations and programs and their
relevance to child health. This picture is built up from secondary published data.
However, when presented in compartmentalized fashion, secondary data does not easily
help in constructing a larger picture. The larger picture emerges as one compares this
data, against the impressions gained from the local level field study of CRY partners.
The picture is further strengthened by the varied experiences of public health in the
country brought into this analysis.
First Level Critical Issues
The larger picture has several levels or layers. At the surface or ‘tip of the iceberg’
are the commonly recorded and noticeable child health related indicators
(symptoms). These relate to areas such as mortality, morbidity, and nutritional
status. In recent decades newer risks have been identified - children at risk to various
threatening social forces such as children in prostitution, children in forced labor,
street children etc. These together constitute the first level critical issues.
The indicators of child health show that the situation is quite poor. Official statistics
lull one to think that considerable and steady progress is being made. But a
dispassionate analysis would prove that it is quite the opposite. The infant mortality
rate in 1997 as per the official estimates was 71 per 1000 live births. Two thirds of
these deaths happen during the first one-month and 70% of all deaths are due to
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malnutrition and infection. The decline in these rates has slowed down in recent
years. We don’t have to look far to find the immediate reasons. The most important
reason for this situation is malnutrition. In spite of 50 years of self-rule, more than
50% of the children do not get enough to eat. Similarly, more than half the women in
childbearing age do not get enough to eat and essential nutrients are not available to
them. Hence one third of these women bear babies who are underweight at birth
and who have a greater risk to survival and development. Thereby the burden of
deprivation is transmitted across the generation.
Another important immediate cause of mortality is infections. The important infections
are lower respiratory tract infections, diarrheas and neonatal period septicemia.
Infections and malnutrition form a vicious cycle as malnutrition leads to lowered
immunity against diseases, and the repeated infections setting in results in further
malnutrition. 70 percent of infant deaths in the country are due to these twin causes
of malnutrition and infections.
Ti.e ptvsical environ.Tent in the family also contributes to mortality and morbidity of
children. This would mean access to safe water and sanitation, adoption of hygienic
practices and availability of adequate housing. Again, one finds that 50 years of self
rule has not changed this situation much. Though official figures seem to suggest
that as a result of the intense focus on provision of water in the er • Her decade, more
than 80% of habitations have access to safe water, the fact is that it is not so. Two
under-emphasized aspects, namely that at least a quarter of the facilities (bore-wells)
is not functional and up to 50% of the supposedly safe sources is not safe by virtue of
being contaminated indicate differently. The facilities available regarding sanitation is
so little (less than 25% rural coverage) that it does not give any protection. It is no
wonder that a major cause of morbidity and mortality is diarrhea.
A possible bulwark against morbidity and mortality is a well functioning health system
with curative, preventive, promotive and rehabilitative elements.
Though a
countrywide primary health care system accessible to all had been envisaged even
before the country gained independence, and even though most of the infrastructure
and part of the personnel envisaged have been in place, the service delivery has
been sadly negligible. Immunization coverage is low in many districts, with 30%
chi.drer, not receiving any vaccination. Moreover, 20% of children with acute
respiratory infections do not receive any treatment, and two thirds of children in the
critical period of 6 - 9 months do no receive complementary feeding for want of
health education. The infant mortality and neonatal mortality are positively influenced
by the availability of quality health care provisions close to the community. Therefore,
the persistently high levels of these indicators point to lack of such facilities. The
same factor is a key reason for the high level of maternal mortality rate (437 - 570
per 100,000 live births).
Going beyond the statistics, we need to differentiate which social groups are most
affected. The data confirms what we already know from common sense. The NFHS
98 shows that child of illiterate rural mothers, children of SC / ST women and children
- 71 -
of low standard of living families have higher mortality sometimes almost twice as
high. IMR is 43 for high standard of living families and 39 for low standard of living
families. A gender bias is also seen as expected, with mortality rates among girls
being 20% higher than that among boys.
Maternal mortality rate is estimated at a high level of 437 - 570 per 100,000 live
births. It is linked to inadequacy of health care services and poor health of the
mothers, which in its turn is related to poor nutritional status of women reflected in
the situation that over 50% of reproductive age group women are anemic and a large
percentage are malnourished. It is the poor, the dalit and the tribal women who are
malnourished and who have less access to health care (60 - 65% of tribal maternal
deaths take place without any health care interventions).
Apart from malnutrition the level of chronic morbidity among child bearing age
women is also high, 50 - 80% of women have reproductory tract infections and about
25% have sexually transmitted diseases and in high prevalent districts above 4%
apte-natal mothers are HIV positive.
The modern medical system and its practitioners (allopathic practitioners) are
reductionists in their approach. Hence health status measurement indicators are all
focussing on physical health. However as our understanding of the dimensions of
health expands and as the society confronts the disease producing factors, it is found
that these indicators are insufficient. Social scientists are in search of identifying
more sensitive indicators.
In assessing child health issues we are confronted with the need to understand
sickness of society as a whole that manifests in the extreme cruelty on the most
vulnerable sections of it. The phenomena of street children, children in forced labour,
children in prostitution, female feticides and other forms of child abandonment,
confront us with an extreme sickness of the society. These children are not only
deprived of their basic amenities for growth and development, but their basic right to
life is affected or they are forced to life long torture and misery. The state on its part
in effect does not provide any protections or services to these children.
The estimated 20 million children in forced labor, are forced to work in physically
dangerous situation in agriculture or hazardous industry. In addition they are
deprived of just wages, just working and living conditions, basic right to education,
health care and right to recreation. These children don’t have the hope of catching
up with their peers or of a semblance of ordinary life.
The children forced into prostitution estimated at 500,000 are bound in brothels in
Indian cities. They are perpetually violently abused. Their physically immature
reproductive system is easily prey to sexually transmitted diseases and HIV infection.
The psychological scarring from the abuses stunts emotional growth for life.
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The number of street children in the metropolitan cities is estimated to be 5 lakh.
They face violence abuse and exploitation while they live and work on the streets and
are without the protection of the families. These children are prone to substance
abuse, STDs and HIV/AIDS. Ttlus the first level of issues in child health can rightly
be described as indicators as they point not only at child health but also at a sick
society. This understanding of the child health situation tak^s us to the issues critical
to child health operating at the next level.
Second Level Critical Issues
Next we move to observe another level of phenomena at the local community level
and find out the connections between the community level phenomenon and the first
level symptoms observed. The phenomena at the community level include unsafe
physical environment (water, hygiene, sanitation), break down of the caring systems
at the family and community levels, food and income insecurity at the family and
community levels and child exploitative forces operating at the community level.
There are a large number of families that are at risk. These are the families of the
land less labour or marginal landholder belonging mostly to dalits, tribes and other
depressed castes. Being casual labourers or single parent families, they are unable
to earn enough to feed the family. The mothers are forced to work outside the house
and then spend 11 -12 hours a day in their twin roles as wage earners and fan
carers. They have little time or energy to provide the caring needed for small
children (let alone bigger children). As result of these factors, the family caring
systems for the young child is in danger of breaking down.
Only one third of mothers breast-feed for more than one month and only 1/3 initiate
appropriate top feeds during the weaning phase. The toddlers are left to the care of
their elder girl siblings (as even elder adults have to go for work) as there are no
provisions for creches.
The family food security is compromised. The sources of food for the poor family
used to be the following- what they grow for themselves, the cheaper locally available
food items, subsidised food from the PDS and other poverty scheme and food
available in the open market. With the changes in agricultural policies and practices
and the control exercised by middlemen, small farmers are not cultivating food
(instead they cultivate cash crops) and have to buy them in the market. Increasingly
small farmers are also loosing their land The PDS and poverty schemes are in
shambles as discussed earlier. The result of these factors is that if they do not have
cash reserves and the family is in danger of starvation.
The local middleman who provides loans (seeds, fertilizers, and pesticides) exercises
much control, as he fixes the post harvest prices of the grains. Recently crop failure
from adulteration of these items lead to mass suicides of farmers in AP.
Added to this is the fact that they can look to little support from the community, as
they are from the bottom rung of the community. Their access to whatever social
- 73-
support structures that exist is curtailed. They are easily duped or induced by the
small money offered by the exploitative organized forces around them - child
traffickers and child labor industries.
These factors that operate at higher level also contribute to child health. Therefore,
these factors constitute the second level of issues critical to child health.
Third Level Critical Issues
We need to ask several questions on the issues operating at the first and the second
levels. Why isn’t the welfare state providing them the minimum supports and
protection? Why is it that community level support structures (such as creches for
very small children of working parents, health care and education, access to simple
credit etc) all of which can be made available with minimum budgeting are not being
provided? The answers to these questions will lead us to different process happening
to maintain this situation. These result from the various national policies governing
the different sectors of the society We find the following characteristics in such
national policies. Continued centralization of power and dismantling of social support
structures and re-treating of the state from its existing welfare commitments.
Beaurocratized health systems showing apathy to people’s needs and preventing
people’s initiatives. Civil society initiatives getting fragmented and co-opted by the
dominant interests i.e. the market forces, which have now expanded into social
sectors. These are some of the results of such policies. The primary influence in
policymaking today, it appears, is the industry or market forces.
The local governance system (panchayat raj) is by des n kept dis-empowered.. As
per the act, Panchayat Raj has responsibility over thirty odd developmental areas.
The PR is eminently capable of providing local need based services and facilities if
only they are empowered (with finance and required technical and decision making
powers). Kerala’s People Plan Process has demonstrated that local planning
produces local and sustainable solutions to what appears to be complex problems.
Another process taking place is the dismantling of the existing social support
structures. Policy changes in the health sector are resulting in denying access to
servises to the poor. We see this in the form of debarring those who cannot pay (user
fees) from the public health services, or reducing the content of public health
programs to only ‘cost effective’ ones, or transferring secondary and tertiary care
structures to private sector (effectively barring the poor). Simultaneously, policies are
allowing profit oriented drug industry to dictate the pricing of essential drugs (making
them unaffordable). The state is similarly withdrawing from other social sectors also.
Coupled with the state withdrawal there is a cooption of the state beaurocracy taking
place. Increasingly, the guideline for the decision making is not emerging from the
ground realities of people’s needs, but from the lobbies of industrial captains. The
latest health policy is typical case. The process of formulation of this policy
demonstrated that, the feedback from the health networks, public health
professionals and people’s coalition for health had little impact on the policy draft.
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4
However, seven questionable and commercially oriented recommendations of an
industry core group on health (appointed by the Prime Minister), have been
incorporated. The induction of higher technology and costly consumables into the
public health programs is another pointer of this cooption, where the real gainer is the
manufacturing industry and the looser is the alreadv cash starved public health
program.
This is leading to market invasion of public health sphere, which
traditionally had ^ot attracted market forces due to the low profit margins.
Yet another phenomenon taking place is the cooption of and thereby fragmentation
of civil society responses. The NGO community is a prominent section of the civil
society and who have been closer to tne people and their needs. We are witnessing
an increasing crop of NGOs (who are connected to or floated by politicians and
beaurocrats), who have easier access to state funds and whose agendas are
determined by the agendas of the funders. They in reality function as sub
contractors for the state funders. Thus the cooption of civil society actors has
fragmented and made less effective the advocacy role of civil society, with regard to
the marginalized groups.
The net results of these processes are the critical issues we examined earlier and
found to be operating at the primary and the secondary levels.
Fourth Level Critical Issues - The unfair Globalisation
Beyond these national level forces, we find the international forces quite active in
influencing the national policies and quite entrenched. This is the fourth level of
issues and they exert considerable influence on national policies. The World Bank,
WTO and trade related treaties, the UN agencies operating under varied levels of co
option (by the international market forces) are the major forces operating at
international level.
These bodies are primarily the voices of the richer nations and the multinational
corporations with the under-developed nations having little voice. The World Bank’s
influence on policy making in every sector has become entrenched and the state
governments are also directly entering into agreements for loan with the Bank and its
‘conditionalities’. The conditionalities for obtaining loans include - reducing states
role in development sectors, to primarily regulatory role, reducing state investments
in social sectors, reducing subsidies for the poor, and allowing greater role for private
sector through friendly regulations and financial instruments and opening the sec ors
for international competition. Another con-commitant result is that even as the loan
becomes debt for the state, the money gets spent without public consent or audit (on
hardware benefiting mostly the elite). They are not scrutinised by the financial
accountability structures in the same manner as state or central budgets
The 'AfTO and trade related treaties, compel the national laws to be modified, which
in effect expose the small producers of goods and services to unfair international
competition.
With the result the small, marginal farmer/producer sector is
endangered. So also the small health care providers. Simultaneously the UN related
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bodies, which are meant to be a democratic forum, have been co-opted to become
appendages (to varying extent) of the financial institutions. Hence their agendas
reflect the multinational industries agendas.
Two events currently being initiated by the WHO point to this direction. The WHO has
endorsed the Global Alliance for Improved Nutrition (GAIN) (involving giving
assistance to multinationals selling "fortified foods” in developing countries, in
lobbying for favourable tariffs and tax rates and speedier review of new products for
them). Similarly WHO’s involvement in the Global Fund for AIDS, TB, Malaria is an
example of selective, piece meal approach (with charity funds from industry) to world
wide health crisis, when the solution require a comprehensive people based
approach.
This analysis of critical issues has brought out the intimate interconnection of the
surface level symptoms with the deeper maladies and processes affecting at different
levels. Solutions to these problems are not easy and should be explored for from all
the levels. When we see through this larger frame the ramifications of the ‘tip of the
ice berg' phenomena becomes clearer. In this study all these levels of phenomena
have not been studied in equal depth. In pointing the direction for interventions this
larger framework is adopted by the study team.
Pointing at need for intervention.
The foregoing analysis of the problem points at the need for multi-dimensional
intervention addressing the issues at different levels. An examination of the possible
spectrum of interventions is required before we focus our attention to the
recommendations specific to CRY and its partners (brought out in the next Chapter) In
the following sections the author has taken the liberty of reflecting on the
measures/strategies required, both general and specific to health sector.
A general rights oriented approach to health
Right to health approach
approacn in
in health
health interventions,
interventions, would be premised on the fact that
it is constitutional duty of the government to provide the wherewithal for the health of
the child.
Hence government has the responsibility to provide the enablinq
dimensions (namely the environment, infrastructure, services and resources for
tackling all the determinants that impact upon the health) of the child At the same
time, if the child (within the context of the family and community) remains passive
recipient of the governments programs, health is not ob-,ined. Health, as per WHO
definition (and other working definitions), is a creative process in which the individual
the family and the community are active participants. Hence the community (child)
has not only the right to health promoting environment but also has the responsibility
for creating health, through actions by themselves, families and the communities.
Hence any facilitator need to be active
at both these dimensions. The following are
general strategies:
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J
1
•
Critical understanding of the linkages between the macro policy issues
and the local level problems is to be developed
•
Skills to influence the overt and covert decision making processes and the
stamina to engage in long term public processes for influencing people-oriented policies
are to be built up.
•
Build on people’s strengths in health - whether of local traditions or skills,
local resources, social capital, experiences of livelihood struggles or ability to find out
innovative solutions. This requires the support of the larger health system. The people’s
primary role in health creation needs to be recognised and valued by the higher levels of
the health system. Then the limitations resulting from marginalisation will be minimised.
•
Initiate "People’s Plan Process” where people’s (child’s) articulated needs
are the priority and they themselves become the actors for meeting these needs and not
an external agency (however competent or resourceful in health). This process requires
a good deal of preparation and ground work to ensure perfect democratic practices and
total transparency.
•
Only when the survival needs are met can the groups move to the next
levels of action. Hence temporarily relief activities or gaps in services will need to be
met, in order to move the group towards greater actions for their health. Proper
perspective to understand and interpret such measures in the framework of right oriented
approach has to be built up among all the actors involved in this process. Each step of
planning and implementing by the community (children) could be an empowering
process, building the knowledge, skills and confidence leading to bigger steps in health
creation.
•
Arrangements at different levels to keep vigilance on the operations of the
larger health systems are needed. This has to be initiated from the community level
upwards. Through this process, the community need to monitor deviations from health
or from expected health services.
•
Solidarity structures reaching up to apex levels need to be developed to
magnify the power and reach of community controlled decision-making processes, for
child health and to make it operative at higher levels.
•
Networking and coalition building and advocacy need to be initiated at the
macro level. However networking can happen constructively only between equals.
Sustaininn networking nnd coalition building requires ability to respect and accommodate
other views, which are not contrary to the core values of the group. Hence issue based
networking with specific roles of each group requires to be identified. Sharing of
resources across organisational boundaries is another binding force.
■
Dynamics pertaining to greater control of marginalised g.oups over
appropriate health technology and people oriented health systems need to be brought
out by people based ‘action research’. This will counter the myths being created
continuously by the dominant vested interests through manipulated research..
•
Government policies and decisions relating to child health needs to be
challenged and influenced. Confront the medical profession and industry (two dominant
actors presently in health and who currently have vested interest of keeping people dis
empowered) to re-orientate their thinking and policies.
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Specific Strategies
1. Reproductory and child health Services- a theoretical construct
Women in the reproductory age group and young children need several types of health
care interventions namely, antenatal and delivery care, post natal care, neo natal, infant
and care of disabled children and child care, control of communicable diseases, care of
reproductory tract infections and STDs, contraception measures etc. Though many of
these interventions are to be provided through the public health system, in practice very
little is available at the level of the rural village.
Most villages have a traditional birth attendant (Dai), who may or may not have been
trained by the public health system. In addition many villages have a traditional healer
(often male). It is also possible to find in every village (or in a close by village) young
literate women with aptitude and interest to take up health worker roles. They constitute
a voluntary stream of health care providers based at villages and operating in villages. It
is an important investment for the NGO to build the capacity of such a team, to deliver
the first contact health care that they are capable of, in all the need areas identified
above. Such personnel identified, trained and formed into a team become the most
important part of the village level health corps.
Similarly there is a group of official health workers constituting the formal stream of
health workers operating in villages. Workers and helpers of Anganwadi Centres of the
ICDS and Multi Purpose Health Workers and Helpers attached to Health Sub-Centres
constitute this stream at the lowest rung. The workers attached to PHCs also belong to
this stream even though they operate at a higher level. Currently we may observe quite
a few problems with this formal stream. Such problems can be remedied by the
intervention of a committed NGO who could motivate them for more effective service
delivery. Subsequently, this stream can be brought together with the non-formal stream
to build up the Village Health Workers Corps.
The next step should be to make this corps accountable to the village community so that
it may be able to deliver crucial health care. However a suitable democratic mechanisms
for their selection, role definition, remuneration, monitoring as well as capacity building
needs to be developed. The village health committee could be such a mechanism. It is
necessary to enhance the power and reach of the health committees. In the present
situation, genuine decentralisation of governance is not being allowed to develop in most
states. It becomes necessary hence to have a representative federation of peoples
organisation, that has federated the village, the panchayat, the mandal levels and above
committees, into a democratic apex structure An apex body of people's organisations
has the potential power to exert influence at higher levels of the health structure
Such a mechanism will be able to increase the efficiency and effectiveness of the
existing resources by attempting at the following.
• Increasing the working hours in Anganwadi Centres to full day instead of the present
•
Admitting pre-schoolers into the facility.
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•
Improving the quality of the nutritional supplement and quality of service provided.
•
Making it a base for women’s health activities also at the village level.
•
Capacity building of the staff and supportive monitoring by the community.
• Enhancing the mobility and reach of the sub centre and PHC teams, so as to
regularly reach services to the village.
<*
Enhancing the professional and technical competency of the teams
•
Making the team accountable to the local governance structures and mechanisms.
• As per local needs enhancing the resources (medicines and supplies) available with
the team.
In this ‘theoretical construct’ that we have presented, a functioning partnership is
expected between the two streams of village health workers, namely official and
voluntary. We must be aware that there are blocks to this partnership developing. The
health beaurocracy even at the peripheral rung and even if they are from the village
itself, are not voluntarily going to cooperate with the civil society structures. They are
accustomed to ‘reporting upwards and ordering downwards’. Hence until such time that
‘co-operation related targets’ are officially part of their performance areas, innovative
strategies will have to be found to foster such co-operation. Some experiences of
People’s Plan Process of Kerala, shows that if the beurocracy experiences support and
improvements in their ‘key performance areas’, as a result of this partnership they are
more open for it. Hence an external facili or has a creative role to play to facilitate
mutually beneficial co-operation. At the same time continued assertion of people’s
power and the right over the public services, need to be kept up.
It becomes necessary to have a larger force mobilized, through issue-based networking,
campaigning and advocacy. It may be possible to promote policy and program changes
in certain areas at the level of the district structures. However for some of the crucial
changes and responses needed, sustained state and national level advocacy campaigns
become necessary.
1. Nutrition and child care
With widespread malnutrition among mothers, infants and children and adolescent girls,
addressing the nutritional issues is an urgent and priority problem. There are several
levels of needs of the mother and child in the area of nutrition. They include nutrition
supplementation in pregnancy, early initiation and maintenance of breast-feeding,
we< ling and supplementary feeding, nutritional support for the toddlers and pre
schoolers (anganwadi population), school nutrition programs and nutritional
supplementation and education for adolescent girls, and enhanced PDS quota to “below
poverty line” families.
In addition agricurtural policy issues related to family and
community level food security needs to be addressed.
The basis for these interventions are premised on the facts that:
■ India is presently producing all the food items needed for its population
- 79 -
■ The nutritional problems have remained intractable, their root causes being the
iniquitous socio-economic political situation and lack of political will to solve them.
■ A vast infrastructure for nutrition security and a national nutrition policy has come into
being based on decades of experience of confronting the nutritional problems of its
vulnerable groups.
The nutrition related infrastructure has the objective of providing urgent and temporary
relief interventions to meet the survival needs of vulnerable sections, while the larger
national effort towards food and nutrition security of the population bears results.The
wide spread nutrition relief programs, are underperforming and not responding to the
urgent needs of the vulnerable groups. (These include the ICDS, School Nutrition, PDS,
and Food for Work).
Strategic responses are required at different levels2.
■
Efforts towards making the ICDS effective in accomplishing its objectives
Enhancing the resource allocation to bridge the existing gaps in infrastructure coverage
and supplies -Only 50% anganwadijs are housed in their own centres -coverage only in
70% development blocks and -only 1 in 5 children in the 0 - 6 year age group are
enrolled - disruption of food distribution on the average was 64 days per angwanwadi per
year (NIPCID Evaluation) Sustained advocacy by coalitions of civil society groups would
be essential to achieve this.
Targetting of the most vulnerable segments namely below 3 years old, pregnant and
lactating women and adolescent girls. For this to happen the centre must become
accessible to the poorest women both through its working timing and community
outreach. At present the overworked AWW with feeding duties for the pre-schoolers is
not able to do this. Hence additional cost effective supports need to be worked out.
Enhancing the affectiveness of the program in relation to under emphasised objectives.
This requires better surveillance and supportive supervision, enhanced capacity building
especially for nutrition and increased community interaction.
Improving the convergence of services especially between the departments of Health,
Education (primary) and Panchayat Raj. More system level efforts are needed as
opposed to the present efforts at convergence around immunization. This would require
the priority for child nutrition and health is enhanced in these departments, with adequate
capacities built in and concomitantly systems developed for joint effort with WACD (
being the pivotal department).
Enhaficing community involvement and ownership. At the policy level decentralization
and Revolution need to brought in so that program can be owned and managed by
* The following four sub-heads have incorporated ideas from ‘Wasting Away, Antony Measham and Meera
Chatterjee, The World Bank, 1999’.
-80-
decentralized structures especially the panchayat. Thi may require intermediate
structures at the district level that can facilitate it given the low capacity of pa.ichayats at
the present juncture. Bottom up planning responding to local needs and resources
thiough the initiative of mother groups would be part of this process. (The detailed
recommendations of FORCES on ICDS is appended as Annexure -)
■
Promoting family and community level nutrition security
Programmatic approach to family level nutrition insecurity is through the TPDS and Food
for Work Programs. The following deficiencies in TPDS need to get addressed.
- The really poor are pushed out by the better off families and appropriate mechanisms
for preferential access for the poor need to be built-up over a period of years.
Monthly allocation of food needs to be enhanced. Estimates based on calorie gap
argue that another 30 KG of food grains per month is required in addition to the present
10 kgs. The subsidy for the poorest need to be maintained so as to be affordable for
them.
Make the mechanisms workable through devolving the ownership to communities eg
panchayat managed fair price shops, cooperative shops, group managed PDS etc.
Rapid response during food calamities, to reach the vulnerable and in adequate
quantities.
■
Promoting community level (and higher level) nutrition security
Family level nutrition security through centralized programs (even when they are
devolved to an extent) are unlikely to be the answer in the longer term. This is because
factors affecting the ‘vulnerability’ of the family and the child at the community and macro
level need to addressed, keeping in mind the analysis of the problem in the earlier
section. We need to develop models based on successful experiences. A hypothetical
model suggested by Dr Vandana Shiva is included for further reflections.
Elements of a People-and Food Security-centered
Distribution System
Food
Procurement and
Genuine surpluses exported at
Fair price through state agencies
Centi^ procures from varioub states to maintain buffer stock to ensure national food security,
and to provide foodgrain for nutrition and food related schemes at the national level and for
those that are directly u nder the centre.
Surpluses sold to Rashtriya Annakosh
- 81
State procures from the Gram Sabhas within it, to ensure regional food security and to
provide foodgrain for nutrition and food related schemes at the regional and district levels.
Surpluses sold to Kshetriya Annakosh
Gram Sabha procures locally to ensure food security for the village,
and to provide foodgrains for nutrition and food related schemes
and programmes such as PDS, ICDS, Food-for-Work programmes.
Surpluses sold to Gram Annakosh
.J
Women-led household level food security based on improving
women’s capacity to grow and retain food.
This includes promotion of sustainable, low external input agriculture.
?
■ Strengthening the nutrition related institutions and capacities (which are primarily in
the public sector) the steps include :
- Quality and effective nutrition monitoring through strengthening National Nutrition
Monitoring Beauro (NNMB) and bring out quality surveillance through ICDS
- Strengthening research and training by enhancing the priority of national and state level
institutions for public nutrition and specific monitoring of their outcomes in the national
programs.
- Strengthening nutrition capacity at all levels of the related national programs, such as
AWW, ANM, Nutrition supervisory team, medical college departments etc.
- Promoting inter-sectoral co-operation between departments of WACD, Health, Primary
Education and Panchayat Raj. This may require developing task forces, joint protocols,
joint training , refined output indicators, high level annual monitoring and such measures.
An important recommendation3 in view of resource crunch for mid day meal program is
to refocus on pre-schoolers in national mid day meal program and the ICDS to have
emphasis on below 3 year olds and vulnerable mothers and adolescent girls.
■ Political commitment to nutrition of the vulnerable segments needs strenghtening.
Enlightened policy and programs though existing in paper are not getting implemented
(such as National Nutrition Policy 1993 and Plan of Action and National Nutrition Council
referred to in earlier chapters). Possible actions include:
- high profile, advocacy oriented public seminars, with specific action plans, -the
involvement of Human Rights Commission and other Statutory Bodies, in the follow up
etc.
3 IBID
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- Pressure through ju< iary to meet constitutional responsibilities. (Interim order of
Supreme Court 28 November 2001 in PUCL Petition on the “Right to Food ", Converts
the benefits of eight nutrition related schemes into legal entitlements, directs all state
government to begin cooked mid day meals for all children in government and
government assisted schools, directs state and central governments to adopt specific
measures to ensure public awareness and transparency of these programs)
- It also requires wide spread campaigns to bring the agenda to the centre stage of
public debate.
2. Safe physical environment
Safe physical environment for the child is contributed by availability of protected water
a .d sanitauon facilities. Water and sanitation infrastructure requires high investments
from government or large international agencies. We have observed from preceding
chapters that policy for universal coverage exists and that programs of the concerned
departments have been under performing. In spite of the decade of water in the 80s and
of the claims of 87% coverage by the government our ground level observation was that
50% of villages had one source of safe water (corroborated by other studies quoted
earlier in the critical issues).
■ The interventions require partnership between government, civil society facilitators
and community groups. There is need to inculcate ideas of hygiene at the personal
family and community levels. This has been an area resistant to change and mass
awareness campaigns are needed.
■ Women (mothers) are the primary agents most concerned with the physical
environment for the child. Their active role in decision making especially related to
appropriate water and sanitation technology is required. Active participation of women in
planning, implementing and maintaining these resources is required,
(through
panchayat committees, anganwadi mothers groups and mahila mandals) Involvement of
women is required through the above forums for regular water quality monitoring and in
promoting implementation bythe concerned governmental departments
■ Promoting of goals of the 9th plan, for 100% coverage of habitation for water and
extension of rural sanitation to 50% habitation. 100% safe water and sanitation coverage
for schools, anganwadi, sub centers and promoting them as models for hygiene
education
3. The child under stress and risk
A whole series of phenomena are, manifesting in recent decades where the child is
pushed into extremely dangerous or risky situations. This has its roots in the economic
insecurity of a large number of families belonging to landless labour and marginal farmer
groups. The new economic policies resulting from ‘globalisation’ has made a further
onslaught on these families with increasing indebtedness, casualisation of labour,
feminisation of poverty urban migration and wreaking the family caring systems. With
very little support structures existing at the community level or from the state, the family
is forced to pressurise the child to be an income earner or to fend for him/ herself.
Occasionally as an outcome of the broken family the child is abandoned or exposed to
<•
-83-
abuses also. The exploitative forces existing at the lu^al level such as the child
trafficking mafia, child labour industry moves in and ensnares the child through duping or
offering inducements to the family.
There is an urgency for developing programs for protecting or rehabilitating children in
forced labour, street children, children forced into prostitution, HIV/AIDS affected or
infected children, as well as for educating adolescent children in life skills. There is also
an urgent need to enhance the community’s caring structures to support deteriorating
family caring systems. In the absence of well established model programs a variety of
programs need to be tried out. The following areas of intervention are listed, which
includes components that need to be acted upon by the government, civil society
facilitators, as well as by community.
■ Lobby for the present umbrella act covering children rights “Juvenile Justice Act
1985” to be more comprehensive (Universal Child Rights code) and for adequate
mechanism for their implementation.
■ Campaigning against male preference in society and eradication of female feticide
and Infanticide and punishing of guilty medical professional abetting the crime (pre natal
a diagnostics act implementation) Promote innovative programs that enhances the status
of girl child eg Kishora Shakti Yojana and adolescent girls life skill education.
■ Abolition of child labour through universal free and compulsory elementary education,
support to families of children in forced labour and deterrent punishment for employers of
children. Ensure effective implementation of child labour act 1986 and national child
labour policy 1987 and National Program for Elimination of Child Labour.
■ Support campaigns against trafficking of children, ensure implementation of
Devadasi Act and National Plan of Action (for integrating women and child victims of
sexual exploitation) Promote programs for vulnerable children such as children of sex
workers.
■ Promote demands and right of street children through alliances between government,
nodal networks and local NGOs for running services that respond to their needs. The
needs identified have been for basic shelter protection from police and criminal
harassment and sexual molestation, appropriately tailored health care, education,
vocation support and recreation facilities.
■ Promote implementation of “People with disabilities Act 1995” and campaign for
recognising the rights and contributions of the disabled children. Promote programs in
the areas of disabled friendly environment in public places and facilities integrated
schools, community based rehabilitation, enhanced medical and surgical facilities at the
district level for disabilities, locally adapted and manufactured prosthesis supporting self
help groups and vocational rehabilitation etc.
■ Promote awareness regarding HIV/AIDS and against discrimination of the affected
both by public institutions and civil society organisations. Promote community based
programs for the care of affected / infected children and to support the families.
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j
VI
RECOMMENDATIONS TO CRY
The last section of the previous chapter presented a wide spectrum of intervention areas.
The recommendations to CRY are developed in that wider context. While making
recommendations to CRY we have besides, looked into CRY organisation.
CRY is well located to make strategic contributions to health of the children in the country.
Cry’s capacity as a National Resource Support Organisation (funding agency), its location as
a key partner network of organisations active in child issues, its intimate connections to
national campaigns on child issues and the connections CRY has with the private sector,
give it an advantageous location to facilitate and intervene. However in the past Cry's
interventions in health have been adhoc and unplanned. Hence the strategic planning
process, CRY is entering into is timely and opportune.
The recommendations given here for CRY are at a preliminary stage and may undergo
some additions and refinement as the other aspects of this study gets completed. The
recommendations are organised starting with the micro level i.e. the partner NGO and
moving to higher levels.
Partner NGOs
The budget allocation on health sector is said to be 8 to 10% of total CRY
disbursements. In the 6 partner’s studies, average allocation for health was 6% (if the
specialised projects were separated). This is too low and we would recommend scaling it
up to 20 - 25%. In the existing allocation to health, it is anticipated that a large chunk
would be going to less cost-effective relief programme (Nutrition supplementation and
curative services are termed in this report as relief programmes).
Within the health sector programmes we would suggest highest priority be for
empowerment programmes and least priority for relief programmes. We do realise that
both relief programmes and service delivery programmes are important especially to
gain acceptance with the community at an early stage of work. However, the direction of
programmes should move towards empowerment and advocacy, within the same issues
and the relief programmes could be phased out. Some CRY regions are already using a
grid to map out and prioritise the different types of health activities. This could be a
suitable aid to guide the partner activities in the empowerment direction. Partner NGOs
are likely to make a case for relief programmes such as nutrition supplementation in
communities with severe nutritional deficiencies. In case the local situation and needs so
demands to temporary relief input, it should be in the context of an overall empowerment
oriented strategy in which the community also accepts the ^hort term nature of such
interventions and with adequate community contributions and participation right from the
start. There will be a need for perspective building of the partner team and community
leadership, on the political nature of health and the governmental responsibilities in
people’s health.
’
-85-
The newer interventions could be arrived at through criteria such as community’s priority,
local competency, severity of the issue etc. Another criteria for the newer interventions in
health could be that it is a complimentary programme that could be built into existing
programmes in other sectors especially education. This would require innovative
programmes and would have the benefit of sectoral integration (e.g.: child-to-child
activities in health or school adolescent health or school mental health could enhance
the pre-primary / NFC education). As people are generally unaware of the determinants
of health, initial tendency noticed is to suggest curative services. Hence a process of
awareness building and analysis becomes necessary to arrive at programmes that would
be community empowering and aimed at the root causes.
A deficiency we notice in the CRY partners is the lacunae of competent personnel who
could anchor an effective health programme. We notice the health core team consists of
dais or herbalists or doctor or social worker whose perspectives are either narrow
technically confined or lacking sufficient knowledge of the health sector. It is our view
that doctors will have only a limited technical role in empowerment oriented health
interventions.
Hence there will need to be a systematic effort to train committed senior level staff in
health sector concerns. A 3 months field based training programme with follow-up could
be the minimum requirement. (Longer programmes along the same lines would have
more advantages) We understand there are several resource agencies offering such
capacity building programmes some of which are already linked to CRY e.g. CINICHETANA resource centre. Hence a systematic preparatory effort in the area of
capacity building is important and for developing customised programmes, a team of
perspns with competencies is needed to facilitate training of the core health team of
NGO.
Programmes to strengthen local providers Traditional Birth Attendants either trained or
untrained and indigenous practitioners known by various names and to systematise their
linkages with the community and health care system is a key area that CRY partners
should take up. Such an intervention aims at making community level health care
sustainable. The major successes of NGO models in health care in the last two decades
have been due to the pivotal role played by strengthened local providers in improving the
health of the communities e.g. Neonatal health promotion through trained local providers
as demonstrated by Search-Gad-chiroli. Innovative training methodologies and materials
are available from such experiences.
NGO interventions often induct these providers into their staff and thereby promoting
their accountability to the NGO organisation alone. However it is our belief that while
strengthening these providers, their linkage and role with the community structures and
the larger health care system also need to be strengthened.
The functionaries of the government systems the ICDS worker and the sub centre ANM
and male worker are important community level resources, whose services are often
ineffective (even when they are present physically). Important interventions could be to
-86-
J
develop two-way linkages and accountability mechanisms with community structures as
well as capacity building of these functionaries. Given the policy direction in the RCH
programmes for greater community involvement and monitoring there is better scope for
acrltical 3 way partnership Community - NGO - Government systems.
Health Surveillance
There need to be systems for gathering and analysing both baseline and ongoing
information, which would bring local problems to visibility and for action. The following
areas have been suggested for collecting information. Mother and child care including
safe delivery, neonatal care, early childhood illnesses, and epidemic diseases. A
simplified community based health surveillance system could be established.
A priorty effort needs tn*be on awareness generation and perspective building on health.
Health has been mystified and irrational beliefs on many practices such as infections are
quite prevalent. ‘Doctor, Drug, and Hospitals’ have been promoted and hence people
see these as the solutions to health problems. Whereas the real determinants of health
or disease are the environment (socio, politico economic as well), the individual habits
and life style, the genetic potential of the individual and also the effectiveness of the
health care systems. Hence the role played by the health care system both the Indian
systems and allopathic systems is only a limited one (though an important one).
A perspective on health as a responsibility (of individuals and communities) and as a
right to be demanded and obtained, need to be promoted which could lead to concrete
community actions. This perspective could be complimented with a set of messages for
promoting personal health and community’s health. The various people’s media could
be utilised as well as mass media.
Community mobilisation and facilitating larger networking among the community units as
well as at the NGO level is already an accepted strategic intervention nmong CRY
partners. Building in a health dimension into this mobilisation would enhance the ability
to intervene effectively ?n health issues. As examples the ‘parent teachers committee’
could develop an understanding on school health and their responsibility in promoting it,
or larger network of NGOs could exert pressure on the PHC systems to be more
effective.
District or Taluk level.
Facilitating an efficient two way referral system
The community level care providers can handle majority of health contingencies that
come up generally provided they are competent and supported. However a small
percentage of problems which includes emergencies (including obstetric) and
complicated diseases will require referral to higher level. Presently these referral
-87 -
channels are not existing nor a system for two-way referral, that is the patient is sent
back to first contact care for follow-up with instructions after the emergency is dealt with.
Though as per norms for a population of a lakh all secondary level referral facilities ought
to be present, the reality experience is that if it exists, it is an exception. Hence the
secondary level referral centre is often a taluk or district level hospital. It could also be
voluntary sector agency or a private sector hospital but without effective referral systems
and controls worked out.
A programme of lobbying and advocacy, strategised through people’s network, for
provision of minimum primary and secondary level health care, would be an important
intervention. Though it may require prolonged peoples action, it is an important measure
because it affirms the governmental responsibility for people’s health.
As expressed earlier an important objective of the micro level intervention is to foster
people’s movement that advocates and pressurises for their basic needs. In some
zones CRY partners are in the process of facilitating peoples movements focussing on
basic survival issues. A health dimension needs to be built into the agenda of the
movement through a process of clarifying the connections between health and livelihood
issues. The connections may be already obvious or may require ‘action research to
bring out the ill health-underdevelopment - alienation from resource connection. A
people’s campaign built on critical information can be very effectiveness.
Strengthening Panchayat Raj Institutions for Child Health
Decentralisation of governance in most states appear to be still as populist idea, in that
Pancnayat Raj Institutions are not delegated finances and powers. Given the
opportunities existing from the legislative framework, protracted peoples pressure from
the bottom could wrest greater devolution of powers.
Panchayat Raj elected
representatives need to be educated for health roles and responsibilities and towards
interventions for health supportive facilities (e.g. water, sanitation nutrition as well as
accountability of public health functionaries).
A system of ‘health watch’ could be the initial step towards community monitoring of
health services from village to district level.
Direct role for CRY at Regional and Sub Regional levels
Focus on regional health priorities
Facilitating the partner programmes to focus on the regional and local priorities would be
an important intervention. When there are several partners in the same sub-region,
common priorities being built into the partner programmes would enhance the outcomes
of their interventions. For example malnutrition among children is a priority issue in many
pockets of the country. Co-ordinated work at several levels among partners of the area,
community groups and through direct advocacy by CRY at the higher levels have greater
chance of generating responses, that can address the problem. Isolated works done by
one partner NGO are unlikely to bring about lasting charges.
-88-
Action Research
Apart from certain national and regional priority issues in child health already discussed,
sub regional and district (local) levels there would be priorities, which are ignored (as the
health system plans vertically). Identifying unaddressed child health priorities from
particular sub region and bringing it into policy level visibility through action research
would be an important role for CRY. CRY need to develop the competencies for this
function.
Capacity Building
CRY’s professional resources for health regionally are very limited presently - resources
need to be built-up for capacity building of partners for health. Competent resource
personnel with pro-poor perspectives would be available at the district .'avel or sub
regionally. They need to be identified and arrangements worked out with them for
cngcing capacity building of partners. Competency for direct lobbying and advocacy in
child health (including for action research) need to be developed regionally. Possibly a
cadre of ‘CRY Fellows’ with health professional background could be thought of, who
would assist regional teams for partner capacity building.
Direct Intervention
Some direct CRY interventions for child health regionally could be in the following areas.
Strengthening ICDS functioning at the district levels, children at risk and promoting
alternate systems of medicine (ASM) especially herbal medicines for child health in
regions where the traditions is fast loosing ground.
ICDS programme is the single integrated program meant solely for the health of the child
and available countrywide to a large measure. However, as brought out in the earlier
chapter, there are several weaknesses to the programme. Providing critical and cost
effective inputs to strengthen the program would be worthwhile. A particular input worth
exploring is capacity building and follow up of anganwadi workers at state or sub-state
levels, as this is an important lacuna.
.r .ie irauition of herbal medicine is culturally acceptable low cost and effective for most
common ailments, while at the same time having little side effects. However the tradition
is fast disappearing under the onslaught of allopathic medicine. As a result of WTO
induced policies, self-reliance at the family and community level on herbal medicines
could be an important coping strategy.
There is a need to develop a mechanisms for integrating and monitoring of programmes
for health needs of children at risk namely - children with disabilities, children in difficult
circumstances adolescent girls. At present these areas are getting little effective
attention. Basing on experience gained by specialist partners, CRY could think of
interventions in this area.
CRY at National Level
Getting a health sector policy strategy and plans in place (this exercise being part of that)
l
- 89 -
As core values of CRY includes democratic functioning and transparency, the policy
development process would require extensive consultation. Consultations would be
required not only at the national and regional levels of CRY organisation, but also at the
levels of partnership and people’s organisations facilitated by CRY partners. It may be
profitable to also dialogue with NGO networks interested in child issues. A mandate
originating from such grassroots consultations will be focussed, with partner ownership
and likely to have the planned impact. It is strength of CRY network that such process is
already in practice in the organisational culture.
Upgrading organisational systems and procedures related to health.
Developing partnership criteria for health sector (as spelt out in the earlier
recommendations) and developing assessment criteria for monitoring and impact
evaluation at different levels is important systems improvements required.
J
Health Sector budget needs to be increased (suggested figure 20 - 25% of total budget)
to make effective CRY network’s health interventions. We have already discussed the
type of interventions, which are to have an empowering, and advocacy focus. There is
an increase in health sector financing resources from multilateral (World Bank) and
bilateral international agencies, with policy directions for involving private sector and
NGOs. Policy guidelines will need to be evolved in the context of critical collaboration
that is called for with such agencies and government. CRY’s expertise in resource
raising will be an asset for the new initiatives.
Monitoring and impact assessment need special attention.
A particular lacuna
experienced is the lack of baseline data at the community level and partnership level,
which would need to be attended to. The study team has taken the liberty of suggesting
targets for impact, keeping in mind dovetailing with programme intent of government
health ministry and related departments. However we recognise the targets need to be
arrived at in consultation with CRY partnership and commui / based organisations.
It is necessary to upgrade the perspectives and understanding of PSU teams nationally.
A suitable training module and resource team needs to be identified. The module to
contain an alternate perspective on health and an understanding of the policy
environment. In addition knowledge of the health systems and National Programmes
pertaining to the child health and an understanding on health advocacy and teaching of
skills to monitor and evaluate health programs should be the minimum core of the
module. A two - phased programme of totally three weeks with on site exposures would
be needed. Ongoing inputs and discussions on issues arising from ground experience
and discussions on issues arising from ground experience should form part of the annual
meets of the PSU teams.
The study team found capacity building for playing an effective role in health sector
programs a felt need of the PSU team members.
-90-
?
Several broad priorities affecting the children in the country have been identified in the
discussions in the earlier chapters. CRYs health policy and medium term plan at the
national level would need to reckon with these. Though these issues are countrywide
multifactorial and have been resistant to effective solutions CRY would need to take on
the challenge. CRY need to define what role in a larger canvas it can play given its
limitations, of size, resources, personnel etc. The author puts forward the following
suggestions for further reflection and deliberations.
Nutrition
The following categories from the poor, require special attention for improving child
nutrition, namely children 6-36 months, pre- schoolers (3-6 years), pregnant and
''•’Ctatir.g ".others and -dolescent girls. Two broad strategies are currently operational
though their efficiency and effectiveness are low.
1. Direct nutrition interventions of government of which the key programs are ICDS,
NMMP and TPDS.
2.
Empowerment efforts towards family and community nutrition / food security.
District or Sub District level effective and efficient models are required. Public programs
due to their inherent weaknesses of centralization, sectoralization beaurocratization and
inability in community facilitation can not make these programs successful. The present
policy environment being positive about public -private (NGO) partnership, there is the
opportunity and the challenge to develop successful partnership programs. As shown in
the case studies of Medi-Citi ICDS and T N Science Forum’s Child health and Nutrition
Initiative (Annexure 2), there is scope for successful innovative partnership at the district
and sub district level.
In principle such a model could include the following strategies:
■ Role in implementing at district or sub district levels the ICDS program, however with
2 flexible agenda.
■ Ownership by people, CBOs, People’s movements etc and developing of suitable
district level mechanisms for facilitating it.
■ Convergence of services of Health, WACD, Education (Primary) and Panchayat Raj
Departments, through suitable MOU and Task Forces.
■ Enhancing the structure and competence of the ground level and supervisory
functionaries (including additional personnel for addressing the target group 6-36
month olds and adolescents and mothers)
■ Adequate surveillance, documentation and publicity.
Complimenting such a district nutrition program, efforts at community mobilization,
empowerment, towards family and community level food security need to be taken up.
These could have the dimensions of enhancing women’s capacity to grow and retain
food (sustainable, low external input agriculture), community grain banks, through local
orocurement of food grains, use of locally procured grains for food related programs.
-91 -
Such a program could be facilitated through CRY associates / and like-minded NGOs at
the mandal level. At the program level (district or sub district) it would be a direct
involvement of CRY, leveraging required personnel, contacts and minimum additional
resources. It may become necessary for CRY to co-partner it with other resource
agencies, depending on the financial implications for effective outcomes.
Health of the child at risk.
We have analyzed the situation of children in extreme risk such as street children,
children under trafficking, children in forced labor, HIV affected / infected children etc.
We nave seen that by and large these children have been excluded from public
programs, and even where some initiative do exists it is narrow, sectoral, institutionalized
and not likely to meet the comprehensive needs of these exploited and deprived
children.
5
Q
An alternative model at a district or sub district level is needed, which is community
based, integrated (survival, protection, growth and participation needs are included) and
bringing about convergence of the government departmental services. The strategies
would be similar as for nutrition, however being new areas, intensive process would be
required in identifying the nature and extent of issues and appropriately specific
responses. Promoting the health of these children would require creative responses, as
they will not be in a position to access regular health resources. Some of the ideas to be
explored are peer counselors, peer health guides, health surveillance built upon children
and their contacts.
Simultaneously CRY would need to espouse the cause of these children at the policy
and program level for greater policy attention. Hence each of these efforts need the
support of an active, national level, advocacy resource.
Healthy physical environment
Safe water and sanitation are two key ingredients of the child’s safe physical
environment. The mothers at the community level would need to have control over these
resources if they are to be available for the children. We have already read the analysis
that though safe water and sanitation are priorities of public programs, a large
percentage of the poor are not having access to these facilities.
CRY could undertake to facilitate implementation of locally suited plans for water and
sanitation for the most marginalised groups at a regional or district level. Through action
research, and advocacy peoples needs could be brought forcefully to the decisions
makers.
Women’s group capacities and skills for building these facilities need to be enhanced, as
well as for planning, maintenance and monitoring of quality public services. One medium
term target could be to ensure all ICDS centers and primary schools in the area, have
the above facilities. Women’s groups are empowered to maintain and monitor them as
well as adopt personal hygienic practices.
-92-
Health care
It is opportune time to develop district health action models, which demonstrate active
involvement and roles of the various stakeholders. The primary stakeholders are
women’s groups, CBOs, Panchayat Raj Institutions and other federated people’s
organizations in a district. Other stakeholders include NGOs, retired health orofessional
of the area with a social motivation, community level health personnel, private sector in
health and the public sector in health and the mass media.
Both the demand and supply aspects of health care and health promotion need to be
developed. Demand side includes a ‘peoples health watch’ starting from village level
and federated at the district or higher level. Basic health care skills and information
related to public programs need to be transferred to the community. Mechanisms for
convergence and effective functioning of the various health related services, need to be
developed - best expressed as participatory district level plan. The various stakeholders
could enter into a formal MOU regarding the implementation of such a plan.
The country’s public health system has failed to deliver the goods. The system as we
have noted is rigid, under-funded, centralized and not based on people’s needs. As
stated earlier there are opportunities in this system for partnership. One such possible
program is the “Border District Clustei Program” of UNICEF. CRY could work towards
developing in the medium term a district health action model program.
These four areas are presented for direct Involvement for CRY at the national level
(through a region or sub region) as it would require considerable energy and resources
(though most of the resources should be leveraged from public and other sources).
Simultaneous with such a focussed action, there needs to be policy advocacy at the
state and national level to expand rapidly the coverage of such initiatives. Hence an
effective national and state level ‘Advocacy Resource Group’ is necessary.
- 93 -
VII
IMPACT INDICATORS
I.
PARTNER I COMMUNITY LEADERSHIP LEVEL
HEALTH CARE
PRESENT
IN 5 YEARS
No of pregnant women covered by awareness
camps
100%
No of pregnant women who have had 3
comprehensive Antenatal Checkups (in checkup,
supplementation and immunization)
100%
trained
100%
No of safe
attendants
deliveries
conducted
by
No of neonates attended by trained personnel
100%
No of babies exclusively breast fed for first 3
months
50%
No of infants weaned at 6 months
No of infants fully immunized for the six killer
diseases.
100%
No of under 6 year olds monitored for nutrition
100%
No of moderate and severe malnourished children
< 10%
No of preschoolers receiving
education
early childhood
90%
No of homes with herbal / home remedy knowledge
and access to remedies
—
No of major childhood illnesses attended at
<
community level by trained personnel
100%
No of two-way referral facilitated for complications
90%
No of school children covered by school health
100%
No of adolescents covered by comprehensive
adolescent health programme
90%
No of children with disability served and provided
supports
90%
90%
No of children at risk covered by a comprehensive
health programme (dropouts, working children,
abandoned children etc)
No of villages / hamlets having access to complete
PHC / Sub Centre programmes
-94-
. 90%
HEALTH CARE
PRESENT
IN 5 YEARS
No of villages / hamlets with trained local health
personnel (Dais and indigenous practitioners,
anganwadi)
100%
No of villages / hdnilets with access to childcare
programmes (ICDS, Pre School Camps, Creches)
90%
No of schools (Govt and Private)
comprehensive school health programme
with
90%
No of schools / villages with special programmes
for children at risk
90%
No of schools / villages with disability programs
90%
HEALTH SUPPORTIVE FACILITY
No of villages / hamlets with round the year access
to safe water (as per government norms)
100%
No of villages / hamlets with maintenance facilities
in place regarding safe water
100%
No of villages / hamlets with functional community
toilet facilities
100%
No of /silages hamlet? with maintenance facilities in
place for community toilets
100%
No of villages / hamlets with sanitation facilities
(waste water and slids)
75%
COMMUNITY MOBILISATION
No of villages / hamletswith ‘health committes
(inclusive of panchayat representatives) formed
and trained
100%
No of health committees monitoring community
based public health service in health watch and
serveillance of health
75%
No of school committees formed and trained for
comprehensive roles (including health)
100%
No of school committees promoting school health
75%
| Health perspective incorporated into wider peoples
100%
network / movement's facilitated by the NGO
Health Advocacy events taken up by such health
cells of peoples networks
-95-
1 Campaign
Annually
HEALTH CARE
PRESENT
IN 5 YEARS
NETWORKING
II.
NGO forums of the area activated on health issues
(inclusive of disabilites, health of children at risks)
100%
Active participation in communicable disease
control societies of the district (new structure deing
promoted by .... For civil society participative)
100% of
operation
societies
CRY PARTNERS
HEALTH CARE
PRESENT
IN 5 YEARS
No of partners helped to initiate integrated health
programme
100%
No of partners with competent health core team
100%
No of partners facilitated in local need based rights
based planning and monitoring for health (inclusive
of disabilities, children at risk)
100%
No of partners supported with ongoing capacity
building resources for health
100%
No of partners supported through district / sub
regional level ‘health watch’ mechanisms
100%
No of partners supported through district / sub
50%
regional public health task force (Proposed
mechanism of government NGO / Civil Society
Committee
for
overseeing
public
health
implementation
III.
CRY REGIONAL
HEALTH CARE
PRESENT
IN 5 YEARS
No of partners supported through 'Action Research’
on new and emerging concern
No of partners supported through 'resources’ for
new and emerging concerns
CRY Regional teams with competent team and
resources in health
-96-
50%
J
IV.
CRY NATIONAL
HEALTH CARE
Health policy and strategy and plan in place and in
practice.
Competent team with background and experience
to anchor health plan
20 - 25% budget allocation for health activities
CRY active in National Task Force on Child
Nutrition
CRY active involved in national forum for child
health rights, implementation and monitoring
CRY supported resources developed for research
and advocacy on new and emerging child health
concerns
- 97 -
PRESENT
IN 5 YEARS
VIII
CONCLUSIONS
CRY started this study endeavor, from the organizational need for a systematic evidence
based and empowerment oriented involvement in health issues of the child. At this juncture
of organizational evolution CRY felt prepared for new challenges and a more comprehensive
role in takjing forward the rights of the child.
The study looked at in detail the micro-situation of child health through the experiences of
CRY partners and the community groups linked to them. It brought in the macro perspective
affecting child health from an analysis of child health status, public policies and programs
impinging on child health and the priorities and concerns of civil society actors in this area.
This analysis made use of the clarity in perspectives emerging from the decades of
experiences of voluntary sector health activists.
J
At the macro-level the health situation of the child is shockingly grim and should havespurred all the actors to find immediate solutions. Diseases and death among younger
children remain persistently high even though all the technological solutions (involving low
cost investments) for preventing them are known to us. More than half the children of all
ages are starving (malnourished), some more acutely than others in spite of half a century of
developmental efforts and surplus food rotting in the bulging go-downs of the government.
The basic protection offered by safe physical environment of safe water, sanitation and
housing is not available to more than three fourths of the children. Even water provisioning
claimed to have been reached to majority of habitations (as per existing norms) in reality is
ot accessible to considerable sections of the remote, marginalized lower sections of the
society as the technology often is not functional Most shocking is that in recent decades the
tender age of children have been abandoned to the depredations of a section of society
obsessed with profit, control and selfish gratification. Statistics alone cannot bring to the
reader the agony and misery of 20 million child laborers, 20000 - 5 lakhs child prostitutes, at
least half a lakh (annually) AIDS orphans and other abandoned children.
As the bloom of childhood is prematurely snuffed out in the lakhs of child laborers, street
children, children in prostitution children with disabilities and the AIDS orphans and other
abandoned children, the state looks the other way chanting the mantra for all problems privatization. The international elite club of industrial captains and their national counterparts
in their relentless pursuit of ‘profit over people' in the priced open markets of the country
carelessly trod on the corpses of the millions of defenseless children and mothers. These
realities expressed figuratively above do not detract from the truth being brought out by
researchers through solid facts. Our own micro study convinces us of the magnitude of
problems.
What is to be done. CRY should not ‘reinvent the wheel’ nor should it be only ‘advocates’
keeping their hands away from the nitty- gritty of people’s struggles for a better quality life.
CRY’s strategies should build on the experiences of voluntary sector activists (that CRY is
already a part of). Within an overall long-term strategy, different types, levels and
geographically located strategies and activities need to be entered into. Even where CRY
rightly is investing in partner’s temporary relief oriented efforts for the child, the larger
-98-
perspective of influei mg government at the micro and macro level and the linkages to be
fostered at the micro, meso and macro levels should not be lost sight of How much of the
national resources are spent for child health and community’s health will be making the
difference ultimately.
Individual issues are also important as they are urgent and they lead to consolidation of
affected community’s energies for the larger livelihood struggles through solidarity groups.
In health sector CRY needs to consciously build resources and capabilities within itself so
that it can be an able facilitator through its partners and linkages. Specific steps are needed
at each level through inducting key health personnel, specific skilled training, systems for
measuring health improvements, identifying support resources in health, undertaking
research on specific geographic health issues etc. At the same time health knowledge, skills
and perspectives need to be demystified so that CRY organization itself understands health
through the interplay of health determinants and hence clarifies the same with the
partnership network and beyond. This is necessary to confront the exploitative, monopolistic,
disease creating (iatrogenic) health system and its masters the health industry.
Thus health sector involvement is specialized and yet generic in that what improves lives of
children, their families their communities and the society improves the health.
This study would provide CRY the blue print required for engaging r long term health
involvement.
- 99 -
REFERENCES
■
‘Shaping Policy : Do NGOs Matter', Aseez Mehdi Khan, PRIA, 1997.
•
CRY, a View of the Organisation, (Internal Document 1), 2000
■
‘A program for children and women in India’, plan of operations 1999 - 2002, GOI with
UNICEF.
■
Imrana Quadeer, Economic and Political Weekly, Oct 10, 1998
■
India , National Family Health Survey-2, MOHFW, 1998-99
■
'A Public Health Perspective’ Imrana Quadeer, Anubhav, Feb '99.
■
Report of NNMB, NIN, ICMR, Hyderabad, 1984.
•
Report of Task Force on Health and Family Welfare, Karnataka 2001.
■
‘Control of communicable diseases’, Report of Independent Commission of Health in
India, VHAI, 1997
•
‘Risks in motherhood’, David Payne, World Health, May - June 1998
■
Manual on JE, IIHFW, Hyderabad 2001
•
'Whatever Happened to Health for All by 2000 AD', The National Coordination
Committee of Jan Swasthya Sabha, May 2000.
■
‘Strategic Plan of AP State AIDS Control Program’, APSACS, 2001.
•
‘Draft National AIDS Control Policy’, NACO 2001.
■
International Labor Organization - A. P. Project on Child Labor 2000
■
'Child Prostition, the Ultimate Abuse’, Report of National Consultation on Child
Prostitution, UNICEF, New Delhi, 1995
•
‘Shocking Neglect of Rights of Disable Persons’, Javed Abidi, PUCL Bulletin, Dec 2001.
■
Paper presented at National NGO meet on HIV/AIDS, Dr Deepti Dingaonkar, Thane
May 2002.
■
‘Demographic - Danger Signals', Sabu George, Frontline, Feb 2000.
■
'Children Vs The State', Background Paper for the Third National Consultation of
FORCES, September 1997.
■
‘Women in the informal sector’, Indu Pathak and Pushpa Patnaik, NIUA.91
'Macro Economic Trends and Female Employment’, Jayati Ghosh in, Gender and
Employment in India, Delhi, 1999
■
‘Women Workers in Agriculture’ Jeemol Unni, in Gender and employment in India Delhi
1999
■
‘Empowering Women’, Rajamma P Das, in Proceedings of the Nutrition Society of India
1995
•
'Agriculture' in Alternate Economic Survey, JP Singh and Alok Darsh, Year 1991 - 98
-
'Economic Reforms and the Child’, Archana Prasad, Background Paper for MFC
National Meet, FORCES Secretariat, 2000.
■
'National Health Policy', MOHFW , GOI, New Delhi, 2002
■
'National Population Policy 2000: Re-examining Critical Issues’, Mohan Rao and Devaki
Jain, EPW, April 2001.
•
Investing in Health, The World Bank, 1993
- 100-
.j
■
The Report of the Independent Commission on health in India, Health for the Million, Nov
-Dec 1997.
■
Bulletin of Rural Health Statistics in India, Rural Health Division, DGHS, MOHFW, GOI,
June 1998
■
Save the Children, Mission, Vision, Values Statement, 1997.
■
Vision statement of CARE, India
■
Election Manifesto, Bharateeya Janatha Party, 1998
■
The Agenda for Governance, National Democratic Alliance, 1998
■
The Program of the Communist Party of India (Marxist), (updated by the special
conference) Thiruvananthapuram, 2000.
’
‘Struggle for an Alternative Path’, Draft Political Resolution of the 18th Congress of the
CPI.
"
‘Wasting Away’, Antony Measham and Meera Chatterjee, The World Bank, 1999.
■
‘Starvation Deaths, Overflowing Godowns’, Vandana Shiva, Background Paper for MFC
National Meet, September 2001.
■
‘SEARCH’, Anubhav Series, VHAI New Delhi, 1998.
■
‘Maternity and Child Care Code: A Concept Paper, Maharashtra FORCES, in Report of
National Seminar on Campaign for Maternity Child Care and Development, New Delhi,
Jan 1999.
*
- 101 -
Annexure 1
1.
SIX CASE STUDIES OF PARTNERS
Children Welfare Society (CWS)
BACKGROUND
CWS was started in 1993 by the local zamindar who was interested in
intervening in the severe problem of child bonded labour in the area. In
collaboration with CRY 5 non-formal education centres were started as well
as strategies to free the children from bonded labour in the carpet
industryOver the years the program spread to 28 villages which were freed
from child labour in carpet industry. However child labor in agricultural sector
continues.
OBJECTIVES
•
Working towards creating child labour free villages in the targeted
block.
•
Women’s empowerment to assume greater responsibility in the
development of family and community.
•
Work towards empowerment of tribals by way of issue - based
organisaton.
SPECIFIC OBJECTIVES
•
To continue running 21 NFE centres and work for reactivation of
Government Schools.
•
To provide basic health facilities to children.
•
•
To eliminate child labor from sectors other than carpet also.
To mobilise the community to struggle for their rights.
DIRECT COMMUNITY ACTION
Health Care
Main Health Problems
The main health problems affecting the children were as follows
SL.
No.
Age-group
Health Problems
1.
0-2 years
Pneumonia and URI, Malnutrition, Dysentery and
fever
2.
2-6 years
Whooping
Diarrhoea
3.
6-14 years
Malaria, Typhoid, Rheumatic fever, Malnutrition.
cough,
Source: Focus group discussion
- 102 -
Measles,
Malnutrition
and
Safe Delivery Care
Delivery care is managed by village dais. CWS conducted three day training
of local dais from all programme villages by the health worker (who herself is
a dai, with omy tour days training on the subject) However, this is a valuable
input towards safe delivery care as no government training of dais has taken
place.
The quality of care needs to be assessed, as there were tangential
community feedback about delivery-related death and neo-natal tetanus.
Neo-natal Health Care
The only health care available is through older women in the family and the
neighborhood. The only intervention project has made for this age group was
pulse polio immunisation that had very good coverage.
Tangential information suggests that care for neo-natal health problems is
deficient in the cultural knowledge base and fatalities are happening as a
result.
Under Two Care and Health Care
Given the reality that both women and men are daily labourers in a large
r.umber of families regular care of the under two year olds is compromised.
Women carry the children to the work place or they are left with the care of an
elderly relative at home. If there is an elder daughter of around eight years or
more considerable responsibility for mothering falls on her, with the resultant
implications for her own development.
Health care is provided by local vaids in the first instance. Other trained
health care is not available at the village level or sub-center level (most sub
centers are not functional).
Project intervention has been in enhancing the skills of vaids. The quality of
the training given to vaids and herbalists need to be assessed.
Three to Six Care and Health Care
There is a little institutional arrangement for the care of pre-schoolers as only
three Anganwadies (ICDS Centre) is present in the twenty villages of the
project area. Feedback on these institutions sho-'ed that they are not
functioning well.
Health care as for under two group is through the local vaids
Project intervention has been through the PPS / NFE schools that admit
children of this age the schoolteachers have been trained to use herbal
- 103 -
medicine. Complicated cases are referred to the doctor of the programme.
No other interventions are made.
Six to Fourteen years Health Care
Vaids and PPS / NFE schoolteachers provide medicines for common
ailments. In five model schools (for school health) children are promoting
herbal medicine at home. Herbal nurseries are being promoted in several
villages.
c
At the main centre, a large herbal garden has been developed, as well as
several medicinal formulations.
A survey of handicapped children revealed seventeen of them,
they are being facilitated solely in the area of schooling.
Presently
j
Sports club and certain recreational activities are promoted for recreational
needs in a few villages.
A qualified ayurvedic doctor holds a clinic once a week in main centre in
addition to the resident full time vaid. The doctor is available to visit project
villages in case of specific need, need makes periodic visits to the centres.
Health Supportive Activities
Kitchen garden has been promoted in all the villages through facilitating
nurseries and has been a successful initiative. Tangential information points
to a positive influence on the diet of the people.
Health education is happening through NFE schools and health camps held
annually and through annual health mela. Schools have taken up herbal
medicine promotion, and presently in five villages through children it is
reaching the community.
Safe water
Ten out of 24 villages (41 per cent in contrast to.... per cent at national and
....per cent at state levels) have borewell supply of water round the year,
where as the remaining villages do not have adequate borewells or the water
yield does not last for through out the year. Hence, they are at risk of
waterborne epidemics as was shown by the disastrous cholera epidemic of
the previous year. Additionally there is no system in place to monitor the
potabality of water from the borewells (the bores have been constructed only
upto 50 feet depth resulting from the corrupt practices of the contractor).
Contamination of the borewell water is suspected from anecdotal
experiences.
The program has not made any intervention as yet in this area.
- 104-
l
Sanitation
No latrine facility exists in the villages, though Ambedkar villages were to be
provided with public toilets. No sanitation facility exists for both liquid or solid
waste.
Programme has not made any intervention in this area.
Village Based Health Cadres
The programme is promoting revival of the village-based vaids and giving
some training to traditional dais. In addition all NFE teachers are trained to
handle kit of herbal medicine for the school children. The NFE teachers being
also activists of the peoples organisation, (they) monitor (for) epidemics and
are the first to bring health emergencies to the attention of authorities.
Community Mobalisation
Effective community mobalisation exists in the programme villages.
groups have intervened in the following health issues.
These
They have promoted complete coverage of pulse polio campaign, a
programme that Government department took strong initiative in.
Two other campaigns have been promoted by them for Tetanus immunisation
and Safe deliveries. Local dais were identified and got trained by the
programme for safer delivery practices
In the three ICDS villages community groups through panchayat loaders are
monitoring the Anganwadies. In one village punitive action was taken against
the Aganwadi worker for negligence.
During the cholera epidemic of the previous year political pressure was put on
government structure to come to the villages and take measures.
Several pradhans and higher level functionaries were elected to the
panchayat on the platform of the people’s organisation (VOP). There are
expectations on them to perform on behalf of the people’s needs. Their
capacity for functioning in their roles is being built-up through training offered
by the programme.
Government Interface
Government resources in the project area are poorly functioning. It is
understood that there are one community health centre, three primary health
centres and corresponding number of sub centres are required as per
government norms in this area. The community health centre practically
functions at a low level of competency, without the required specialists,
investigation facility, transport facilities etc. Hence no surgeries are obstetric
emergency interventions are carried out here (there is only one specialist, a
physician). Minor surgeries and periodic tubectomy camps are held apart
- 105-
from the outpatient clinic.
The national program including TB Control
Programme are very poorly implemented. The medical staff did not appear to
be serious about the community extension programmes that are to be
implemented as per norms. It was gathered that the Primary Health Centres
were operating far below the staffing norms and the sub centres were
practically not existing.
It was learned that only in 3 of the 24 programme villages ANM visits took
place at least quarterly, and in another village occasionally. In the remaining
villages no visits are taking place.
The programme has collaborated on the single activity of pulse polio
campaign. During the cholera epidemic of the previous year the District
Health Authorities were successfully mobilised by the programme to respond
to the emergency. Otherwise no interface with health structure has been
established.
♦
Larger Networking
The federation of people s organisations (VOP) has been successfully builtup. It was understood that they are in the process of working out federation
procedure, structure and functioning along democratic and transparent lines.
They have forcefully intervened in the issues of land alienation T through the
action of the peoples organisation a number of acres of common land were
re-claimed by the poor in the villages.
They have also successfully
intervened in raising minimum daily wages for agricultural workers from) Rs.
10 to Rs. 25/- They have also intervened succefully in child labour issues
when the linkage to the primary issue of land alienation became clear.
The federation was involved in the campaigns for Pulse Polio and for Safe
Delivery. There are some doubts whether these health issues have been
interpreted from a rights based perspective or only as service delivery issues.
No other direct health intervention has been taken up.
Partner Competence Building
The health core team has undergone the following training :Seven-day training programme on communicable diseases;
Five-day training programme on AIDS prevention;
Five-days training programme on Herbal Medicine;
Three-days training programme undergone by the health workers on the dai
training.
All these trainings were advertised programmes from various resource
centres in UP and not tailor made based on felt need of the staff.
CRY s direct Capacity Building has come through the quarterly visits where
perspective building and process orientation inputs are given. However there
has not been any perspective building on health issues.
- 106 -
J
Vaid samelan has been an appropriate training based on local resources
througn the exchange of the information by the vaids facilitated by the
programme. This has been a specific, tailor made, ano based on local
resources programme, whose output has been good.
Strengths And Opportunities
Programme
•
The programmes taken up (primarily in education sector) have gone
beyond service delivery and have managed to organise the community for
peoples action for basic rights (the peoples movement that evolved is
vibrant and democratic and sustainable).
This also points to the
successful process of awareness generation and strategy building. The
program has achieved that.
•
Working with structures of governments - the people’s movement
facilitated by the programme has successfully involved in the local
governance structure and have got several members elected into it.
These members accept their responsibilities for mediating with the higher
levels of the government towards community needs.
•
Herbal medicine promotion is a relevant effective potentially sustainable
intervention. This programme could be developed for greater coverage
and diverse with an economic component for gro ing herbal plants for
income generation.
•
The panchayat elected representatives of the progrmme affiliates,
potentially can mediate effective functioning of government programmes
at village level. Given the disempowere state of panchayatraj in UP there
is need to develop long term strategies to intervene effectively.
•
The forum of VOP need to develop a health perspective towards
leveraging public health infrastructure to be responding to peoples health
priorities.
Organisation
CWS has built-up a collective democratically functioning core team of
dedicated individuals. They have developed a larger perspective on sectoral
issues and their linkage to primary concerns of the people such as access to
resources and livelihood issues.
The organisatic n has also developed credibility with government buroaucracy
due to the facilitatory role played in the health campaigns. Opportunity exists
for critical collaboration in health sector programmes particularly towards
ensuring accountability of the local functionaries.
Limitations And Threats
Programme
- 107-
•
Need based trainings for the various functionaries and community leaders
have to be developed and appropriate resource persons identified who
can implement them.
•
Government interface, which is practically non-existant, as of now needs
•
to be developed with clear and tactful strategies.
Private sector in the programme area presently consists of vaids, ozas
and RMPs. The spread of RMPs who are both rational in treatment and
pricing of their services and are denegrating e rich herbal traditions and
cause the eroding of their status.
Programme could consider
interventions with RMPs through the people's movement (VOP) for
rational services.
Organisation
•
•
•
The project leadership is weak in vision and commitment, as they are
belonging to the local feudal elite structure, ability to side with issues of
the poor is suspect. Hence, there is a threat of sabotaging the process.
The capacity of health team in perspective and in public health areas is
weak. The part time doctor from Ayurvedic background is an excellent,
rational, local clinical resource. His potential is being tapped only for
clinical work presently. It should be explored whether with additional
perspective building he could be moulded into a trainer - within the
programme and for other programmes of the region.
The central person in the health care team, who herself if a dai, needs to
get intencive training - in perspective, knowledge and networking skills. It
is felt that suitable person to anchor the health programme is needed, who
has the required background, experience and perspective.
Future Health Priorities
•
•
•
Malaria which has become a large problem since the last decade will continue
to grow as no intervention are in place, and as it requires a larger responses
of several governmental departments as well as of the community.
Pollution of water and soil will develop as a problem due to indiscriminate
usage of fertilizers, insecticides and other, chemicals in agricultural practices.
Health problems of carpet industry workers are presently
[
....
chronic respiratory,
dimming of vision and muscular wasting and joint problems, This may
decrease as the program has made interventions on child labor.
Role played by CRY
•
CRY has played an indirect role in capacity building of the health team.
•
Has supported the curative health programme component - for equipments,
medicines, school check up and salary.
- 108-
J
2.
GRAM SWARAJ SAMITHI
B x .ground
Gram Swaraj Samiti, Duddhi was formed in 1995 as an extention programme
of Gandhi Mission which in turn was set up for realizing the Gandhian dream
of village self sufficiency.
As a part of Gandhi Missions Gram Swaraj Samiti contributed in the following
programmes :
A number of issues like child labor illiteracy, unemployment, migration,
exploitation from local money lenders etc. were addressed through village
peers, progressive people and other like minded NGOs.
Land development programmes were undertaken for the Southern Villages of
Duddhi, resulting in the restoration of land under section 4 of Indian Forest
Act to about 70 - 80% of the forest dwelling tribals.
In '1995, after the demise of Prem Bhai, GSS started working as a separate
organisation but carried forward the same concept and activities till 1997.
Objectives
To work on child labour eradication.
To create total literacy among children and help them jjoin to
mainstream school.
To organise marginal farmers and landless labourers to fight against
land alienation.
To avail health facilities to the children.
To work on alternative agriculture methods.
To start IGP on large scale by introducing cotton, cultivation and
tusser silk production to improve economic status of the villages.
To work for women empowerment by promoting and skill development
in them.
Specific Objective
To start health education program and work for promotion of traditional health
practices.
Major illnesses
The following are the major illness reported to be prevalent in the area of
operation of the organisation.
SL.No.
T.
Agegroup
0-2 years
Health Problems
Malnutrition, ARI
- 109-
2.
2-6 years
Malnutrition, Diarrhoea, Malaria, Whopping
Cough and measles
3.
6-14 years
Malaria, malnutrition, TB and arthritis.
Source: Focus group discussions
HEALTH CARE
Safe Delivery, Delivery care is done by village based dais. Only in four out of
10 villages trained dais are functioning.
Programme has no organised intervention in this area. At a personal contact
level complicated pregnancies are guided to next level of expertise, which is
at the district head quarters.
Immunisation, It is reported the pulse polio coverage Is almost hundred percent.
Other immunisations are not carried out.
Programme is involved through its staff and the activists of Bhoomi Haqdari
Morcha in facilitating pulse polio campaign in the programme villages as well
as fourty villages were the movement is active (2500 Children).
Neonatal Health Care, No facility exists in this region for neonatal care other then
elder women of the family. Neonatal deaths are high in this region.
There is no program intervention in this area.
Under two care and health care, There is a lack of facilities for care taking of
children of working parents. As is happening in the sub region either mother takes
child to the working situation (however un-suitable) or an older woman in the family
looks after the children (if available). Elder sister takes over this responsibility if she
is around eight years resulting in her own development being effected.
Health care facility is at the first instance by herbalists and ozas (faith healers)
who also use herbal medicine and subsequently by RMPs. Herbal skills and
availability are on the wane, the RMPs on other hand are increasing in
numbers and influence while providing irrational and expensive services.
The programme intervention is to revive the herbal practice. Occasionally
interaction with RMPs towards rationalising their pricing has been done which
has been un-successful. As with complicated pregnancies referral is not
systamatised but on personal contact basis.
Two to six health care, No systematic health care exists other than what was
described under two year olds. There are Anganwadies existing in 2 out of the 10
villages. However they are not functioning properly.
Programme intervention is through the pre-primary schools run in 10 villages.
Monthly ones an ayurvedic doctor’s clinic is held which also caters to other
sick people in the community. In the current year, the frequency of clinic (is)
- 110-
has been reduced to quarterly once. (It is our opinion that such clinict nave
only minimal value. Health education and health monitoring components are
weak in this activity. Monthly clinics without village based supportive services
are only minimally useful. This clinic activity needs to be re-organised.)
Six to fourteen year olds, No specific health care programme exists for this age
group other than what is mentioned already.
The programme intervention is through PPS and night schools for working
children. However, health interventions are not present or minimally present.
Annually programme organises Bala Mela that has some health education
component as well recreation component.
Others, There are no facilities for early and interventions for the disabled children.
Programme identified 38 children, 23 boys and 15 girls with disabilities
through a survey and they are assisted for education. There are no health
interventions as of now.
HEALTH SUPPORTIVE ACTIVITIES
Safa^Vater, Year round protected water is not available in most villages. In summer
some of the existing bore wells dry up, in the rainy season open wells get
contaminated producing water borne epidemics.
There is no program intervention in this area.
Sanitation, Sanitation amenities are very minimal or non-existent in the villages.
There is no program intervention for sanitation.
Village based Health Cadre, Swasthya Saheli (Voluntary Activists of the Morcha)
meetings are held monthly in all the ten villages where health inputs are imparted by
the health core team member. The quality and the outcomes of these meetings need
to be assessed. Some of the sahelis are also herbalists.
As mentioned earlier there are only 4 trained dai’s in the ten villages.
Quarterly once the morcha meetings are held in every village, during which
also some health inputs are said to be given. The quality and outcome of
these inputs need to be assessed.
Herbal Promotion,
Vaid Camelan is heiu one-to-two times annually for three days each where vaids
exchange their knowledge. On an average 50 vaids attend these workshops. These
are documented and made into educational material and used for health education
meetings. A central herbal garden with around 35 plant varieties is being developed.
It is proposed to promote herbal gardens in several villages. A full time vaid is part of
the health core team.
Expansion of herbal promotion could be an important health intervention by
the partners, which is presently not supported by CRY.
t
-111 -
CAPCITY BUILDING
Community leaders, In the health sector there is no c
systematic training to
community leaders being organised by the programme other than referred to already.
Project Team, The vaid member of the health core team had a five day training in
herbal medicine. There was one day interaction with a team from UPVHAI and the
project core team focusing on the perspectives in the health.
No systematic proactive and need based capacity building of the project core team or
health core team is being done in the health area. However in response to initiatives
from agencies such as UPVHA, the program has participated in a tribal health survey
(part of larger socio - economic survey).
COMMUNITY MOBILISATION AND LARGER NETWORKING
Womens groups and peoples groups are existing in the programme villages and in
the surrounding areas as a result of large scale mobilisation promoted by the parent
Gandhian Organisation over the last two decades. In these groups, health issues
such as herbal medicine, protected water, sanitation are discussed. The core group
of the morcha meets regularly (Sakriya Sadassu) wherein also health awareness
inputs are given.
The Bhoomi Haqdari Morcha has made significant gains around the basic issues of
land alienation, forest conservation by people as well as social issues such as
alcoholism. Peoples committees with specific responsibilities for forest conservation
are functioning in the area. Women succeeded stopping in local alcohol brewing and
developed social pressure against alcoholism,
They have also successfully
promoted education of girls.
The morcha contested in the recent panchayat election and several of its members
are now panchayat leaders. They require capacity building on their roles and in
particular on their responsibilities in health. Programme will need to intervene in
these areas.
GOVERNMENT INTERFACE
Government facilities in health are functioning far below their capacity,
The
community health centre at Dudhi is functioning at far below norms with a specialist
care available only in pediatrics. (A dialogue attempted with the government setup
was resisted by the officials, who refused to provide any information).
Programme collaborated in the pulse polio activity resulting in a excellent coverage
In no other activity interface with government health machinery has developed.
However in the education sector interventions by the programme and the morcha has
had successes - such as re-starting eight government primary schools, positioning
- 112-
J
para teachers in three governnr
the health sector also exists.
t primary schools. Hence potential for interface in
STRENGTHS AND OPPORTUNITIES
Programme
Promoting the rejuvenation of herbal medicines is a local appropriate and potentially
sustainable response to the health .needs of the people.
This needs to be
complimented with a quality and a rational emergency health care (possibly through
a well worked out referral system).
There is strong experience of peoples mobilisation and asserting and demanding
basic needs and for public accountability through the bhoomi haqdari morcha.
Building in a health dimension into the morchas agenda would make health
intervention very effective.
The involvement of morcha into the self government system would makes it possible
for leveraging of better implementation of government primary health care
programmes.
Organization
Project holder and team have creditability with the people. The team consists of
enthusiastic dedicated person. The organization has a good reach both through the
pre-primary school (PPS) staff and the activists of the morcha in around 200 villages.
WEAKNESS
Programme
•
Health sector interventions are negligable and budget-wise add upto
only around 5% of total budget. This needs to be strengthened
immediately.
•
A major budgeted health intervention are the school clinics. The
scope and strategy of intervention needs to be overhauled to include
effective health educaton, on going support from village based cadres
and sharply focussed preventive and promotive activities.
•
Health support activities needs to be built-up in the areas pointed out
already.
•
The perspective and capacity building of community leaders and
groups need to be enhanced in health sector.
•
Core team requires intensive perspective and capacity building
regarding health issues
Organization
•
There is a perceived lack in need based and innovative responses of
the programme. This could point to some diffeciancy in leadership
and management system.
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Building second line leadership is a urgent need. Apart from induction
of competent persons into the health core team, simultaneously
enhancing the culture of delegation, accountability etc would be
important.
The tendancy of the project to institutionalise (as seen by the building
up of a structure) could be a disadvantage in distracting from the
movement process - which is where organisations energy should be
focussed.
CRY’S CONTRIBUTION
•
CRY’s direct involvement has been in regular monitoring interactions and
inputs into micro planning this has improved the managerial functioning of the
programme.
•
CRY is also facilitating strengthening of core team, though it is a slow
process.
•
Apart from CRY other resource support for strengthening has come from UPVHAI which is facilitating study on assessment of tribal resources and
needs - resource exchange between CRY partner orgganisations especially
in the area of herbal promotion
CUTURE PRIORITIES (These priorities are common for both GSS and CWS since they are
operating in the same geographical area).
•
Health outcomes resulting from issues of land and forest alienation, non
implementation of minimum wages and resulting poverty will continue to
dominate. Hence, malnutrition is likely to continue to be a major problem with
children. Consolidating the assertive resistance and demanding for rights
need to be continued focus. In this context land improvement and exploring
of income generating new crops would be a complimentary future initiative.
•
The increase in malaria in all ages especially in pregnant women and young
children (for whom it is a dangerous condition) requires attention. The
underlying causes for this increasing phenomenon could be studied for
pointing out effective solutions.
•
Due to the unregulated flow of polluting effluence from the large industries
located in the sub region (Hindalco, Kanodia Chemicals, Cement factories
etc) diseases due to pollution are likely to increase in all age groups
especially among children. As of now no me^nanism from monitoring and
intervening are in place.
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3.
MON FOUNDATIO
AN EVALUATION REPORT
INTRODUCTION:
Mental Health issues loom large over the world today. 2001 has been declared as the Year
□f Mental Health by the World Health Organisation (WHO) It is being realized more and
more that about 50% or more of all diseases presenting could have a psychological overlay.
The stressors and strains of the modern day and age keep increasing.
In India today, the following factors prevail:
•
There is an increase in the breakdown of the traditional family system.
•
A shift from the joint families to nuclear families.
•
Number of working women is increasing.
•
An ever-increasing competition in education and careers await today’s children.
• The society at large is becoming increasingly consumeristic.
These factors are contributing a lot to the increase of mental ill health, which is surfacing as
the me ?si ?g ni nbers of suisr’es, for instance. But these are only the tip of the iceberg. A
much larger extent of today’s children and youth are suffering from mental problems,
whether they come out with it or not.
In this backdrop, there are only a limited number of Psychiatrists in India (about 3000) and
an abysmally low number of mental health facilities available.
10 - 20% of all children under 15 years have some sort of mental health problems as per
global statistics. The statistics gathered by MONF prove that 23% of school children have
mental problems needing intervention.
The MON Foundation began about 8 years ago as an NGO. It was to address issues of
mental health that a group of committed Psychiatrists and Psychologists came together to
form this NGO to conduct appropriate research, training and building awareness about
mental health illness and related areas in Eastern India. It is headed by the Principal
Investigator Dr.Satyajit Ash who is a qualified and committed Psychiatrist.
They began the Mental Health Project for school children with the assistance of CRY three
years ago.
DIRECT ACTION WITH CHILDREN:
The project aims at action towards children with psychological problems in a two-fold
manner:
1. Intervention with the teachers, parents and others.
2. Direct intervention with identified ‘problem’ children.
They selected 4 schools, which are predominantly catering to low socio-economic standard
children. The target population within these schools are the children studying from classes VI
to X.
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Teachers were involved in three aspects of mental heath:
@ Firstly, sensitizing them about mental child health issues.
@ Then, Orientation and Counselling training to enable them to identify and intervene in the
mental health problems of students.
@ At the third level, Life Skill Education classes for the teachers to equip them and enable
them to share this in turn with their students. These classes include enhancement of skills
such as Communication, Anger Control, Decision making, Problem - Solving, and Stress
Management.
Intervention with Children: MON Foundation initiated a survey of around 800 children in the 4
target schools and found that 23.8 % of children have mental health problems needing
intervention of some sort. These 4 schools were selected after interacting with about 6 or
more school authorities. They are all Government aided private schools whose
managements evinced an interest in mental health issues. Initially even to broach the
subject <if mental health was difficult due to the widespread stigma attached to mental ill
health. This survey was done at two levels: the Rutter’s Child Behaviour Questionnaire was
administered by teachers first and this was followed by the Developmental Psychopathology
Checklist, which was given by the Clinical Psychologists of MONF.
Children with identified psychological problems are given counselling and other necessary
therapy by the MONF. At least one success story could be seen at first hand when a
problem child was counselled along with his parents and is now back in school regularly and
is showing better scholastic record and attendance than before.
HEALTH SUPPORTIVE ACTIVITY:
MONF also provided physical health checkup and referral services for some of these
selected target school children. The objective was to generate awareness about the mutual
relationship between physical and mental health. So far about 398 students have been
screened. The common ailments found are anemia, gastro-intestinal problems, dental
problems, skin problems, eye ailments, ENT problems and chest problems. This additional
service has enhanced the mental health project of MONF.
COMMUNITY MOBILISATION & INVOLVEMENT:
This is being done by the involvement of two important segments:
The teachers and the parents core groups. These core groups are formed with the really
committed teachers. For instance about 4 teachers of 20 in a given school are members of a
particular core group.
Sensitizing programmes in the community made parents aware of mental health concepts
and it’s impact on children. These were done only in the limited field of the parents of the
children of the selected schools, which is the target population of the MONF. The parents of
the problem children were involved in the Parents core groups, which works in tandem with
MONF. Lack of time and adequate trained staff ahs made it difficult for the organization to
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J
further follow-up these efforts, something, whit
is very essential for the sake of
sustainability.
GOVERNMENT INTERFACE:
The Department of Science & Technology of the government is helping MONF to reach out
to more number of schools. The DST has specifically funded some of their sensitisation
efforts and has recommended by letter these sensitization programmes to other schools in
the area. The Foundation has been persisting in advocacy efforts at different levels of the
Secondary Education Department also. MONF had organised sensitisation and awareness
seminars for functionaries upto the level of the Secretary to the Government. So far no clear
outcome is visible from all these efforts except for the usual lip service paid.
LARGER NETWORKING EFFORTS:
Through CRY, MONF is providing resource support to other CRY partners to enable them to
have a mental health focus in their work.
Other networking efforts have not been made. This is because the area of work is unique
and there are hardly any other NGOs working in this particular focus area on this issue.
MONF has conducted Sensitization and training seminars and programs for some ngos
havin a child focus, especially for those within Kolkata. They also developed a working
relationship with these ngos and continue to interact with them. These ngos include some
CRY partners. This is limited
the CRY partners in the city limits of Kolkata. This could be
enlarged to include CRY partners and other NGOs of the entire Eastern Region and also the
nation, in a phased manner. MONF can be utilised as a National Resource support group on
Mental Health Issues. They can prepare and present a module on Mental health issues for
the Capacity building programmes of the Cry DSU members at the regional and National
levels.
PARTNER/STAFF COMPETENCIES/SKILLS:
Dr.Satyajit Ash, the Principal Investigator is a professional Psychiatrist with a good amount
of commitment and motivation. The Research Associates also are competent and are
motivated to work for the Action Research project.One of the Clinical Psychologists had
additional training in Conflict Resolution at the Henry Martyn Institute, Hyderabad.
OVERALL STRENGTHS/ WEAKNESSES OF THE PROJECT:
STRENGTHS:
•
The organisation has purely pre fessional staff.
•
Mobi of the personnel in tne project have the right attitude and motivation for the project.
They are largely enthusiastic about the mental health issues they are dealing with.
Tne core teachers are motivated personally and are very active. One of them, a lady was
asked why she was devoting her time and energy in the Core group. She became
emotionally charged as she replied,” When I was a child, I suffered greatly because no
•
- 117 -
•
one ever listened to me at home or at school. I don’t want my students to suffer the same
fate. That is my motivation.”
This project is successful and can be a replicable model.
WEAKNESSES:
The fewj associates and staff are part time and temporary and project based. They have
other commitments too and they seem to be rather stretched out in terms of time allotment.
In this context, MONF is doing a pioneering work in this area. This is a model, which needs
replication in other areas.
The issues and concerns which have come out as a result of this action research also
should be disseminated to the other partners and all agencies working for Health and
Development.
OPPORTUNITIES/ ROAD AHEAD:
MON Foundation can be a resource support organisation for CRY in the specific focus area
of Child Mental Health.
Involvement of more and more professionals and fine-tuning the organisation to enable it to
cater to more NGOs and partners is very much necessary in the near future.
documentation of the life stories and impact of the project needs to be done more, perhaps
with the help of a development-oriented journalist.
THE ROLE OF CRY:
There has been financial support from CRY for the Mental Health Project. Since the
Foundation is a professional one, capacity building efforts have not been done from CRY.
On the other hand, other CRY partners in Kolkata and West Bengal have been exposed to
MON in order to sensitize them to Mental Health issues of children. This is a step in the right
direction. CRY needs to go one step ahead and involve MONF in larger Capacity Building
efforts for all the CRY partners in the country, for instance.
CRY can help MONF in dissemination of the right information on Mental Health issues to the
society at large. The CRY Youth wing for instance can take this information to the privileged
youth of India today.
The CRY Development support Unit team also needs to have the Life Skill Education
classes if they have to understand fully the role played by MONi .
CRY can ensure that the Mental health focus on children is given a place in the course
content of the overall child health capacity building programme which it can organise for all
the DSU team members at the National level.
FUTURE SCENARIO:
MONF needs CRY’s support in the following areas:
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?
1. Advocacy ano lobbying for correct Government policies to increase allocation of fund;,
and inputs to the Mental health issues
2. Dissemination and sensitization on Mental Health issues of children for other ngos
including CRY partners from all regions
3. Building up Public Awareness by means of intensive use of media: including print and
audiovisual media by means of portraying human-interest stories.
CRY could contribute financial aid and journalistic support, as well as help in marketing
the news stories in the national and international media.
CRY has a definite role to play in the future vis a vis the Child Mental Health issues.
Children of today and tomorrow have a right to better mental health.
(EVALU ACTION BASED ON A VISIT TO THE MON FOUNDATION ON 7th MARCH 2001 BY
Dr.M.ANTHONY DAVID ALONG WITH Mr.MANAV AND Mr.SOTTO OF DSU, CRY
CALCUTTA)
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4.
AN EVALUATION REPORT ON THE PRATIBANDHI KALYAN KENDRA: PKK,
BANDEL, HOOGHLY DISTRICT, W.B.
INTRODUCTION:
I
In 1974, a group of youth near Bandel got together to start a school for the deaf. They were
not technically qualified at that time but were motivated by their commitment to society and a
strong belief that something had to be done for the disabled. Through the past 26 odd years,
the organisation PKK has grown and evolved in response to the changing needs of the
differently abled. Today it is a professionally and technically managed institution, which
directly provides service to nearly 300 hearing and mentally handicapped children. It also
now supports five community-based organisations in rural areas around Bandel. PKK also is
reaching out now to Bhubhaneshwar where it is involved in a major community level project.
OBJECTIVES:
These are for the RRRC component of the PKK :
•
To strengthen the capacity and activities of the clinic in order to raise its qualitative and
quantitative aspects for early identification of childhood disability.
•
Standardization of the module of services for hearing handicapped, mentally
handicapped & multiple handicapped children developed during the first year of the
project.
•
To conduct training programmes for those whose involvement will directly contribute to
change the quality of lives of disabled children.
•
To undertake various programmes and activities as workshops, seminars, visits etc to
sensitise the community and integrate various services available for the disabled
children.
DIRECT ACTION WITH CHILDREN:
The activities of PKK are seven fold with almost all of them directly affecting the lives of
children who are differently abled:
• RRRC: The Regional Resource and Research Center: It has audiology, mental
assessment, counselling and other clinical services available mainly to children around
•
Banned.
School for the Deaf: This was the initial effort of this organization. It has two types of
services for the children. The formal school caters to childiuii and the aim is to get them
integrated into the mainstream schools. The other service is to the preschool children
•
•
•
with some hearing or mental handicap.
Cooperatives:There are two separate cooperatives which are run and managed by
rehabilitated hearing and mentally handicapped youngsters. The tailoring unit is run by
girls while the Printing Unit helps the boys with handicaps.
Parents organisation of the deaf.
PARTNERS: Parent’s organisation of the mentally handicapped. This is actively
campaigning for the rights of the mentally challenged children.
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•
ADVOCACY and lobbying for implementation of the PWD act, etc.CERM Unit looking
after community Education and Resource mobilisation.
•
Community Based Organisations: These are grass root level ngos with a specific
disability focus which are linked and promoted by PKK.These offer Community based
services especially to the hearing and mentally handicapped children, at their doorstep,
as it were. In one of the CBOs, the MUP, a survey was done two years ago *o reveal the
numbers of disabled children in their area of work: 44 villages: The survey showed that a
total of 256 children were disabled; 52 of them mentally disabled; 128 Physically
disabled; 20 visually disabled and 56 hearing disabled. The children whb were identified
are given intensive therapy esp. in the area of hearing disability. This is done at three
levels:
1. The Community Based Rehabilitation workers visit the homes of the disabled
children to teach them and their carers, simple skills which can enable them
to join the mainstream. One mentally disabled child we saw at her home was
able to study at a normal government school due to these efforts.
2. At the headquarters of the MUP in Mohammedpur, classes are held for
children and their parents/carers on a weekly basis where rehabilitative skills
are taught.
3.
In case of severe mental or hearing handicap, such children are sent to the
PKK clinic or RRRC at Bandel for further assessment or follow-up.
On the whole the experience at PKK as seen in and through the CBOs was that the village
children have a better chance of integrating in the community. They are better accepted by
their peers and others in the village community. So the outcome of the CBOs intervention
through CBR was on the whole encouraging.
PKK provides support to about 1800 children through various approaches as detailed above.
COMMUNITY MOBILISATION AND RESPONSIBILITY:
PKK works almost exclusively with a disability focus. That too specifically for the hearing and
mentally handicapped. With this focus however,there are attempts at mobilising communities
such as Parents of the deaf and mentally handicapped, cooperatives for the differently abled
youth, etc. Through the CBOs, PKK is working at the village level for the assessment and
service of the handicapped. There are four existing Cobs around Banned area. One of
these, Mohammedpur Udnyaan Parishad(MUP) is an ngo with a multifaceted approach and
activities. PKK has pnme-moved that community disability prevention and rehabilitation be a
part of their umbrella of activities. So PKK provides the technical wherewithal for the CBR
part of the MUP. The other CBOs are largely working with CBR as their mainstay.
The Bhubhaneshwar project which the PKK is now taking up in a large way is different. Here
PKK plans to implement the program directly and with a planned and systematic involvement
of the community at various levels.
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GOVERNMENT INTERPHASE
Largely PKK has worked very well with the government, especially in tune with the needs of
the differently abled.
A large component of PKK's funding is from the GOI Ministry of Social Justice &
Empowerment. This is for the infrastructure and recurring costs of the organization.
Training and exposure to the government officials at various levels such as AWWs,
Supervisors, CDPOs, School Teachers and the like is being done by PKK, in its special
focus areas.
The objective of this exercise is to expose them to the disability perspective and to help them
give the service they should, to the differently-abled children. Most of them were enlightened
on this issue due to this intervention by PKK. Some of them like a School teacher shared
experiences like how she could help a physically disabled child by making sure that his class
was always in the ground floor, year after year. What is possible if only we want to do
something for these disabled children, was discussed in many of these interactive sessions.
Most of the learning was an experiential sharing which helps the functionaries to come out of
their self-built walls and grow out!
LARGER NETWORKING EFFORTS:
PKK has block and district as well as State level networking of NGOs and others involved in
caring for the disabled. The objectives of these exercises were to share information and
expertise and to lobby for advocacy at governmental levels. The outcome is yet to be
materialised as it takes time and much more effort.
So far they have not tried networking with NGOs with a general or comprehensive focus.
Recently they had some experience in working together with other NGOs during last years
flood relief efforts. This was successful to some extent in that it widened the horizons of PKK
to go beyond of their disability focus. PKK needs to continue to network at two levels:
• At the District or regional/block level with all other NGOs to develop a comprehensive
development plan of the area.
• At State and country level of various other NGOs working with disability focus.
COMPETENCIES / SKILLS OF PARTNER/STAFF:
The project holder Mr.Subrata Bannerjee is a committed and sincere person who is the
founder of PKK and a special educator himself. The organisation has staff who feel that PKK
is not just an employer but a home away from home.
The core staff members and staff who are technical are all well trained. Most are graduates
with specialized skills and technical training such as Audiologists, Clinical Psychologists, etc.
Out of the ten odd technical full time staff they have, about 7 are technically qualified. The
- 122-
others are mult talented and zealous and committed to thei
different tasks.
vork and so are being utilized at
Motivation and commitment levels in the staff members are generally very high due to the
good work culture prevailing at PKK.
S i RENGTHS AND WEAKNESSES OF THE PROGRAMMES & ORGANIZATION:
STRENGTHS:
The strengths of the programmes and the organisation are:
•
The experience and expertise arising from 26 years in the field.
•
The project holder and the core members of the staff show commitment and motivation
to help the handicapped. Their involvement in PKK is not merely a “job” between 9 to 5.
They are fully involved in caring for the handicapped children. As one of the core
members of staff put it, “PKK is not just our employer, it is our home away from home”.
The fact that these staff continue to work happily in Bandel which is two hours away
from Kolkata, and also the fact that at least one of them had left Kolkata to work in PKK,
go to prove these facts.
•
•
Technical support in terms of latest equipment such as computerised audiology aids.
•
Wholesome and committed work-culture which prevails in the organisation.
Skilled and technically trained manpower.
• Wholistic c ;tlook of the holder and core staff vis a vis the focus group of children, i.e.the
differently-abled.
WEAKNESSES:
•
The focus of the organisation being totally on disability can be a weakness, as a wholistic
development focus is not seen. The total development of the community at large in the
target areas is not achieved due to the narrow focus.
•
Long-term evaluation needs to be done in terms of changing direction if necessary. PKK
has been an “evolving" organisation and as it is poised to go into a direct
implementation role, it is time for reflection and redefinition of the vision and mission of
the organization.
•
Development and delegation in terms of second line leadership needs to be done in a
more structured way. The present project holder seems to e more or less indispensable
for various aspects of the functioning of PKK. But what happens after him? The
sustainability of the organisation needs to be ensured by consciously building up second
line- leadeibiiip.
•
There seems to be some interpersonal relationship problems in the adolescent and
teenage groups of disabled children of PKK. Specifically focussed training or awareness
workshops could be held for these teenagers on issues of Adolescent health &
interpersonal relationships, communication, etc.
•
The implementation of the PWD act. Networking and lobbying at various government
levels needs to be more focussed. The excellent rapport the organization enjoys at least
with the GOI Ministry concerned should be encashed as it were in this area.
• A good systematic database of available resources both governmental and otherwise is
lacking in the context of the RRRC.
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OPPORTUNITIES, ROAD AHEAD:
• While continuing with the disability focus, PKK can network with other ngos and go for
comprehensive development of the area, or block.
• A proper database of disability focus can be developed not only at the regional level, but
also at the national level with adequate help.
• The direct implementation role on which PKK is just setting out at Bhubhaneshwar
should be properly documented and the benchmarks to be clearly set out. Proper
documentation can mark it out to be a model and replicable experiment.
• The value based work culture prevalent at PKK with the excellent interpersonal
relationships within the staff and with the children and parents could be documented and
replicated in other partners.
ROLE OF CRY:
The RRRC has been made possible by the financial contribution of CRY.
i
The turning of the organisation towards community based services from a purely institutional
approach is due perhaps largely inputs from CRY. Thus we can say that CRY’s input has
helped PKK decide its priorities properly.
I
CRY has not directly done much capacity building in PKK understandably because PKK is a
specialized and focussed Partner, which can be a Resource Support Organization.
RECOMMENDATIONS TO CRY:
In future CRY can develop a legal cell which can, amongst other things help PKK to further
advocate for PWD act and also lobby for other Disability friendly legislation if found
necessary.
In the larger canvas, CRY needs to also focus on Child Health Rights and set up a legal cell
to look into all issues of Child Health/Development related legislation. This legal cell can help
PKK advocate for the PWD and other such differently-abled friendly acts and their
implementation.
CRY can help PKK in documenting the community based project at Bhubhaneshwar and
also the value based work culture of the organisation.
Further development of links with PKK can be done with a view to project it in future as a
Resource support organisation especially in the field of Hearing Handicapped.
(EVALUATION BASED ON A VISIT TO THE PKK ORGANISATION, BANDEL ON 5 & 6
MARCH 2001 BY Dr.M.ANTHONY DAVID ALONG WITH Mr.MANAV & Ms.SOHA OF CRY
DSU, CALCUTTA)
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5.
SUNDARBAN SOCIAL DEVELOPMENT CENTER: INTEGRATED WOMEN &
CHILD DEVELOPMENT PROJECT (SSDC): AN EVALUATIVE REPORT
INTRODUCTION:
A group of educated youth hailing from remote areas of the Sundarban region within the
South 24 Parganas District of West Bengal came together in 1986 to start on their own. the
Sundarban Social Development Center,SSDC. The SSDC began its activities in 3 villages
and now has grown to about 50 villages. The Integrated Women and Child Development
project in specific is targeting 8 villages and 45 hamlets in the So' Jh 24 Parganas district of
West Bengal.
OBJECTIVES:
• Structural poverty alleviation of the community people especially the most
backward segment with active involvement and participation of the local
•
community.
To organize education and training in different aspects of socio-economic
development and sustainable empowerment for the local people through
advocacy, mass education and pressing the vocational training in different
•
pursuits as per felt needs of the people.
To ameliorate the varied social odds and problems which generally crop up in the
ways of life of the poor especially women and children.
•
To uplift the health status and. sanitation for people, especially for women and
children.
The unique feature of this organisation is that, though they are a grass root level
organisation, they want to be more of a facilitatory organization and not an implementing
one. Rather than relief and charity, they are promoting empowerment and making the people
stand on their own. One concrete way by which they are promoting this is by making all their
services have a user fee.
DIRECT ACTION WITH CHILDREN:
EDUCATION :SSDC runs about 13 Pre-Primary Centers for children in the age group of 2 to
7 years in the target villages. Each PPC has about 50 children.
HEALTH : Preventive health care delivery is done indirectly in collaboration with the existing
governmental health infrastructure. (Local PHC).
Nutrition education is being given to the PPC students and their mothers and other children
too when they come to the Centers. As a planned strategic move, they do not do any direct
nutritional supplementation at the PPCs. Two observations as an outcome of this indirect
nutritional intervention seems to bear out the fact that this is bearing fruit:
• . The attendance in the PPCs is improving in both dimensions, i.e: More number of
children of the village are able to come, nearly 95% i-n a village, for instance. Secondly,
the children who are coming are more regular, pointing out that -^ey are healthier.
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•
The general physical appearance of the children in the PPCs as was observed showed
that a majority of them, i.e. nearly 90% of them are not undernourished.
ADOLESCENT HEALTH TRAINING:
About 312 students of the IX class of schools within the target area are being trained in
Adolescent health. The outcome observed was that these children, especially the girls had a
working knowledge of adolescent health issues such as their own sexuality, reproductive
cycles and major problems, and good habits in maintaining sexual health.
Another important outcome is that these girls have come out
discuss sexual health with others.
their shyness or inhibition to
CURATIVE CARE:
Weekly clinics are being held in 5 villages, in the PPC buildings. Most of the 50 odd children
of the PPC as well as other village children from 0-2 years and adults are seen by the
doctor of the SSDC. This doctor has had an abridged MBBS course and seems to be
competent. He has been working for SSDC for over three years now.
Apart from these village visits, the doctor is also available at the SSDC headquarters,
Polerhat village, every day for a few hours and is made use of by all the villagers close by in
case of need.
Since one of the objectives of SSDC is to uplift the health status, and since they have
observed that the existing governmental health infrastructure is either inaccessible or
unavailable to the people, they have made this provision. The outcome of this intervention is
that affoj-dable curative health care delivery services are available and accessible to the
villagers. That the people value these services is evidenced by the fact that they pay for
them. The ideal intervention here would be to motivate the collective people’s groups of the
villages, i.e. Mahila Mandals, VECs etc, to demand and get the governmental health care
delivery services. But as a beginning SSDC has made the necessary services, i.e. Primary
Health Care, available to the people. A good first step. This can be seen as an entry point for
SSDC. The fact that these services are paid for by the people and are not delivered as
charity or for free shows that the organisation is acting in consonance with their avowed
objectives.
Deworming Camps: Two special deworming camps were held in the last year covering
nearly 1500 children. The problem of thread, pin and hookworms seem to be endemic in this
area and these special camps addressed this. The camps were also used to educate the
people on good sanitation habits and the prevention of worms. Since there has been a
perceptible decrease in the incidence of worms in the SSDC health care facility, the desired
outcome seems to be achieved.
Peferral Services: The ideal two-way referral services with a linkup with the locally available
specialists at the secondary and tertiary healthcare levels is absent. This is being done only
at a personal level. One real problem here is that a proper all weather road is not linking
these villages to the nearest town. This causes a real problem in cases of complicated
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■?
deliveries. As most women here seem to consider institutional deliveries as desirable the
lack of proper transport facilities is a major problem as felt by the villagers.
COMMUNITY MOBILISATION:
In this field the partner agency seems to have achieved most of what they planned to
achieve. As their objective states, “.... Active involvement and participation of the local
community..." A high level of ownership and pride in the achievements is seen at the village
levels. In line with the philosophy of community participation and ownership, the SSDC has
made it very clear that the Village Education Committee owns the PPC buildings and
management, in effect.
i he development of the villages concerned is being done in a systematic fashion by the
mahila mandals and self help groups. In fact, they are mobilising funds for the development
activities of the village and using the same for activities such as repairing the access roads.
They are also planning to build a Creche for their 0 -3 year old children in the near future
and have identified a plot of ground close of the present PPC for the same.
far as health goes, The children pay a certain amount per month as the consultation
charges of the SSDC doctor. In fact this is done like a Health Insurance scheme. The
parents of girl children pay Rs1/- per month and those of boys pay Rs.2.50 per month pc
child. Simple and essential drugs are dispensed at cost price and other drugs are prescribed
where necessary.
As regards sustainability of this curative care service, the villagers of one target village
responded positively when queried about the withdrawal of these services. “We will
ourselves pay and get this doctor to run our village clinic", they asserted.
Training of Village level health workers has been done to a certain extent. Each village has 3
to 5 of these trained women. These village cadres are specifically trained in home nursing
and seem to be able to tackle minor ailments effectively, in consultation and collaboration
with the SSDC health workers. These are about two or three in each village and they have
been trained in simple home nursing. They function at these levels:
•
Catering to the simple health care needs of the village at the first contact level. A simple
Piimary drug kit is available with them and they dispense these drugs as and when
necessary at their own villages.
•
They also work on the clinic days by helping the doctor and collect and bring cases for,
his services.
•
When necessary these women also take the villagers to the Polerhat clinic (SSDC
headquarters) in case of emergencies.
•
These village based cadre women are paid by the Project through the Village level
Education and other such committees.
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Promotion of Herbal and other locally appropriate and available alternative systems of
medicine is just beginning in this area. The people are still having better respect for
Allopathy and they also have a certain distrust of herbal medicines. The Alternate systems of
medicine need to be stressed more and more due to the upcoming trends of globalization,
liberalization and privatization.
Formation of Mahila Mandals, Village Education Committees has been done very well. All
the five villages have functioning structures and two have youth clubs also. The heartening
feature is that these committees are taking up the management of the PPCs as well as other
development activities for the village.
WATER/ SANITATION:
These villages had earlier depended fully upon small ponds and lakes for all their water
needs. But now all these villages have acquired borewells and are using these for their
drinking water needs. Some of the more affluent villagers in all these villages have also got
sanitary latrines constructed and the others are following suit. As the problem of worms is on
the downward trend, it goes to prove the point that the people are using better sanitation.
CASE STUDY:
In the village of Madhya Nilambarpur, stands a Borewell hand pump. The area around it was
well kept and a large notice was nailed to a tree nearby. On enquiring we were told that the
notice gives instructions about the correct usage of the well. The water of the well has to be
used only for drinking and has to be collected carefully and not wasted. No one should spit
or wash their faces, etc in the precincts of the hand pump. It was mentioned that all the
households of the village who use the borewell pay a small amount monthly for the upkeep
and maintenance of the well. Every year the Birthday of the well is celebrated as a
community celebration and the well is serviced, cleaned painted and decorated. A case of
good traditions being encouraged!
GOVERNMENT INTERPHASE:
There is some amount of issue and need-based interface and coordination with the health
infrastructure of the government. As far as Immunization and Family Planning goals are
concerned, the ANMs and other health functionaries of the government take the help of the
health workers and volunteers of SSDC for their own target fulfillment. So only in the area of
National Immunisation Days, (Pulse Polio Immunisation), and chasing Sterilisation targets, is
there any service available to the villages.
The PHC, Subcenter level functioning is very poor as they are not located in accessible
places. As described earlier, the health functionaries of these structures merely chase their
targets in the villages rather than deliver any service.
As far as the ICDS structures are concerned, in about 3 of these villages there are no
Anganwadies because of the low population. The nearest Anganwadies are not easily
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accessible. The services there are also not fully a", ailable. In spite of the excellent
community mobilisation efforts, no steps have been taken so far as to collectively demand
and get the health services from the PHCs and Sub-centres. This can and should be a
pricrity area for SSDC.
NETWORKING EFFORTS:
in terms of Education, there was an excellent effort spearheaded by SSDC in the district
level as they recently(December 2000) organised a Cycle Rally involving about 70 different
•£'GOs working in the district of South 24 Parganas. Over 450 participants cycled and they
submitted a memorandum to the block and district level officials, demanding education for
all. The outcome of this effort was that the issue was brought to the forefront of the media
and the public. This was because the main function was held on a Highway for over two
hours, stalling all the traffic. The Block and District officers have agreed to consider the
demands and initiate necessary action.
Similar networking with other NGOs on health issues is necessary.
PARTNER/STAFF COMPETENCIES SKILLS:
There are vo active project holders who are basically graduates and sons of the soil. They
have an open and committed attitude and have had formal and informal trainings and
exposure in the field of social development. They seem to have together developed the
philosophy of SSDC aided well by appropriate and well-timed inputs by the member of the
Deve'opment Support team
fhe CRY CalcuJa.
These core leaders have good leadership skills and team work abilities. As far as
communication is concerned, they have enough and more skills for their work in the area.
But they need to develop their understanding and speaking skills in English. They also need
to further their skills in Community Health and ASM (Alternate Systems' of Medicine) By
attending some trainings or going for exposure to certain innovative and pioneering
programs such as the Comprehensive Rural Health Program in Jamkhed or the Rural Unit
for Health and Social Affairs(RUHSA) (near )CMC Vellore.
The other team members and health workers who are high school graduates in formal
education have had adequate training. The Health workers of SSDC. for instance have had
about 40 days training in Community Health as well as 15 days triphasic training in
Reproductive and Child Health at the CINI Chetana Resource Centre, Calcutta.
The community leaders VEC and Panchayath leaders are having capacity building on issues
such as Roles and responsibilities of peoples representatives, budget allocations,
Panchayati Raj acts, etc. Appropriate health issues need to be built into these trainings
The Adolescent girls and boys groups are having specially focussed health awareness
tm'ning which is a good experiment worth replicating elsewhere
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I
OVERALL STRENGTHS AND WEAKNESSES OF HEALTH PROGRAMMES:
STRENGTHS:
•
ACCESSIBILTY: Simple curative healthcare is being made accessible at these remote
villages. As already discussed inefficient and inaccessible governmental health care
delivery mechanism makes it necessary for alternative approaches as this. But the fact
they value and pay for these services, and own them up enough to think of managing by
themselves, goes to prove that these are sustainable ventures.
•
SELF-RELIANCE: The villagers are made to pay at various levels for health care. The
parents of the girl students pay Rs.1/- per month and those of boys pay Rs.2.50 per
month in the RFCs as a form of health insurance. This covers only the consultation
charges of the doctor and they pay more for the drugs. All services they get through the
SSDC are paid for in one way or other. So the concepts of free and charity are not seen
here at all. This augurs well for the sustainability of such interventions in the long run.
•
PROMOTION & PREVENTION: Most of the promotive and preventive health care is
done indirectly at the level of the village communities. For instance, though a borewell is
sunk in the village, the management of the maintenance of this well is taken up at the
community level. This makes sure that the village environs are kept clean and thus
promote health. The active groups such as the VECs and the Mahila Mandals contribute
to this.
•
SUSTAINABILTY: The development of village level cadres for health is a venture to help
in the sustainability of health care services of at least the basic nature to be available in
the future when SSDC withdraws from these villages. The village level health
functionaries are already delivering first contact care to a limited extent. If they can be
further trained and used they may upgrade skills and continue as change agents in the
health field: available and accessible by all, at the village level.
WEAKNESSES:
•
There seems to be an undue emphasis on Curative health care at the expense of
preventive and promotive health care.
•
Safe deliveries, for instance the villagers believe are those done in institutions or
Hospitals. Most deliveries (90%) are conducted at the nearest town hospitals. In case of
complicated deliveries, the transport of the pregnant women is a difficult problem. One or
two cases where the delivery took place on the road are quoted. In villages which have
precarious road connectivity trained dais conducting safe deliveries at home should be
the norm for a majority of the deliveries. This of course needs to be backed up by an
efficient screening of high-risk cases and necessary linkages with the two-way referral
systems.
•
The concept of good antenatal care and detection of high-risk cases by screening and
referral of the same is not being followed.
•
The second contact care or referral services are not to-way and need to be built up as a
system. For instance, the specialist doctors available at the nearest town should be
contacted and a two-way referral services initiated where, when children are referred to
them for specific problems, they will be sent back with instructions to the SSDC doctor or
health workers.
I
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Adequate linkages need to be developed with the governmental health functionaries.
Where government services are available or should be available, SSDC should use their
community structures and collectives to make the Government accountable and render
those services. For instance where the subcentres are not functioning properly, the
Mahila Mandals should agitate or represent to the BMOH or other district or higher
officials to ensure that they will function better.
ORGANISATIONAL STRENGTHS AND WEAKNESSES:
STRENGTHS:
•
The project holders are committed and are actively involved in the programmes.
•
AH the staff at various levels share the same vision and mission io empower the people.
•
Tne large! communities -re responding well especially given the fact that SSDC is
working for only about 3 years in these villages.
WlAKNESSES:
•
Exposure and communication skills are needed for the project holders. At present they
are not able to communicate except in Bengali. Lack of communication in either English
or Hindi could be a block to learning and broadbasing their future activities.
•
The interface with the government needs’to be made better. The problem of inaccessible
or unavailable government facilities such as subcentres and anganwadis needs to be
addressed by campaigns, etc.Staff strengths are to bt juilt up on these lines.
_ ISSUES, CONCERNS & GAPS:
The needs in general seems to those of a larger canvas:
•
Accessible all weather roads is a general felt need in these areas
• t Th^ government Health and ICDS machinery are to be made fully functional in the area.
•
The unavailability of any institutionalized shelter facility for children in the age group 0 3 years seems to be the community’s felt need at least in on* village where they are
planning to address this by setting up a creche for such children.
OPPORTUNITIES, ROAD AHEAD:
SSDC is a well-entrenched grass root level organisation with a philosophy, vision and
mission of facilitating communities to ensure adequate empowerment of community groups
like'women. They should work for replication of such successful models both at the micro
level in other vil' iges of the block/district after they withdraw from their present service
villages, and also at the macro level by becoming a resource support group to expose other
such partners or ngos in India.
CRY ROLE:
Apart from financially supporting the Integrated Child and Women Development Project of
the SSDC, CRY has given inputs as :
• framing SSDC health workers both in Community Health and in Reproductive and Child
Health.
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•
Regular monitoring and evaluation and guidance given to the project holders by the
Development support team members.
FOLLOWUP BY CRY:
•
•
The overall accessibility problem for the area in terms of better all-purpose roads needs
to be addressed. This can be addressed by CRY playing a purely facilitatory role. SSDC
functionaries are to be motivated to make the village level community structures like the
VECs and SHGs to lobby at block and district levels for all weather roads. Given the
strengths of SSDC it will be possible to do this.
Further Capacity Building efforts in the direction of Alternate Systems of Medicine should
be provided for the Core health workers of SSDC.
CONCLUSION:
SSDC
is a successful model of a grass root level organization with a right development
perspective. The most important strengths of this organization are the facilitatory focus and
the sustainability status. Replication of such a model in health and integrated development
projects is necessary.
##//////////////////////////////////////////////////////
{EVALUATION REPORT BASED ON A VISIT TO THE SSDC PROJECT ON 2nd & 3rd
MARCH 2001 BY Dr.M.ANTHONY DAVID ALONG WITH Mr MANAV AND Ms
SANGHAMITRA OF THE DSU, CRY, CALCUTTA}
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1>.
A r b (. tie Association of People with Disability)
A.
Organisation
The Association of People with Disability (APD - formerly called as APH) was started
by a group of differently abled persons and well wishers in 1959 to improve the
quality of life of differently abled persons. The basic philosophy and aim of the
organization is to help disabled persons join mainstream society and to help them
become contributing and participating members. Ever since, the organization has
been involved in educating, training and rehabilitating the differently abled persons in
Bangalore so as to cover about a 1000 people at given time. All activities have been
designed to satisfy the needs of all age groups irrespective of community, caste,
creed or color.
The organization with the help of UNICEF conducted a program to train youth in
CBR. As a part of the field work the organization visited Srinivasapura taluk and
found that the taluk hn? one of the highest percentage of disabled persons, that too
belonging to SC and ST community - 1985.
Initially UNICEF supported the
organization to initiate a program to screen and refer disabled to Bangalore and other
places for treatment or to get assistive aids. CRY support to the program sta d in
the year 1994.
From 1998 the organization took a leap to take up total community development
activities by involving local youth, women and teachers. The organization initiated an
orthotic unit in Kamthampalli. Worked with primarily schools to take up children with
disability to study along with normal children. The organization initiated training of
Anganwadi teachers as a part of capacity building exercises to them. Now it is a very
well established program.
B. 1.
Objective of the Organisation
Empowering the differently abled persons to be active contributors in the
society.
Creating public awareness about the needs and abilities of differently abled
a-.J providing opportunities in the existing environment.
Promoting community based rehabilitation.
Developing a resource base for individuals and organizations by settling up
pilot projects.
Networking with Government and NGO’s (National and International) to keep
abreast of current trends.
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B.2.
Specific objectives of the Program
Providing education to disabled children who are school dropouts at 8th to 10th
level.
Provide functional literary to disabled adults.
Conduct a model Anganwadi in Kamthampalli
Train Government Anganwaadi teacher.
Immunization campaign in the taluk as a disability prevention program.
Assessing and developing orthotic aids in the campsite - Kamathampalli.
Organizing youth to take up a meaningful role in Health and education issues.
Supporting government schools to develop infrastructure.
Activities
APD rural program is basically a community based disability program, that has
expanded into certain development initiatives building on their core strength in
disability related work.
In this context they have taken up pre primary schools, community mobilization and
interface with government and making initiatives around larger networking.
1.
I
Direct actions with the community.
Pre-primary school - pre primary schools are run in 3 villages out of which
one school also has a nutrition supplementation program. The impact
assessment of four years of running the school showed that out of 130
children who underwent pre-primary education only 6 children have dropped
out of school. The organization is in touch with the six1 children who are now
attending NFE classes.
Immunization Campaign
In the fifteen focus villages campaign against vaccine preventable diseases is carried
out complementing the government health center’s effort. The percentage of children
completely immunized against the six killer diseases is reported to be over 82%.
Adolescent Group
An adolescent girls group has been organized in which health issues are discussed.
It provides ar. opportunity for adolescent girls to openly discuss themes, which are
otherwise considered taboo - such as sexuality, marriage, gender issues. A gynaec
screening and treatment camp was organized which also included a seminar for local
GPs on Gynaec problems. This is a need based and innovative intervention.
However it is being done low key (impressions gained). A forum for gender related
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health issues need to be incorporated into the aqenda of especially women sanghas
and pai .uhayath comtn.aees.
Disability Related - This being a specialized program on disability, several levels of
interventions related to disability are being carried out. Regular awareness and
training programs for persons with disability, their families and community members
are being carried out. Presently the program is reaching out to 353 disabled children
spread out 97 villages. Parents groups are trained to look after basic needs of
children with disabilities. Through child-to-child activities awareness about disability
and early identification and prevention of disabilities has reached larger number of
families.
12 Camps were conducted in the year for screening and treatment of disabled
persons. 49 new cases were detected and follow-up care was given to 211 cases.
24 ANMs of the health department under- went training on early detection of disability
and about caring for pregnant mothers. They in turn contacted 71 pregnant and
nursing mothers and gave need based health education.
Out of V disabled students who were coached in the special condensed course 4
students completed their SSLC and 13 got through in parts
A leadership workshop was conducted for 58 disabled youth, which helped them in
building self-confidence. They took the lead in organizing World Disability Day in the
taluk and conducted a public rally to draw the attention of Government and public to
the issues of the disabled.
Parents of disabled children were given an exposure visit to meet disabled people
carrying on normal life. This program motivated the parents to invest in their disabled
children. This is a successful effort to change the prevailing belief of seeing disabled
children as a liability and hence not to invest in their development.
No work is being done in the area of mental disability. This group is ideally placed to
take up this dimension, given the necessary supports.
2.
Community Mobilisation
Several community groups have been organized. In five villages sanghas were
organized and has successfully started savings and credit. These sanghas formed in
poor villages have saved about Rs. 18,000. These sanghas are being oriented to
take responsibility for their children’s health and education.
Work with panchayat leaders: No significant mobilization or education of panchayat
leaders related to priority child health issues of the community is happening it
appears. This would be an important intervention even though the panchayat is not
an empowered body at the movement.
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3.
Government interface
The APD team works in close collaborations with the ICDS centre and the sub centre
ANMs in the area of pregnancy care and promoting immunizations. Though they are
not directly providing these services to the community, however the facilitation of the
village based government cadre has produced good results. It is reported that
Pregnancy care is 90%
Children protected against six killer diseases is 82%
Pregnant women protected against tetanus is 92%
Apart from that the program initiated the following interventions.
Anganwadi teachers training.
8 Programs were organized to train anganwadi workers especially regarding pre
school education and which helped them to develop syllabus for the classes. On an
average 18 Anganwadi workers attended the courses. Follow-up was done with all
the training. As a result the Aganwadi workers are able to provide better care to the
children, especially in providing a stimulating learning environment and not merely
nutrition supplementation.
1
A workshop was held for the primary school teachers to develop awareness on child
health and disabilities. As a result the schoolteachers are able to, screen for
disabilities among the students and support the health worker in school health
sessions.
ANM workshop.
A workshop for 24 ANMs was conducted on topics relating to disability, care of
pregnant nursing mothers and immunization. The group found the training useful
and has requested for future workshops.
Seminars were conducted with the government doctors as well as private doctors to
increase the awareness on disability issues. This has resulted in better functioning of
secondary level orthopedic referral facilities in the taluka.
Some correctional
surgeries are now being performed at taluk hospitals, free charge. Activation of the
government orthopedic facilities in the area is significant achievement even though it
still needs to get systematized.
4.
Larger networking efforts
The group is involved in the taluk level NGO Network meeting. This appears to be at
the early stage of getting to know each other and no agendas for common actions
has been developed. No direct outcomes have come about yet.
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People in the area were mobilized to participate in the "right to education campaign"
and the public meeting at Bangalore on World Disability Day This exposure to public
articulation of issues is building peoples confidence in influencing public policies
Linkage has been developed with a private school in the area for supporting
education of disabled children in their school. The school is collaborating in disability
education and making the school environment friendly for disabled children.
The larger networking effort is in a rudimentary stage. The staff of the program
requires exposure and training for mass mobilization and advocacy. In the long term
advocacy confined to the NGO networks alone will not be sustainable and effective.
5.
Partner staff competence building
The staff in disability work has received the basic competency training from APD.
This training is about a year’s duration and is community based. Hence the training
has developed the skills in the staff for their present tasks of community based
disability work.
Besides some staff being disabled persons themselves; are
committed to the work.
The social workers and teachers have their basic academic training (Graduate).
They have received task oriented in service training of one week to one-month
duration, which has been very beneficial for skilling, them for their tasks. It is to be
noted that these in service training were innovative and appropriate for building their
skills.
There is supportive supervision through the weekly planning and reviewing meetings
and through periodic visits from APD trainers to the field situation.
The staff team has the minimum competencies for their present roles and some of
them are already functioning as resource persons. However if the program wishes to
develop into an integrated health and development initiative apart from the core
thrust on disability, competent core team on health would be required. At present the
core team does not have a socio political perspective on health and managerial skills
for a broader health program.
6.
Overall strengths and weakness of the health program
(The program is evaluated against the overall opportunities for intervention visualized
oy the evaluation team, not only against the plans they had formulated)
Program Strength
f
This specialized community based health program with disability focus has
addressed the preventive promotive curative and rehabilitative aspects of disability
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well. They have had good results especially in the direct involvement areas of
disability work as per the outcomes already brought out. This can be enhanced
further with a dimension on mental disability.
Though some outcomes are seen in the other health areas, they are not the same
order of effectiveness.
Good rapport has been built up with the community especially as an outcome of the
direct involvement. This has enabled them to mobilize the community to take up
some responsibility in the children’s health and education. This needs to be
strengthened further.
The government interface has been strengthened. Both the support given by the
program, to community level government program and the dialogue entered into with
government functionaries have contributed to this.
Program Limitations
■f^he evaluation team thinks the strategic planning efforts of ADD Rural need to
improve. There appears to be come unclarity on evolving directions of the program
i.e. whether to develop further in community based disability work or into an
integrated health and development program. This area needs to be addressed
based on community’s priorities and their ability to own them on the one hand, and
on the other hand taking into consideration the core competencies and guiding
principals of the organization.
For the same reason, some of the present priorities of the program need to be
reevaluated, such as the appropriateness of adopting certain villages and validity of
continuance of nutrition supplementation activities.
Program lacks good quality education material for health education of the community
groups.
There is no intervention with the community based health providers such as dais,
herbalists and RMPs.
This sector has important contributions to make in
sustainability of the program.
The program’s ability in mobilizing grass root communities and empowering them for
political action is a weak area. This is also reflected in related activities such as
mobilizing panchayat bodies, and issue based networking at a wider level in support
of local health needs.
A possible intervention in this context could be developing local mechanisms for
‘health watch’.
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The organization- strength
The organization inherited a positive image of strong values, from the swamiji who
donated the property. This image has been maintained.
There is a positive staff culture of openness transparency and accountability to each
other. Accordingly the plans are made and reviewed by the group themselves.
The organization has invested in staff capacity building so much so that some of the
staff is becoming local resource persons.
The Organization- Weakness
There is need for a competent core team in health. Such a core team need to have a
minimum required training in health, atleast three months training in community
health program management in a good field based facility.
CRY’i» Role
Presently the role played by CRY relates to program monitoring activities, input to
staff on planning and management, especially financial management and support to
the capacity building programs for the staff indirectly. CRY has also facilitated the
group for larger networking - NGOs in disability work, education network (NAFR)
Other Roles CRY Could Play
Facilitating strategic planning of the NGO and the required capacity building of the
core team.
Action Research on priority health issues of children in the area and bring them to
visibility e.g. it has been noticed that the working girl children in sericulture related
industry have significant health problems.
Publicizing the successes and leanings of the community based disability work, and
promoting this component among othe' CRY pa iners.
Promoting priority child health issues into the agenda of state level coalition for health
(Jan Swasthya Abhiyan.)
Interventions into the government health system at the state and regional levels
especially in the area of making ICDS structure more effective.
I
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Annexure 2
1
CASE STUDIES OF INNOVATIVE
CHILD HEALTH PROGRAMS
SEARCH, Gadchiroli (Based on field visit to SEARCH and the documents of
SEARCH especially ‘SEARCH’, Anubhav Series, VHAI New Delhi, 1998)
The pioneers of SEARCH, Gadchiroli are the doctor couple trained in Public Health
Research, Abhay and Rani Bang.
Eady in their community involvement they recognized the effectiveness of community based
research in policy changes for improving the lives of people. They settled in one of the most
backward and remote districts of Maharashtra for their life’s work.
Community Based Rural Health Care
SEARCH started its health work directly in a programme area of 58 villages of Gadchiroli
district covering a population of nearly 50,000. The main emphasis of this work is to make
community based health care possible through a band of trained community health workers
who are able to take care of the majority of the health needs. The villagers nominate health
workers who are called the arogyadoots (messangers of health), and all Traditional Birth
Attendants (TBAs or dais) in the village are involved. They are trained by SEARCH on a
continuing basis.
In addition to treating common illnesses, conducting deliveries and providing health
education, these workers are unique for they have also been trained to diagnose and treat
gynecological diseases in women, pneumonia in children, and care of neonates. A number
of them have also been trained and worked as investigators for collecting data for the
studies undertaken by SEARCH. When necessary they refer cases to the SEARCH hospital
at Shodhgram.
The non programme area (the control area for field research) has 47 villages with a
population of 45,000. Outside its direct programme area, SEARCH assists people when
they approach the organization for some assistance of advice.
The Team
The SEARCH team consists of 5 doctors, including Rani and Abhay, three nurses, lab
technicians, a deaddiction team, a keertankar who gives religious cultural discourses in the
villages, a team working with youth, 6 field supervisors, women social workers, computer
programmer, statistician, office and support staff. The community based workers are 120
dais and 80 arogyadoots - 35 women and 45 men. The gatekeeper, driver, registration
clerk, deaddiction workers - many of the workers at Shodhgram are ex-addicts. The
gatekeeper spins on a charka and keeps himself producttyeliptCippupied.
Participatory Approach
Through their experience with the community SEARCH team recognised that only when the
people were involved in research problem identification and finding appropriate solutions to
- 140-
I
the problem, they owned it as theirs. The usual research and recommendations method
alienated people from their own health problems.
Control of pneumonia in children and primary neonatal care in villages were two outcomes
from action research initiated by SEARCH team. SEARCH team focuses on problem areas
of people where government attention is not given in terms of policies and program.
In two years (189-90) nearly 2000 cases of pneumonia in children were treated by the
trained Arogyadoots and dais with resultant case fatality less than one per cent. The
childhood mortality due to pneumonia in the intervention area of 58 villages declined by 75%
the infant mortalitty rate by 33% and child mortality by 30%.
SEARCH has made two bold departures in programme to control acute respiratory infections
in children (ARI). One to entrust TBAs and village level health workers the responsibility to
manage pneumonia in children, thereby achieving almost 100% coverage of pneumonia
attacks in children in their action area. Second, even the neonates with pneumonia are
managed in the villages because parents are almost never willing or able to shift the baby to
hospital.
Since the government ARI control programme has not incorporated such steps, its affectivity
remains low..
Primary neonatal care in villages
Mortality in newborn babies within one month of birth constitutes nearly two thirds of the
infant mortality rate in developing countries.
A study was started in 1995 in 39 villages to observe and record the type of diseases home
cared newborn babies in rural areas suffered from. Thirty six femal arogyadoots from these
villages were trained to visit families, examine newborn and record the findings. The study
revealed that 95% newborns were home delivered 56% suffered from one or more major
illness (prematurity, birth weight less than 2 kg, pneumonia, sepsis, birth asphyxia,
hypothermia or breast feeding problems) and 52 infants out of every thousand died. Only
2% were treated by a doctor and barely 0.4% were hospitalised. It was thus obvious that
newborns needed to be cared at the village level.
In 1996 a primary neonatal care system was evolved in 39 villages and now trained
arogyadoots visit hori.es, examine newborns and manage the sick ones. The neonatal
mortality in these 39 villages had decreased by 56% and Infant Mortality rate had come
down from 74 to 44% lower than national figure of 74/1000 live births.
The two programmes - pneumonia management and primary neonatal
care developed by
SEARCH have the potential to reduce child mortality by 50%.
- 141 -
The Tribal friendly hospital
SEARCH started a hospital treating 15000 patients annually. This hospital which looks like a
tribal village has been planned taking the socio-cultural characteristics of tribals. The waiting
area, the outpatients section, is modeled after the ‘ghotul’ the discussion hall of the tribal
village.
Here tribal educators in the local language carry out health education. The in-patient
buildings are small hutments where patients and relatives can stay, as the relative is a
caretaker for the patient. The medical team has taken the effort to document the tribal
health practices (including herbs used) as well as the local terminology used to communicate
symptoms and problems. The socio-culturally friendly atmosphere has contributed to the
acceptability and success of the hospital.
Significance of SEARCH work
SEARCH’S work with children have demonstrated that complex tasks involved in the medical
care of infants and neonates can be handled by the semiliterate or illiterate health workers
present in the community. Taking up from the learnings already demonstrated a decade
back by Jamkhed project, SEARCH has demonstrated the same village health cadre based
approach will work for neonatal care. In the process they have demonstrated bringing down
infant mortality and especially the most resistant component, the neo natal mortality, through
cost effective strategies.
Another contribution with regard to child health is through demonstrating the gross under
reporting of infant and child mortality by the government sources. It has focussed policy
makers attention on the need for better, care strategies. This has resulted in SEARCH
being asked to train government functionaries for childcare in Maharashtra.
SEARCH has demonstrated as Jamkhed had done earlier that participatory and democratic
training methodologies could develop highly skilled local personnel, regardless of their
educational background.
SEARCH has made several other contributions in the areas of women’s health, sexual
health, adolescent sexuality and alcoholism as a social and health issue. For the purpose of
brevity in this case study, these areas are not being expanded.
The action-research outcomes of SEARCH have not remained localized to Gadchiroli.
Through active networking, capacity building and policy advocacy, the influence of SEARCH
in child health policy is strongly felt at Maharashtra level as well as at national and
international levels.
Learning for CRY
SEARCH is a resource support organization for child health issues and resourceful partner
for CRY. Though the SEARCH model at the ground level focuses only on health sector,
- 142-
where as CRY has a multi sectoral approach in their interventions, the successful strategy
for child health care need to be taken forward. SEARCH is also good resource for CRY for
capacity building in ‘direct health care’ for CRY partners and on ‘right based approach to
health’ for CRY team.
2
MediCiti, Medchai - ICDS Program
Special Nutrition Program
available by the program)
‘SNP’
(based on field visit and limited documents made
The SNP was started in ICDS - Project in Medchai during May 1999 had the following aims:
Improving the nutritional status of the pregnant and lactating mothers and children from the
age group of 6 months to 6 years, reduce the IMP, MMR, Infant Mortality Rate, improve the
immunization coverage community participation and the pre-school attendance in the
Anganwadi Centers.
The SNP was started initially in 3 centers, increased to 10 and then 15 and gradually to 157
centres.
In the beginning packed food with shelf life was served twice a week like groundnut- jaggery
laddu, ragi porridge, biscuits, egg, chudwa etc.were distributed. Subsequently low cost
locally available and acceptable food is being distributed. The accepted items are sweet
pongal, wheat upma, idly, khichidi. These items are consumed with great relish and totally
accepted by the community.
The ‘mothers committees’ having been given 3 days orientation training on ICDS activities
and motivated to participate, by the ICDS functionaries. These mothers committees are
regularly participating in all the activities at Anganwadi centers.
Pregnant Women
The Anganwdi workers conduct survey of pregnant women in the village. They register their
names and motivate them to take precautions such as: TT Injections, IFA tablets, regular
ANM checkup, balanced nutritious meal and also facilitate through institutional delivery, safe
delivery.
Lactating mothers:
Their services to lactating mothers include:
Encouragement of colostrum feeding, regular weighing, education on breast feeding,
immunization, introduction of complementary feeding, ORS, hygienic handling of the child
and reference to the doctors. They also advice on family planning measures to eligible
couples and encourage timely FP operation .
- 143-
f
Children : 0 - 3 Toddlers
Advice to mothers to feed infants, hygienically and nutritionally to ensure optimum physical
and mental health and on timely immunization.
3-6 years preschoolers
In all the 157 Anganwadi Centers the ‘preschool’ is regularly functioning for the overall
development of the child before they move to the primary school. The World Bank has
supplied the centers with outdoor and indoor play materials and preschool kit, which is
helping in their development. These activities are helping the children to develop physically,
mentally, emotionally and socially.
This has also helped in improving the attendance, social participation of children and
mothers in all the 157 centers. In addition there are 53 ECE (Early Child Education)
programs running under DREP within these centers.
Adolescent Girls
Survey of adolescent girls in the entire project areas was done and mebandazole (for de
worming) and IFA (for prevention and treatment of anemia) are being given to all of them.
MediCiti Involvement
MediCiti is assisting immunization and free health check, through their village health clinics
and CHVs and they are monitoring health in the project area. They are providing transport
for institutional deliveries (through a simple phone call). They are given 50% concession for
treatment in the Medi-City hospital including surgeries by providing ‘health card scheme’ at
Rs. 50/- per head, per year.
Strengths and weakness of the program
The program was unable to provide data on the outcome and impact of the project so far.
However based on observations the following analysis is being made.
This is a good example of an effective collaborative Government -NGO program covering a
fairly large area (157villages). The community actively participated in the construction of the
centers, for which funds came from the World Bank. The centers have adequate equipment
for indoor and outdoor activity for the children, which is quite different from anganwadi
centers elsewhere. The center attracts and retains children. The ‘mothers group’, i.e. parents
of the enrolled children are involving in the running of the center by helping out voluntarily by
turn. These helps to maintain cleanliness ensure adequate food distribution and enrolling of
the eligible.
- 144l
The program took the initiative of negotiating with the department of WDCD, to provide
cooked local diet. This superior to pre -cooked food transported from elsewhere, both in
nutrition content and in acceptability.
The program also has initiated convergence of services of health, ICDS and primary school
education, through its center. This initiative is worth duplicating, even though not easy to
bring about in practice.
The program also provides ongoing capacity building inputs to the lower level functionaries
of the ICDS program an aspect not emphasized from the department.
There are a few limitations to the program as well. To start with it is not a replicable model,
as the NGO involved has brought in considerable financial and other resources into the
partnership (being a tertiary hospital). Without the financial backing of the institution the
partnership may not have sustained, as there was a prolonged period of twelve months
when the government funds had not been released to the project.
There is no community ownership of the program, even though the mother’s group is actively
involving. The roots of this issue are linked to the poor decentralization being implemented
by the state, as well as effectiveness of community organization carried out by the agency.
It is an institutional approach to nutrition as opposed to community empowerment approach
and unlikely to be sustainable. For the same reason one does not expect uch changes in
the family level or community level nutritional behaviors.
- 145 -
3.
Community Initiatives to Improve Child Health and Nutrition in Tamil Nadu,
India: Strategies and Preliminary Results on Nutritional Impact - India
Background
This programme was started in May 1999, and is being implemented in roughly 500 villages
in 10 blocks in Tamil Nadu. Supported by UNICEF, the programme is’executed by the NGO
Tamil Nadu Science Forum. The programme has three main aims:
- Improve the use of primary health care services;
- Improve children's health and nutritional status; and
- Organise and empower women around their health needs.
The programme organised village health committees (VHCs), which each selected a local
health activist. These voluntary health activists were trained together, and more intensively
in the field, in talking to mothers about nutrition and diseases, and to pregnant women about
nutrition, delivery, breast-feeding and other health matters. The VHCs also met to read and
discuss health books, and helped the health activist to promote nutrition and health
education.
The main strategies used to address child health are:
At the family level:
- identify children at risk by weighing each child
- constantly follow up each child at risk and assist families to prevent malnutrition or
reverse it by appropriate health education and better use of existing health services
At the community level:
-
-
strengthen primary health care and Tamil Nadu Integrated Nutrition Programme (TINP)
services through advocacy
make child malnutrition the most important index of health for local planning, and
sensitise panchayat members as to its significance.
The activists were given intensive training in child health and nutrition to:
Analyze the combination of factors that led to particular cases of malnutrition; identify those
factors that can be addressed in their individual and social context; discuss with the family
about the child's risk factors and the importance of addressing those factors; and reinforce
the initial message by repeated visits at the family level as well as through cultural programs
and village-level meetings.
Programme principles:
The interaction between the health activist and the mother is central to the programme, and
is based on principles derived from experience:
1. Respect . The mother and pregnant woman are seen as intelligent people coping with
difficult conditions, and not as ignorant people who won't listen to sensible advice.
2. Understanding. The focus is therefore on understanding why a mother does not follow
advice, rather than blaming her for not doing so. She already has a world-view, formed
- 146-
by her own experiences an what she has learned from her community. That world-view
guides her health practices for herself and her child. The advice she is given by the
programme often differs from her own information; to succeed, one must integrate this
advice with her world-view, by discussing in detail why it makes sense and how if can be
adopted within the limits of her resources.
3. Skilled and patient negotiation. This kind of dialogue is difficult, time-consuming and
requires considerable skill and confidence on the par of the person giving the advice.
Training the activist in dialogue takes time; she must learn not only to advise, but to
counter arguments and elaborate ways in which advice can be adopted in a resource
poor setting. The activist needs support from a group of trainers who visit her regularly,
provide her work with legitimacy and constantly encourage and provide her with further
training.
4. Peer discussion and reinforcement. One-to-one sessions between the activist and
mother are complemented by group meetings called by the activist to discuss specific
issues (e.g. feeding the colostrum). In such a meeting, a mother will invariably say they
have fed the baby with colostrum and the baby is healthy; this can be used as "proof of
concept" to convince others. This kind of negotiation with a larger group also requires
skill, and often the block-level trainers help the activist to conduct such discussions.
5.
Preliminary results on child malnutrition
As part of programme activities, children aged under five were weighed at the beginning of
the programme and again roughly 1.5 years later (in October-December 2000). Of 7,133
children weighed during both periods, the percentage of children with a "normal" weight
increased from 34.5% to 45.8%. The percentage of "grade 1" children increased by 1.3
percentage points, while the percentage of children in grades 2-4 decreased by 12.6 points.
If one compares each child's status at the two times of measurement, one finds that 34.9%
of children improved their category, while 13.5% deteriorated; the remainder stayed in the
same category. That is, there was a net categorical improvement among 21.4% of the
children.
These results understate the programme's impact, in that the nutritional status of a cohort of
under-fives is not static in the absence of positive interventions in their favour. Rather, one
expects their nutritional status to worsen. In areas of the State where the programme is not
being implemented, one finds that the overall nutritional status of a cohort of children aged
under five deteriorates over a 1.5 year time period; indeed this pattern is commonly found
throughout India.
Organisational insights
Explanations for these positive results can be found in the actions of the health activist: the
programme's design and operations place great emphasis on motivating her and making her
effective:
- 147 -
When measuring the activist's work, she is not blamed for children who are malnourished
or
in
poor
health.
The
emphasis
is
rather
on measuring
her
work, i.e. talking to mothers and pregnant women. If children have worsened, the
reasons are sought in her training or in programme design. Investigation sometimes
reveals that there are underlying factors beyond her control, such as diarrhoea
epidemics.
-
The activist is always praised in front of the mothers. To boost her respect in the village
and her self-confidence, village meetings are organised in which she is honoured and
called to talk to the village community. These measures gain her respect locally and
motivate her to work harder.
An egalitarian and intensive relationship between the trainers and the activists is
important. The motivation of these trainers, and their willingness to meet with mothers,
often over a period of days, are crucial to providing the activist with a good example as
well as the skills she needs.
The activists’ voluntary status is important to their motivation. The activists and the
village understand that the work is done for the sake of improving children's nutrition.
To ensure that the focus of the activist is on actually meeting mothers and pregnant
women, administrative tasks such as report writing and maintaining records are kept to a
minimum. The trainer is responsible for monitoring the programme, and is primarily
responsible for administrative tasks; the activist is asked to maintain only one page from
which all relevant data are gathered.
While the preliminary results will need to be independently verified, they suggest that this
programme might provide a viable model to reduce child malnutrition. More time will be
required to determine how long it takes to raise a community's capacity sufficiently to
address malnutrition without ongoing support from an NGO; and to determine the cost of this
model.
There are three further considerations relating to sustainability and replicability. First, the
model requires supportive primary health care and nutritional services, which have
traditionally been provided by the State. These services need to be reinforced. Second, this
model is predicated upon intensive outreach counselling and personal relations. While
resource constraints play a role in malnutrition, much of child malnutrition can be explained
by behav ours. Poor feeding practices are common, and the in-home management of illness
can be much improved. These problems can only be addressed through a dialogue that
intensively and repeatedly seeks to ensure that the right behaviour has been understood and
is being practised. There does not appear to be a shortcut or substitute for this approach.
Third, the community's involvement is important: it provides support to the activist and
examples of positive behaviour for others.
- 148-
J
Annexure 3
1.
SUPPORTING DOCUMENTS
GAPS IN EXISTING LAWS, PROGRAMMES & SCHEMES AND IDENTIFIED
REQUIREMENTS (Maternity and Child Care Code, a concept paper, Maharashtra
FORCES)
The required and prevailing laws, programs and schemes may be grouped and considered
according to the table of ECD needs. The gaps between need and present provision are
summarized below.
Period
Ante-natal
Required Interventions
Present Status
Right to choice (Universal
access to FP, including
MTP)___________________
Not fully available
Protection of female foetus
(Ban on selective abortion)
Pre-diagnostic Sex
Determination Tests
1994
Right to nutrition (Maternal
nutrition
and
universal
access to health services)
through
Maternal
protection
schemes in some States
and nutritional support in
some states.
Access to
health care inadequate.
Not available
Education for childcare
Cash
Act,
support
Childbirth
(Universal
access to safe facilities)
Not fully achieved
0-2 Years
Right to nutrition (Access to
mother’s^, milk exclusively
for four months from child
birth)
Infant foods and breast milk
substitutes Act (1992)
Comprehensive, Maternity
Protection Act, Fund or
scheme for all, especially to
those
working
in
the
unorganized
sector.
Maternity Benefit Act and
Employees State Insurance
Act (1948) provide for only
three
months
and
is
available only to women in
the organised sector.
Safe
childbirth
Employer contribution may
be required in the case of
organized sector.
Age appropriate framework
for
stimulation
towards
holistic development.
- 149 -
Limited
maternity
entitlement in cash in some
states
and
nutritional
support in some states
I
Period
3-5 Years
Required Interventions
Right to care and protection
(Uniform adoption law and
maternity entitlement for
adoptive mothers)
Minimum
standards
of
childcare in crdche / Day
care centre and institutional
care homes.
Present Status
Stress
on
holistic
development by the ICDS
scheme,
however
inadequate.
Hindu
adoption
and
Maintenance Act (1956),
Guardians and Wards Act
(1890) and Hindu Minority
and
Guardianship
Act
(1956). No entitlements for
adoptive mothers.
Several Acts (6) providing
crdches for children below
six mostly available only to
women in the organized
sector.
No provision for
women in Govt, or public
sector service, or for those
working in tertiary sector or,
under the Shops and
Establishment Act.
Lack of childcare services
for agricultural workers and
for regulations of founding
homes, orphanages and
children’s
Homes
Comprehensive Child Care
Act Fund and scheme
providing access to day
care for young children at
locations, timings and of
nature
and
quality
appropriate and convenient
to mothers, especially for
those in unorganized sector
with new and flexible ways
of
acquiring
financial
contributions
from
employers / contractors of
women in the unorganised,
sector.
Right to care and protection The ICDS and the Acts
and a Comprehensive, age imentioned
above
all
- appropriate Child Care |provide for children up the
Act, Fund or Scheme, as <age of six. The lacunae are
above,
applicable
to similar.
:
children up to the age of
six.
I
- 150-
?
Period
Special Needs
2.
Required Interventions
Supplementary care and
support, Right to education
and holistic development.
A
compulsory
Child
Development
and
Education Act to provide
free
and
universal
education,
development
appropriate to age.
Policy related to prevention
and early detection of
disability.
Present Status
Proposed
Compulsory
Education Bill restricted
children aged 6 - 14.
Persons with Disability Act
(1993) not implemented.
Regulation of all early
childhood education which
would
ensure
minimum
standards
in
early
childhood education.
No such comprehensive
laws of rules. Some ad hoc
rules passed
in some
States (Maharashtra and
Delhi),
some
under
consideration. Some court
rulings with respect to
admission tests.
Rights
of
homeless,
refugees ethnic groups,
single parents, migrants,
itinerants, nomads, riot-hit,
pavement dwellers and
those in illegal settlements
to all the services and
provisions.
Special
facilities
in
response to needs of each
group.
No special entitlement at
present to ensure that such
children are not deprived of
their rights.
FORCES’ Recommendations on ICDS
1.
Upgrade facilities and infrastructure
There is a need to upgrade the physical infrastructural facilities of AWC.
Adequate indoor and outdoor space and separate storage space should be
made available. Taps & hand-pumps should be installed within the premises
of all A WCs & toilet facilities should also be provided.
2.
Issue guidelines for locating Aanganwadis and setting their timings to
correspond to needs of target group.
- 151 -
HP-'®?
y 9,
Proper, planning should be done to locate A WCs more appropriately so that
beneficiaries could avail the services under ICDS more easily.
3.
Redesign outreach to under-threes and pregnant and lactating women and
make provision of Daycare arrangements cum Aanganwadis.
Efforts to increase the outreach of ICDS to pregnant and nursing women and
to children below the age of 3 years must be well planned. It must be kept in
mind that women are engaged in home-based works, household tasks, and
as workers in unorganized sector. ICDS with its wide outreach and high
investment does not Provide day .cafe for the hard pressed working mother,
nor does it relieve older girls to attend school. Therefore the question of
timings of A WCs is crucial for the improvement in outreach. The proposition
of converting anganwadies into creches/day care centres for facilitating the
comprehensive coverage of younger children- needs to be emphasized.
4.
Revise nutrition programme, distribution system and type of food supplied.
The nutritional Programme of ICDS has several drawbacks: poor quality food,
inadequate quantities given at irregular intervals. Such nutritional support is
not conducive improvement in nutritional status and needs serious rethinking.
Surely it is time to insist that the nutrition component of the ICDS and mid day
meal come from local sources, utilizing culturally acceptable foods and be
protected from any technological manipulations that the world does not know
about as yet. Caution needs to be exercised in giving genetically modified
foods.
5.
Increase emphasis on neglected components of ICDS package, particularly
education.
The emphasis on the immunization and nutritional aspect of ICDS needs to
be re examined and equal emphasis should be put on all components of
ICDS' package of services.
1
6.
Initiate Convergence of Services at both planning and field levels.
The real target must be all-round improvement in the health/nutritional status
o1- mothers and children. It calls for convergence of other supportive
services, which include safe drinking water, environmental sanitation,
women’s empowerment Programme, day-care services, non- form. 11
education and adult literacy. Only when Such convergence is done at the
policy level and with meticulous planning then convergence of other services
with the ICDS scheme will complement and help in the realization or the
dream of child development in India
- 152-
j
7.
Revamp Status, remuneration .and conditions of work of the Aanganwadi
Workers
The AWW is a tremendous resource and we need to prioritize her job
responsibilities. Provision should be made to regularize their services like any
other para-professional worker.
We can remind the Govt, that it has already committed itself in the New
Education Policy of 1986 (chapter on ECCE) to bring child-care workers at
par with primary school teachers in the long run, though it has not yet spelt
out how long it will take and in what steps this will be achieved. A W\\”s salary
must at once be raised and they must get at least minimum wages if not at
pur with primary school teachers & that should only be a starting point.
8.
Revise Training and Evaluation to include critical missing components
Training needs of the ICDS, should be implemented and that will require
greater commitment on the part of the government and financial inputs too.
The aim of ICDS training is to develop all the functionaries of ICDS into
agents of social change. It is strongly recommended that in addition to
NIPCCD there must be a variety of models of training at differerlevels and
stages and a diversity of patterns specifying only the approach and a
minimum irreducible set of goals.
9.
Build in flexibility in management and design of ICDS and include ground
principle, of partnership between Government, NGOs and People groups
In addition to NGOs the state needs to encourage Gram-Panchayats, MahilaMandals, Business Houses. Trade Unions. Educational Institutions, Parents
Groups etc., to make arrangement for childcare services. By opening its
doors and getting away from fixed schematic patterns, and by encouraging a
variety of models and managerial inputs in the management of creches and
Anganwadi centres, the state will be able to address the issue of child
development more comprehensively.
10.
Increase overall allocation for Maternity and Early Childhood Care and
develop strategies for alternate source of funding
The great -future of ICDS lies in its development from a state financed and
implemented intervention into a community-planned) community-administered
and community- underwritten Programme but backed by the resources from
the state. Trust and flexibility are the two essential factors tH at contribute to
the sustainability of partnership so the partnership should be based on
principles of equality and rnutu:\1 appreciation of each other's role. The
government may-decide how much funding can be given per child per day or
year) and the local body, community structure or NGO could work out a
- 153 -
flexible programme suited to local conditions and needs. Accountability will be
both financial and programmatic, to government and to the community and
can be ensured by appropriate procedures. Responsibility and even authority
if need be, should be fairly shared. The involvement of both partners in
formulation of policies, and implementation should be done in a democratic
manner and participatory methods should be encouraged in programme
planning, implementation, monitoring and evaluation. Funding Resource
allocated for ICDS need to be substantially increased. A completely fresh
approach to the issue of resources for ICDS scheme will have to be adopted.
The question of increased resources for childcare will have to be faced if
ICDS goals and objectives are to be accomplished. A minimum annual
amount calculated as a fixed share of, the GNP , for childcare services, will
have to be allocated keeping in mind tha* the children below the age of 6
years constitute 18% of the population. Our estimates show that a daycare
provision with hearth and development inputs (including the salary of the
childcare worker), requires Rs. 151- per day per child at current prices and
current inflation levels.
A National Children's Fund need to be setup which can receive :
> public contributions through tax exempt donations,
> imposing a cess for child care, # industry based contributions,
> permitting fees and charges at local levels that are at present not allowed
to agencies receiving grants from government schemes,
> Contribution by communities to daycare arrangements in material,
financial and management terms.(Communities can contribute in these
ways but this must not be equated with total self reliance )
> # convergence of funds from all development programmes. All existing
schemes will have to be scrutinized to find out what can be released for
childcare.
11.
Universalize ICDS and coincide it with removal of identified shortcomings.
Any attempt of universalization of ICDS will require a serious step to eradicate
the shortcomings within the Programme and ensuring more effective and
efficient implementation of the existing services to maximize the outreach and
impact of ICDS. Only when the convergence of other services with ICDS is
done at the policy level and with meticulous planning can the convergence of
other services with the ICDS scheme develop at the program level.
- 154-
J
Annexure 4
FIELD STUDY
RESEARCHER TABULATION FORMAT
Instructions
1. Please encircle the correct response
2. Be specific wherever possible
3. Where necessary, please elaborate
Organization
:
Chief Functionary
Place :
1.
Date
Target Community
a.
Are you working with an identified target group, in Villages / Slums based on
previous study / survey ?
Target Population
i.
Household
Children...
Special Focus Group
Target: Villages
ii.
b.
Population
Slums
How often does your team meet the target group
Daily
c.
Hamlets
Weekly
Monthly
What are the priority diseases affecting children
Age Group
Diseases
Evidence
Remarks
0-2 Years
3-6 Years
7-14 Years
2.
Health Care
a.
What are the health related activities you are doing ?
problems and successes ?
i.
Activity
MCH (Mother and Child
Health)
Sex selective abortion
prevented
No. of Safe Deliveries
Neo - Natal care
U - 2 Care
Creches
Anganwadis
Other Programmes
3-6 Care
Anganwadis
Other Programmes
- 155 -
Success
Evidence
What are the
Problems
Remarks
Activity
ii.
Success
Evidence
Problems
Remarks
Nutritional
Supplementation
Anganwadi
Kitchen Garden
Public Distribution System
Others
iii. Curative Care and referrals
(Frequency Code : D -
Daily, W - Weekly, M Monthly, O - Occasionally)
Camp
Clinic
School checkup
VHW Care
Traditional Practitioner
Care
Referral
Fund
Transport
Linkage
iv. Health Education
School
Child - to - child
Mother’s Group
Community Groups
Community Leaders
Other groups
v. Special Programmes
Differently abled
Others
b.
I
Health Supportive Activities
i.
ii.
Activity
Safe Water
Chlorination
Borewells
Piped water
Success
Sanitation
Latrines
Soap Pits
Compost Pits
Clean Surroundings
iii. Village Health Workers
- 156 -
Evidence
Problems
Remarks
Health Workers
Volunteers
Dais
Traditional Practitioners
RMPs
iv. Health Watch
Health information
Monitoring Govt. Services
v. Others
3.
Trainings
Group
Subject
Duration
Resource
Person
Outcome
Activities
Outcome
Evidence
Problems /
Remarks
a. Community
Child Leaders
VHWs
Dais
T. P.s
RMPs
Local Leaders
Govt. AN Ms
Others
b. Project Team
Health Staff
Core Team
Leader
Others
4.
Health Resources
Resource
a.
Government
Sub centre
PHO
ICDS
Centre
Others
b. Private
MBBS Doctor
RMP
- 157 -
Remarks
TP
Others
5.
Community Involvement I Community Structures / Networking
Resource
Activities
Outcome
Evidence
Problems I
Remarks
Children’s groups
Parent’s groups
People’s groups
Panchayat
Committees
Campaign Coalition
6.
Budget
Hqad
Amount
Local
Contribution
CRY
Contribution
Remarks
Programme
Trainings
Salaries
I
Administration
7.
Future health priorities
Priorities
Reasons
Possible
interventions
Support Required
Local
8.
Govt.
Corpo
rate
Remarks
CRY
Health Forecast
Areas
Short Term (5
Years)
Medium Term (10
Years)
- 158-
Remarks
9.
Partner/ Community Prob e
Areas
Proj.
Holder
Core
Team
a. Basic
Qualification
b. Attitude
c. Knowledge
d. Skills
•
Communicatio
n
•
Leadership
•
Team Work
•
Health Care
•
Team work
•
e.
Others
Systems &
Structures
•
Delegation
•
Transparency
•
Accountability
•
Others
- 159 -
Health
Team
Comm.
Leaders
Comm.
Groups
Children
Groups
Position: 478 (8 views)