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RF_NUT_9_A_SUDHA
National Consultation
on Developing Socio-medical Tools for Early
Identification of Acute Hunger and Starvation
for Effective Administrative Action
JNU
13thIVIay,2010
CSMCH-JNU,
SADED-CSDS, CES
Office of Commissioner to the Supreme Court
Public Health Approach to Early Detection
of Acute Hunger: the Challenges &
Possibilities
Ritu Priya
(with Lakshmi Kutty, Kumaran, Dilip,)
CSMCH, JNU
2
The Challenge
Children 0-6 yrs. -50% moderate and
severe malnutrition
-90% mild, mod., severe
Adults -- 40% chronically energy deficient
Households- 40% deficient in calorie &
protein intake
3
Fig.12 Distribution (%) of children (1-5 Years) according
to Gomez classification and Sex
o
CJ>
2
c
o
o
o
45 -i
40 35
30 25
20 -
15 10 5
0 -
CL
E
■
9.2
s£
OJ
Q.
43.3
Will 41.11
6.4
? ;
Normal
□ Boys
□ Girls
41 -5]
Mild
Moderate
r 6.4
Severe
Fig.13 Distribution of Children (1-5 Years) according to
Gomez Classification and Age
50 -i
43.4 43.4
42.5
45 Hl-3 Years
40.1
□ 3-5 Years
40 35 30 25 . .. •
20 15 9.9 8.0
6.6 6.1
10 ..
5
__
0 -■
n
Normal
Mild
Moderate
Severe
Gomez Grades
NNMB
2002
4
India:
65% child deaths have mild-mod-severe
malnutrition as underlying cause
15% child deaths have severe malnutrition as
underlying cause
[Source: Palletier, D. L, E. A. Frongi I Io, D. G. Schroeder, and J. P. Habicht.
1995. The effects of malnutrition on child mortality in developing
countries. Bul-letin of the World Health Organization 73 (4): 443-48].
5
Classification of Biological Conditions of Food Deficit
Starvation—severest deficit linked to hunger and destitution;
• tip of the iceberg.
Chronic undernutrition—food intakes habitually lower than that necessary to meet
genetic potential;
•Social and biological inter-generational link
•Diminished perception of 'adequate food' and of hunger due to habituation
•Largest segment of the malnourished—40-50% children mod-severe.
•Manifests as stunting in children.
Acute undernutrition—sudden lowering of food intake or lowered utilisation of the
food ingested due to illness. Acute malnutrition in the normally well nourished tends to
pass over and full recovery occurs; if the food deficit/disease persists for long, then
chronic malnutrition could set in.
Acute on chronic undernutrition—sudden lowering of food intake or lowered utilisation
of the food ingested due to illness in those already subsisting on lower energy intakes
than required.
This is the condition of concern for today's discussion.
6
Acute on Chronic Undernutrition
•Sudden lowering of food intake or lowering of utilisation of the ingested food due
to illness
•In those already living at the brink of subsistence :
•Further increase in susceptibility and severity of disease.
•A vicious cycle of malnutrition and disease sets in, and
• Finally could end in death; I MR, Child death rate and adult death rates increase under
such conditions.
• Could be a sporadic case, as due to illness in the individual and a vicious cycle of
undernutrition and disease setting in.
•Or it could be an epidemic of acute undernutrition as a larger community level shortage
of food.
With 40% households and 50% children in chronic undernutrition the danger of
this happening in times of drought/flood, food price rise, sudden breakdown of
livelihoods or food supplies etc. becomes very high.
7
Hunger
Psychic/hedonistic hunger= the feeling of desiring more food
even when biological need is fulfilled (hedonistic /psychic hunger)
Incomplete need fulfillment =the feeling of need for more food
with an intake that is less than fulfilling biological need
Hidden hunger=the condition of lower intake than required for
achieving genetic potential but without the feeling of hunger due
to habituation (as in chronic malnut.)
Hidden hunger=micronutrient deficiencies due to quality of food.
8
Classification of communities/populations by nutritional
emergency status
Whole village/community near destitution, hunger and starvation, such as
some remote tribal villages; maha-dalit communities in Bihar;
Heterogeneity in most populations/villages/communities—with some betteroff with surplus; others having adequate in normal times but needing coping
strategies during drought etc.; a substantial section BPL; and a section of
households/individuals living lives of destitution. The last three have chronic
malnutrition among children in significant proportions.
Varying proportions of these various economic classes requires diverse
strategies in times of nutritional crisis. No state or district in the country
seems to be without substantial number of households with inadequate food
intakes, ranging from 10% to 80%.
[Underweight. Children 0-6 = 23% Kerala to 60% MP]
9
Diverse approaches to dealing with hunger and
starvation in this context:
■ Type 1--Requires state action in provisioning.
■ Type 2-Approaches would have to vary depending on the
proportion of households needing specific inputs—
10-20% hh. with food deficit some time of the year; 2040%; 40-70%; 70+%.
Better off could provide some support to the poor
through community action
10
Broad Approaches:
■ Macro level—Deal with the macro issues of employment and food
availability/access. Universal PDS, agriculture etc. are the solutions
■ Micro level—Identify the most vulnerable and address their situation urgently
on an individual/household basis. Special focus on the most vulnerable such as
destitute hhs., elderly, infants, single women, disabled, etc.
■ Meso level —Identify communities with hunger through a system of
nutritional surveillance that is able to give rapid rough results so as to provide
them emergency relief collectively.
■ Plurality of approaches with Contextual diversity—1+(2 where few hungry
hhs.; 3 where large no. of hhs.); 1+3+2 i.e. macro systemic solutions plus
nutrition surveillance ongoing, identification of the most vulnerable to ensure
their access to services, collective response whenever the nutrition surveillance
shows that conditions of acute hunger are developing.
11
How do the administrators perceive
the problem?
What information do they need to
act?
WHAT EXACTLY CAN A DISTRICT
COLLECTOR DO TO DETECT ACUTE
HUNGER EARLY?
12
Possible Methods for Identifying Community
Level Acute Food Deficits
Existing Methods in Use
1. Starvation death as marker of household hunger and
destitution-may be extendable to community
2. Identification of Drought affected areas—based on rainfall and
farm productivity
3.
Surveys for Self-reported Hunger [period of 'not having two
square meals a day7]—indicates chronic undernut. unless
repeated at short intervals and trends traced over years.
13
Proposed additional methods
4. Market off-take—from PDS+market—declines relative to previous years in a year of
normal or low production.
5. Anthropometric Indicators
•Anthropometric indicators at individual level—
--[Adult/Children;
-Weight for height/Height for age/Weight for age/BMI
-Gomez classification, NCHS standards/z-scores/WHO stds]
•Anthropometric indicators at a collective level—sentinel surveillance for declines in
anthropometry, eg using the ICDS monthly data
6. Village level listing of vulnerable population-- individuals / households/
communities--for special attention by village level functionaries in communication with
the community and Panchayats.
7. Rapid assessment of changes in food intake patterns --through group discussions in
the community.
14
HOW DO WE MAKE CHOICES
BETWEEN METHODS ??
15
Diverse Scientific & Administrative Paradigms
HOLISTIC
VS
The REDUCTIONIST & PARTIAL
16
HOLISTIC vs REDUCTIONIST
PARADIGMS
•
•
•
•
•
•
•
HOLISTIC
Plurality of approaches
Recognising Contextual Diversity
Macro to micro levels of data and
action
Triangulation for multi-dimensionality
of context
Uncertainty and subjectivity is
recognized
Decentralised information and data
base as well as community level action
Complementarity of Action
Segments—Administration, Academic,
Civil Society Organisations, Community
HOW???
REDUCTIONIST
•
•
•
•
•
•
•
Singular solutions
Universalist, One size fits all
Only one level of data and
action—Macro or Micro
Decontextualised data crunching
Singular objectivity, certitude of
evidence
Centralised data bases with
centralized management
Supremacy of One's Own
Role/Discipline Emphasisedlittle dialogue
17
THE METHODS AND TOOLS FOR
IDENTIFICATION, VERIFICATION AND
DETECTION OF ACUTE HUNGER
18
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2. Identification of Drought Affected
areas
Based on rainfall and farm productivity
20
3. Surveys for Self-reported
Hunger
Reported period of 'not having
two square meals a day'
21
4. MARKET OFF-TAKE—from
PDS+OPEN MARKET
Declines relative to previous years in a
year of normal or low local food
production
22
5. Anthropometric indicators at a
collective level
eg using the ICDS monthly data
As sentinel surveillance, not merely growth
monitoring of the individual child
23
6. Village level listing of vulnerable
population-- individuals /
households/ communities
For special attention by village level
functionaries in communication with
the community and Panchayats
24
7. Rapid assessment of changes in
food intake patterns
through group discussions in the
community.
25
Socio-Medical Tool for Early
Identification of Acute Hunger
Summary of Discussions
• Mapping vulnerable populations
- Consistently reported starvation deaths, SC/ST, PTGs,
special groups within communities (women headed
households, disabled, aged)
- Above average prevalence of SAM & Severe
Undernutrition for 0-6 yrs
- Using existing data
• Identifying signs of acute hunger
- Community reporting of
• Increased distress migration
• Decrease in market off take of food (PDS & Open market)
• Increased mortality from common illnesses
Summary of Discussions
• Community reporting of households with
- Distress sale of assets
- Begging for food
- Consumption of pseudo foods
— Distress borrowings from moneylenders
- Distress migration
Summary of Discussions
• Tool to be approved at the National level
• Tool to be used by local groups to advocate for
relief measures with local administration
• Advantage of the tool is that it will bring
rigour to existing data collection efforts and
make the process systematic
• Studies for mapping vulnerability
CENTRE OF SOCIAL MEDICINE & COMMUNITY HEALTH
SCHOOL OF SOCIAL SCIENCES
JAWAHARLAL NEHRU UNIVERSITY
New Delhi-110067
6th May, 2010
Dear
The Centre of Social Medicine & Community Health-JNU, the Office of the Commissioner to the Supreme Court on the
Petition of the PUCL vs Uol & others, Centre for the Study of Developing Societies-South Asian Dialogues on Ecological
Democracy (CSDS-SADED) and Centre for Equity Studies (CES) are collaboratively organising a technical workshop to discuss
the optional tools and methods for identification of starvation deaths and early signs of food shortage in a community such
that it enables the civil administration to act effectively in response. The one-day National Consultation on Developing
Socio-medical Tools for Early Identification of Acute Hunger and Starvation for Effective Administrative Action is to be
held on the 13th May, 2010 at Jawaharlal Nehru University, School of Social Sciences-I Committee Room.
The problem of chronic malnutrition is a curse at least 40% of Indian households live with, 30-40% of adults and 50-60% of
children below 6 years being undernourished.
Methods for identifying the chronically malnourished through
anthropometric indices using reference standards are fairly well worked out and in use. However, the methods for
identifying acute hunger and malnutrition are less developed or used. While 'wasting', i.e. loss of weight against height, is
the marker of a sudden or acute dip in food intake, it has several limitations, and there is little by way of a working
consensus among nutritionists, public health persons and administrators on how to identify this in individuals, population
groups and communities, especially for the Indian/South Asian context. Since these are relevant for emergency situations of
acute food shortage and life-saving provisioning of foodgrain, there is a need to develop them on an urgent basis.
The primary objective of the identification under consideration is to develop working criteria that can be used at a mass
level for initiating action by the administrative machinery. They could also be used to support advocacy for administrative
action. A third purpose of this surveillance would be the mobilization of civil society and community level action on the
issue of acute hunger.
Given your experience and expertise in relation to the subject, we would value your participation in a technical
deliberation. Please do find the time to be with us and contribute in developing meaningful tools that can be
operationalised for minimizing the hunger and starvation. Travel by 2nd AC train or air will be reimbursed and local
hospitality provided. Our apologies for the short notice.
With best wishes and regards.
Ritu Priya
(Professor,
Centre of Social Medicine
& Community Health, JNU)
Harsh Mander
(Special Commissioner, Supreme Court
& Director, Centre for Equity Studies)
Enclosed: (1) Concept Note, (2) Tentative Programme
1
National Consultation on Developing Tools for Early Identification of Acute Hunger for
Effective Administrative Action
The Centre of Social Medicine & Community Health, JNU, the Office of the Commissioner to the Supreme Court
on the Petition of the PUCL vs GOI, CSDS-SADED and Centre for Equity Studies are organising a technical
workshop to discuss the optional tools and methods for identification of starvation deaths and early signs of
food shortage in a community such that it enables the civil administration to act effectively in response.
The Problem
The problem of chronic malnutrition is a curse at least 40% of Indian households live with, 30-40% of adults and
50-60% of children below 6 years being undernourished. Methods for identifying the chronically malnourished
through anthropometric indices using reference standards are fairly well worked out and in use. Of course, the
uncertainty and probabilistic nature of any such assessment constantly leads to contentions and further refining
of the methods, from the Gomez classification to the z-score based cut-offs, to the reference curves and to the
most recent WHO standards for child growth of 2006. The ICDS is meant to regularly measure weight of each
child registered with the anganwadi and plot it against a graph that marks the expected healthy increase of
weight by age.
However, the methods for identifying acute hunger and malnutrition are less worked out. There is little by way
of a working consensus among nutritionists, public health persons and administrators on how to identify this in
individuals, population groups and communities, especially for the Indian/South Asian situation. Since these are
relevant for emergency situations of acute food shortage and life-saving provisioning of foodgrain, there is a
need to develop them on an urgent basis.
Given the high levels of chronic undernutrition, a high proportion of our people live at bare subsistence
consumption of food. Any further lowering of food intake leads to loss of survival. While 'wasting', ie. loss of
weight against height, is the marker of a sudden or acute dip in food intake, it has several limitations. One is the
operational barrier of heights being difficult to measure with reasonable accuracy in field conditions by
community level workers. Weights are easier to measure and are more inclusive for assessment of malnutrition.
The second is that acute malnutrition is often accompanied by communicable disease and this can be viewed as
the primary problem and argued that the loss of weight has been secondary to it. If the child dies, the disease is
often contended to be the cause of death rather than the deficiency of food. Given this perception, the
response then is to provide medical care and not food relief. Systems of nutritional surveillance need to be set
up that can detect acute declines in access to food and nutritional status early enough so that public action can
minimise the hunger and starvation.
The primary objective of the identification under consideration is to inform the definition of criteria that can be
for used at a mass level for initiating action by the administrative machinery. They could also be used to support
advocacy for administrative action. A third purpose of this surveillance would be the mobilization of civil society
and community level action on the issue of acute hunger.
2
Identification for Administrative Action
Currently there are two ways in which the administration recognizes acute hunger and responds with pre
emptive action.
1.
One is by acting in favour of a household where a starvation death has occurred to provide relief to its
surviving members. Starvation, ie death due to severe deficiency of food intake, which is below the
energy requirement of basic physiological functioning, has been conventionally identified by the civil
administration by an autopsy that shows presence of no food in the stomach. Then the household of
the person who died of starvation, gets emergency relief (10kg. food grain, work for food etc.). As per
the colonial Famine Code, even 2 grains of rice found in the stomach is 'proof against starvation as
cause of death. This definition often makes it difficult for the civil administration to accept the 'proof of
a starvation death despite all circumstantial evidence to support the contention.
A JSA group had worked on this problem some years ago and has developed a methodology for identifying
starvation deaths for initiation of administrative action and advocacy for the same. The office of the
Commissioner of the Supreme Court in the case of PUCL vs GOI has also worked out a methodology for
identifying deaths that require urgent relief for the household of the dead person. It addresses many of the
challenges faced in investigating any reported cases of starvation deaths in a meaningful way for the people
suffering such levels of destitution. We would like to discuss these and any others, so that all of us can be better
informed on them as well as create a consensus on what is the technically appropriate method for the stated
objectives.
2.
Other than starvation deaths that draw attention to the plight of individual households, there is the
provision for declaring districts as 'drought affected', so that then relief works and other measures for
application at population level can be initiated. This is an extremely important measure and its
implementation requires to be strengthened.
However, this measure has its limitations. For instance it will not apply to a situation of food shortage
which is due to rise in food prices or a situation of sudden unemployment such as closure of factories.
Also it will not be able to identify specific pockets of hunger and the most vulnerable are often left out
as beneficiaries of the relief works. Some community level means of identification have to be developed
for local action. The method(s) will need to have a ready data source that allows constant monitoring or
surveillance of nutritional status and a system for quick recognition of declines in it.
At one level, the local situation can be monitored by economic data such as trends in the sale of
foodgrains in the area. The second method possible is by data on consumption of food items, and the
third is by anthropometry. It is considered worthwhile to develop multiple ways of surveillance and a
system that is able to use them all together. The surveillance should also be closely linked to a response
mechanism that immediately acts on the information about declines in nutritional status. One
suggestion, as in the attached note, is about using the ICDS growth monitoring system for not only the
individual level identification of child malnutrition but also for surveillance of the collective situation in
the community.
3
There is need to discuss all the possible options and form a working consensus on what would be the
best tools and methodology for early identification of acute food shortage and hunger before it results
in starvation deaths, given the present knowledge and possible sources of data as well as the
requirements for the civil administration to act. This may be useful for responding to the immediate
crisis at hand. However, for building systems in the longer term, we would not like to restrict ourselves
to the present constraints of data sources and would like a detailed discussion on what could the wish
list of tools be for the most effective and rational methodology .
Thus, we hope to have one session at the brainstorming for presentation of the methods for identifying
starvation deaths, with initial presentation of the various methodologies. The post-lunch session would deal
with other tools for early identification of acute hunger at a collective level. The focus is explicitly on developing
tools that enable the administration to institute emergency responses through a multiplicity of pathways.
Tentative Programme
Venue: Committee Room, School of Social Sciences-I
Jawaharlal Nehru University, N.D-110067
Date: 13,h May, 2010
9.00am:
Registration & Tea
9.30am:
Welcome: Rama Baru, Chairperson CSMCH
Introduction to the Workshop
Introduction of Participants
lOam-lpm:
Technical Session I
Chair—N.C. Saxena
1.
Challenges in Identification and Verification of Starvation Deaths & Acute Hunger --Harsh Mander
2.
Overview of Public Health Approach to Early Detection of Acute Hunger: the Challenges &
Possibilities—Ritu Priya
3.
Guidelines by the Jan Swasthya Abhiyan Hunger Watch Group on Verification of Starvation Deaths
& Detection of Hunger in the Community —Vandana Prasad
4
ll-11.15am TEA
4.
Experiences of the Investigations into Starvation Deaths—State Advisors to the Commissioner's
Office
Round Table Discussion on Criteria for Defining and Verifying Starvation
Closing remarks for 1st session by Abhijit Sen
l-2pm: LUNCH
2-5pm: Technical Session II
Round Table Discussion on Methods for Early Detection of Acute Food Deficits in the Community
Chair—Imrana Qadeer
1.
Tools based on Food Production, Availability & Access
2. Anthropometric Tools
TEA
3.30-3.45
Discussion on Draft Resolution
5.15-5.30
1.
On the definition and identification of starvation death
2.
On methods for early detection of large scale acute hunger
TEA & Snacks
5
8! Review
@ Management of severe acute malnutrition in children
Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler, Alistair Hallam
Lancet 2006; 368:1992-2000
Published Online
September 26,2006
DOI:1O.1O16/SO14O6736(06)69443-9
Valid International Ltd, Oxford,
UK (S Collins MD, N Dent MSc,
P Binns RGN, P Bahwere MD,
K Sadler MSc, A Hallam BM BCh);
and Centre for International
Child Health, Institute of Child
Health, Guilford Street,
London, UK (S Collins, K Sadler)
Correspondence to:
Dr Steve Collins, Valid
International Ltd, Unit 14
Standingford House, 26 Cave
Street, Oxford
0X41BA
steve@validinternational.org
Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or
three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral
pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1-5 years.
13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable
child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does
not recognise the term “acute malnutrition”. Inpatient treatment is resource intensive and requires many skilled and
motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the
effect of treatment; case-fatafity rates are 20-30% and coverage is commonly under 10%. Programmes of
community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These
programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce
opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In
community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This
approach promises to be a successful and cost-effective treatment strategy.
However, as acute malnutrition becomes more severe,
normal physiological mechanisms that adapt the organism
to low food intake become more pronounced.^12 These
“reductive adaptations" affect every physiological function
;,IJ-1S mobilising energy and nutrient reserves
in the body?
and
decreasing
energy
<
- and nutrient demands; they are
' the organism
’ l to maintain
initially beneficial 'and" allow
homoeostasis. However, as the severity of nutritional insult
increases, these adaptations progressively limit the body’s
ability to respond to stresses such as infection.15”17 In
practice, inpatient units treating SAMI are commonly
confronted by extremely ill patients who need intensive
medical and nursing care. Most of these units are in the
poorest
of the .poorest countries and have severe
r------ x parts
C
f
1 -Il
1
. Cf T—1
capacity constraints, m particular, very few sidled staff. In
addition,
most
carers of malnourished nauents
patients come from
—--------- —
the
poorest
families
and
have
great
demands
on their time.
wasting is defined with a weight-for-age indicator. As
To
achieve
an
impact
at
a
population
level,
management
these different forms of malnutrition have different
protocols
must
take
these
socioeconomic
realities into
causes and require substantially different treatments,
account, balancing the potentially conflicting demands
clear nomenclature to differentiate them is needed.
Case-fatality rates in hospitals treating SAM in and ethics of clinical medicine with those of public health.
developing countries average 20—30% and have remained
unchanged since the 1950s5 despite the fact that clinical Worldwide public-health significance of
management protocols capable of reducing case-fatality malnutrition
rates to 1-5% have been in existence for 30 years. In 1992, Malnutrition is a major public-health problem throughout
’i over
this failure to translate scientific knowledge of what is die developing world and is an
50%
of
the
lff-11
million
children
under
5
years
of age
needed to treat malnutrition into effective large-scale
who
die
each
year
of
preventable
causes.
18
”
21
However,
interventions, was criticised as “nutrition malpractice”;6
- 13 years and numerous studies and —
clinical
manuals while the child-survival movement commonly acknowgreater"discrepant bet^een'actual ledges the importance of undemutrition, defined as low
later, there is an even t
- ■ - - and’ our weight for age,22 the importance of acute malnutrition is
practice in most institutions treating SAM
seldom mentioned. For example, none of the five papers
knowledge of what works.
The treatment of severe acute malnutrition occupies a of the recent child survival series in The Lancet mention
unique position between clinical medicine and public acute malnutrition.22 This is a serious omission; acute
health. The causes are essentially poverty, social exclusion, malnutrition is an extremely common disorder, associated
poor public health, and loss of entitlement,7 and most cases with high rates of mortality and morbidity and requiring
can be prevented by economic development and specialised treatment and prevention interventions.
* ’ •' there
’ ; are about 60 million children with
public-health measures designed to increase dietary —
Worldwide
moderate
acute
quantity and quality alone, with no need for clinical input, u.--------- ------ and 13 million with severe acute
Introduction
Severe acute malnutrition (SAM), is defined as a
weight-for-height measurement of 70% or more below
the median, or three SD or more below the mean National
Centre for Health Statistics reference values (that will
likely be replaced by new WHO growth curves1), which is
called “wasted”; the presence of bilateral pitting oedema
of nutritional origin, which is called oedematous
malnutrition”;2 or a mid-upper-arm circumference of less
ttem 110 mm in children age 1-5 years.3-4 Many advanced
by concurrent infective
cases of SAM are complicated
<
illness, particularly acute respiratory infection, diarrhoea,
and gram-negative septicaemia. By contrast, chronic
malnutrition (termed “stunted”) is defined by a
height-for-age indicator. In addition, a composite form of
malnutrition including elements of both stunting and
www.thelancet.com Vol 368 December 2,2006
1992
Review
malnutrition. About 9% of sub-Saharan African and 15%
of south Asian children have moderate acute
malnutrition23 24 and about 2% of children in developing
countries have SAM.24 In India alone, 2-8% of children
under 5 years of age (over 5 million children) are severely
wasted25-27 and in many poor countries such as Malawi,
SAM is the commonest reason for paediatric hospital
admission.28
The risk of mortality in acute malnutrition is directly
related to severity: moderate wasting is associated with a
mortality rate of 30-148 per 1000 children per year29,30 and
severe wasting is associated with a imortality rate of
73-187 per 1000 children per year.29 This equates to over
1-5 million child deaths associated with severe wasting
and 3 • 5 million with moderate wasting every year. These
umbers do not include children who die of oedematous
.alnutrition (kwashiorkor), a form of SAM that in some
countries is more common than the wasted form, and
probably, therefore, underestimate the total number of
child deaths directly associated with acute malnutrition
(table).
High case-fatality rates for SAM
Over the past 50 years, in most resource-poor settings,
case-1■fatality rates for severe malnutrition treated in health
facilities have remained at 20-30%—for marasmus
(wasting malnutrition) and up to 50-60% for
kwashiorkor.531 By contrast, since the 1970s there have
been management protocols capable of achieving
case-fatality rates of 1—5%,15 3233 and well-resourced
humanitarian agencies using these protocols frequently
achieve mortality rates under the 10% level stipulated in
the international Sphere Project standards.4,34,35
Current management protocols
At present, an exclusive inpatient approach to the clinical
are of SAM is recommended. The core of accepted
Regionst
Under-5 population Wasting prevalence
Wasting numbers
2000(xl000)
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(%)
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117547
707584
286489
.
41
: -
10929
7 t 2"7-| :::::i 7 :H046 77B 7 2209
60228
13139
2905951
1444214
: : 7 671290 -: 7 291918:
3577241
.
....
7::7:
-
39
7
• ueastdevelopedcountries ^-1104587: 7^777:B’^IOTota|
168942
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Latin AmericaandCarlbbean
B Developing countries
Total
421767: : ! vOWB
S6S768
890
3114
<2498577| Bin 73331
4
" 159454
Annual mortality numbers
e2Z scores »3Z scores
below WFH
and severe
- '
WHO management protocols is ten steps in two phases
(stabihsation and rehabilitation).236-39 The approach
requires many trained staff and substantial inpatient bed
capacity. Where these are available and sufficient
attention is paid to the quality of care, there is good
evidence that these protocols can substantially decrease
case-fatality rates in both stable environments33,40-” and
during emergency humanitarian interventions.34,45
However, despite the success of these protocols when
implemented in specialised units, their publication has
not led to widespread decreases in case-fatality rates in
most hospitals in the developing countries.4647
The persistence of high case-fatality rates is commonly
attributed to inappropriate case management as a result
’ ’ .5>48 The accepted view is that wider
of poor knowledge/
implementation of the WHO guidelines through
in-service training and incorporation into medical and
nursing curricula is the key to substantially decreasing
case-fatality rates worldwide.25,37,49-52 However, whereas
there is good evidence that adequate training of health
staff i*1
management of SAM is essential if the
implementation of the WHO guidelines is to be effective,
the evidence base supporting the view that the wider
implementation of the WHO guidelines is key to the
reduction of case-fatality rates is weak. There have been
no published controlled trials looking at the effect of the
use of the WHO protocol in operational settings. In their
absence, the evidence of the positive effects of these
’; comes from observational studies done in a
protocols
few selected hospitals or well-resourced, nongovernmental-organisation, humanitarian operations,
These studies all suggest that the availability of sufficient
resources,53 particularly skilled and motivated health
staff, is a vital determinant of success and effectiveness.
In practice, the many skilled staff needed are rarely
available. For example, in Malawi in 2003-04 there were
only 1 • 13 physicians and 25 • 6 nurses per 100 000 people,
1736132
4350164
S
7963209iv,:.-7:
5313373
J
2 Z scores).” tSevere mortality rate-132/1000/year (average of five studies, range 73-187 children with mid-upper-arm circumference <110 mm).
Table: Worldwide burden of acute malnutrition in children aged lessthan 5 years
www.thelancet.com Vol 368 December 2,2006
1993
!
Review
In the 1970s, these problems prompted moves to
demedicalise the treatment of SAM and move the locus
of treatment away from hospitals to communities, into
either simple nutrition rehabilitation centres, existing
primary health-care clinics, or the homes of those
affected.31-74 The results from early outpatient treatment
programmes were variable. Some achieved low mortality
rehabilitation units in Malawi, only reducing them from and positive effects on growth while children were
25% to 20%.55 The paucity of skilled health staff is not attending nutrition rehabilitation centres, but usually
w Malawi
...
restricted to
and in 20 of the African countries these benefits were not maintained after discharge.75-77 In
most affected by acute malnutrition there are fewer than others, mortality and relapse rates both during treatment
four doctors and 22 nurses per 100000 people.54 The and after discharge were high72-78 and rates of weight gain
World Bank has identified the lack of skilled human were low.7980 The requirement for children to attend each
resources as a fundamental constraint to the day and eat in the nutrition rehabilitation centres has
improvement of health outcomes and the reaching of also resulted in low programme coverage, often Pr°ving
with mothers "and resulting in Vhigh
Millennium Development Goals.56 In practice, shortages to
’ be unpopular
’
of skilled staff commonly preclude the effective and default rates.42
In 2001, Ashworth reviewed 27 such programmes from
sustainable implementation of WHO guidelines for the
the
1980s and 1990s.81 Only six (22%) of the 27 achieved
management of SAM.
case-fatality rates of less than 5%, average weight gains of
Effect of HIV and tuberculosis
more than 5 g/kg/day, and relapse or readmission rates
HIV and tuberculosis are increasing the workloads of of less than 10% Ashworth ^concluded ^that* borne
hospital units treating SAM through both the direct treatment is rarely successful81 and that the early
effects of infection and the indirect negative effects on discharge
~ of severely malnourished patients from
" ’hazardous,,52 In 2005,
livelihoods and food security. HIV and tuberculosis inpatient treatment units is usually
infection decrease skilled human resource capacity in Ashworth updated her review to include! an additional six
health services, raise the prevalence of SAM, and studies of ready-to-use therapeutic food. Five (83%) of
increase case-fatality rates.43'44,S7M In sub-Saharan Africa, these six studies were considered to be successful; a far
a high proportion of severely malnourished children greater success rate than in those studies not using
admitted to nutritional rehabilitation units are now also ready-to-•use therapeutic food.82
Two other programmes, both
in Bangladesh, have
HIV positive,5557-*3 particularly those with marasmus.5759
.
In 2000 in Malawi for example, 34% of the severely reported successful rehabilitation
malnourished children admitted to the Blantyre Queen discharged to home care after 1 week of inpatient
Elizabeth hospital nutritional rehabilitation unit were management with mixtures oflocal foods combined with
HIV positive.57 Although experience in resource-poor, the provision of multivitamins and minerals.42’83 The costs
sub-Saharan countries has showni that
that many
many for home-based treatment of US$29 and US$22-30 were
normal
nutritional
HIV-positive children can recover
-------------------- substantially lower than those of US$156 and US$74-60
status when given standard treatment protocols for for hospital care.83-84 Similar improvements in
SAM without antiretroviral drugs,58'64 their recovery is cost-effectiveness of care85 were seen in home-treatment
slower than that of uninfected children. HIV infection programmes in Jamaica,
is also associated with high rates of complication and
Ready-to-use therapeutic food
case fatality.55,57'59
The Ashworth review indicates that the recent
Treatment at home and in the community
development of ready-to-use therapeutic food has greatiy
Concerns over the limited capacity of hospital units to eased the difficulties associated with providing a suitab e
treat SAM are not new. Since the 1960s, the high cost and high-energy, nutrient-dense food that is safe for use in
poor success rates of inpatient treatment have prompted outpatient programmes. Ready-to-use therapeutic food is
debate over whether hospitals were the
the best
best places
places to
to an energy-dense food enriched with minerals and
treat SAM.6566 There are several well-known weaknesses vitamins, with a similar nutrient profile but greater energy
of a centre-based approach: limited inpatient capacity and
<-----nutrient density, than F100, the diet recommended by
and lack of enough skilled staff in hospitals to treat the WHO in the recovery phase of the treatment of-------SAM.,86 In
contrast
to
the
water-based
F100,
ready-to-use
therapeutic
large numbers needing care; M the centralised nature ot
—------ ---------.
hospitals promotes late presentation and high opportunity food is an oil-based paste with an extremely low water
therapeutic
food
costs for carers; and the serious risks of cross infection activity.
«— t 87 As a result, ready-to-use
.
. does
for immunosuppressed children with SAM and the high not grow bacteria even when
allowing
in —
simple packaging
mortality rates before and after discharge.31'6*-72 These Cl.
’ it to be kept unrefrigerated omn.
concerns persist today.”
for several months. As the food is eaten uncooked,
15 ofthe 26 districts had on average fewer than 1 • 5 nurses
per facility, and five districts had fewer than one nurse
per facility; there were ten
1 districts without a Ministry of
Health doctor, and four districts without any doctor
(Vujidc M, World Bank, personal communication).
Perhaps as a result ofthese constraints, the use of similar
protocols had little effect on CFRs in nutrition
www.thelancet.com Vol 368 December 2,2006
1994
Review
heat-labile vitamins are not destroyed during preparation
and the labour, fuel, and water demands on poor
households are minimised. The production process is
simple, and ready-to-use therapeutic food can be made
from local crops89 with basic technology that is readily
available in developing countries.9091
In a clinical trial in severely malnourished children in
Senegal, energy intakes (808 kj/kg/day vs 573 kj/kg/day,
p<0-001), rates of weight gain (15-6 g/kg/day vs
10-1 g/kg/day, p<0-001) and time to recovery (17-3 days
vs 13-4 days, p<0-001) were all significantly greater in
those receiving ready-to-use therapeutic food than in
those receiving F100.92 Trials in Malawi have also
successfully used a take-home ration given to children in
the recovery phase of the treatment of SAM. In one, a
ke home ration of 730 kj/kg/day (175 kcal/kg/day)
severely
-uccessfully rehabilitated HIV-negative,
" i a
malnourished children, after early discharge- from
nutrition rehabilitation units providing initial, phase-one
care according to WHO protocols. Rates of weight gain
(5-2 g/ke/dav
' ” r vs 3-1 g/kg/day) and the proportion of
'
e/ recovering
7
---- weight for height (95% vs
children
to 100%
/o/Q relative
icxaiivt risk pxxvj
*
.-z- CI
— 1-1-1-3), were
78%
[RR] 1-2,
95%
significantly better in the ready-to-use therapeutic food
groups when comiipared with groups receiving a larger
- - - flour
-• ’
amount of energy from com-soya-blend
supplied
by the World Food Programme.28 In the same trial, 56%
of the HIV-positive children treated with ready-to-use
therapeutic food also achieved 100% weight for height.64
In another trial implemented in rural nutrition
rehabilitation units, 730 kj/kg/day of locally made
ready-to-use therapeutic food given during the
rehabilitation phase of treatment produced significantly
better rates ofweight gain (3 • 5 g/kg/day vs 2- • 0- g/kg/day),
'
. Centralised treatment increases
inpatient facilities,
barriers to access for rural communities where acute
malnutrition is most prevalent. Increased barriers to
access and opportunity costs serve to delay presentation,
making the disorder harder to treat, and increase the
number of patients with complications. These barriers
increase costs and case-fataHty ratios55 and decrease the
proportion of severely malnourished children who are
able to access treatment, thereby reducing coverage
(unpublished).
Community-based management of acute
malnutrition
During the past 5 years, a growing number ofcountries
and international relief agencies have adopted a
community-based model for the management of acute
malnutrition, called community-based therapeutic
care.9*-97 This model provides a framework for an
integrated public-health response to acute malnutrition,
treating most patients with SAM solely as outpatients and
reserving inpatient care for the few with SAM and
del also
complications.7i73 The
The mo
model
also aims
aims to
to integrate
integrate
treatment with various other interventions designed to
reduce the incidence of malnutrition and nnprove public
health and food security. Programme design attempts to
into accOunt the socioeconomic factors, particularly
poverty, high workloads for women, and the exclusion
from health and education services that contribute to the
late presentation of cases of acute malnutrition.
Programmes are therefore very decentralised to minimise
geographical barriers to access73 and include intensive
community consultation and mobilisation to maximise
understanding and participation. This design minimises
the costs to families and maximises access to treatment.
recovery (79% vs 46%, RR 2'8 95% CI 2,5—3*1), and The decentralised design also means that, in
mortality (3-0 vs 5-4%, OR 0-5, 95% CI 0-3-0-7) than non-emergency situations, there are few cases of SAM at
lid the standard inpatient treatment with F100, followed any one access point and the quantities of ready-to-use
by outpatient supplementation with a large one-off ration therapeutic food required to treat them are therefore
(50 kg) of corn-soya-blend flour.93 However, the rates of small. In current Ministry
. of Health implemented
weight gain on the ready-to-use therapeutic food regime programmes in
in Malawi, for example, a health-centre
were far lower than the 10-15 g/kg/day that can be treating 15 children with SAM per month reqmres 160 kg
achieved with a ration of730 kj/kg/day. The combination (eight boxes) of ready-to-use therapeutic food. This small
of low rates of weight gain and low mortality rates quantity can be delivered easily together with other
indicates that this was probably due to sharing of the routine health supphes. This eases the problems
ration
associated with integrating community-based therapeutic
“rhe development of ready-to-use therapeutic food has care into existing health services, even in resource-poor
allowed much of the management of SAM to move out of
hospitals. By shortening the duration of inpatient
treatment from an average of 30 days to only 5-10 days,
the move towards using ready-to-use therapeutic food in
the recovery phase of treatment reduces the resources
needed to treat SAM, which improves cost-effectiveness.
The provision of phase-one inpatient care for all cases,
however, still requires substantial resources and entails
substantial opportunity costs for carers. A requirement for
inpatient care also means that programmes must be
implemented from hospitals and large clinics with
www.thelancet.com Vol 368 December 2,2006
settings.
The use of mid-upper-arm circumference as the sole
anthropometric indicator for screening and admission
into community-based therapeutic: care
care also
a*so facilitates
community participation, helping to devolve responsibility
for selection of patients towards the community.
Mid-upper-arm circumference is an indicator of acute
malnutrition that reflects mortality risk99"102 and has
recently been endorsed1 as an independent criterion for
admission
into u
therapeutic
feeding programmes by an
J
“
informal consultation of WHO.103104 The use of this
1995
Ig Review
measure requires no complicated equipment and can
easily be taught to community-based workers, making it
practical for use in resource-poor settings.105106
Community-based therapeutic care's clinical approach
is based on the fact that the severity of SAM, its prognosis,
and the determinants of successful treatment are
primarily dependent on the time to presentation.2850-55,68"107108 SAM is classified on the basis of whether
there are coexistent life-threatening complications109
(figure). Children presenting with SAM complicated by
life-threatening illness receive inpatient care according
to the WHO treatment protocols. Those with SAM but
without life-threatening complications are treated
through weekly or fortnightly attendance in outpatient
therapeutic programmes. In outpatient therapeutic
programmes, they receive an 837 kj/kg/day
(200 kcal/kg/day) take-home ration of ready-to-use
therapeutic food, a course of oral broad-spectrum
antibiotics, vitamin A, folic acid, anthelminthics and, if
appropriate, antimalarials. To increase access to treatment
and encourage earlier presentation, outpatient therapeutic
programmes are decentralised and implemented through
standard primary health-care units or even non-permanent
access points. This approach results in most children
presenting at a stage when they can still be treated
effectively as outpatients by front-line health staff, which
greatly reduces the need for trained clinic staff, thereby
easing integration into routine health services.
Case-fatality rates among 23511 unselected severely
malnourished children treated in 21 programmes of
community-based therapeutic care in Malawi, Ethiopia,
and Sudan, between 2001 and 2005, were 4-1%, with
recovery rates of 79-4% and default rates of 11-0%. 74%
of these severely malnourished children were treated
solely as outpatients.94-95 103 Coverage rates for nine ofthese
programmes have been estimated with a new
coverage-survey technique designed to provide more
precise coverage estimates of health-care programmes.110
Average coverage was 72-5%,95 103 substantially higher
than coverage rates seen in comparable centre-based
programmes which are often less than 10%.111112 Similar
positive results have recently been published from Niger,
where Medecins Sans Frontieres (MSF) cared for more
than 60000 children with SAM with an approach based
on outpatient therapeutic programmes. About 70% of
patients were treated solely as outpatients and overall
case-fatality ratios were about 5%.113
Community-based therapeutic care has also shown
promise as an intervention to assist children with SAM
infected with HIV. A cohort trial in Malawi assessed the
effectiveness of community-based therapeutic care in the
treatment of SAM in HIV-positive and HIV-negative
children and examined its use as an entry point for
home-based care programmes targeting people living
with HIV/AIDS.114 59% of the severely malnourished
HIV-positive children not receiving antiretroviral drugs
recovered compared with 83-4% of the HIV-negative
1996
Severe acute
malnutrition
I
Without complications
With complications
MUAC <110 mm
1 Bilateral pitting
oedema grade 3*
(severe oedema)
or
Bilateral pitting oedema
grades lor 2* with
MUAC illOmm
or
2 MUAC <110mm
and bilateral pitting
oedema grades 1 or 2
(marasmic kwashiorkor)
and
• Appetite
• Clinically well
• Alert
or
3 MUAC <110mm or
bilateral pitting oedema
grades 1 or 2
and one of the following:
• Anorexia
• Lower-respiratory-tract
infection*
• Severe palmar pallor
• High fever
• Severe dehydration
• Not alert
Outpatient therapeutic
care protocols
Inpatient care
IMCI/WHO protocols
Figure: Classification of severe acute malnutrition used in community-based
therapeutic care
MUAC=mid-upper-arm circumference. ICMI=lntegrated Management of
Childhood Illness. ‘Grade l=mild oedema on both feet or ankles;
grade 2=moderate oedema on both feet, plus lower legs, hands, or lower arms;
grade 3*severe generalised oedema affecting both feet, legs, hands, arms, and
face. tIMCI criteria:3’ 60 respirations/min children age <2 months;
50 respirations/min for age 2-12 months; 40 respirations/min for ages
1-5 years; 30 respirations for age >5years.
children (p<0-002, unpublished). However, at a mean
follow-up of 15 months after discharge, 53% of
HIV-positive children had relapsed into moderate acute
malnutrition compared with 10-4% of the HIV-negative
children. HIV-positive children therefore need continual
community-based monitoring after discharge and, for
treatment to be optimally effective, community-based
programmes for SAM must be integrated with
home-based care and antiretroviral-drug programmes
for HIV. In this study, the uptake rate for voluntary
counselling and testing for children attending the
-programme
---- ------------was greater than 90%, far greater than
usually seen in Malawi (unpublished). This finding
shows a high potential for synergy and integration
between community-based therapeutic care, home-based
care, and antiretroviral-drug programmes for HIV.
Programmes of treatment for SAM tend to be highly
cost effective in terms of additional years of life gained
www.thelancet.com Vol 368 December 2,2006
Review
because they precisely target resources at children with a
very high mortality risk. Initial data indicate that the
cost-effectiveness of emergency community-based
therapeutic care is comparable to mainstream
child-survival interventions, such as vitamin-A provision
or oral rehydration therapy for diarrhoeal disease.
Estimates from two established emergency programmes
were US$101-197 per admission which is equivalent to
between US$12 and US$132 for each year of life gained
dependent on the assumptions made for the mortality
rates of untreated SAM.115 The exact figure depends on the
density and prevalence of severe acute malnutrition, the
numbers of acutely malnourished children treated, the
infrastructure present, accessibility, and the estimation of
case-fatality ratios in untreated SAM.103115 jAlthough these
^re 1broad ranges, they are below the $150 threshold
^escribed by the World Bank as highly cost-effective. The
development of local production of ready-to-use
therapeutic food with new cheaper recipes based on locally
available grains and pulses should further reduce costs.
Conclusion
Where sufficient resources are available, the WHO
inpatient treatment model for SAM can achieve low
case-fatality rates. However, exclusive inpatient
i
treatment strategies are resource-intensive and require
many skilled staff. Because the prevalence of SAM is
highest in resource-poor environments, there is usually
a substantial mismatch between the many patients
requiring treatment and few skilled staff and scarce
resources available to treat them. The HIV/AIDS
pandemic is further lowering resource ;availability and
’ ' 1
increasing the numbers of acutely malnourished
children, Aggravating this mismatch and increasing
case-fatality rates.
New approaches for the management of SAM, such as
:ommunity-based therapeutic care, complement the
existing WHO inpatient protocols. These programmes
use ready-to-use therapeutic food to treat most children
suffering from SAM as outpatients, reserving inpatient
treatment for those with complications. They are
designed to decrease barriers to access, encourage earlier
presentation, reduce opportunity costs associated with
treatment, and encourage compliance by patients.
Treatment ofmost patients with SAM solely as outpatients
reduces inpatient caseloads to more manageable levels,
which helps decongest crowded inpatient units, decreases
the risks of nosocomial infection, and increases the time
available to staff to devote to the sickest children. These
new approaches have greatly reduced case-fatality rates
and increased coverage rates—initial data indicate that
they are very cost effective.
t
: wayvforward
:
1
The
Community-based therapeutic care should now be scaled
up in both emergency and non-emergency settings and
appropriate training included in medical, nursing, and
www.thelancet.com Vol 368 December 2,2006
primary health-care curricula. To start this process,
WHO, UNICEF, and the UN Standing Committee on
Nutrition recently convened an informal consultation on
the community-based management of severe
malnutrition in children. The meeting began the process
of incorporating these techniques into the WHO
guidelines.103 This is an essential step. However,
improvements in treatment protocols, programme
design, and training are, by themselves, insufficient. If
community-based therapeutic care is to attain its
maximum potential in reducing avoidable child mortality,
there must be changes in funding priorities and child
survival strategies. Leveraging these changes will require
strong evidenced-based advocacy highlighting the global
importance of SAM and communicating clearly the fact
that highly
. cost-effective interventions exist.
WHO should adopt the term “acute malnutrition" to
differentiate wasting and oedematous malnutrition from
growth faltering and stunting. Acute malnutrition has
different causes, different indicators, and requires
different interventions to chronic malnutrition. Without
a clear and appropriate nomenclature these differences
are obscured, which results in confusion over treatment
strategies and mixed messages going out to
policymakers.
Second, the global importance of SAM as a major cause
of avoidable mortality must be better communicated and
the child survival agenda must give greater priority to
treatment of the disorder. This" requires SAM to be
included as a specific cause of death in
mortality-surveillance data and included as a diagnosis in
standard morbidity surveillance. Without this, the high
numbers of deaths and high morbidity attributable to
SAM will continue to go unrecorded and un-noticed. ,
Third, nutritionists should communicate the fact that
there are successful and highly cost-effective interventions
for SAM. Although the hospital-based treatment of SAM
is more cost-effective than many of the mainstream
child-survival interventions, such as treatment of severe
diarrhoea in hospitals or vitamin-A distribution,112”6 this
has been poorly communicated to policymakers and
funders. Community-based therapeutic care promises to
increase this cost-effectiveness further. There is a need
for more cost effectiveness data and for these findings to
hers.
be communicated to policymake
Last, an appropriate indicator ofacute malnutrition, such
as mid-upper-arm circumference, should be included as a
standard element in both growth monitoring programmes
and integrated management of childhood illness to allow
these programmes to diagnose acute malnutrition more
effectively. This indicator is essential if cases of SAM are
to be caught early, before complications arise and while
cheap outpatient treatment is possible. At present,
growth-monitoring programmes do not include any
indicator ofacute malnutrition and integrated management
of childhood illness includes only “visible severe wasting",
an indicator that is subjective, difficult to use in practice,
1997
I
Review
and unreliable.104,117 Mid-upper-arm circumference is easy
to use and efficient at identifying those children who need
specialist interventions—without this, most cases of SAM
will go undiagnosed and untreated.
Achieving die fourth Millennium Development Goal of
a two-third reduction in childhood mortality will not be
possible unless SAM is addressed effectively. For
interventions to fulfil their potential, policymakers must
give SAM an urgency commensurate with its global
importance as a leading cause of preventable childhood
mortality.
Conflict of interest statement
The authors work for Valid International Ltd, an organisation that has
been engaged in the research and development of community-based
therapeutic care. S Collins and A Hallam are also unpaid directors of
Valid Nutrition, a not-for-profit company established to research and
manufacture ready-to-use therapeutic food in developing countries.
Acknowledgments
This work was supported by funding from Concern Worldwide. Concern
Worldwide has been engaged in the research and development of
community-based therapeutic care but has had no influence over the text
of this review.
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4 " care—ai new paradigm for
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2000
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
A Protocol for preventing Starvation
The objective of this proposal is to establish processes of investigating starvation
that are transparent, reliable and respectful of the dignity of the survivors; and
mandatory protocols for intervention for relief, prevention and accountability.
Definition of Starvation
It is remarkable that Famine Codes of the past, and contemporary Codes, do not
contain an agreed definition of starvation. It is important to begin by defining
starvation carefully and rigorously, and yet in ways that are accessible to the lay
public.
Hunger may be understood as the denial of adequate food to ensure active and
healthy life. If hunger is prolonged to an extent that it threatens survival, or renders
the person amenable to succumb because of prolonged food denials to curable
ailments, then the person is living with starvation. If these conditions actually lead to
death, then this is a starvation death, even though the proximate cause in every case
would be a medical failure. But the cause of death is not the medical failure, but the
prolonged denial of nutrition that led to a person succumbing to medical conditions
which a well fed healthy person would easily be able to combat and survive.
This definitions of starvation and modes of verification in this chapter and its
annexures, are derived very substantially from an excellent document Guidelines for
Investigating Suspected Starvation Deaths', prepared by the Jan Swasthya Abhiyan)
Hunger Watch Group, based on a consultation organized in Mumbai in 20031.
The document points out firstly that 'starvation is ultimately not primarily a techmeal
i This conference was attended by and attended by Veena Shatrughna (Deputy Director, National
Institute of Nutrition, Hyderabad), Vandana Prasad (Paediatrician), Narendra Gupta (Prayas), Sumta
Abraham (Christian Medical Association of India), Sarojini (SAMA and Convenor of MFC), C. S. Kapse
(Professor, Department of Forensic Medicine, D. Y. Patil Medical CoUege), Neeraj Hatekar (Professor,
Department or Economics, umversiiy or ivrumoai), sanjay Koae irn. l>. stuaent, uepartment 5f
Economics, University of Mumbai), Abhay Shukla (Co-ordinator, SATHI Cell, CEHAT), Neelangi
Nanai,
Amita
Pitre
and
Qudsiya
(all
researchers
at
CEHAT).
1
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
issue, but is rather related to deep-rooted socio-economic inequities, which require
radical and systemic solutions'. It adds that 'while approaching the issue of hunger
related deaths, we should start with the basic fact that starvation and malnutrition
related deaths are public health problems requiring community diagnosis. In this sense they
differ from classical "disease related mortality". The diagnosis of a death due to
tuberculosis may be approached as an individual diagnosis. But the diagnosis of a
“malnutrition death" cannot be just an individual diagnosis; we have to document the
circumstances prevailing in the family and community along with the individual to
reach such a conclusion'.
It adds that the dilemma is deepened because 'generally prevalent "baseline"
malnutrition, gradually worsening severe malnutrition and definite starvation merge
with each other along a seamless continuum. In a community which is used to barely
subsistence intake, three years of drought reduces this further and then some families
start eating once a day, a few poorest families eat on alternate days ... where exactly is
the dividing line between malnutrition and starvation? When exactly does the
situation change from "a chronic problem" to "an alarming situation' ?
Public officials, the lay public and sometimes even professionals believe that
starvation requires no intake of food. This underlies some of the denials when post
mortems of the corpses of the deceased show some grains of food, or investigators are
able to find some foodgrains in the homes of the person who recently died, and the
cause of whose death is being contested. The Hunger Watch group defines starvation
as levels of food intake that are: unsustainable for the continuance of life itself. In
observed, is that 'malnutrition, starvation and
assessing this, one challenge, as already
<
starvation deaths seem to lie along a continuum. How is it possible to demarcate one
from the other?'
■ ' daily
' " ' or less may be presumes to be
An adult who eats 850 kilocalories of food
starving. This cut-off is based on research that shows that a person who weighs 50
kilograms, if she or he engage in no physical activity altogether, they require at least
850 kilocalories merely to stay alive, even though they perform no work at all. Thus if
it is established that the adult had access to less that 850 kilocalories, then this is not
compatible with life itself, and the person is undoubtedly starving2.
2 In the word of the hunger watch group (mimeo, 2003), 'Based on a requirement of 07 Kcal / kg /
hour a 50 Kg person needs about 850 Kcal per day to maintain oneself at Basal Metabolic Rate, without
any physical activity'. Thus any food intake that is sustainedly lower than 850 Kcal per day would be
incompatible with life in due course and is an indication of starvation'.
2
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
Another reliable physiological indication of starvation is a BMI (Body Mass Index) of
16 and less. Body Mass Index or the BMI is the ratio of the weight of the adult in
kilograms to the square of her height in metres. This is a very good indicator of adult
nutritional status as it is age independent. Values of BMI that fall between 20 and 25
are deemed to be normal. On the other hand, significant research finding is that in
adults, if BMI is below 19, mortality rates start rising. Mortality rates among adults
with BMI below 16 are nearly triple compared to rates for normal adults3. Thus in
adults a BMI of 16 and less should be used as a cut off point to demarcate starvation
from under-nutrition.
The nutritional status of children is easy to derive from the child's weight and age,
and most ICS workers are trained in assessing this. NCHS standards for ideal body
weights for children, both male and female are available. Classification systems based
on these standards enable us to decide from the age of the child and its weight if the
child has a normal nutritional status or is either undernourished or overweight. The
weight of the child should be compared to the ideal weight for that age mentioned in
the NCHS standards. A percentage of up to 80 per cent is deemed normal, 60 to 80
percent is deemed mild to moderately malnourished, and below 60 per cent the
situation is severe, below 50 per cent alarming.
Verifying Starvation
The duty to investigate and verify complaints of starvation must be shared by public
officials, elected representatives, affected people and local communities, and
professionals. Each must have clear and well defined roles.
In practice, if large numbers of people die of starvation, it occasionally captures media
attention, and there is transient public outrage. Government officials in every part of
the country, hotly deny allegations of starvation deaths. Most claim that the deaths
result from illness, some even quibble that people were just chronically malnourished,
but not starving. Issues of food security and hunger surface briefly in public
consciousness, whenever there are media reports on starvation deaths. The brief
public outrage that follows such reports lead almost invariably to unseemly wrangles
about whether this was indeed a starvation death, with angry denials by officials, post
mortems and other evidence being mustered to establish that there was indeed some
3 'Guidelines for Investigating Suspected Starvation Deaths', by the Jan Swasthya Abhiyan) Hunger
Watch Group (mimeo, 2003)
3
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
grain in he stomach of the diseased or available to the family and therefore this does
not constitute a starvation death.
Apart from this, even the media and political establishment tend to react only when
reports emerge of actual starvation deaths surface; reports of destitution that led to
this final collapse fail to stir interest or action. There is in this sense, in both State and
non-State circles a certain 'normalisation' of destitution, of conditions in which people
are forced to live with starvation. They can expect the State to act or public opinion to
be outraged only when people begin to die.
Few people die directly and exclusively of starvation. They live with severe food
deficits for long periods, and tend to succumb to diseases that they would have
survived if they were well nourished. Official agencies do not recognize these as
conditions of starvation, and instead maintain that the deaths were caused by the
proximate precipitating factor of infection. We have also seen that starvation does not
require absolutely zero food intake, but rather prolonged periods of such low food
intake as to be incompatible with survival.
In the aftermath of media complaints of starvation deaths, while analysing deaths due
to starvation, the official investigator usually conducts a conventional enquiry in
which he or she fires a series of humiliating questions soon after the death has taken
place to the victim's. This would only leave scars on the family of the deceased. The
usual line of questioning is about whether the individual or family had access to any
food at all in the period immediately preceding the death, or whether the death was
due to illness or natural causes. There are sometimes post mortems to show even a
few grains or wild leaves and tubers on the stomach, to demonstrate spuriously that
the death was not due to starvation.
Investigating the Living by Public Officials
The National Human Right Commission in its investigation into alleged starvation
deaths in Orissa4 some important and human principals have been established. First of
these is that death is not necessary as evidence of starvation. In the words of Mr.
Chaman Lal, former Special Rapporteur of The National Human Rights Commission
4 'Feedback from Dr. Amrita Rangaswamy on Starvation deaths', Tanushree Sood, CES, Mimeo, 2005.
4
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
(NHRC)5, 'A person does not have to die to prove that he is starving. This insistence
on death as a proof of starvation should be given up. Continuance of a distress
situation is enough proof that a person is starving'. We agree that medical post
mortem inquiries do not serve much in the process of preventing starvation deaths
and in assuring the right to food. Indeed, it hurts and humiliates those families and
communities who have lost people painfully to starvation. Citizens, especially the
ones who are starving, have a right to dignity. Starvation is also rarely an isolated
instance, but reflects instead prolonged denials of adequate nutrition to households,
communities, or social categories. Such people are usually very impoverished and
dispossessed or destitute.
The discourse around starvation, especially among public officials and the media,
should shift in such times from not just those who died, but those who survived but
are deeply threatened. They need to recognise starvation to be a condition not just of
the dead but also of the living. It is crucial to understand and accept that death or
mortality is not a pre-condition for proving the condition of starvation. Long-term
unaddressed malnutrition and endemic prolonged phases of hunger must be
recognised as situations of starvation, and the duty of the state to prevent deaths of
persons who are living with starvation.
There are many ways that allegations, complaints and fears of starvation arise. In any
such situation, the focus of the investigations by public officials must focus not on the
dead, but on the living survivors, and people of the family, class or community who
may be similarly threatened. This would ensure that the survivors of the deceased are
not traumatised further, and measures for relief and prevention are put in place
without delay.
But it is important also to establish the veracity of complaints of starvation deaths.
This should be done by processes of community investigations and verbal autopsies
by public health officials in collaboration with local people. Both these processes may
proceed side by side.
In the event of complaints, through application or verbal, made in the media, by
affected people or activists or any other source, local panchayat representatives and
revenue official must inform the District Panchayat head and the District Collector
5 Personal communication
5
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCE v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
immediately, who in turn will inform each other, the local officials, and panchayat
functionaries at various levels. They would be debarred from issuing denials, in the
absence of investigation by public health functionaries, and instead the effort should
be to identify the sources of distress, and respond to mitigating and ending these.
It would be the duty of the District Panchayat head, with the District Collector, the
Chief Medical Officer, heads of departments of civil supplies, women and child
welfare, social welfare and forests, to personally visit the location expeditiously, and
in nay case not later than 48 hours after receiving the complaint or information is
received. They should investigate the overall field situation in the family and
community: not whether there was a starvation death, but whether the specific family,
as well as in that location the local community (such as Musahars) and the social (such
as single women) and class (such as landless workers) categories to which she or he
belongs, subsist in conditions of prolonged deprivation of adequate food with dignity,
or in continuous uncertainty about the availability of food, or dependence on charity
or debt bondage for food. On receiving reports of people living or dying of starvation,
may be analysed, by a process described sometimes as verbal autopsy. They should
meet the family of the victim, and learn from them about their general food and
livelihood situation, and with the neighbourhood, and the local community, tribe,
caste, class, gender or age group to which the affected people belong, and the village
(or urban settlement) at large.
This public investigation should be conducted in consultation with and seeking the
support of the affected people. It may occur in two phases. In phase one, discussions
are held with the family of the victim and some neighbourhood families. During these
discussions, the victims' families may be asked questions about the food and
livelihood conditions and deprivations of the individual and the household, access to
food and work, periods of hunger, and so on. The idea is not only to probe death and
its causes but only to understand the poverty and destitution faced by the families and
by similarly affected people. Attempt should also be made to understand the root
cause of poverty such as livelihood crisis, heavy debt, crop failures etc.
In the second phase of investigation, discussions should be carried forward with the
other members of the tribe, caste, class, gender or age group to which the affected
people belong. During these discussions, questions may be posed about the food and
livelihood conditions and deprivations of the class and communities of deprived
people, their access to food and work, and periods of hunger. Broader questions
6
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
regarding functioning of the food and livelihood schemes may be asked, such as (i) is
there an operational anganwadi centre running in the village, (ii) is the nearby
government school providing midday meals to the children, (iii) does the ration shop
provide foodgrains in the right quantity, price and on time, (iv) how many elderly
persons in the village obtain social security benefits or pensions from the state and so
on. At the same time, the people should be provided enough space to reveal situations
on their own. They should not be crowded out by questions from the investigator. It
may also be worth asking if any change has occurred in their way of living over the
years. In other words, have the government policies brought about a change in the
way of living of the people? There is a need to document the circumstances prevailing
in the family and community at large special focus needs to be laid on tribal and
backward rural areas. Also there may be cases of starvation of individuals who for one
reason or another are without families, or abandoned by their families and excluded
from their communities. The investigations should be sensitive to these as well.
These findings should be recorded by the District Panchayat head and District
Collector in writing, and their report shared and explained in the local language to
affected people and communities, local elected leaders and local officials. The report
should contain a clear time bound action plan for intervention.
State Interventions in Situations of Suspected Starvation.
Even without awaiting the outcomes of the community investigations to establish
starvation deaths, public authorities of the Panchayat and district administration must
implement a range immediate measures, as soon as they are convinced that conditions
of grave and threatened food and scarcity prevail in a local area of community, which
result in people being forced to live in conditions of prolonged under-nutrition and
even starvation.
Once it is established that there exist conditions of people of a dispossessed
community, class or social category who live with starvation or grave threats to their
food and livelihoods security, it is the duty of the State (jointly of the District
Panchayat and district administration led by the District Collector) first to provide
relief in case of conditions of starvation or long term unaddressed under-nutrition and
failure of food schemes to prevent or remedy this. In its current form, 'gratuitous
relief is in the nature of charity. Such an ideology cannot bring about long term and
7
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
permanent change in the condition of people who are vulnerable to starvation or the
system of administration. Thus, such kind of an ideology needs to be converted into a
system of entitlements. In other words, relief needs to be in the form of entitlements
and not charity.
If a certain region has been diagnosed as suffering from intense hunger, the state
should be alarmed immediately, and be asked to place systems of relief, immediate,
short term and the long term.
1. Relief for Family of Deceased: The first immediate relief must be for the affected
family itself that has suffered the loss of persons for reasons associated with
prolonged deprivation of adequate and assured food with dignity. Some of the
measures that may be relevant include:
a) ensuring immediate food availability to the family, free of cost for at least for a
period of six months and then continuously on a more permanent basis at highly
subsidised rates. This would be by the distribution to them of special AAY cards with
the specific provision that they would get their food entitlement without any cost for
the initial six months;
b) ensuring early sanction and release of insurance under NFBS, and release of an ad
hoc amount of the same amount for all dead as compensation regardless of whether or
not they were adult bread earners;
c) identifying in consultation with the survivors in the family, the reasons for
livelihoods denial, collapse or insecurities and assisting them to build a secure
livelihood through measures like land allotment and restoration in case of alienation;
d) ensuring their coverage of all food and livelihood schemes for which they are
eligible such as ICDS, MDM, NREGA and old age, widows and disability pensions;
e) for children, ensuring their admission to SC ST hostels if they choose, so that their
education, food and protection is secured;
e) organising psycho-social support through professional and trained lay counsellors
to the survivors of the deceased;
and (f) for infants, small children, expectant and nursing mothers, doubling their
quota of food entitlements, hospitalisation where necessary, arrangements for
nutrition rehabilitation, and health-care including immunization.
8
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
2. Relief for others identified to be similarly threatened: The next stage of intervention
would be for the community, class or social category to which the family of the
affected person belongs. This must begin with publicising and opening NREGA works
for all those who seek it, within a week of the receipt of the information. The ceiling
on 100 days for one member of each family must be relaxed for the affected people for
a period of 2 years from the time a situation of starvation is identified. Simultaneously
the mid day meal in the school will be extended to all days in the year, and open to all
children, even if out of school, and old and disabled people and single women who
seek it. The ICDS centre will also provide children of 3 to 6 years hot cooked meals
twice a day instead of once, and this will be open also to pregnant and lactating
mothers, and single women.
This must be followed with a careful official as well as well publicised affected
people's social audit of why they could not access their food rights from the food and
livelihood schemes relevant for them. For instance, were their small enrolled and
regularly availing of the services of ICDS, and was their decline of nutritional status
identified and addressed on time; if not, why not? Were the older children in school,
and did they access regular and nutritious mid-day meals? Did they have ration cards,
AAY or at least BPL, and did they regular receive the prescribed quota of 35 kilograms
of subsidised food grains from the ration shop; if no, again why not? Did all old
people receive pensions, and were these distributed at their doorstep on time every
month? The same questions would apply to widows and disabled people in states
with schemes for pensions for these groups. Did they seek job cards and work, and
was this given to them in accordance with their legal entitlements under the NREGA?
From such an enquiry, the reasons for failures of food and livelihood schemes, and the
exclusion of these most food vulnerable people from their reach, should be clearly
diagnosed. The District Panchayat and Collector should clearly fix responsibility at all
levels, punish those found guilty, remedy gaps of funds, resources and personnel, and
address issues of discrimination and social exclusion. There should then be a time
bound coverage of all affected and threatened people by AAY ration cards, job cards
under NREGA, old age, widow and disability pensions, and ICDS services, including
nutritional rehabilitation and hospitalisation where found necessary, within a period
of one month from the date of initial information. Failures to do so, if they result in
further loss of life or deterioration in people's nutritional condition, will be the
personal responsibility of the district leaders of the Panchayat and administration.
9
DR. N. C. SAXENA, COMMISSIONER AND
HARSH MANDER, SPECIAL COMMISSIONER OF THE SUPREME COURT
IN THE CASE: PUCL v. UOI & Ors. WRIT PETITION (Civil) No. 196 of 2001
In the long run, local structural sources of pauperisation will be identified and local
solutions developed in consultation with the gram sabha and village panchayat.
These may include failures to implement land reforms, tribal land alienation, caste
discrimination, micro minor irrigation and watershed development, availability of
formal credit for agriculture and artisans, access to forests and choices of agricultural
technology and cropping patterns.
10
/
Feudal Politics
Of
Starvation & Malnutrition
Report from Rewa
Prepared by
Samaj Chetna Adhikar Manch, MPLSSM and Right to Food Campaign
Madhya Pradesh Support Group
Meet the Koi Adivasis
Who have a history soaked in thirst
And geography parched with hunger
The crumbs left in our cooking pots
Is more precious to us than our spouse
The little water in the pond
Is what we cling to for survival
In eyes blurred with woes
Swim burning questions
Ofgovernment aid
That has drawn a blank.
This is our plight!
Qayaprasad QopaC
An introduction to Koi Advivasi
Madhya Pradesh holds 1st rank among all the States/UTs in terms of ST
population and 12th rank in respect of the proportion of ST population to total
population1. ‘Koi’ is one of major tribe of Madhya Pradesh. They are among the
most excluded tribal communities in Madhya Pradesh.
The word ”Kol" appears to have been derived from the Mundari word ko ,
meaning ’’they," or from horo, hara, har, ho, or koro —"the men"—by which the
Kols identify themselves. The Koi lent their name to the language group formerly
known as the Kolarian, and now better known as the Mundari or Austroasiatic
Language Family. The Kols are mentioned as a generic category of people in
eastern India in medieval texts. In the imperial period, the word "Koi" acquired a
pejorative meaning as it became a synonym for the savage, the lowly, those
performing menial jobs, the militant, and the aggressive2.
Q
Location -- A great tribe of Chota Nagpur,which has given its name to the
Kolarian family of tribes & language.They are distributed all over Chota
Nagpur,whence they are migrated to central India. The tribe that today bears the
name Koi is restricted to a part of Madhya Pradesh and Uttar Pradesh. Earlier the
1 Census of India 2001
Encyclopedia of World Cultures, Volume 3 - South Asia by K. Singh
3 The tribes & caste of the central provinces of India, Vol. Ill by R.V. Russell & Heera Lal
2
Kols were described as one of the most widely spread. But now they are identified
with the Koi tribe only, distributed in twenty-three districts of Madhya Pradesh
and nine adjoining districts of Uttar Pradesh.
Language and Culture- The Koi no longer use their ancient language and have
adopted Hindi and the Devanagari script. Koi family is Patriarchal. The word
Munda is the common term employed by the kols for the headman of the village.
Monogamy is the rule but polygamy also occurs. As there is an adverse sex ratio
with the Koi females outnumbering males. The over all sex ratio of the Koi in
Madhya Pradesh is 948 females per 1000 males which is lower than the national
average of 978 for all STs4. The sex ratio in the age group 0-6 years of 969 is
lower than that of all STs at the national level (973).The Kols pay a bride-price
(chari ), which consists of small cash, a calf or a goat, and such ornaments as a
bangle (kangan ), toe ornament (lacha ), etc. In recent years chari has given place
to dowry (dahej), which comprises of cash and utensils.
Literacy & Educational Level- The overall literacy rate is lower among the koi
in comparison to Gond & Korku tribe of Madhya Pradesh. Koi having overall
literacy rate of 35.9 only whereas it is just 22.9 in case of females. Even among
Koi literates, 7.2 per cent are either without any educational level or 47.1% have
attained education below primary level. Literates, who are educated up to
metric/secondary/higher secondary, constitute 6.6 per cent only. Graduates and
above are 0.6 per cent while non-technical & technical diploma holders constitute
a negligible proportion (zero).
Livelihood and Subsistence - They work more often as daily wage laborers,
collectors of forest produce, and gatherers of wood fuel. A few Kols own land, but
most are landless. Koi tribe is mostly agricultural laborers with 70.4% involved in
it for their livelihood, while 12% constitutes cultivators. Other works accounts for
16.6%.
Life ofKoi in Rewa District
Though India is progressing fast to attain pinnacle at different levels and get
transformed into developed nation from a developing country. But nothing has
changed for the ‘koi’ adivasis, both historically and geographically. In fact, time
has stood still for the ‘Koi’ adivasis. They are not only trapped by caste based
fuedalism but they are now forced to bear feudalistic attitude of official of forest
department. As a result, conditions has deteriorated more sharply due to
4 Census of India 2001
negligance of the government towards ensuring the basic rights of the most
vulnerable tribal group.
Rewa District lies in the eastern part of Madhya Pradesh. Java is amongst the nine
block of Rewa. Total number of Villages covered under the java block is 244
having 87 gram panchayats. The total population of Java according to Population
census 2001 is 1, 43,662 & 16.64% are SC population & 18.65% population
belongs to ST.
Though the Java block is dominated by dalit & tribal popluation but still they are
worst suffers in the block.Feudalistic pressures has barricaded all the door to
progress for koi advasi & even put a question mark on the existance of koi
advidasi. They are made to strive for starvation & malnutrition.
Tyranny ofMalnutrition
One year old Meena D/o Sukhchain Adivasi has taken his last breath in Nov’09. He
was severely malnourished with grade-IV malnutrition. She was taken to NRC at
Sirmour in Sep 09 but official ofNRC sent her back avowing that no beds vacant to
admit her. After that on 30 Sep ’09 the activists of Samaj Chetna Adhikar Manch
admitted her in Java NRC. Meena was discharged from NRC on 14th day without any
sign ofimprovement. She was still in grade-fV during the discharge. As a result the
family lost oftheir twinkling star Meena within 15 days ofdischarge.
Meena s sister Himanshi, 20 months is also struggling the battle oflife with grade-III
malnutrition. She was also refused to get admission in NRC. Himanshi is being taken
care only by her mother as her father has migrated to earn livelihood. The family is
surviving in very odd circumstances & cant afford for private treatment of their
malnourished child. Sukhchain of Village Kuthila has a family of 6 members and
depends mainly on wage earning and resort to distress migration almost through out
the year to Uttar Pradesh where they work as laborers under private contractors.
Though they have Job cards under NREGA but had got public employment only for
20 days & its payment is still pending one year. The food insecurity of the family has
aggravated as they do not have a ration card.
Two little sisters Himanshi & Meena were not the only child to be clutched by
malnutrition in the area.
That child’s eyes were almost closing; he was not even able to see properly. The
possibility of his standing up is distant. He is a resident of Ramgadhwa village
which is adjacent to Atrailla, another small village. There are 22 more children
like Deepak in this village who are reeling under
malnutrition. As such, the ‘anganwadi’ building
of Atrailla is quite magnificent but these children
have no access to it. It is unfortunate for these
children that they neither get anything from the
anganwadi center nor are their names registered
under the category of children affected by
malnutrition. The center is near their homes but
they have no access there.
When the weight of only 23 children from
Ramgadhwa village of Java Block in Rewa
district was taken, not even a single child was
found to be of normal weight. All of them were
found to be suffering from malnutrition, whereas the anganwadi workers who
belong to higher caste claim that not even a single child is suffering from
malnutrition. Actually Rewa district has always been a fortress of feudalism and
caste distinctions have always kept the deprived classes at a distance. The same
happened here. And till these children are not considered as suffering from
malnutrition the probability of their treatment will remain remote.
Large numbers of children (0-6 years) are in grip of malnutrition in Java block of
Rewa district in Madhya Pradesh. Birsa Munda Bhu Adhikar Manch (Birsa Munda
Forum for Land Rights) Rewa, Samaj Chetna Adhikar Manch and Right to Food
Campaign Madhya Pradesh Support Group surveyed village Kalyanpur,
Ramgadhwa & Kuthila of Java block in Oct’09 to trace out the state of child
health in the block & related socio economic circumstances that are leading to
degradation high level malnutrition in the block.
During the survey it was found that children & mothers are not getting the benefits
of the services of the Aaganwadi centers & are discriminated on the grounds of
caste & creed. Children are malnourished but not getting admissions in NRC due
to lack of sufficient facilities to provide medical care to large number of
malnourished children. Underprivileged villagers in Java block are mostly Halit &
tribal. Their life is full of scarcity. The standard of living is very pity as they do
not gets work under NREGA or even if they got it for 10-20 days, their payment
are still pending for more than one year. They are not supplied with sufficient
ration of their ration cards. They are forced to migrate to distant areas in hunt of
their livelihood. After the survey they referred 30 severely malnourished to NRC
at Java on 30th Oct’09. But out of them only 10 children of grade IV were
admitted & rest are sent back to wait for their turn.
Recently on last week of Nov’09 seven more children were traced as malnourished
with two children in grade -IV, four children in grade-III and two children in
grade-II of malnutrition from Kalyanpur, Ramnagar and Ramgadhwa village of
Java block. This evidently illustrates the apathetic attitude of the administration
towards child health care & its accountability to ensure food security for its
people.
83 Percent Children Malnutritioned
The gravity of the situation arising due to malnutrition in this area can be gauged
from the fact that in eight villages 83 % children are suffering from malnutrition.
Out of these, 9% children are suffering from severe malnutrition. In the villages of
Mohaniya and Ramgadhwa of Jawa development block the situation is very
serious. If we are to believe the 12th round of the Bal Sanjeevani campaign then
the percentage of malnutrition is 48 in Rewa district when the serious cases of
malnutrition are 54. In fact these 8 villages tell a different story which appears
very grave.
Name
village
of
the
Total no.of Mai.
children who Grade 1
were
weighed
Mai.
Grade 2
Mai.
Grade 3
Mai.
Grade 4
Normal
Ramgadwa
23
10
4
8
1
0
Kuraily (Koni)
9
3
2
1
0
3
Mohaniya
5
1.
2
0
2
0
Kalyanpur
7
0
1
4
2
0
Ram nagar
13
2
8
2:
1
0
Kuthila
4
0
2
1
1
0
Harijanpur
7b
0
0
o
0
lb
Khaptiha
02
0__
2
o
0
o
Total
73
16
21
16
7
13
Percent-age
28J
100
2L9
21.9
__________________
9J8______________
17.00
Reference : /Analysis of the weights(Malnutrition Status) taken by independent groups in each
village in the presence of the community between 25th -30th September ‘09.
_____________________:___________________ :_________ :________________
When the district officer in charge of the Woman & Child Welfare Dept, was
asked for information regarding malnutrition cases , he replied that he is not
authorized to talk to the media regarding the data. Only the collector will talk
about malnutrition. So what should be inferred by this? The question here is, why
will only the collector talk about this data ? Due to this ambiguous situation a
clear picture regarding malnutrition is not visible. Due to the effect of feudalism
they are kept at a distance from their rights.
Sketching the life in Kalyanpur Village
A schedule caste girl Priyanka d/o Sanat kumar was in the grade-IV of
malnourishment when she was taken to Nutrition Rehabilitation Centre (NRC) at
Java in Rewa district. But she was refused to get admission in NRC & she was not
even referred to any other health institution w
in-spite of such a degrading health
condition. The socio economic condition of
the family is very pity. Though they are 13
having Ration card but ration is distributed J" “ llr''
■Aon the fixed day of the month. Therefore
many a times it gets lapse due to lack of
money on that particular date. They are also 1!
supplied with the job cards but unfortunately
there are no jobs under NREGA since last
three months.
They family is unable to have a balance &
nutritious diet. Children do not get milk,
egg, butter, ghee or any other protein
enriched diet. Children, pregnant & lactating
'
mothers do not get any benefits of
Aaganwadi center (AWC). Growth monitoring of children is done only twice a
year.
Motilal S/o Jayprakash is 18 months old but just having weight of 7 kgs only. He
was referred to NRC & stayed their for 14 days. At NRC his health was recovered
by 50%.Motilal thereby shifted from grade-IV to grade-II of malnourishment. But
still he continued in grade II with no further improvement. Jayaprakash do not got
any work on his job card from last three months. They get ration under the BPL
ration card but in lack of employment Motilal’s father is forced to take loan on
high rate of interest. Sometimes they are forced to take Chapatti with salt & chili
only. Do not get any services of AWC.
Sushma D/o Pappu Basor is fourth grade malnourished child. Pappu along with
his whole family was forced to migrate mostly through out the year in search of
livelihood. They are unable to carry out their tradition work in lack of Bamboo
wood. They migrate to Kanpur & worked as rag-pickers. They have not received a
single day work on their job card. It is difficult for them to manage at least two
meals a day. In such a nasty circumstances, they are unable to admit their child to
NRC for 14 days.
Although Aaganwadi center is functional in village Kalyanpur but women &
children are deprived of benefits of its services due to existence of persistent
caste discrimination. The aaganwadi worker (AWW) is a Brahmin women &
follows discriminatory practices with the children & other beneficiaries of Dalit &
Schedule tribes. They cannot even think & talk for their rights.
Status of Child Survival in Ramgadhwa & Kuthila
Deepak S/o Ramnarayan Koi (of Schedule tribe) was in grade-IV of malnutrition,
when he was repudiated to be admitted in NRC. The socio economic status of
family is very poor. They got work only for 12 days in one whole year on his job
card. As they do not get work in their village or nearby they are forced to migrate
to other area that leads to malnutrition among women & children. Due to
migration children are easily entrapped by seasonal disease. And malnutrition
along with seasonal diseases escorts the vulnerable children to more serious health
condition.
A one month baby Jyoti D/o Ram Prasad Koi is merely of 2 kgs. The economic
status of the family is extremely disappointing. They are neither having Ration
Card nor having Job Card.
24 months old, Uma D/o Ram Bhajan Koi of Schedule tribe is in third grade of
malnutrition. Similarly, Rashmi D/o Munna Lal -36 month, Sangita D/o
Shiwachan- 24 months & Archana D/o Ram Saroj - 12 month old are also in
grade III of malnutrition.
All the children mentioned above keeps on moving between grade III & IV of
malnutrition. The overall livelihood scenario of dalit & tribal in the village is very
awful. They buy ration under PDS whenever informed for supply. They are
forced to migrate to Shankargarh, Allahabad in Uttar Pradesh as there are no jobs
for them under NREGA. Under NREGA, most of them got work only for 10 to 12
days maximum in one year’s time. Their are some villagers who got work only for
a single day. Even for these 10-12 work they are not paid with full wages but are
given only half of their wages after evaluation of their work by Panchayat
Secretary.
When villagers demanded work on their job cards, they are not given receipt
against their application. But they verbally informed by Panchayat Secretary that
there is no work for large number of people and as per the work requirement some
people are already supplied with work. Now they should contact whenever some
new work will be started.
Aaganwadi center is run by aaganwadi helper. AWW belongs to upper caste, so
she seldom comes to AWC. AWW & her helper do not go for home visits to
monitor women & child health progress & informed them regarding the services
of the center. Not many children come to AWC in such circumstances.
Ashish S/o Ramai Adivasi, 12 months from Village Kuthila was severely
malnourished with total weight of merely 5.3 kgs. Due to malnutrition he turned
very weak in spite blightful poverty, family is not even provided with ration card
nor do they got a single day work on their job cards. So they migrate even for a
year to Uttar Pradesh for most of the time.
The Aaganwadi Center in Kuthila village is being run by the helper as AWW do
not approach to AWC being women from upper caste. The Health department
officials & staff never visit the village to provide any sort of health services. In
lack of proper medical & nutrition care, many children are malnourished in the
village. People here survive in very difficult state of affairs & are using fuel woods
in dark to prepare their food. But they are not provided with any support services
by the government.
Nutrition Rehabilitation Center (NRC)
We are all aware that children who are
suffering from severe malnutrition need to be
admitted to the NRC for 14 days where they
are treated completely and re examined 4
times, thereafter. But when these children are
sent to the NRC they are sent back and
advised to wait for their turn.
f'-:'
k® • J
J
The same thing happened with Amar, seen in
the picture alongside. One year Amar belongs
to Ramnagar village and when his father O
Raghuvansh took him to the NRC for getting
him admitting in Java a month back, he was sent back twice. He was also advised
to wait for his turn. It should be known that 6 children are suffering from
malnutrition in Ramnagar.
Ever since January 2008 when the NRC was started in the Community Health
Center at Java it has had a capacity of only 10 beds. This means that only 10
children can be admitted there at one time. Other than this not a single additional
child can be admitted even though he may be suffering from severe malnutrition
and may even lose his life. Does that mean that the children will be admitted only
when the authorities want.
Wrong Figures Are Produced By The WCD Department
There is neither a peditritian nor an A.N.M. for this NRC, due to which a lot of
difficulty is faced in the management. Shri M K Pande, (Block Medical Officer)
acknowledges that he is unable to admit more children due to shortage of capacity
although malnutrition is widespread in the area. The Women and Child
Development department is trying to hide the real picture by producing erroneous
figures. The figures produced by them after the survey are incorrect. In actual fact
the situation is much worse. They also say that the children brought to the NRC
are not examined on time. .Even if the children have come once it is not clear as to
what happens to them in future.
Left to Die
On the 30 of September ’09 36 children from 22 villages were brought for being
admited to the NRC at Java village but only 10 were admitted and the remaining 26
were sent back. Now these children could live or die! The government did not
any responsibility for this. In simple terms these children were left to die. The
administration did not even consider referring them elsewhere.
15,000 Children Died In Last Three Years
According to the figure based on the infant mortality rate (72/1000) on an average
1.25 lakh children die in the state per year. In Rewa district, according to the infant
mortality rate , on an average 4000 children die every year. If we are to believe the
figures, 15,000 children have died in the last three years. Just in this year 1869
children have succumbed to death between April and September.
Year
Infant deaths
(as per state
Government data)
Actual deaths
(according to the
Mortality rate)
2006- 07
1324_________ 4386
2007- 08
972_________ 4833__________
2008- 09 702_________ 3928__________
Sept 2009 503_________ 1869__________
Total
2998
15016
Reference: M.P. Government Health Department
Difference
3062
3861
3226
1366
12018
Two types of conflicting figures are seen in the table. According to the registration
carried out by the government 3000 children have died in three years but 15,000
children have died in Rewa district according to the death rate even though they
were not registered. It means that the government did not exhibit these figure of
12,000 deaths on the website thus giving false figures. These are figures for
infants only, but if we consider figures for children upto 5 years this crosses
20,000.
Sorry State OfAffairs In The State
The figures of the third round of the National Family Health Survey reveal that in
Madhva Pradesh 60 % children are suffering from malnutrition which is much
scarier than the national average of 42.5 %. Out of these children also 13 % are
affected by extreme malnutrition. According to the sample registration carried out
by the Family & Health Welfare Dept, of the Government of India,in Madhya
Pradesh 72 children below 1 year of age die for every 1000 children bom live,
which is the highest in the country. This means that in the state 1 lakh and 33
rhildrp.n nf_ihe_ctatp are-in thp
thnncand infante Hip
v.vfj----- J
ZV
V1XXX<*XVXX
v/x
uxxv
prin nf
uvvxvv
anemia ,that is, lack of blood. In spite of this only 186 NRCs are being run in the
state, which is highly insufficient.
No serious efforts are being made to combat malnutrition in the state, wherever
children die due to malnutrition some immediate action is taken but subsequently
things return to their slovenly slipshod pace. This is visible from the fact that even
though 60% children are suffering from malnutrition , the state government has
neither formulated a nutrition policy nor has any serious effort been made to
combat the scourge of malnutrition.
Feudalism crushed the forest rights claims of tribal
Now the work to dig-up the trench had been started in the Rajnagar village of
Tiketanpur panchayat and agriculture farms of tribal are covered this trench.
Under the forest Rights Act,2005 tribal had submitted their claim forms in may
2008 on the land which they are cultivating since generations.60 acres of land has
been possessed by 27 families.But forest department officials were unable to
digest that. So they decided for excavate a trench on that land in July 2008.A
trench is tunnel which is about 3 meter broad & 15-20 feet deep,so that it cannot
be crossed over by cattles or for transferring resouces.This trench will take over
the farms & homes of 5 tribal families.Along with this tribal will also be debarred
of other forest resources live fuel wood, animal foder, and other forest products
which are one of the major source of their livelihood.
According to Ramdev Charmkar, 175 tribal & dalit families had land in their
possession since 1980s.Forest department officals have adopted brutal attitude to
displace these tribals & dalits.And those beeten up by the forest department had
left their holdings.Thus now only 27 families are left with 60acres of land.So the
new tactics of digging has been adopted to take over the land of these 27 families.
Government Officers deceived Tribal
“Under the FRA the tribal from Khara Panchayat has submitted their claim forms
in July 2008. In last week of Jan’09 village patwari, panchayat secretary, forest
officer & DPIP secretary visited the village & told them that to get the patta they
need to give Rs.500 per bhiga (5acre) land. Villagers were made to take loan’s at
high rate of interest from Thakur. Villages in lack of knowledge about the forest
Rights Act gave the amount of Rs.500 or 1000. After taking away the money they
had not visited the village again.Whenever adivasis approched them for patta they
were treated badly by these officials.
Our mining lease is ‘gifted’ to feudalism
This year too, the ‘koi’ adivasis of
Khara Panchayat, Jawa Block,
Rewa district in Madhya Pradesh
will be not be granted the lease to
5f.
break stones. For the past five
years, they have been pleading to
ilRJI’s
be allowed to break stones in the
lii
stone quarries that are in their
village. They are entitled to have
access to the natural resources in
their own village but they are
denied their entitlements. Hence,
they are compelled to migrate en
masse to the neighbouring
Shankargad. Shankargad in Uttar
lEII Pradesh also has stone quarries.
Khara Panchayat in Rewa district
of Madhya Pradesh has 60 to 70
families, numbering around 200
persons. With the exception of a miniscule 15 to 16 children and old people, all
the rest have migrated in search of a livelihood. Those left behind in Khara village
are seen either with a hammer or a crowbar in their hands.
o
<
■■
am
If you go in a flashback to Tapaspurva village in Khara Panchayat, their only
source of livelihood is breaking stones in the stone quarry. Illegal stone-breaking
continues unabated in the mines that belong to the Forest Department. Lawful
mining also goes on, but on a comparatively smaller scale. Owing to scanty
rainfall here in the past four to five years, the crops have failed and hence chances
of employment in the agricultural sector are almost non-existent. (One may
wonder where these fields have come from, but hold on; we will shift our attention
to that later).
The people here considered the possibility of getting a sanctioned access to these
mines, which would eventually pave the way for obtaining a mining lease, thereby
making it their main source of livelihood. Five years ago, they repeatedly
approached the Panchayat to this effect. The Panchayat paid no attention to their
applications. Their efforts continued as they sent their applications to the Chief
Executive Officer and to the Sub-Divisional Magistrate. They gave them an
assurance. In 2007, the adivasis sent an application the Mr. D.P. Ahuja, the
District Magistrate. Nothing happened. In 2008, they sent yet another application
to Ms. M. Geeta, the then District Magistrate.
Ms. Geeta gave them the assurance that if the Gram Sabha gives the approval,
they would have to pay INR five thousand and they would get the lease. The
adivasis returned with some hope and decided to demand a Gram Sabha in their
own village. However, till date, no Gram Sabha has taken place, and the adivasis
are denied entitlement to the natural resources in their own village.
Why are the adivasis demanding a mining lease?
As mentioned earlier, the adivasis depend solely on mining leases for their
livelihood. Agriculture, is also to some extent a means of livelihood, but is
entirely dependent on the rainfall. That is why they have no other choice other
than breaking stones for a living in the stone quarries. Siyasharan from Purva
village says that it takes 15 days to break stones to fill a 10-wheel truck,
truck. This
fetches them INR 2500.
^51 fl
This works out to each
labourer earning INR 70
to 80 per day. But this is
not a regular income.
When Forest Department
officials come on surprise
raids, the stone-breakers
are compelled to abandon
their implements and run
for their life. Sometimes,
they do not return to
■ - y
work for a few days. To add insult to injury, the Forest Department officials carry
away the heaps of broken stones. If the adivasis are caught off guard, they are
fined. In the year 2006-07, Laxmi and Bhola were fined.
When the contractor from Uttar Pradesh comes with his truck, the broken stones
are sold to him. The villagers say that a certain contractor from Uttar Pradesh
called Agrasen Mishra comes to buy their stones. He is lawfully not authorized to
buy stones, but he is in league with forest department officials. Had the villagers
been given the mining lease to break stones, they would have earned around INR
10,000 for the same amount of stones. Besides, it would be a lawful and dignified
means of earning a living. That is why they are demanding a mining lease to break
stones.
Why does the Gram Sabha not pay heed to their proposal?
Precisely, what is the reason behind the Gram Sabha’s refusal to accept the
proposal of the adivasis?
Raj Narayan Adivasi, who is the deputy Sarpanch and village head says, “The
proposal will be accepted only if there is a Gram Sabha. When there has never
been a Gram Sabha, how will the proposal be passed? The Gram Sabha has not
I met even once for the past five years. We
I made many attempts. We approached the
Sarpanch, then the Secretary, but all in
vain. Tired and helpless, we have given
wimrS up hope.”
-
'
We probed a little further as to why the
Gram Sabha never met. Everyone is
speechless. Breaking the silence, Raj
Narayan himself says that whenever he
speaks about their rights and entitlements,
it becomes very irksome for everyone. He
says that in the run-up to the Panchayat
elections in the year 2004, the Sarpanch
contested the elections promising to
■ provide agricultural land to every adivasi
■ in the village. Therefore, all the villagers
B supported the Sarpanch and voted him
" into power.
After his victory, the
Sarpanch never uttered a word regarding the land to the adivasis. He says, one
fine day he went to the Panchayat Office and reminded the Sarpanch about his
promise. The Sarpanch refused point blank to give the land. He further threatened
that if anyone broached the issue in future, he would shoot and reduce him to
smoke.
Raj Narayan recounts how he challenged the Sarpanch saying that if they did not
get the land within three days, they would grab it themselves. He says, “three days
later, the adivasis came together under the banner ‘Birsa Munda Land Rights
Campaign’ and forcefully appropriated a piece of land. This was in July 2005.
The Panchayat sent information to the local administration in this regard. Higher
officials from the Forest and Police department came on the scene. In this way,
they tried to warn and threaten us. But we did not accept defeat. Five hundred of
us adivasis took turns round the clock to keep guard.
Eventually, the
administration allotted this land to us.”
“The defeat of the Sarpanch in the elections was seen as a defeat of the Panchayat.
Today, we are bearing the brunt of this defeat at the instance of the Sarpanch and
several people of the upper caste. For many days after the incident, they harassed
us in different ways - by blocking access to our settlement and by verbal abuse.”
Why did the adivasis not lodge a complaint with the police station to this effect?
To this, they respond, “when the local administration and the police is hell-bent on
labeling us ‘naxalites’ to whom should we address our grievance?”
These are Naxalites from Jharkhand:
“On the basis of the report from the Sarpanch, the local administration is engaged
in declaring that all adivasis are Naxalites. Media clippings of that time reveal how
the Government made our campaign for our entitlements appear as acts of
naxalism. Wherever we go, people call us naxalites. Strangely, in this very Purva
village, some time ago, the villagers had caught the ration shop-keeper indulging
in malpractices in the distribution of ration. This is another reason why the
Sarpanch, the Deputy Sarpanch and upper caste people are annoyed with the
adivasis.
Neither employment nor guarantee:
Despite our consistent efforts to demand employment, not a single person in this
village has been given a job card. They have the job cards but they are worthless.
All the people got together and made an application to the Sarpanch asking for
employment. The Sarpanch bluntly refused saying, “Do what you like, you will
not be given the job cards.” No matter which department you approach or this
purpose, we have ‘our men’ in all high places.
The lease was given to the Collector:
Eventually, the Panchayat has granted the mining lease to the Collector. Don’t be
surprised! The mining lease was not given to the Collector or the District
Magistrate, but to Vishvanath Singh, a man of the upper caste whom the people
reverently address as ‘Collector’. The Panchayat made a public exposure of how
feudalism works. In response to the adivasis demand for five long years, the
mining lease was awarded to the ‘Collector’ for ten years. One wonders how the
mining lease has been awarded when the Gram Sabha has not been held at all.
Going by Panchayat records, no Gram Sabha has been held. It is quite another
matter which persons might have been present for this ‘Gram Sabha’
Violation of adivasis’ rights and traditionalforest rights:
After the enactment of Forest Laws, whenever people approached the Panchayat
either individually or collectively with their applications, the Forest Rights
Committee (which exists only on paper) in the Panchayat did not accept them.
The people had to file their claims at the Jawa Development Office. A year later,
no one knows what happened to those claims. Neither has any forest department
official has disclosed the truth about the claims nor what happened to their claims.
If you go to the Block Development Office, you are told that their claims have
been sent back to the Panchayat. And if you go to the Panchayat, you are not told
anything. The feudal lords have tried to snatch even this entitlement of the
adivasi. The reason for the disappearance of their claims is that the adivasis have
demanded entitlement to the mining lease, forest produce and rearing of fish. This
has become a nuisance for the Panchayat as they do not want the adivasis to get
these entitlements. When the adivasis made claims to their entitlements, forest
department officials demanded a bribe of INR 500 to 1000 per claimant. The
adivasis refused to pay these bribes, hence the annoyance.
Owing to drought conditions, nothing was cultivated on the controversial piece of
land. The adivasis have neither got the mining lease, nor their entitlement to the
benefits of the Employment Guarantee Scheme. The job card is just another piece
of paper — an empty promise. Hence the entire village of Purva has migrated in
search of greener pastures. Feudalism has once again strangled the prospects of
the adivasis and proved to be an obstacle to their development. One expects the
administration to ensure that the marginalized get the benefit of the welfare
schemes. Instead, the government has got into an overdrive to declare the adivasis
as naxalites, thus depriving them of their livelihood and entitlements.
Children are dying but administration is still snoozing
Abraham Lincoln's once said that “government of the people, by the people,
for the people, shall not perish from the earth”. But if the executive bodies of
the government which are very pillar the government itself is exploiting &
exposing threats to the primitive tribal groups though the use of feudalistic
attitude then existence of the tribal groups will soon be endangered. The PTGs
are made devoid of their basic rights. Their is no employment for them, no
schools, no aganwadi centers, no medical care for them. They are forcibly
displaced from their natural inhabitation. And such conditions are created in
which they are dying of starvation & hunger.
Asian Human Rights Commission (AHRC) has also released urgent appeal
under the Hunger alert programme on the condition of starvation & hunger in
Rewa district.
Though the Samaj Chetna Adhikar Manch, MPLSSM, Right to Food Campaign
and its support groups has also acquainted the district administration regarding
the awful situation of malnutrition of Java block of the Rewa district. Still the
sirnatinn didn’t change a bit even. District administration remains apathetic to
ensure food security & to curb malnutrition. Under PDS the vulnerable poor
are neither provided with regular supply of food grains nor in definite
quantity- No mid day meal in schools & SNP in AWCs are being distributed in
Schools & AWCs since more than a month in Ramnagar, Kureli, Kalyanpur,
Kuthila & Ramgadhwa villages of java block due to the non identification of
self helps groups (SHGs) for preparing nutritious food for children. According
to the villagers, immunization has not been done since last six months in these
places. The payment of wages under NREGA is pending for more than a year.
Despite the fact that the villagers are deprived of their rights to food and work
caused by lack of livelihood and the malfunction of government schemes, the
state government as well as local administration have not taken any substantial
action for those children and their families till now. They are thus forced to
migrate to in search of livelihood resulting in bed effect on the health of
children & are continuously seized by malnutrition.
State response on starvation protocol
S.no
State
Reference no.
Response received
1
Karnataka
15.2.2010
Chs 56/2010
2.
Punjab
11.2.2010 No.
27/3/2006/IFD/204
3
Goa
Dt. 2.2.10 by
Directorate of
Women & Child
Dev.
4.
Meghalaya
16.2.2010
A detailed protocol for state action in the context of starvation deaths has
been sent to all the DCs. According priority to the implementation of
NREGA. So far during the current year 55.76 lak households have been
registered and issued Job cards, 1387.36 lakh person days of employment is
generated; 27.24 lakh households are provided employment; 2.81 lakh
households have already competed 100 days of employment; the average
person days of employment generated per household is 50.92 and the total
expenditure incurred is Rs. 1811.87 crores. During the last year, the
expenditure under NREGA was around Rs. 357 crores.
There has been no starvation deaths reported in the state or any allegation
of starvation deaths. However, a careful watch is being kept to prevent
starvation deaths among the poor and vulnerable households.
All the concerned have been directed to strictly comply through this office
letter no. 27/3/2006/IFD/164 dt 3/2/2010. They have been asked to sent there
report to the Director Food, Civil Supplies & Consumer Affairs, Punjab.
the good quality of supplementary food is provided under SNP to improve
the nutritional and health status and thereby reduce the incidence of
mortality, malnutrition and school - drop outs. Also focus is given in
building a strong foundation for proper psychological, physical and social
development of child.
Under SNP, DTH packets of cereals and pulses are provided to pregnant and
nursing mothers as well as to the children in the age group of six months to
2-1/2 years. All the 1212 AWCs operating in the State provide SNP for 25
days in a month and 300 days in a year. For the year 2009 — 10 (upto
December) an average of 45442 children in the age group of 6 months to 6
years, 12404 pregnant and lactating mothers have been covered under the
SNP.____________________________________ __________________ _
Incidents of starvation deaths have never been reported from the various
block and districts under ICDS scheme of this state government. However,
filed officers have been instructed to remain vigilant and to take necessary
and appropriate steps if such situation arises.
Judging from the consolidated reports furnished by the CDPO, the status of
Action need to be taken on their
response
5.
Meghalaya
24th Februrary,
2010
6..
Himachal
Pradesh
15thFeb, 2010
malnutrition is much lower compared with the report of NHFS III. This may
be due to the fact that the figures reflected in the consolidated reports cover
children enrolled and attending AWC, whereas the report of the NHFS III is
taken per household and also covers villages with no AWC.
However, it may be stated that the reported figure in the NFHS III report
with regard to Meghalaya has been a matter of concern for this State
Government. In the meeting held at ND on 1st Dec,08 with Officials of the
MoWCD, this matter was elaborated upon and discussed and decided that a
joint survey is to be conducted between Social Welfare Officials, ICDS
functionaries, Distt Social Welfare Officals, Project Officials with the
Officials and functionaries of the Health & family Welfare Deptt so as to get
more clarity on issue of data on malnutrition and report on this is being
awaited.
Further, North Eastern Hill University, Deptt of Anthropology has also been
assigned to undertake an evaluation study of SNP in 14 selected projects with
effect from 2008 -09 and a report on this is also being awaited.
Meghalaya has already implemented and complied with the directives of Gol
to provide SNP at the revised nutritional norms respectively since April,
2009. Moreover, in order to meet the gap in terms of requirement of nutritive
value of SNP foodstuff, this department is taking up with the State Planning
Deptt for allocation of additional fund.
This has the approval of the Competent Authority’______________________
Incidents of starvation deaths have never been reported from the various
block and district level offices under ICDS scheme of this state government.
However, field officers have been instructed to remain vigilant and to take
necessary and appropriate steps if such situation arises.__________________
The state have circulated the suggested protocol to all DCs in the state for
information and for evolving local, area specific strategies to combat
starvation by ensuring convergence of all Govt, programmes and services.
The state has not reported any starvation death so far. The state also has a
fairly extensive education, health and ICDS Network. The PDS system is
functional and the State Govt, is suppleemting the Govt, of India’s support
with its own subsidized pulses, edible oils and iodised salt. The state also has
extensive social security coverage. Nevertheless there is no denying that
constant vigil against this pernicious evil needs to be maintained and we
intend to remain vigilant.________________________________
STARVATION: IMPACT AND REPONSE:
A Tracking Survey Instrument
Notes for Researchers
Definition of S tarva tion
Hunger: denial of adequate food to ensure active and healthy life.
Starvation: If hunger is prolonged to an extent that it threatens survival, or renders the
person amenable to succumb because of prolonged food denials to curable ailments,
then the person is living with starvation.
If these conditions actually lead to death, then this is a starvation death, even though
the proximate cause in every case would be a medical failure. But the cause of death is
not the medical failure, but the prolonged denial of nutrition that led to a person
succumbing to medical conditions which a well fed healthy person would easily be able
to combat and survive.
The focus of this study is not to retrospectively establish the fact of starvation deaths,
but instead to examine state response in the aftermath of a death which involved major
and prolonged food denials. It looks primarily at state response to the surviving
families, and to members of tribe, caste, class, gender and social category groups who
Eve threatened with similar starvation conditions. It also looks at social (primarily local
community responses) to starvation.
Features of Starvation
1. Starvation is ultimately no.t primarily a technical issue, but is rather related to deep-
rooted socio-economic inequities, which require radical and systemic solutions
2. Starvation and malnutrition related deaths are public health problems requiring
community diagnosis. They differ from classical"disease related mortality".
3. Dilemma is deepened because 'generally prevalent "baseline" malnutrition,
gradually worsening severe malnutrition and definite starvation merge with each
other along a seamless continuum.
4. Public officials, the lay public and sometimes even professionals believe that
starvation requires no intake of food. Starvation is levels of food intake that are
unsustainable for the continuance of life itself. An adult who eats 850 kilocalories of
food daily or less may be presumes to be starving. This cut-off is based on research
that shows that a person who weighs 50 kilograms, if she or he engage in no physical
activity altogether, they require at least 850 kilocalories merely to stay alive, even
though they perform no work at all.
5. Another reliable physiological indication of starvation is a BMI (Body Mass Index) of
16 and less. Body Mass Index or the BMI is the ratio of the weight of the adult in
kilograms to the square of her height in metres.
6. Nutritional status of children is easy to derive from the child's weight and age.
Weight of child compared to the ideal weight for that age mentioned in the NCHS
standards. Percentage of up to 80 per cent normal, 60 to 80 percent mild to
moderately malnourished, and below 60 per cent severe, below 50 per cent alarming.
Survey Instrument
Please seek informed consent of the family of the deceased, and assess at every stage if
the interview is causing avoidable distress. In such a situation, please call off the
interview immediately. Also respect the dignity and suffering of the bereaved family.
Please select one or more willing members of the family of the deceased as informants,
preferably adults. If the deceased is without a family, please talk to neighbours or
friends, if any.
Before the interview, please collect any official documents about cause of death, such as
post mortem report, or inquest, of report of administrative enquiry.
Please hold interview if possible in the household of the deceased
1. Details of Informant(s)
1. Name of Informant(s)
2. Relationship with Deceased
3. Age of Informant(s)
4. Gender of Informant(s)
5. Did Informant(s) live in same household as deceased at time of death?
6. If not, how does informant(s) know about conditions of death?
2. Details of Deceased
If interview is in home of the deceased, please give details of the home, in terms of
size, assets etc
1. Name of Deceased
2. Age of Deceased
3. Gender of Deceased
4. Approximate date of death
5. Did he/she work?
6. If so, what work?
7. Was deceased bonded? If so, details.
8. Description (free-wheeling) in words of informant(s) of the circumstances and
conditions of death of deceased
9. What in the views of the family was the cause of death, with reasons?
10. If this view is in conflict with official records of the causes of death, what does
the informant(s) feel about the official view(s)?
11. Was the deceased food deprived before death?
12. If so, what was the length of time period of this food deprivation? What was its
extent? What was its nature? What in the opinion of the informant were the
causes of this food deprivation?
13. How did the deceased cope with prolonged food deprivation?
14. Was the deceased thin, losing weight, with sunken eyes and cheeks, finding
difficulty in walking and everyday activities etc?
15. Was the deceased ill before the death? If so, details of ailments, length of time,
treatment etc.
16. Was the deceased a working and earning member? If so, what was the livelihood
and status for one year before death (earnings, regularity, conditions of work etc)
3. Details of other family members
1. Have any other members of the household died in the past 2 years? If so, please
ask the same questions as about the deceased who is the subject of the
investigation.
2. Who are the other members of the family who survive the deceased? Names, age,
gender, relationships with the deceased?
3. Did any or all of these family members suffer from food deprivation? If so, what
was the length of time period of this food deprivation? What was its extent?
What was its nature? What in the opinion of the informant(s) were the causes of
this food deprivation?
4. How did the survivors cope with prolonged food deprivation?
5. Are the survivors thin, losing weight, with sunken eyes and cheeks, finding
difficulty in walking and everyday activities etc?
6. Are the survivors chronically ill at the time of the investigation? If so, details of
ailments, length of time, treatment etc.
7. Who (if any) are the other earning members of the household? If any, what was
the livelihood and status for one year before death (earnings, regularity,
conditions of work etc)
8. Are any of the surviving members of the deceased bonded? If so, details.
9. Did any member(s) migrate over 3 years before the death? If so, details?
10. Did any member(s) sell/ mortgage immovable/ moveable assets over 3 years
before the death? If so, details?
4. Access to government schemes
Did deceased or eligible members of various food and livelihood schemes access these:
•
For children below 6 years, and pregnant or nursing mothers, did they access
services including supplementary nutrition from an operational anganwadi
centre running in the hamlet/village?
•
If not, does an ICDS centre exist in their hamlet?
•
If their small children were enrolled and regularly availing of the services of
ICDS, was their decline of nutritional status identified and addressed on
time; if not, why not?
•
Do children from 6 to 14 years in the nearby government school access
midday meals?
•
If not, does the nearest school serve hot cooked MDMs?
•
Were the children enrolled in the school? If not, why not?
•
Do they have a ration card?
•
If so, is it APL/ BPL/ AAY?
•
Does the ration shop provide foodgrains in the right quantity (35 kg per
month), price (see annexure 1) and on time (when sought every month
regularly)?
•
Did pregnant mothers get NMBS/JSY assistance?
•
Did deceased (if working) or any working adult member of family have a job
card under NREGA?
•
If so, how many days of work did they get in the past year?
•
Did family get assistance under NFBS if deceased was earning adult? If so,
how much and how long after death?
•
Did all old people receive pensions, and were these distributed at their
doorstep on time every month?
•
The same questions would apply to widows and disabled people in states
with schemes for pensions for these groups?
5. Conditions of Community and Social Group
The National Human Right Commission established that death is not necessary as
evidence of starvation. Discourse around starvation should shift from not just those
who died, but those who survived but are deeply threatened.
Therefore, in the second phase of investigation, the researcher should identify the other
members of the tribe, caste, class, gender or age group to which the affected people
belong and discussions should be carriedforward with them, in focus group discussions.
1. Broader questions regarding functioning of the food and livelihood schemes may be
asked, such as
•
is there an operational anganwadi centre running in the village,
•
is the nearby government school providing hot cooked midday meals to the
children,
•
does the ration shop provide foodgrains in the right quantity, price and on
time,
•
how many elderly persons in the village obtain social security benefits or
pensions from the state and so on.
2. Have any other members of the relevant tribe, caste, class, gender or age group to
which the affected people belong died in the past 2 years, for reasons that people
believe were connected with serious and prolonged food deprivation? If so, please
discuss in the same questions as about the deceased who is the subject of the
investigation.
3. Do any or all of the surviving members of the tribe, caste, class, gender or age group
to which the affected people belong suffer from food deprivation? If so, what was
the length of time period of this food deprivation? What was its extent? What was its
nature? What in the opinion of the FGD participants were the causes of this food
deprivation?
4. How did they survivors cope with prolonged food deprivation?
5. Are many of the members of the tribe, caste, class, gender or age group thin, losing
weight, with sunken eyes and cheeks, finding difficulty in walking and everyday
activities etc?
6. Are the members of the tribe, caste, class, gender or age group chronically ill at the
time of the investigation? If so, details of ailments, length of time, treatment etc.
7. What is their livelihood and status for one year before the death being investigated
(earnings, regularity, conditions of work etc)
8. Are any of the members of the tribe, caste, class, gender or age group bonded? If so.
details.
9. Did any member(s) migrate over 3 years before the death? If so, details?
10. Did any member(s) sell/ mortgage immovable/ moveable assets over 3 years before
the death? If so, details?
6. Conclusions about food deprivation
1. Conclusions from the above about the overall field situation in the family and
community: not mainly whether there was a starvation death, but whether the specific
family, as well as in that location the local community (such as Musahars) and the social
(such as single women) and class (such as landless workers) categories to which she or
he belongs, subsist in conditions of prolonged deprivation of adequate food with
dignity, or in continuous uncertainty about the availability of food, or dependence on
charity or debt bondage for food. It is reiterated that the idea is not to probe death and
its causes but only to understand the poverty and destitution faced by the families and
by similarly affected people. Attempt should also be made to understand the root cause
of poverty such as livelihood crisis, heavy debt, crop failures etc.
2. Conclusions about the access to food and livelihood schemes, and barriers thereto,
faced by the local community, tribe, caste, class, gender or age group to which the
affected people belong, and the village (or urban settlement) at large.
These conclusions should be recorded in writing, and shared and explained in the local
language to affected people and communities, local elected leaders and local officials,
and theirfeedback incorporated.
7. State Interventions in Situations of Suspected Starvation:
This section should be based on feedback from 4 sources a) enquiry from family of
deceased; b) enquiry from the community, class or social category to which the deceased
belonged; c) discussions with local and district level officials and panchayat members;
and d) personal observations of researchers.
1. Relief and food rights for Family of Deceased:
a) Did state or panchayat authorities ensure immediate food availability to the family? If
so, details of amount, periodicity, cost if any, terms etc.
b) Did state or panchayat authorities organise food availability on a more permanent
basis at highly subsidised rates to family, by the distribution to them of AAY cards, or at
least BPL cards?
c) Did state or
' panchayat authorities ensure early sanction and release of insurance
under NFBS?
d) Did state or panchayat authorities ensure their coverage of all food and livelihood
schemes for which they are eligible such as ICDS, MDM, NREGA and old age, widows
and disability pensions?
e) Did state or panchayat authorities ensure for children of families of deceased, their
admission to SC ST hostels if they choose, so that their education, food and protection is
secured?
f) Did state or panchayat authorities organise psycho-social support through
professional and trained lay counsellors to the survivors of the deceased?
g) Did state or panchayat authorities organise for infants, small children, expectant and
nursing mothers, supply of SNP from ICDS and hospitalisation where necessary,
arrangements for nutrition rehabilitation, and health-care including immunization?
h) Did state or panchayat authorities identify in consultation with the survivors in the
family, the reasons for livelihoods denial, collapse or insecurities and assist them to
build a secure livelihood through measures like land allotment and restoration in case of
alienation?
2. Relief and food rights for others identified to be similarly threatened: for the
community, class or social category to which the family of the affected person belongs.
1. Were there any organised official efforts to identify reasons for failures of food
schemes to prevent and address starvation, including the following:
•
Careful official and well publicised social audit of why they could not access
their food rights from the food and livelihood schemes relevant for them?
•
Were their small children enrolled and regularly availing of the services of ICDS,
and was their decline of nutritional status identified and addressed on time; if
not, why not?
•
Were the older children in school, and did they access regular and nutritious
mid-day meals?
•
Did they have ration cards, AAY or at least BPL, and did they regular receive the
prescribed quota of 35 kilograms of subsidised food grains from the ration shop;
if no, again why not?
•
Did all old people receive pensions, and were these distributed at their doorstep
on time every month?
•
The same questions would apply to widows and disabled people in states with
schemes for pensions for these groups?
•
Did they seek job cards and work, and was this given to them in accordance with
their legal entitlements under the NREGA?
2. Did district Panchayat leaders and Collector, within 3 months from the date of initial
information:
•
fix responsibility at all levels for the starvation death
•
punish those found guilty of lapse in their duties
•
remedy gaps of funds, resources and personnel
•
address issues of discrimination and social exclusion
•
ensure time-bound coverage of all affected and threatened people by AAY ration
cards, job cards under NREGA, old age, widow and disability pensions, and
ICDS services, including nutritional rehabilitation and hospitahsation where
found necessary.
•
were there further deaths after the first death from similar conditions of severe
food deprivation?
3. In the long run, were local structural sources of pauperisation identified and local
solutions developed, possibly in consultation with the gram sabha and village
panchayat?
(These may include failures to implement land reforms, tribal land
alienation, caste discrimination, micro minor irrigation and watershed development,
availability of formal credit for agriculture and artisans, access to forests and choices of
agricultural technology and cropping patterns). Were any of these addressed? What was
the impact if any of these measures?
4. If any funded NGO works in the area, please consider it also as a duty bearer and ask
similar questions as about the role of the state.
Report of the Balangir starvation death case
Date of visit: 17th September 2009
Person visited: Sameet Panda, researcher with the office of the State Advisor
Pradeep Baisakh, who works with MiRC, Aide et Action. He is also a
Development Journalist
Initial source of information: Local Oriya daily “Dharitri” reported the matter on
15th September 2009
The story as per the initial source: Three starvation death cases were reported in the
local Oriya daily “Dharitri” on dated 15th September 2009. As per the report three
persons namely Siba Prasad Bariha (3), Gundru Bariha (1) and Bimla Bariha (35) died
respectively out of starvation from Buromal village of Bhanpur Panchayat under
Khaprakhol block of Balangir district of Orissa. Three deaths occurred consecutively
on 6th, 7th and 9th September 2009 respectively. Late Bimla Bariha, wife of Jhintu
Rariha is the mother of Siba Prasad and Gundru.
Procedure followed
followed in
The member team visited the Chabripali hamlet
Procedure
in the
the visit:
visit:
of Buromal village on 17th September 2009. Prior to the visit a letter was sent on 15
September 2009 to the District Collector of Balangir copy marked to the Chief
Secretary, Secretary R&DM and the Commissioner’s office in New Delhi for onward
communication.
Details of the family:
Name of the deceased’s: Ms Bimla Bariha (35), Sibaprasad Bariha (3 year old male
child), Gundru Bariha (one year old female child)
Head of household: Jhintu Bariha (42), husband of Bimla and father of Siba and
Gundru
Name of the hamlet: Chabripali (in Buromal village of Bhanpur Panchayat under
Khaprakhol block of Balangir district)
House type: Kuchha
Land holding status: Nil
Occupation: casual/migrant labour (no regular earning)
Availability of ration / entitlement cards: No
(Jhintu Bariha is staying separately from his parents after his marriage, about eight
years ago. His father is having a BPL card but Jhintu does not possess any entitlement
card of his own, so he is not availing any benefits - PDS and others)
Brief profile of the village: Chabripali hamlet is part of Buromal revenue village
inhabited by 70 households. It is around 90 kilometers away from District head
quarters (Bolangir) and 20 kms away from Block headquarters (Khaprakhol).
Scheduled Tribes constitutes around 80 % of the total population. Most of the people
are poor and agriculture and forest are the main source of source of their livelihood.
Due to acute poverty, a good number of villagers, mostly from SC and ST
communities have been migrating out in pursuit of livelihood every year.
Individuals interacted with:
Jhintu Bariha (aged about 42), husband of Bimla and father of Siba and Gundru
Champo Bariha (about 80), father of Jhintu Bariha
Minji Bariha, (aged about 70), mother of Jhintu Bariha
Jaibihari Bariha, local ward member
Chudamani Nag, Sarpanch and also with other villagers
Ms Rebati Meher, Anganwadi worker of Chabripali mini AWC
Dr. Meher the junior doctor present in Chabripali Mobile health unit
Chandramani Seth, BDO, Khaprakhol
Deben Pradhan, Sub-Divisional Magistrate, Patnagarh
Dr. Balaram Panigrahi, In-charge at the district hospital, Balangir
Sanjay Kumar Habada, Collector in charge Balangir district.
The Report
The child Siba Prasad Bariha (3) and the infant, Gundru Bariha (1) were said to be ill
and succumbed to the illness one after another. Mother Bimala also died after two
days of the death of her children. Jhintu Bariha and his son Ramprasad Banha are the
two surviving member of the nuclear family. During the visit, the team met his
parents - Champi Bariha (80), father and Bimpi Bariha (70), mother. Who are living
in a small hut with very meagre belonging. Their younger son Bhurshava Banha also
stays with the grandparents. Jhintu and his son were taken by the government
authorities for treatment in Bolangir hospital. During discussion, the old couple told
that they have a BPL card bearing no: 52, by which they get 25 kilograms of nee @
Rs 50 per month. Mr. Champi Bariha is also a NOAP beneficiary and gets Rs 200 per
month as old age pension. Though Ms. Bariha is entitled to receive old age pension,
she has not got it yet. Champi Bariha says he used to beg when he was in good health
but now is unable to go as he is not keeping well for last few months.
The team also interacted with the villagers of Chabripali after discussing with the old
couple. All were of the opinion that Jhinktu Bariha and his family had been suffering
from regular food deprivation, though there was difference of opinion about the cause
of the death.
About Jhintu and his profession:
Jhintu Braiha has almost been regularly migrating out of state in search of livelihood
for last some years-particularly after his marriage. Three years before when he was
working in Madhya Pradesh in an agriculture farm as an agricultural labourer, he got
an electric shock which partially damaged his left hand and left leg. As a result, he
could not again go out to work but tried manage in the village, where he along with
his wife used to do minor agricultural works here and there. But, as there was dearth
of such work in and around, he had no option but to go out again. Last year, he along
with his family migrated to work in the brick kilns of Andhra Pradesh after taking an
advance of Rs 10,000 from a labour contractor. The advance money was to be used to
repay his debts. Jhintu fell sick during the work in Andhra Pradesh so he was brought
back to the village in June 2009. Whenever they are in village the family tries hard to
gather adequate food for them but they hardly succeed. This time around, it was very
difficult for Jhintu to work as he was too ill and Bimla also cannot go out full time for
work as she had small Gundru (the one year old girl child) in her lap. As the whole
family was suffering badly from gross inadequacy of income, the only help coming
was the share of PDS rice from their old parents.
Food intake of the family:
Ramprasad (aged about 7), is the elder and the only surviving child of Jhintu Bariha.
The team met him at the Balangir hospital and asked him about the food intake of the
family. As per him he use to take mudhi (puffed rice) with black tea given by their
grandparents, rice with either salt or with any wild spinach collected from the; forest
but when asked about the food at the night he started crying. When insisted he told
that he used to sleep empty stomach in the night. Whenever he asked for food in t e
night the parents used to give him a glass of water to drink and used to ask him to
sleep quietly. He told that he was at least not going empty in night while he was in
Andhra as a migrant child.
1.
The total food and monetary inflow to the family of five are :
1. 12 % kg of rice-half of the rice their old parents were getting under 25kg rice
scheme under PDS
2. Some from the old age pension that Champi Bariha used to get
3. Some meagre occasional help from the community by way of begging from
neighbourhood
The above description of food intake for the family of five may clearly give a picture
of the severity of the vulnerable condition of the family. The inadequate food intake
was taking heavy tool on the health of the whole family which in turn was reducing
their ability to work to earn. They were therefore caught in the vicious cycle of
poverty and starvation.
1 This description is as per the version of the old parents of Jhintu-Champi and Bimpi. Jhintu, who
team met in Balangir hospital, described in the same way
Ms Bimpi, the old mother of Jhintu, has still a clear way of describing the starved
situation of the family. She says that when the small two children would cry out of
hunger, they start sucking the breast of their mother with the hope that milk would
come out and drive their hunger. But their hope would be dashed as nothing would
come out. She emphasises “How can there be secretion of milk from the mother s
breast if the mother herself does not get enough food to eat?
Champi and Bimpi clearly tells that the deaths are due to starvation, though the two
children had fever at the time of death-but that is due to prolonged starvation and
breakdown of the immunity system.
What doctor has to say:
The team met Dr. Balaram Panigrahi, the in-charge medical officer at the head quarter
hospital Balangir. He said, both Jhintu and Ramprasad were suffering from loose
motion and fever when admitted in the hospital. About the treatment he said that
though Jhintu tested negative to malaria, but responded positively to anti-malana
doses; this is clinical malaria. Ramprasad was given a bottle of blood as he was
identified anaemic, which is symptom of presence of splm-which is caused by
malaria. So he also can be called to have clinical malaria. On the starvation aspect ot
the family, the doctor said that one has to visit the food history of the family to
ascertain the prolong food deprivation if any.
A probable conspiracy:
The mobile health unit camping at the village from 10th September 2009 informed the
team that they found one hundred and twenty two cases of malaria positive in the
village and all of them have been administered anti-malana doses. The population oi
the hamlet is 370. When enquired if there is any past record of malana deaths in the
hamlet in last two-three years, the doctor present replied in negative. By that time the
team had already interacted with many villagers, many of whom were not observed to
have any post-malarial weakness and were looking quite alright-this led to suspicion.
One of the team members interacted with the villagers and was informed by a group
of youth sitting in the village that only four five people had fever, but many villagers
were asked to take anti malarial doses. Mr. Bideshi Meher (about 41), had no fever,
but his blood was tested and he was administered malana doses. After taking anti
malarial pills, he fell ill. “The doctors told that malaria has spread and I should take
these medicines. If I do not take these I will have malana.” says Bideshi. After he felt
uncomfortable taking the malaria doses, he decided to discontinue them and now he is
well! He also showed the anti-malaria pills and doctor prescnptions to the said team
member. Santosh Meher, a youth shared that same was the case with him, that he was
also administered the malaria doses though he had no fever. But Santosh was not
ready to cooperate to show his prescriptions and medicines.
It may be noted that the villagers were generally tight-lipped on the matter. Some
people in the village (apparently those who have a good landed property and seem to
be influential) attempted to eavesdrop the discussion of the team with the old parents
of Jhintu and also tried to join. It is they who told to the team, during an informal
small village meeting, that it’s a malaria death. The same people followed the
movement of the team-understandably to keep track of the interaction of the team
with different stake-holders. They also followed, uninvited, while the team went to
the village school where the mobile health unit was parked. All these forced one of
the team members to find out way and have an independent interaction with some
villagers. There is a feelings of the team that a conspiracy has been hatched by the
administration to name this as a malaria related death, which otherwise is a clear case
of starvation death case. In order to cover up, the doctors have administered malaria
doses to many who did not have any fever. This may be the cause why the media
initially reported it as a case of starvation death, but later it was reported as malaria
one. However, further probe is needed to establish the truth behind this probable
conspiracy’.
Action taken by the administration:
Though it acted very late but the Sarpanch gave the family 12.5 kilograms of rice
under gratuitous relief (GR) on 9th September 2009. Another 32 families have also
been provided with rice under GR facility by the Panchayat to prevent further hunger
and starvation in the village. The medical officer from the mobile unit after getting
the information visited Jhinktu’s family and sent him and his son to the Patnagarh sub
divisional medical hospital and subsequently they were shifted to the district head
quarter hospital Balangir for further treatment.
The BDO of Khaprakhol, Mr. Chandramani Seth and the SDM Patnagarh Mr. Deben
Pradhan visited the village on 11th September 2009. They sanctioned an IAY house to
the deceased’s family. The collector-in-charge of the district Mr. Sanjay Kumar
Habada also visited the village on 13th of the month and handed over a cheque o s
10, 000 to the deceased’s family under National Family Benefit Scheme. He a so
asked the BDO to sanction disabilty pension to Jhintu and an old age pension for
Jhintu’s mother-Bimpi under Madhubabu Pension Yojna (state pension scheme) on an
urgent basis. The administration showed its helplessness in providing an Antodaya
card to Jhintu’s family as they are bound by the quota fixed by the state and centre.
Functioning of food related scheme:
The team tried to understand the functioning of food related scheme in the short span
of time.
i. Public distribution system (PDS)
It was found that Jhintu Bariha, though poor and landless, is not covered under PDS.
He is not a BPL Card holder. Since 1997, BPL list has not been updated m the state,
not to talk of Jhintu’s village. Though Jhintu has been staying separately since long
but has not been covered under BPL. If we go by village statistics there are altogether
70 households out of which BPL - 29 household, AAY-8 household and 23
household have got APL cards. This shows that 20 households does not have any
card. As per the BDO Khaprakhol the APL card has been allocated to the families
whose name appears in the 1997 BPL survey. Others family have not been allocated
any cards. As the state is yet to finalise the 2002 BPL survey many of the poor and
needy family are deprived of any ration card.
ii. The Two-rupees per kg rice scheme:
It functions well in the village and all the families entitled to it are told to be getting
its benefit, except 20 families. Therefore the family of Jhintu could not take any
advantage of it.
iii. Integrated Child Development Services Scheme (ICDS):
There is a functional Anganwadi centre in the Buromal village and Chabripali was a
tag village of the centre. Though it is only one kilometre away from the centre, it was
reported that none of the beneficiary from the village have got a single grain from the
centre. As Jhintu had two children under the age of six they were entitled to benefits
of ICDS scheme but they never got a morsel of grain from the centre. The children
would have got two kilograms of rice each which could have played a major role m
preventing starvation of the family and other families with children and lactating
mother and suffering from acute food deprivation. As per the villager the Anganwadi
worker (AWW) never visits their village.
After report of starvation death, a mini Anganwadi centre has been approved for
Chabripali hamlet. Ms. Rebati Meher from Chabripali hamlet has been appointed as
the AWW for the centre. The centre runs in the house premises of the AWW. As per
her the centre was started on 15th September 2009 and the centre has thirty eight (38)
ICDS beneficiaries and 10 emergency feeding beneficiaries. The required ration has
already been delivered to the centre.
iv. Mid day meal scheme:
There is a primary school in the Chabripali hamlet. As the children interacted the mid
day meal is being provided regularly in the school. Hot cooked nee, dal and soya
chunk curry is being provided as noon meal in the school. As per the children the
elder child (Ramprasad) used to go to the school and take meal but he was not
regular- as he often migrate out with his parents. The school was closed at the time of
visit as the mobile health unit was camping in the school building so the school
records could not be verified.
v. National maternity benefit scheme:
No mother is provided the benefits of the scheme though many of them delivering in
the home. Most of the mothers were unaware about the scheme as well.
vi. Status ofNational Employment Guarantee Act
It is to be mentioned here that National Rural Employment Guarantee Act (NREGA)
is being implemented in Bolangir since February, 2006. The mandate of the Act is to
provide minimum 100 days of employment to each registered rural household. It was
found that since last 8 months NREGA work has been stopped m the village. As per
the people they would never opt for migration if they would get regular employment
under NREGS. While interacting with the villagers, one Mr. Sira Hati was of the view
that even if they get employment the wage payment is never on time which is
discouraging them to work under NREGS.
Are these starvation deaths?
a. Champi and Bimpi Bariha (parents of Jhintu): The parents of Jhintu clearly say that
as the family of Jhintu was taking grossly inadequate food for a very prolonged
period, the deaths are due to starvation. Even though the children were ill and feverish
just before their deaths, they succumbed to starvation. They assert “anybody who does
not get proper food for a long time will naturally have feverish as the immune system
collapses and the health gradually deteriorates leading to death. This is what exactly
happened with the kids and their mother.” They add “Simla almost stopped taking
food after her children’s death. She took food after persuasion of the villagers and her
relatives. She died after two days. But the fact is less than two days of fasting cannot
take anybody’s life. She also was starving for a long time. Had Jhintu and Ramprasad
not taken to hospital, they would also have died”
b. Jhintu Bariha: He says that they have been starving as they do not have adequate
income for he is unable to work. The gradual starving condition led to the illness
culminating in death.
c. Villagers: Some say its malaria related deaths and some say its starvation deaths
d. Administration: Both the Collector-in-charge and the BDO say they are malaria
deaths. They have some reasons why these could not be starvation deaths. They are
(a) he had borrowed rupees 1000 from the ward member recently (b) he had borrowed
ration of about 1000 rupees from the grocer shop (c) and he had borrowed 4000
rupees from somebody else and finally (d) on 8th August, the old parents of Jhintu got
their quota of 25 kg rice.
The administration intended to say that as Jhintu had borrowed so much of money and
parents had also got the PDS rice just before the death of the women, they would have
taken food and therefore its not a starvation death.
e. Team’s view: These are clear cases of starvation death. The food intake pattern
suggests the family has been starving for months together and finally succumbed to
illness and died as a result. So, chronic hunger and malnutrition coupled with fever
led to the deaths.
The team in fact asked the Collector-in-Charge what he understands by starvation
death. The Collector-in-Charge answered that if somebody does not get any food to
eat for six or seven consecutive days and succumb to death due to that can be called
starvation death.
Recommendations:
The Constitution of India ensures live with dignity to all its citizen as a fundamental
right (Article 21). The Supreme Court of India has told it time and again that to ensure
the fundamental right the state is bound to safe guard basic minimum requirement of a
person. To protect someone’s life requires availability and accessibility of food to
every person, on top of all. The States is to ensure that the citizens have easy access to
foodstuff. Keeping it in view, the Govt, has launched several food security and wage
employment programmes for the villagers.
The incidence of alleged starvation death can be termed as non-implementation/
improper implementation of food security programmes and NREGA. It is also vitally
concerned with the BPL fixing criteria and updating of the BPL list. Keeping it in
view, the team recommends to the administration to take the following measures in
order to save the poor from chronic hunger and starvation death.
1. The 2 rupees per KG rice scheme should be extended immediately to cover all
the families, not limiting it to only the ration card holders.
2. Process should be initiated so that the poor and vulnerable people who are not
covered under BPL category should be covered under APL category at the
earliest. As already ordered by the honourable Supreme Court the state should
expedite the distribution of Antodaya card to the six categories of families
sighted by the Honourable court under it order on dated 2nd May 2002. The
Antodaya list should be updated earliest possible and adequate steps must be
taken to ensure that this is done with due delicacy to cover all the deserving
families.
3. The ICDS centre should be functional in every habitation and quantity and
quality need to be ensured while distributing food.
4. The pregnant women entitled for National Maternity Benefit Scheme should
be provided with the benefit without fail.
5. NREGA is the best law to provide guaranteed wage employment to the poor.
But it is not being properly implemented. The labourers are not getting their
dues since months together. So, the administration should take steps to
immediately ensure payment of pending wages to the labourers who worked in
the past and start the NREGA works in the village afresh.
6. Primary Health Centres and Community Health Centres need to be revamped
with allotment of more doctors and Para-medical staff to provide ready and
adequate health service to the poor.
7. Last, but most importantly, an inquiry must be ordered by the government to
be done by an independent high-powered committee to probe into this case,
how a conspiracy has been hatched to suppress the failure of district
administration on alleged starvation death. At the same time how the ditnct
administration deceivingly administered 120 people with malaria doses with
the intent to give it a name of malaria death.
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Letter on WHO 2006 Growth Standards, by Marko
Kerac and Andrew Seal
This new 2006 WHO Growth standards: What will they mean for emergency nutrition programmes?
Dear Editor
Whilst welcoming the principles which have driven the development of the new 2006 WHO growth standards
(see news piece this page), we wish to draw attention to important practical implications for emergency nutrition
programmes. We think it is important that these are explored and discussed in detail before the new standards are
implemented in operational settings.
The need for new growth standards
An internationally valid, ’gold standard' range against which child growth can be assessed has long been needed.
There are several reasons why the previous NCHS (National Centre for Health Statistics)/ WHO Reference data
fell short of this ideal:
1. It was constructed on a cohort of North American children, from a single community and a single ethnic
group of European ancestry.
2. Data was gathered from 1929- 1975, a long period during which nutrition varied greatly. The main issue
of concern was that infants were pre-dominantly bottle-fed rather than breastfed, as is considered ideal
today.
3. Statistical methods have advanced significantly since the original NCHS/WHO growth curves were
constructed in the 1970's. Applying better statistical techniques to the same dataset was what led to the
CDC 2000 growth references.
4. Increasing numbers of studies in both developed and developing country settings found that apparently
healthy, breastfed children were being labelled as abnormal according to the NCHS/WHO References.
l h’.urc !
Gtrnp.anhort
tor
p.'MT.I h
I •
r
. 7. u'l k
12 .
------- WOW -------- WHQP5 --------MHCW
----------------------------------------------------- NCMSPf?
MGRS (Multi-centre Growth Reference Study)
The MGRS1 ran from 1997-2003 and was explicitly designed to generate a growth standard to show how
children should grow, rather than just a reference that allows comparison. Following extensive screening to
select only those children free of health or environmental (socio-economic/ nutritional) constraints to growth, a
total of 8,440 children were observed at six international sites (Brazil, Ghana, India, Oman, Norway, USA). The
study had two components: longitudinal work followed children from birth to 24 months; a cross-sectional study
observed children from 18-71 months. State-of-the-art statistical techniques were chosen to construct growth
curves from this data. Key outcomes from the MGRS are:
1. The strongest evidence yet that a single international child growth standard is valid. Free of
environmental and nutritional constraints, children of very different ethnic groups all grew the same: only
3% of length variance was due to inter-site differences.
2. New z-score and percentile refer ences charts/tables for weightforage, length/height-for-age, and weightfor-length/height.
3. Additional standards not present in NCHS/WHO Reference: Body Mass Index (BMI); Mid upper arm
circumference (MUAC); skin-fold thickness; and motor developmental milestones.
4. A devoted website with extensive literature relating to MGRS and the new standards.
5. Free downloadable software which may, in the future, enable both individual and population
anthropometric status to be calculated using either NCHS/WHO Reference or WHO Standard data.
Differences between the old and new growth curves
'"here are important differences between the old references and the new standards. There is however no easy or
vonsistent way of transforming anthropometric measures between the two: the growth lines do not run in parallel
with simple shifts up or down. Factors affecting the magnitude and direction of differences between old and new
cut-offs include: a child's age; a child's length/height; which measure (i.e. WHZ; WAZ or HAZ) is being
considered; whether the child under consideration is above or below median; and whether the z-score or % of
median is being considered. As an example, shown below are the weight-for-age percentile lines (P) for boys
between 0 and 36 months. The curves cross, sometimes more than once, illustrating that the magnitude and
direction of the difference between the NCHS/WHO Reference and the WHO Standards is dependent on the age
of the children and his location on the distribution.
In short, the net effect of the new standards on the measurement and diagnosis of growth and malnutrition is
complex!
Implications for emergency nutrition assessments and feeding
programmes
Comparability and interpretation of nutrition data
Interpreting trends in nutritional status and setting agreed thresholds for action are important for emergency
nutrition programmes. With the adoption of the new WHO standards the ability to easily compare the results of
current surveys with previous data will be lost, and this will make new data more difficult to interpret.
This problem could be overcome by allowing for a period of dual-analysis of survey data. If results from surveys
are analysed using both the new WHO Standards and the currently used NCHS/WHO Reference, then sufficient
data and experience may be built up with the new system whilst assuring 'backwards compatibility'. Though
potentially complex and confusing for non-specialist policy-makers, this approach would eventually enable trend
and risk models to be recalibrated and appropriate new action thresholds set. However, a note of caution must be
added. Although software is available from the WHO web site that can be used to analyse surveys (WHO Anthro
2005), at the moment it does not deal with cases of oedema in the standard way, making calculation of the
correct estimates of Global Acute Malnutrition (GAM) and Severe Acute Malnutrition (SAM) difficult.
2. Prevalence assessments using z-scores
Weight-for-length/height is a key anthropometric measure for emergency feeding, widely used in malnutrition
prevalence surveys to assess the need for, or effect of, a nutrition programme. It is therefore important to know
what are the expected effects of the WHO Standards on the measured prevalence of GAM and SAM.
. Effect on SAM ~ a marked increase
Overall, the new WHO standards will increase the measured prevalence of SAM through increasing the value of
the weight for height <-3 z-scores cut-off. The difference is maximal (1kg) for infants with lengths around 60
cm. As length increases, this difference narrows and from 76.5- 86cm length, the NCHS/WHO Reference cut-off
is temporarily higher by about 0.2 kg. With yet further height increase, the WHO Standard cut-off again
becomes greater. There is a second peak difference of 0.6 kg for children above 100 cm.
. Effect on GAM ~ small but unpredictable
For GAM the weight for height cut-off is <- 2 z-scores. The pattern of differences for -2 z-score follows that for
-3 z-scores but, due to their different magnitudes, may lead to an increase or decrease in prevalence depending
on the height profile of the surveyed populations and the relative contribution of SAM to GAM.
3. Feeding programme enrolment and discharge
. Feeding programme enrolment if using % ofmedian
The percentage of the median has long been the de facto field measurement for the admission of children to
selective feeding programmes (therapeutic for SAM; supplementary for moderate acute malnutrition). As yet,
WHO do not provide % of the median tables for use with the new Growth Standards. However, if these are
tabulated something unexpected is observed. Paradoxically, in contrast to what we saw with z-scores, when the
new standards are applied in percentage of the median measurements, there is an overall decrease in the cut-offs
r acute malnutrition. This would therefore lead to a decrease in the numbers of children eligible for selective
feeding. Both the 70% and 80% curve follow the same pattern.
. Feeding programme discharges if using % of median
Discharge from selective feeding programmes typically takes place when patients achieve 80 or 85% of their
median weight for height. With application of the WHO Standards, these cut-offs will be reached at a lighter
weight so children will, on average, be discharged earlier. The effects of this change on relapse, re-admission or
case fatality rates are currently unknown.
. Feeding programme enrolment if using z-scores
If agencies move to using z-scores based on the WHO Standards as entry criteria for selective feeding
programmes what changes in admissions can be expected? We mentioned above that the -3 z-score cut-offs have
increased with the new standards meaning that more children will be diagnosed as severely malnourished and
therefore eligible for admission to therapeutic feeding. To assess what magnitude of difference this could entail
we looked at historical data from 3 refugee operations in Africa and Asia. The numbers of children eligible for
admission to therapeutic feeding increased by between 500 and 600%-. If programmes plan to use the new WHO
~ andard z-score cut-offs they may need to plan for at least a 5 fold increase in patient load.
. Feeding programme discharges if using z-scores
If patients are discharged at -2 z-scores then the impact on average treatment duration in any programme will be
variable, depending on the particular height profile of the population. Conclusions The new WHO standards
represent significant theoretical advantages over the old NCHS/WHO growth references. However, their
introduction poses a number of potentially serious operational challenges, which, in the opinion of the authors,
have not yet been adequately discussed or addressed.
In emergency settings, the likely effect is a great increase in the diagnosis of SAM, and a possible increase in
GAM - if assessed by <-3 and <-2 Z-scores respectively. This might be seen as a great opportunity to enrol more
children in therapeutic feeding programmes (TFPs). However, if this line is pursued the funding implications and
possible diversion of resources away from food security, livelihoods, and other public health interventions need
careful consideration.
There is however another, perhaps more serious possibility: if % of median remains the field programme
admission criteria, significantly less children might be admitted to programmes. This risks confusion between
different programmes, misallocation of resources, and potentially harmful impacts on clinical care and public
health outcomes. It is crucial that operational agencies work to achieve a consensus on the way ahead.
Recommendations
We believe that the new WHO standards represent both great opportunities but also great challenges for
emergency nutrition. They should not be implemented in haste. We call for a body comprising UN and NGO
implementing agencies to be rapidly established to coordinate a response to this operational challenge.
Sincerely,
Marko Kerac, Valid International and College of Medicine, Blantyre, Malawi, and Andrew Seal, Institute of
Child Health, London, UK
1 www.who.int/childgrowth/en/
2
unpublished data
DRAFT PAPER
PANCHAYAT LEVEL DATA BASES:
A WEST BENGAL CASE STUDY
Aparajita Bakshi Indian Statistical Institute
Jun-ichi Okabe Yckchami National Urawsity
STUDYING VILLAGE ECONOMIES IN INDIA
A COLLOQUIUM ON METHODOLOGY
December 21 to 24,2008
Y v \/
VY V
XY X
PANCHAYAT LEVEL DATABASES: A WEST BENGAL CASE STUDY
Aparajita Bakshi, Indian Statistical Institute
Jun-ichi Okabe, Yokohama National University
1. INTRODUCTION
This paper studies the overall status of data available at a gram panchayat in West Bengal.
The puipose of this study is to assess the potential of the gram panchayat database as an
instrument for planning and policy implementation.
Under the system of centralised planning, there was little development of local-level
databases in India. However, the need for decentralised databases at the village level has
been felt for some jears. The success of the panchayat system in decentralised planning
in West Bengal and subsequently the 73nl and 74th Amendments to the Constitution of
India necessitated the development of databases systematically from below. In 2001 the
National Statistical Commission of India recommended that a Committee of Experts be
constituted to review the record with respect to basic statistics for local-level
development and suggest a minimum list of variables on which data need to be collected
at the local level.1 As a result, the High Level Expert Committee on Basic Statistics for
Local Level Development was established to consider different aspects of the problems
of databases for local level development.2
The focus of the High Level Expert Committee has not been quite the same as that of
the National Statistical Commission. The National Statistical Commission focussed on
Hock level statistical organization as key to the construction of local-level databases,
whereas the High Level Expert Committee has focussed on
in the course of its
pilot studies. The Committee recommended that the gram panchayat should consolidate,
maintain and own village-level data. Indeed, a village is the very first stage of collection
and recording of data, and village-level data are at the very root of statistical system in
rural India. This study of panchayat-level data has been stimulated by this perspective of
the High Level Expert Committee.
1 National Statistical Commission (2031), para 9.2.22 and 2.7.8.
2 Government of India (2006).
234
There is no standardised system for collection of local level data in India. Large scale
sample surveys do not fulfill the data requirements for local level planning since such
surveys usually provide estimates at the national and State levels. Thus, according to the
National Statistical
Commission
(2001),
‘‘there
should
be
a set
of core
variables/indicators on which statistical data should be compiled and aggregated at
appropriate levels, analysed and published at regular intervals of time. The sources of this
data could be both the decadal population census and administrative records of the
Government Departments. Further, additional data requirements for local level planning
specific to local area also should be looked into and the local bodies should be given a
free hand in deciding their data requirements, which otherwise could not be met through
the standardised system” (para 9.2.21).
In order to assess the potential of the panchayat-level data base, we took up a relatively
advanced gram panchayat and review the overall set up of its statistical system. Our study
is limited to a single gram panchayat since the total statistical system of the panchayat raj
institutions is too complicated to be examined in detail here. We visited the Raina gram
panchayat and conducted interviews with panchayat members and officials on their
administrative set up and collected various data used for their governance. We checked
actual documents and records there. We visited Bidyamdhi village in the jurisdiction of
this panchayat to assess actual records collected and available at the village level. We
identified the main data sources available at the gram panchayat and below for local-level
planning and its implementation.
2. PROFILE OF THE RAINA GRAM PANCHA YA 7AND THE BIDYANIDHI
VILLAGE
We selected Raina gram panchayat in Barddhaman District in West Bengal for our study.
Barddhaman District is a region of relatively high incomes and literacy in the State. In
2005, the Human Development Research and Coordination Centre, Development and
Planning Department, Government of West Bengal carried out a study on ‘Landlessness
and debt in rural West Bengal’.3 As part of the study, census type surveys were
undertaken in seven villages in different agro-climatic regions of the State in May-June
3 The study was directed by V. K. Ramachandran and Vikas Rawal.
235
2005. Subsequently, one of us was involved in detailed surveys on various aspects of
incomes and employment in three of the seven villages the following year. Bidyamdhi in
Raina gram panchayat was one of the villages that were studied. Raina gram panchayat
was specifically chosen for this study since our previous experience suggested that this
panchayat was more efficient and successful in implementing different development
programmes compared to the other village that were studied in 2005-06.
Household level data collected in the 2005 and 2005-06 surveys were available to us. This
enabled us to assess the quality of some of the data available at the gram panchayat,
based on comparisons with the survey data.
2.1 Prefile cfRaina
Raina gram panchayat in Raina I Block is situated in the South Eastern part of
Barddhaman District. Raina gram panchayat consists of 13 mouzas4 covering a
geographical area of 20.8 square kilometers. The total population of Raina
gram
panchayat is 14967 (Census of India 2001) of which, 35.2 per cent are Scheduled Caste
households and 4.5 per cent are Scheduled Tribe households. The literacy rate in this
panchayat is 75 per cent, which is higher than the average literacy rate in West Bengal.
The panchayat office is situated in Rayna mouza, which is also the Block headquarters.
Rayna is 25 kilometres from the district town Barddhaman and is well connected to the
town by road. The nearest railway station is also Barddhaman. There are 10 primary
schools, one secondary school and one higher secondary school in the gram panchayat.
There is one Primary Health Centre and two sub-centres.
Barddhaman district is one of the most agriculturally advanced districts in the State and
leads in the production of rice and potato, the two main crops of West Bengal. Bound by
the Damodar River on the east, Raina is an agriculturally advanced area. According to the
Census of India 2001, 79.3 per cent of the geographical area of Raina gram panchayat is
agricultural land, of which 95.6 per cent is irrigated. The main sources of irrigation are
canals and tubewells. Mainly three crops are grown in the year in this region. The main
crop is Aman (monsoon) paddy (July to October), which is mainly rainfed. In the
4 The mouzas under Raina GP are, Pipila, Ibidpur, Fatepur, Bidyanidhi, Hakrishnapur, Bokra,
Birampur, Rayna, Raynagar, Jot Rajaram, Bishwesharbati, Maheshbati.
236
irrigated tracts, a second crop of potato or oilseeds are grown in winter or a short
duration paddy is grown in summer. Since there is some overlap in time in the winter and
summer crops, either of the two crops is grown in a single plot. A high value aromatic
variety of paddy (Gobindo-bhog) is grown in the region during the Aman season.
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Total population
Geographical area (in sq km)
Scheduled Castes (as percentage of total population)
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95.6
The Raina gram panchayat consists of 12 sansads (rural wards). Eight of the sansad seats
in the present term (2008-2013) are held by Communist Party of India (Marxist) and four
by the All India Trinamul Congress. The panchayat Pradhan is Madhabilata Dhara, a
Dalit woman.
2.2 Prefile (fBid^inkh Village
Bidyanidhi is situated about four km from Raina panchayat office. The village is two km
off the main road that connects Rayna to the district town Barddhaman and is connected
to the main road by an all-weather road.
The population of Bidyanidhi was 669 in 2001, and total geographical area is 1.35 sq km
Dalit households constitute 48.6 percent of the population in Bidyanidhi. There are no
Adivasi households in the village. According to the survey data, the households resident
in Bidyanidhi owned 60 ha. Of the total ownership holdings, 84 per cent is irrigated. The
actual area that is irrigated in any year is however lower because the mam source of
irrigation a deep tubewell and only half of the total command area of the deep tubewell
238
can be irrigated in a year.5 Thus the irrigated plots receive water every alternate year. A
small proportion of land is also irrigated from tanks.
There is one pre-school child education centre (Shishu Siksha Kendra) and Integrated
Child Development Services (ICDS) centre and one primary school in Bidyanidhi.
During our visit to the village, the total enrollment in the Shishu Siksha Kendra (children
in the age group of 3 to 6 years) was 22 and the number children registered at the ICDS
centre (in the age group of 0 to 6 years) was 60. The total number of children enrolled in
the primary school was 40. The primary school had two class rooms and two teachers.
There are eight functioning self-help groups in the village. One of the self-help groups is
a men’s group while the remaining are women’s groups.
3. DA TA BASES A VAILABLE AT THE GRAM PANCHA YA T
Prior to our field investigation, we collected some information from the Strengthening
Rural Decentralisation (SRD) Cell of the Panchayats and Rural Development
Department on the type of data that are generally available at the gram panchayats. We
obtained the following list:
1. Census of India village-level data, in electronic form and in hard copy.
2. Household-wise data from the Rural Household Survey (RHS), in electronic form and
in hard copy. Data were collected for each household on 12 out of the 13 indicators
suggested by the Government of India.
3. Data available in the Self-Evaluation Format. In order to evaluate the functioning of
the gram Panchayats and also to provide incentives to the gram panchayats to improve
their administration, the West Bengal Panchayats and Rural Development Department
have started providing a Self-Evaluation Format to each gram panchayat since 2006-07.
In this format the panchayats have to evaluate and assign scores for the different
indicators specified in the format. Panchayats receive financial incentives from the State
government based on this evaluation. The format deals with two sets of indicators, a)
5 The command area under the deep tubewell is 35.6 hectares.
239
improved institutional functioning and good governance and b) better mobihsation of
revenue and utilisation of resources (GoWB 2007). Most of these indicators are compiled
from the panchayat registers or other village registers, or from the Census and census
type surveys. The panchayat does not need to generate any additional data for completing
this format. However, the format has the merit of bringing together a number of
information on the panchayats and could also enable cross-sectional and year to year
comparisons.
4. Village-level development profile (Grantpanchayater unmyan byabasthar (hitra). The SRD
cell is preparing Block level booklets for 3354 gram panchayats in 341 Blocks in the
State. The booklet will map the position of each gram panchayat in the Blocks with
respect to 17 socio-economic indicators like heath, education, food security, nutritional
status, household sanitation, performance in rural development schemes, resource
mobilisation and utilisation. The gram panchayat level data on the 17 indicators are
compiled from the administrative reports of the panchayats and the secondary data
sources. The booklets will enable the gram panchayats to evaluate their relative
performance on the selected indicators and plan their activities along those lines. This
booklet is under preparation and was not available at the Raina gram panchayat at the
time of our visit.
5. Data collected under the SRD (Strengthening Rural Decentralisation) scheme. The
formal coverage of the SRD extends over 821 gram panchayats in 12 districts. However,
in some districts some gram panchayats not covered formally by the scheme voluntarily
have implemented similar programmes of sansad-^ise community-generated data. Raina
gram panchayat is not covered under this scheme and hence this data base was not
available at the gram panchayat.
6. Backward Region Grant Fund (BRGF), formerly RSVY, (Rashtriya Sama Vikas
Yojana) baseline data. The BRGF scheme covers all gram panchayats in 11 backward
districts of the State. Data on 170 indicators are compiled from secondary sources in this
data base. Raina is not in a backward district; hence the data was not available at the gram
panchayat.
240
Our visit to Raina gram panchayat revealed that the village-level data on population and
amenities from the Census of India 2001, household level data from the RHS and the
Self Evaluation Format were available at the panchayat office. The panchayat also
maintains various other records and registers and have access to village level data from
other departments, which provide useful information for local-level planning. We
identified the most important sources of data at the gram panchayat as the ICDS records,
the rural household survey and some other registers maintained by the panchayat and
other departments.
3.1 VillagICDS Records
The Integrated Child Development Services (ICDS) was initiated in India in 1975 with
financial and technical assistance from the UNICEF and the World Bank. The ICDS
programme offers supplementary feeding facilities for children below the age of six,
pregnant women and lactating mothers, pre-school facilities for children aged three to
six, maternal and child health care services such as immunization and vitamin
supplements and nutrition and health education for mothers.
The ICDS was initiated in Raina I panchayat in 1984. The ICDS centre at Bidyanidhi was
set up in 1999. Prior to that, there was a single ICDS centre for Bidyanidhi and Birampur
villages. At present, there are 18 ICDS centres in Raina gram panchayat and 236 centres
in Raina I Block. The ICDS workers are also known as Anganwadi workers.
The ICDS or Anganwadi worker maintains several registers. Some of the registers are
described below.
i) Childregster. All children in the village in the age group 0 to 6 years are recorded in
this register. The date of birth, age, sex, school enrolment and monthly weight of
each child is also recorded.
ii) Food vegsterfor children. All children in the village in the age group 7 months to 6 years
are recorded in this register. A daily attendance of children who take food from the
Centre is also maintained.
iii) Food registerforpre^ntwren. A register similar to item (ii) above is maintained for all
pregnant women in the village
241
iv) Pre-school student’s regster. The names and daily attendance of children in the age group
3 to 6 enrolled for pre-school education at the ICDS centre are recorded in this
register. This register does not include children in the village enrolled in other
schools.
v) Renter for pregiant isuomen This register records the names, month of conception,
probable date of delivery, immunization details, and other details of pregnant women
in the village. The date and place of birth and sex of the child is also registered after
delivery.
w) Grouith chart cf children A growth chart with monthly recordings of height and weight
of children in the age group of 3 to 6 is maintained by the ICDS worker.
vii) Immurazation regster. The ICDS worker and ANM maintain an immunization register
for new bom children in the village recording the dates of vaccination and where the
vaccination was taken. In case the vaccination was taken at a private facility, the
ICDS worker records the date after verifying the papers.
viii) The ICDS centre also maintains registers for stocks, accounts and expenses
ix) Village sicrcey regster. The ICDS worker conducts a village household survey every five
years. The register found at the Bidyanidhi Centre was made in 2005. The register
allots a page to each household in the village. The following information on each
member of the household can be obtained from the register
a) Name
b) Relationship with the head of the household
c) Age
d) Sex
e) Educational attainment
f) If SC/ST
g) If landless/marginal cultivator
h) Occupation
0 Date of Birth (of children)
fl Comments: In this column information on deaths, marriages or migrations
are recorded, though exact dates of the event are not always available
Although the village survey register is updated every five years, information on births,
deaths, marriages and migrations are updated regularly. In case of births and marriages,
the names and details of the new members are recorded in the register. When a new
242
survey is conducted the households that have divided are recorded separately and
households that have migrated permanently are deleted from the register. However, in
cases where a part of the household have migrated (for example, a son and his family
while the parents stayed behind), details of all members of the undivided household are
recorded even when the migration is permanent in nature.
The High Level Expert Committee on Basic Statistics for Local Level Development is of
the view that registers maintained by the Anganwadi workers have the potential to
provide a basis for a village-level database (Government of India 2006, p.17). That is the
most significant finding in the pilot studies of the Committee, particularly since no
attention was given to the registers of Anganwadi workers when the National Statistical
Commission of India examined the basic statistics for local level development.
The village survey register of Anganwadi workers contains most of the core information
collected in the Census of India. In addition, information on births, deaths, marriages
and migrations are updated regularly and the register itself is updated every five years,
while the Census data are available decennially.
Moreover, the village survey register and child register have the potential to provide
information to assist or substitute for the Gvil Registration System. Although the
National Statistical Commission stated that the Gvil Registration System has the
potential to provide estimates of vital events at the local level (National Statistical
Commission (2001), para 2.7.8), according to the panchayat officials at Raina the registers
maintained by Anganwadi workers were most reEable among the other sources.
3.1.1 An assessment (fthe quality cf.ICDS records at Bidyanidhi
A census type household
survey was conducted in Bidyanidhi village, Raina gram panchayat as part of a study on
‘Landlessness and Debt in Rural West Bengal’ in June 2005. The household level data
collected in this survey was available to us. We attempted an assessment of the quality of
ICDS records available at the Bidyanidhi ICDS centre through a comparison of the
ICDS records with the survey data.
The ICDS centre maintains a register of the names, age and other details of all children
in the village below the age of six. We were able to get the child register for the year 2006
243
from the ICDS centre.6 From this register we obtained the names of all children bom in
the village between January 2000 and June 2005. We compared this list with the list of
children aged five years and below from the survey data.
According to the ICDS register, 59 children were bom in the village between January
2000 and June 2005. According to the survey data the number of children in the age
group 0 to 5 years in June 2005 was 61. The names of 54 children were found in both the
lists.
We looked into the discrepancy in detail and allowed for some divergences on account of
due to temporary or permanent migrations and misreported age during the survey7. As a
result of this analysis we were able to conclude that the coverage of the ICDS in
Bidyanidhi village is complete and the quality of the ICDS records is excellent.
3.2 Rural Household Sunjsy
The Ministry of Panchayats and Rural Development has been conducting a Below
Poverty Line (BPL) Census (also referred to as Rural Household Survey) through the
State Governments since the Eighth Plan period (1992-1997). The survey was initiated
with the ideology of narrow targeting of development schemes in post-liberalisation
India. The objective of this Census is to identify households below the official income
poverty line in villages at the beginning of the plan period for identification of
beneficiaries for various poverty alleviation schemes. The survey was imposed by the
Central government on the State governments leaving no room for local-level
6 The 2005 child register was not readily available because the present ICDS worker at the centre had
in the ICDS list which were not found in the survey list. In three of the five cases,
the households in which the children belonged (identified by the name of the child’s father) were not
found in the survey database. It could be that the households were not present in the village at the time of
the survey or were not covered in the survey for some other reason. There is also a possibility that the
household had setded in the village after June 2005 (but before January 2006). In the remaining two cases,
the children’s names were not recorded during the survey (Both the children belonged to the same
household and the error was corrected during a later survey conducted in the same household ^ 2006).
There were seven children in the survey list who were not found in the ICDS list. All these children were
reported to be five years old. Hence there is a very high possibility that their age was under-reported during
the survey and hence their names were not registered in the ICDS centre. There are reasons to believe that
the ICDS data on age are more accurate than the survey data. First, data on the date of birth of the
children were not coUected in the household survey, but the ICDS register records the date of birth of each
child. Secondly, in four of the eight cases, other children from the same households were recorded in the
ICDS register.
244
organizations to select beneficiaries for Central government sponsored schemes. Though
the RHS can be used to provide serial data on certain indicators, the purpose of the
survey is to exclude certain people from the development schemes. The number of poor
households is already specified by the Central government based on the Planning
Commission estimates of the incidence of poverty in the region. The BPL census grades
the relative deprivation of households on 13 indicators in a scale of 1 to 5. In West
Bengal 12 of these 13 indicators were used for the survey. Households obtaining the
lowest scores in the twelve indicators in the survey are identified as being below poverty
line such that the total number of BPL households in the village corresponds with the
number estimated by the Planning Commission. Beneficiaries for specific centrally
sponsored schemes on housing and samtation are also identified on the basis of scores
obtained by households on some specific indicators on condition of housing and access
to sanitation (Government of West Bengal 2007).
The RHS was conducted in Rama gram panchayat in 2005, prior to our ‘Survey on
Landlessness and Debt.’ There was widespread discontent among the panchayat officials
regarding this survey, as it was felt that the data collected in the survey was inaccurate
and consequently the list of beneficiaries selected was also inaccurate. The panchayat
conducted another survey of a similar nature in the same year and reported the cases of
discrepancies to the Block officials.9 Some of the discrepancies were amended later but a
large part of the discrepancies were not attended.
The Est of BPL households and the scores obtained by the households on each of the
twelve parameters were available from the Raina gram panchayat office. The complete
data of all households from the RHS were not available at the gram panchayat.
3.2.1 A n valuation (fthe RHS data. We tried to assess the quality of the data collected in
RHS by matching the data on some of the parameters with our survey data. The two data
sets would be roughly comparable since both the surveys were conducted in the same
year. There were 36 households in the BPL list of which 32 households could be found
in our survey list. Our analysis is restricted to these 32 households.
8 This methodology used in the BPL Census for the Tenth Plan period (2002-2007) was suggested by an
Expert Group. The list of parameters and the scores used are in Annexure 1.
9 The household level data collected in this alternate survey was available at the gram panchayat.
245
Femtle-headed housdjdds - A household being headed by a woman was considered as a
“special kind of disability” (P12) in the BPL Census. Of the 32 households, 12 were
female-headed households according to the BPL Census. We found that seven of these
households were effectively not female-headed households. In case of two households
the wives were reported as the head of the household even when the husband was
present and economically active. In five cases, the widowed mother was reported as the
head of the household when the effective head of the household was the working adult
son.
Land ownership - Of the 32 households only one was reported to own land in the BPL
Census. According to our survey 12 households owned land, though the sizes of land
holdings were very small and in all cases less than 1 acre.
Education status cfthe most educated menher cfthe family - in 13 cases the education status of
the most educated member of the family in the two data sets did not match.
Earning capability status — there were some discrepancies in the two data sets. In many
households adult women members were not reported to be working thus gaining higher
scores for households.
Means cf livelihood - in six cases, the means of livelihood was reported as
daily/ agricultural/ other physical labour in the RHS whereas according to our survey the
household was self employed in agriculture or in some other occupation or held labour
oriented regular job in unorganized sector. In two cases agricultural labour households
were classified as ‘organized sector7 worker and ‘regular worker in unorganized sector7
respectively.
ix out of the 32 households the score
Educational status cfchildren cf 9 to 14 years — only in six
assigned in RHS matched with our survey data.
Thus the RHS records seem to be inaccurate and the discontent about this survey among
panchayat officials was justified.
246
3.3 Records rmintained by the ^amparuhayat and ether departments
The gram panchayat maintains various records for administrative and other purposes and
a considerable amount of information is available from such records. In most cases, the
registers maintained by the gram Panchayats and other departments relate to the different
development programmes implemented at the village level. These registers and records
are maintained to track the allocation and expenditure of funds and assess the progress
of different schemes. A brief description of the registers maintained at the Raina gram
panchayat office is in Table 2. The High Level Expert Committee on Basic Statistics for
Local Level Development emphasized that the village level registers should be
standardised and provide serial data at the village level (Government of India 2006, p.31).
Table 2 Description efrenters maintained by Raina ^ampanthayat
NarrEc/Te&ter
Type cfirfomution azailade
Ifauzdade at the
Corments
GP*(ffice
Public works done by panchayat
under various schemes/allocations
(SGRY, MP fund), description of
work, date of proposal,
commencement and completion,
proposed and actual expenditure,
benefit accrued
Cases of birth and death
Yes
Panchayat land and
property tax register
Name of head of household, size of
household ownership holding,
market value of land and building,
tax assessment
Yes
Tubewell register
Number, type and location of all
tubewells constructed by GP
Water bodies leased out to SHG,
periodic earnings
Vehicle number and toll tax
collected
Names of landless agricultural
workers, PF account numbers,
monthly contributions
Register maintained in prescribed
NRE GA format
Yes
Works register
Birth and death register
Lease of water bodies
register
Toll tax register
Landless Agricultural
Workers PF
NREGA** register
Yes
All households in the
village are taxed. Even a
landless household has to
pay a minimum annual
tax of Rs. 3 per annum.
Yes
No
Yes
Yes
The register is maintained
by the Collector
At present there are 1500
PF account holders in the
GP.
The register is
computerized
*Gram panchayat
“■“■National Rural Employment Guarantee Act
The gram panchayats sometimes conduct independent household surveys for evaluation
of various development programmes. The Raina gram panchayat recendy conducted two
household surveys recently on instruction from the Zilla Panshad to evaluate the rural
saniution scheme. The surveys were conducted in 2007 and 2008. In the 2007 survey,
247
information was collected on sanitation and on the type of ration card (APL/BPL/ AAY)
owned by the household. In the 2008 survey, information was collected on access to
toilets and some socio-economic features of the households, such as social group (SC,
ST, Others), number of literate members and the educational attainment of the most
educated member of the household. These survey forms, which provide information on
each household, are available at the gram panchayat office.
Gram panchayats have access to registers at the village primary school and primary health
centre. The school maintains regular registers on attendance and performances of each
student and registers for accounts and stocks (inventories like chairs, tables etc.). The
school also maintains a register of all children in the age group of 0 to 13 years in the
village based on an annual survey of all households in the village conducted by the school
teachers. The survey is generally conducted between November and December. A
separate sheet is allotted for each household in the village with children aged 13 years and
below in the child register. If there is more than one child in the household they are
recorded in the same sheet. Each year the child’s ^e and enrolment status is updated,
even when the child is not enrolled in the village primary school or ICDS Centre. The
teacher at Bidyanidhi Primary School informed us that though they prepare this register
independently, the ICDS workers help them in preparation of the register.
The block primary health centres and sub-centres prepare a monthly report on a
prescribed format to be sent to the Block office every month. This report contains
information on births and deaths, treated cases of different diseases, vaccinations and
birth control methods. The monthly report, however, cannot be obtained from the
primary health centre on demand.
The Block primary health centre, ICDS centre and the panchayat form an interlinked
health and childcare system. Every fourth Saturday of the month a meeting is conducted
at the gram panchayat office with the ICDS supervisor, the ANM and health supervisor
and panchayat officials. A monthly data sheet is prepared recording the number of births
and deaths, cases of morbidity, status of sanitation and drinking water supply for the
gram panchayat. This monthly data sheet is on public display at the panchayat office.
248
4. CONCLUSION
The High Level Committee report suggested that nine categories of information be made
available at the panchayat office for local level planning and administration (Government
of India 2006, pp.1-2). The information available at the Raina gram panchayat on each of
the nine categories is summarized in Table 3.
Our study suggests that the gram panchayat has substantial potential to generate and
maintain statistical data at the level of the gram panchayat and below. Administrative
records of some departments around the gram panchayat are closely interlinked and
there is considerable data sharing between the departments. Though this is true for the
Ullage we studied it might not be true for all of India According to the pilot study
conducted by the High Level Committee, there is no such formal data sharing
mechanisms between different agencies working at gram panchayats in Maharashtra and
Haryana (Government of India 2006, p.25-26).
According to us, the ICDS records forms a very important and reHable data base at the
village-level and have the potential to assist or partly substitute for the functions
performed by the Population Census and the Gvil Registration System. The ICDS
registers have the advantage over Population Census data in at least two ways. First, the
ICDS records provide the most up to date records at the village level. Secondly, unit
level household data are available from the ICDS. Panchayats do not have access to unit
level household level from the Population Census. The High Level Committee also
mentions the high potential of the registers maintained by Anganwadi workers
(Government of India 2006, p.17). However, it must be understood that our case study
focuses on a weU running gram panchayat. In other parts of West Bengal or in other
States in India where the panchayat! raj institutions are weak, the quahty of village
administrative records may not be so good. (According to our study at a village in
Maharashtra, for example, the quahty of ICDS data was not so good).
A major disadvantage of panchayat-level data bases is that there is no uniformity in the
types of registers maintained at the different panchayats across the country. The High
Level Committee recommends that the Directorate of Economics and Statistics in
respective States should play an important role in ensuring statistical quahty and
249
standards by providing the necessary guidelines and training to panchayat staff in the
consolidation and maintenance of local level database (Government of India 2006, p.31).
West Bengal does not have an integrated system of land records and agricultural statistics
as there is no village level plot-wise data on land ownership, tenancy, land use, cropping
pattern and agricultural production.10 In the absence of such data, one major lacuna in
village-level data base in West Bengal is the inability to integrate household level data on
demographic and human development indicators available from village sources with the
economic indicators on land ownership, tenure and crop production. Data on land
ownership and tenancy are maintained at the block land and land reform offices and
panchayats have access to this data. But the data are not updated periodically, which
Emits the use of this data for local-level planning.
Village records available at the gram panchayat and other departments may prove to be
very useful for village studies. The panchayat administrative records will be useful if the
village studies are concerned with the aspects that the panchayat administration has been
formally recording. Furthermore, household level data on many parameters are available
at the panchayats and villages from multiple sources (ICDS registers, village school
registers, household surveys conducted by the gram panchayat), which can be used for
village studies if we are allowed to access such data. In the case of Raina gram panchayat
and other village level agencies that we visited, they were very forthcoming in sharing
information with us. However, one has to be cautious of the fact that the quality of the
data may vary across panchayats.
10 The erstwhile ryotwaii States in India have village level agencies to collect seasonal data on land
ownership, tenancy, land use, cropping partem and crop production for each plot in the village. The
permanently setded States Kerala, West Bengal and Onssa do not have such a system (see the paper titled
“Land use and crop area statistics in West Bengal - a discussion on village record based statistics and
sample survey based statistics” presented in this colloquium).
250
Table 3 Status (firfomution azaUaUe at theRaina ^amparichayat
Type ofinformation
Ifrecords
available at
GP
Basic Facilities
No
Number of factories
Commercial
establishments
Bridges, roads
No
Yes
No
No
No
Forest area, orchards
No
Yes
Distance from nearest
facilities
No
Yes
Population
Yes
Yes
Birth and death
Yes
Yes
Morbidity
Yes
Marriages
No
No
Migration
No
No
Educational status of
villagers
Yes
Yes
Land utilization statistics
No
Yes
Livestock and Poultry
Number of market
outlets
No
No
Yes
Yes
Employment Status of
villagers
No
No
If
accessible
to GP
from
other
source
No
Source of
information
Comments
Facilities that are present are of
common knowledge. GP
maintains registers of the
current facilities being
constructed.
Common knowledge
GP tax register
Location of such facilities are
common knowledge, other
information may not be
available unless constructed by
GP. If constructed by GP,
details can be obtained from
Works Register
Block Land and
Land Reforms
Office
Census of India
Census of India,
I CDS household
survey register
GP registers, ICDS
registers, PHC
registers, Monthly
reports
Monthly report of
ICDS, ANM and
Health supervisor
The information is known to
panchayat officials. Census data
are often outdated.
ICDS registers provide more up
to date data than Census.
ICDS worker records in her
register but date not recorded
Some information on
permanent out-migration can be
obtained from ICDS records
Panchayat
sanitation survey
2008, ICDS
household survey
Block Land and
Land Reforms
Office
Livestock Census
Common
knowledge and GP
tax register
Household level record available
Village survey register has
occupation data
251
REFERENCES
Government of India (2001), Report (fNational Statistical Cormission, available at
<http-y / mospi.gov.in/ nscr/hp.htm>
Government of India (2006), Report cfHi&Lettl Expert Comnittee on Basic Statisticsfork real
Lend Deriapment, Ministry of Statistics and Programme Implementation Social Statistics
Division Central Statistical Organisation.
Government of West Bengal (2007), Annaal A dTrirnstraUTe Report 2006-2007, Panchayats
and Rural Development Department
252
Appendix: Description ofparameters used in Rural HousdiddSuriey
Parameters
_____________
^cores
-------------------------- ------- ---------------2
3
4
5
1
Irrigated
land
<1
Irrigated
land
1
<>2
Irrigated
land
2
04
Irrigated
land
>3 acres
1 (Pl) Effective landholding of No land
acre or Nonacre or Nonacres or Non-irrigated or Non-irrigated land >6
the family (together with
irrigated land <2. irrigated land 204 land 3 <^6 acres
acres
land cultivated as registered
acres
acres
Barga holder)
Partially Pucca house Pucca house
Hut with only 1 Hut with >= 2
2 (P2) Nature of Dwelling house Houseless
room
rooms
>6
3 (P3) Number of garments per No. of garments <2 Greater than 2, Greater than 2, Less >4, with winter
Less
than
4,
but
than
4,
with
winter
garments,
but
<6
member
garments
no winter
garment
Can manage at least 2 no shortage of food
Can manage < 1 Can generally
Can manage < 1
4 (P4) Food security
square meals during all security
square meal a day square meal a day manage 2 square
seasons
during
the
major
meals
a
day
but
during the major
sometimes
fails
part
of
a
year
pan of a year
owns all or any of the
owns at least 3
owns at least 2
owns at least 1
5 (P5) Ownership of consumer no ownership
following items items - Cycle, Radio, TV,
computer, refrigerator,
Electric Fan, Pressure
colour television,
Cooker
electrical cooking utensil,
costly furnitures, Light
motor vehicle or
commercial vehicle,
tractor, two or three
wheeled mechanized
vehicle, power tiller,
grinding machine,
cooking gas connection
Primary <= class Greater than class V upto graduate level/ Masters’
6 (P6) Educational status (of the illeterate
V
but less than ClassX professional diploma degree/professional
most educated member of
degree
the famil})
others
only
adult
male
&
only
adult
male
women
&
child
7 (P7) Earning capability status all members are
women
labourers,
labourers
infirm/old/ children labourers
no child labour
, no regular earner
* :rs viz.,
daily/agricultural/ ot agriculture and self employed rural labour oriented regular others
vi job in the
8 (P8) Means of livelihood
unorganized
organized
sector,
job in the
artisan/hawker,
her physical labour provides own
medical
practitioner,
sector
those
who
do
not
labour at field
advocate, own business,
employ others
production agency
no school dropout
school
dropout
and
school
dropout
and
school dropout
never goes to
9 (P9) Educational status of
not
employed
and
work
outside
work
at
home
school
children of 9-14 years
with others
(Highest to be considered
for more than 1 child)
no loan
loans from a
loans from familiar loans from
loans from an
10 Type of loan
recognized
agency
familiar
persons
agency
for
some
persons for
(PIO)
for production
particular purpose
everyday needs
needs
does not have to go out
seasonal
any
anyother
othermeans
meansof reasons other than
temporary
11 Reason for going out of
to earn
employment
livelihood
income
livelihood
(Pl 1) the village for employment employment
of the principal earner of
the family
women head of the expenses; more than none of the above
Aged without
12 Special kind of disability permanently
family income due to
family
assistance
(Pl2)
disabled and
treatment of one of
without any social
the family members
or Government
from an incurable
assistance
disease
SL
253
Rethinking ICDS:
A Rights Based Perspective
The ICDS programme is one of the most important public
programmes in India, reaching out to the most neglected
sections of the population. However, its coverage needs to
be expanded to include every child, pregnant and nursing mothers,
and adolescent girls. Its functions need to be separated, with
a specialised person to provide pre-school education and
another worker to take charge ofhealth andnutrition aspects.
Coordination between the health and education departments
is requiredfor maximum efficiency. Also, it is important to
set clear goals, so that achievements can be assessed and
work given direction.
Dipa Sinha
ittle Savithri ofChittempally Tanda
in Ranga Reddy district was 18
months old, but looked like she was
three months old and weighed only 5.5
kilos. She could not even turn over when
she was lying down, there were no expres
sions on her face, and she had extremely
thin hands and legs and looked terminally
ill. Her family (consisting of her parents,
grandparents, uncles and aunts) had given
up on her, as they could not afford to buy
expensive tonics.
Her mother, Jaya, already had Savithri’s
brother, a three year old, to take care of.
She was now seven months pregnant.
She was 14 years old when she got
married, and now, at the age of 19, she is
expecting her third child. She had to do
all the household chores and also work
on the family land. The only person
who had time to take care of Savithri
was 14-year old Sukhi, her father’s
vounger sister. Sukhi had dropped out
m school, as she was to be married in
a month’s time.
This family is not an exception in rural
Andhra Pradesh. There are thousands of
children who are malnourished, with no
special care, and large numbers of
mothers who are too young to have healthy
children but have had repeated pregnan
cies. Many of these young mothers are
overburdened with work, undernourished,
and in urgent need of healthcare. A large
proportion of adolescent girls are out of
school, and face the prospect of early
According to the second National
Family Health Survey (NFHS-2), conducted
in 1998-99, the infant mortality rate in
Andhra Pradesh is 66 per 1,000 live births.
About 38 per cent of children under three
years of age are underweight, over 50 per
cent of deliveries take place at home, and
only about 60 per cent of children in the
age group of 12-23 months are fully vac
cinated. About 54 per cent of girls in the
11-14 age group, and 20 per cent of girls
in the 15-17 age group, are in school. The
median age at marriage for women aged
20-49 in rural areas is 14.9 years. Further,
there has been little change in the condition
of women and children (especially girl
children) with respect to health in the
last decade. In spite of the hype about
Andhra Pradesh being a “hi-tech” state,
leading the IT industry in the country,
there has been a slowdown in reduction
of infant and maternal mortality in the last
two decades.
The situation at the all-India level
is similar, if not worse. According to
NFHS-2, only 65 per cent ofwomen access
antenatal care, and less than half of
all deliveries take place with skilled
attendance. The maternal mortality ratio
is as high as 540. About 50 per cent of
women are anaemic, and the median age
at marriage is 16.7 years, in spite of a law
against child marriages. The infant
mortality rate is 67.6 per 1,000 live births,
and 45.5 per cent ofchildren under the age
of five are chronically undernourished.
The rate of decline in infant mortality has
slowed down from the 1990s onwards in
World Health Report also puts India
among slow progressing nations in child
and maternal care.
ICDS and Its Impact
This paper discusses the reasons for
dilution of the Integrated Child Develop
ment Services (ICDS) programme. It ar
gues that for ICDS to be effective in
reducing infant mortality, combating
malnutrition and improving child health
there must be: (a) a firm conviction that
every mother and child has a right to
health and well-being and that this is
non-negotiable; (b) an assertion of the
state’s obligation to ensure that all moth
ers and children have access to basic
healthcare and nutrition; (c) a change in
the existing social norms that allow the
violation of the rights of mothers and
children; and (d) uncompromising public
action on the rights of mothers, adolescent
girls and children.
The only institution at the village level
that is responsible for the health and
well-being of mothers, children and
adolescent girls is the anganwadi centre.
The anganwadi centres were created
under the ICDS programme, which started
in 1975 with the following objectives:1 to
improve the nutritional and health status
of children in the age group 0-6 years; to
lay the foundation for proper psycho
logical, physical and social development
of the child; to reduce the incidence of
mortality, morbidity, malnutrition and
school drop-out; to achieve effective co
ordinated policy and its implementation
amongst the various departments to pro
mote child development; to enhance the
capability of the mother to look after the
normal health and nutritional needs of
the child through proper nutrition and
health education.
ICDS was initiated in 33 blocks in 1975,
and expanded to cover almost 6,500 blocks
in 2004. The programme recognises that
in order to reduce infant mortality and
malnourishment, it is extremely important
to also cater to the health and well-being
of the mother. Initially, the focus was on
the period from the time she got pregnant
until she delivered. Later, it was realised
that the mother needed nurturing from
much earlier, and therefore the programme
for adolescent girls, the Kishori Shakti
Yojana (KSY), was started in the year
2000-01.2
marriage or sexual harassment, with little
India, even when compared to countries
To some extent, ICDS has been a
hope of freedom.
like Bangladesh and Nepal. The recent
successful programme. Infant mortality
Economic and Political Weekly
August 26, 2006
3689
declined from 94 per 1,000 live births in
1981 to 73 in 1994. Severe malnourishment has decreased from 15.3 per cent
during 1976-78 to 8.7 per cent during
1988-90 [Chandrasekhar and Ghosh 2005].
However, the dismal status of child health
in India shows that there is a lot more to
be done.
Field surveys such as that recently con
ducted by the Centre for Equity Studies
in association with the commissioners of
the Supreme Court (N C Saxena and
S R Sankaran) show that the overall con
ditions of ICDS in the country is far from
satisfactory, though there are considerable
differences in the performance of the
scheme between different states [Dreze
and Sen 2004]. The experience of many
working in rural India also shows that there
is a huge gap between what is planned
under ICDS and what is actually happen
ing on the ground.
Further, the reach of the ICDS pro
gramme is very limited. There are only
six lakh anganwadis in the country, com
pared with an estimated 17 lakh required
for universal coverage based on existing
norms. Supplementary nutrition is
currently provided to 3.4 crore children,
as opposed to 16 crore children (half of
whom are undernourished) in the age
group of 0-6 years [Dreze and Sen 2004].
Beginnings of a Public Debate
The poor condition of mother and child
health in India is not a matter of wide
concern and public debate. Governments
are seldom pulled up for not succeeding
in providing better access to health and
nutrition to the most vulnerable. Improv
ing ICDS or primary health services is
not on the election agenda of any of the
political parties, and receives only cursory
mention in the manifestos. The state of
child health or the functioning ofthe ICDS
centres rarely make headlines in the news
papers. It is therefore not very surprising
that the anganwadi centres or the primary
health centres (PHCs) do not function ef
fectively, since for any public institution
to function, it is necessary to ensure
accountability through public action.
“What the government ends up doing
can be deeply influenced by pressures
that are put on the government by the
public. But much depends on what issues
are politicised and which deprivations
become widely discussed and electorally
momentous” [Dreze and Sen 1995:87].
The task of protecting the rights of infants
3690
and young children and their mothers is
yet to become a social issue that concerns
everybody.
There have been some positive deve
lopments in the last few years that are a
ray of hope for the women and children
of our country, and need to be worked
upon. Firstly, in response to the writpetition
filed by People’s Union for Civil Liberties
(PUCL) in April 2001, the Supreme Court
issued an order in November 2001 direct
ing the government to ensure that ICDS
is immediately expanded to cover every
hamlet in the country. This order also states
that ICDS should reach every child below
six years of age, every pregnant and lac
tating mother and every adolescent girl.
Further, all SC/ST hamlets in the country
should be covered as a matter of
priority. The impact of a similar order on
mid-day meals, issued by the Supreme
Court on the same day, provides some
important lessons as to what legal action
can achieve when it is combined with
public action.3
Secondly, the present UPA government
in its common minimum programme has
committed itselfto universalising the ICDS
scheme to “provide a functional anganwadi
in every settlement and ensure full cov
erage for all children” (national common
minimum programme of the govermnent
of India, 2004:6).4 Being a coalition
government, its stability depends on its
performance with respect to the objectives
of the common minimum programme.
This can be used by other parties, and
by the public, to exert pressure. As the
performance of the government will be
appraised based on what it has done on
each of the pledges made in the common
minimum programme, the coverage and
quality of ICDS is likely to come under
close scrutiny.
Thirdly, the National Advisory Council
(NAC) has shown keen interest in ICDS,
and made detailed recommendations to
improve the coverage and quality of the
programme. These include a sixfold
increase in financial allocations for ICDS
over a period of two to three years. This
would provide for the expansion of ICDS
to all the habitations in the country, and
for doubling per-child expenditure as a
first step towards facilitating quality
improvements (NAC’s recommendations
on ICDS, August 2004).5
Although there is now an emphasis
on universal coverage of ICDS, the
anganwadi centre is still not explicitly
acknowledged as an institution created
to fulfil the state’s obligation towards
the protection of the rights of the
mothers and children. This issue requires
further mobilisation.
Absence of Social Norms
The issues that are to be addressed
by ICDS, such as matemal/child health
or nutrition or adolescent health, are as
much about social norms as they are
about poverty, access to resources, etc.
For instance, gender discrimination
deeply influences the status of women and
children in the community. Likewise,
attitudes towards women, pregnancy,
nutrition, and early childcare have a great
impact on the status of maternal and
child health.
Especially in rural areas and among the
poor, pregnancy and childbirth are ex
tremely private issues, rarely addressed
beyond the circle of concerned women.
For instance, ifa woman goes to the hospital
and there is no doctor, and she delivers
under a tree, this does not become an issue
of protest in the community. Should an
infant die as soon as it is bom, or a mother
die due to excessive bleeding after delivery,
there is no expression of shock or outrage.
Similarly, if the child is severely under
nourished, it is seen as an act of god,
resulting from some kind of ‘karma’. Anx
ious parents who consult doctors spend lots
of money and are seldom given proper
advice on feeding the child differently.
When girls are married at 13 or 14 years
of age, there is no debate; this is seen as
an accepted norm.
Women and children, the beneficiaries
of the ICDS programme, are not given
any importance in the community and
therefore the anganwadi centre is also not
given any respect. Absence of a social
environment conducive to giving sup
port to the most vulnerable sections of
society, dilutes the services of the
anganwadi worker as well as the healthcare
system. For example, the messages that
women must eat green leafy vegetables,
eggs, milk, fruits and so on when they
are pregnant are so unrelated to the pre
dicament of women that they fall on deaf
ears. The fact that women are not even
eating leafy vegetables (let alone eggs or
fruits), despite being advised to do so for
30 years, is seldom examined. It is as
sumed that it is enough just to tell women
that they should take care of themselves
and eat a good diet. It does not matter that
social norms to encourage such practices
Economic and Political Weekly
August 26, 2006
and support structures to make them
possible, do not exist.
every anganwadi centre should have a on why so many children are malnour
mothers’ committee that meets regularly ished, why there has been an infant death
to review and monitor the functioning of in the village, or why a woman has not been
Creating a New Social Environment the centre. In Andhra Pradesh, this com able to go to the hospital for delivery.
mittee consists of two pregnant women,
Involving the community in ICDS is
Any programme that aims at improving two lactating mothers, two mothers of important so that the village feels a sense
the health of women and children must children in the age-group of 0-6 years, and of ownership of the centre. It would also
begin by addressing the lack of norms. In two mothers ofadolescent girls. It is usually render the AWW more accountable and
the absence of a supportive environment, women who are in the neighbourhood of acceptable to the community.
even the best of services (such as ante the anganwadi centre who are chosen to Responsibilities ofAWWs: The AWW, in
natal care or supplementary nutrition or be members of this committee. The meet many instances, is the only available gov
micronutrient supplementation) do not ings are rarely held. These women have ernment servant in the village and is re
reach the target group. This acts as a sig not been trained, and do not know what sponsible for the most vulnerable groups
nificant barrier against women’s access to their role is supposed to be as members in the community. Yet she does not get the
what is due to them. It is the responsibility ofthe mothers’ committee. The anganwadi recognition she deserves. At the village
ofthe government, through the anganwadi worker (AWW) too is not clear about the level, the AWW is not involved in any of
centres, to work towards creating new role of such a committee. As there is little the village meetings concerning discus
norms that support mothers’ and childrens’ respect for this committee in the village, sions on children, adolescent girls and
rights. To change norms, the entire com it often remains on paper, and makes little women, even those where say, the school
munity has to be mobilised to protect the difference on the ground. There are names teachers are involved. She is not consulted
rights of women and children. Everyone listed only because the AWW has to report on any agenda. At the mandal6 level too,
in the community, men and women, old every month to her supervisors. Since there it is seen that although those in the revenue,
and young have to be involved in a process is no public debate and discussion in the social welfare, education and health de
of debate and discussion on what is best community on the anganwadi centre, its partments sometimes coordinate with each
for the health of the mother and the child. function and purpose, mothers’ commit- other, the members of the ICDS project
e gram panchayat and local bodies must tees become substitutes for a meaningful such as the community development
review the functioning of the anganwadi community involvement.
programme officers (CDPOs) are not par
centres and also the status of mother and
The ICDS programme reaches out to ticipants. Even at public functions, for
child health in the village regularly.
only a small section of the village popu instance, the CDPO never gets invited in
An environment should be created where lation, giving the impression that it is a the way that a mandal revenue officer
the village appreciates a man who brings “project” and not a universal entitlement. (MRO) or a mandal development officer
water, fetches firewood or helps his wife The number of beneficiaries gets fixed on (MDO) are. Right from the beginning, the
with cooking, bathing and feeding the child. an arbitrary basis and there is no flexibility design of the ICDS programme has-been
Such assistance often invites derision, as to change it. For instance, supplementary such that it works in isolation from other
the man is seen to be womanly. If a girl nutrition in Ranga Reddy district is to be departments, and is also poorly integrated
is married off very young, then the com provided to six pregnant women, six nursing with the community. This has resulted in
munity must react and get together to stop mothers, 16 children in the age group of the entire programme receiving little
the marriage. A malnourished child or an 6 months to 35 months, and 30 children importance.
infant death must become the concern of in the age group of 3-6 years. As the
In the village, the AWW is viewed as
the entire village. It is only when this programme excludes a majority of women just a “social worker” paid by the govern
happens that there will be some meaning and children, the active involvement ofthe ment and not as a functionary of the gov
to the food given in the anganwadi centre community is difficult to achieve. The ernment. She gets paid only Rs 1,000 a
and the colourful posters telling the woman ICDS programme is seen not as a rights- month (less than the minimum wage), and
what she should eat. If it is accepted that based institution, but a ‘podi’ (powder) even this amount is not paid regularly. On
the woman has a right to a safe delivery, centre where, once in a while, some white the other hand, the number of tasks that
and that it is the government’s duty to powder is distributed on the basis of the the AWW is expected to perform is im
tect her right, then the ICDS programme AWW’s likes and dislikes.
possible for most workers to complete.
needs to address the social norms that
This lack of public ownership of the
The AWW, as mentioned earlier, is supundermine women’s rights.
programme also opens the door to large posed to cater to the needs ofpregnant and
scale and blatant corruption. It is no secret nursing mothers, adolescent girls and
that in many places the supplementary children below six years of age. She also
Strengthening ICDS
nutrition powder is sold by the AWW to has other responsibilities in the context of
Given that women and children have a farmers as feed for buffaloes. In other other programmes such as family plan
right to health and nutrition, it becomes instances, the powder is strained to extract ning, DOTs follow-up for tuberculosis,
the responsibility of the government to the sugar. So much so that during ‘Ugadi’ and girl child protection schemes. Each of
create, through ICDS, a norm where these in Andhra Pradesh, people ask for the these is a major task in itself, requiring a
rights are not violated. For ICDS to play anganwadi ‘jaggery’ to make the festival lot of effort. Although the needs of the
such a role, the following are some issues sweets because it is of good quality! There three target groups under ICDS (children
that need to be considered.
is more public discussion of how good the under six, adolescent girls, and pregnant
Community involvement in ICDS: To en jaggery is, and how one should try and get and nursing mothers) are linked to each
sure the involvement of the community, it for the Ugadi celebration, than there is other, each group’s well-being raises
Economic and Political Weekly
August 26, 2006
3691
independent issues. While it is true that and whether any deliveries or deaths have planning. Most programmes are ad hoc,
in the long-term today’s children are taken place. Some times, basic first-aid suddenly launched without any prepara
the adolescents of tomorrow and the material is also left with the AWW, e g, tion or follow up, highly centralised and
parents of the day after, right now they are oral rehydration solution (ORS) packets without involvement of the community.
three different groups with specific needs, and paracetamol tablets,
There is, out of the blue, a rally with
calling for immediate attention. Each of
This kind ofcoordination is not the result
school children on institutional delivery,
these is a specialised task requiring of a careful plan of action worked out by a meeting with adolescent girls on
professional skills.
the concerned departments at the higher HIV/AIDS, or a week to celebrate
To begin with therefore, as many have level. Since all the activities are linked, there breastfeeding with no information to the
suggested, there has to be a separation of is a need to understand the significance of community. Usually it happens this way
the 0-3 yearold, adolescentgirls and women’s this kind of convergence. Two small ex
because it is planned at the state or central
programme from the pre-school education amples, drawn from the M V Foundation’s level and suddenly passed down to the
programme for 3-6 year old children experience (see next section), may help to AWWs as a task to be completed. This
[Ramachandran 2005]. The pre-school illustrate the point. In the first case, a meeting makes it very difficult for the AWW, who
education programme for the 3-6 year olds was held with all the AWWs in one mandal
is the frontline worker facing the com
could be linked to the primary school, in Ranga Reddy district and their help was munity, to implement the programme in
with the mid-day meal as supplementary sought in motivating women for institu a meaningful manner.
nutrition. In some villages of Andhra tional delivery. The AWWs said that they
There is no clarity on the roles of the
Pradesh where the centres are linked to the had given up doing that because when supervisor and the CDPO. Since all plan
primary school, it is seen that the atten they did take women along to the PHC, ning, to the last detail, comes from above,
dance at the anganwadi centre is greater there was nobody there to provide the at the level of the project office, there is
because the younger children come to the service, and if they dared to ask, they were no space for any creative thinking. The
centre along with their siblings who are shouted at by the ANMs. The ANMs, for supervision is reduced to monitoring the
in school. Further, the AWW feels part of their part, do not see why the AWWs> different registers that are to be maintained
the larger institution and is therefore should have anything to say about the by the AWW. This top-down approach to
motivated to work. The children also like PHC. Coordination at a higher level, along planning must be replaced by a more
having a proper meal along with the older with informing the ANMs that this is part decentralised system where the AWWs
children in the afternoon. A kindergarten of the role of the AWW, would have are given space to review their experi
section in the school, open to all children been helpful.
ences and share what they think must
in the age-group of 3-6 years, can be
Another instance was a meeting in one be done to achieve the goals of ICDS.
visualised, with the number of teachers mandal, held at the PHC, with the ANMs There should be clarity on what must be
being decided according to the number of and the medical officer and all the AWWs. planned at the level of the central and state
students.
The PHC had been given orders that the governments and what must be left for
There is a need for a separate full time entire population should be immunised for the anganwadi centres, the local com
trained professional worker to carry out filaria within two days. The dates had munity and the local bodies to decide for
the other tasks of providing nutrition for already been fixed for the entire state. The themselves.
the under-3s, ante- and post-natal care, medical officer therefore called the AWWs
immunisation and adolescent health. This for a meeting to instruct them to carry out
person could also be responsible for con this job under the supervision ofthe ANMs. MV Foundation Experience7
ducting meetings in the village with the It would be impossible for the ANMs to
The above recommendations on ICDS
different groups such as women, youth, do it alone, as each of them was looking are based on the experience of the MV
gram panchayat and so on, working to- after 5-6 villages. The AWWs however Foundation in mobilising the community
wards creating a norm in favour ofchildren refused to cooperate, saying that it was the
for protection of child health in eight
and their rights. This person will have to last week of the month and that they had mandals of Ranga Reddy district, Andhra
work closely with the auxiliary nurse t~
to finish all their records k.
in .1
time for their -Pradesh. The MV Foundation, drawing
midwife (ANM) and the health department, monthly meeting, failing which they would on its experience with children’s right
Comprehensive planning and decentral- be pulled up
by their superiors. ThereJ was to education, recently began working on
...
isation: Many ofthe functions of the ICDS a long fight between the AWWs and the the issue of children’s health. Initially,
programme depend on the health depart PHC staff. Ultimately, some of the AW Ws data were collected on every birth that took
ment for their success. For instance agreed to cooperate, while others said they place in the village each month and the
immunisation, ante-natal care, family plan would have nothing to do with the prevalent practices of delivery and child
ning and referral services are all provided programme. In this case too it was felt that care. It was found that almost 50 per cent
by the health department. The role of the it would have been better for the medical of the women delivered at home, and that
AWW is to act as a motivator and a link officer to have a meeting with the CDPO infant mortality was very high. When these
person between the community and these and for the two of them,'to plan the entire figures were compared with PHC statis
services. At present there is
'; no programme together. Smooth coordination tics, it emerged that the government did
institutionalised mechanism for this coor- between different departments is extremely not report most deaths.
dination beyond the village level. At the important for effective implementation of
More disturbing was the fact that
village level the ANM liaises with the such programmes.
even when eight to nine children died in
AWW as a contact person in the village
Closely related to lack of coordination a month in a mandal,
r there was total in
and gets data from her on who is pregnant is the problem of haphazard and top-down difference. It did not become a matter of
3692
Economic and Political Weekly
August 26, 2006
concern for anyone in the village - the
gram panchayat, the anganwadi centre and
the community evaded the issue. At best,
people sympathised with the family. In
variably, it was seen as a personal issue,
not something that required any social
action.
Rallies and marches were organised in
the village on the issue of children’s right
to health. Meetings were held at the village
and mandal level, where this information
was shared with the entire community to
discuss how each of these deaths could
have been prevented. This entire exercise
was also to help create an environment
where the community felt responsible for
the well-being of the children bom in the
village. It was then decided that the gram
panchayat should review the condition of
all children in the village every month
along with all the concerned government
functionaries such as the AWW, the ANM
and the school headmaster.
Members of youth groups and mothers’
committees, among others, also attended
se meetings in the village. Consequently,
in about 50 villages, each month the
ANM and AWW, along with the sarpanch
and the ward members, now review the
number of children who have been
immunised; whether supplementary food
was reaching the children; details on
whether any children died during the month,
and so on. They even discuss cases where
families did not cooperate or refused to get
children immunised, or were unwilling to
take the supplementary nutrition provided
at the anganwadi centre. The gram
panchayat, along with others, then visits
these families and motivates them to
access the services.
Some changes have already taken place
through this process. The gram panchayat
in many villages now feels responsible for
the children in the village. The ANM and
AWW discuss with the gram panchayat
obstacles in delivering services. For
instance, in Sheriguda, the ANM explained
that she was not doing ante-natal check
ups because there was not enough space
with privacy in the village. In response the
gram panchayat decided to convert a
godown into a centre for the ANM and the
material stored in the godown was shifted
to the gram panchayat office.
In some villages the AWW was caught
red-handed while she was trying to sell the
supplementary food, and action was taken
against her. At the same time, should the
AWW require any support from the vil
lage, it is provided. In many villages, there
Economic and Political Weekly
were complaints that the ANM was not
available. She, in turn, claimed to be making
the requisite number of visits. To resolve
this problem, a public announcement (with
drum beats - ‘dappu’) is now made the
previous evening, informing everyone
about the ANM’s visit and asking parents
to send their children for immunisation and
health check-ups. Such issues are now
being tackled at the village level, with
government departments and the commu
nity coming together.
More importantly, as a result of this
process of public mobilisation on child
health, what was so far seen as a private
issue confined to the family (and even
within the family, primarily the mother’s
concern) has now become an issue for the
entire village. In village after village,
ceremonies are held where the sarpanch
gives out birth certificates to all children
below the age of two. Once the backlog
is covered in an institutionalised manner,
all children in the village are given birth
certificates as soon as they are named. For
the sake of the certificate, families are
naming their children within the first month
itself. Through this exercise ofgiving birth
certificates, the panchayat and the commu
nity now celebrate the birth of every child
- a significant shift from the earlier po
sition where the death of a child was
considered as the mother’s fate.
It is in such an environment that the
specific issues of each child are taken up.
The families are informed and motivated
to avail the services available to them from
the ICDS and health departments. At the
same time, there is also a discussion on
giving children time, and sharing of res
ponsibilities within the family. Through
regular review meetings, the community
exercises pressure to ensure that the ANM
comes regularly and that the anganwadi
centre functions.
The community is thus being sensitised
to the well-being of pregnant women,
mothers and children. With increasing
community interest in the anganwadi centre,
the AWW is empowered and ICDS is
beginning to have a presence in the village.
Issues that cannot be resolved at the village
level are being taken up by the gram
panchayat to higher authorities. For in
stance, a number of petitions have been
submitted to the CDPO asking for better
buildings for the anganwadi centres, sanc
tion of additional centres, and steps to
activate non-functional centres. The rights
of mothers and children are becoming a
public concern, with the community
August 26, 2006
demanding from the state what is due to
mothers and children.
Conclusion
ICDS is one ofthe most important public
programmes in India, reaching out to the
most neglected sections of the population.
It can go a long way towards protecting
the rights of mothers and children. India
cannot dream of progressing with high
rates of maternal and child mortality and
extremely high levels of malnutrition.
However, a lot needs to be done to enable
ICDS to reach its objectives. The coverage
of ICDS has to be expanded to reach out
to every child, pregnant or nursing mother,
and adolescent girl. It is important to
demand universal coverage of mothers,
children and adolescent girls, dealing with
the issue from a rights-based perspective.
This involves a clear commitment to the
protection of children’s rights on the part
of the state, and public mobilisation to
ensure that rhetoric translates into action.
Secondly, the functions of ICDS have
to be separated, with a specialised person
to provide pre-school education and an
other trained worker to take charge of the
health and nutrition aspects of the
programme. Active steps should be taken
to implement widely-supported recommendations such as keeping anganwadi centres
open for the whole day, setting up creches
for younger chi Idren, providing take-home
rations for those under three years of age,
etc. Further, there must be coordination
between the health and education depart
ments to provide these services efficiently.
Also, the National Rural Health Mission’s
plan to post community health workers in
each village should be integrated with the
ICDS programme, to avoid creating a
parallel system and to ensure better coordi
nation between ICDS and the health system.
Thirdly, it must be recognised that the
anganwadi centre is expected to perfonn
multiple functions, each ofwhich is equally
important and needs to be carefully thought
out. There is a need to first have a vision
of what is best for the protection of the
rights of mothers, children and adoles
cents, and of the state’s responsibilities in
this regard. Based on such a vision one
could then estimate the required resources,
how these resources can be mobilised and
how they should be spent. It is important
to set clear goals, so that achievements
can be assessed and work given direc
tion. As things stand, the process works
the other way round. There is first an
3693
estimate of the resources available, and
then “realistic” demands andplans are made,
contingent on these pre-specified resource
commitments.
The health and well-being of mothers
and children must be recognised as an
overwhelming priority, and all efforts made
to realise this goal. Children are the future
of the country and cannot wait any longer.
There has to be a serious debate on this
issue, involving all sections of society,
leading to a vision of what we aspire to be.
Backed by a clear vision as well as political
commitment to the rights of mothers and
children, the ICDS programme and the
AWW could play a key role towards the
development of the country. M
Email: dipasinha@gmail.com
Notes
[This paper is based on the MV Foundation’s
experience ofworking on children’s right to health
in eight mandals of Ranga Reddy district. The
author is Health and Population Innovation Fellow
of the Population Council and is associated with
the MV Foundation.]
1 See http://wcd.nic.in/udisha/htm/objectives.htm
(Department ofWomen and Child Development,
government of India).
2 See http://wcd.nic.in (Department of Women
and Child Development, government of India).
3 For further details of these orders, and of the
campaign that has built around them, see
www.righttofoodindia.org.
4 See http://pmindia.nic.in/cmp.pdf.
5 For further details, see www.nac.nic.in.
6 A mandal in Andhra Pradesh, is an admini
strative unit consisting of about 30-40 villages
and an average population of around 50,000.
The administrative structure in Andhra Pradesh
comprises the district, mandal and gram
panchayat.
7 The MV Foundation is a voluntary organisation
working on issues ofchild labour and children’s
right to education. It is currently active in 6,000
villages of Andhra Pradesh.
References
Chandrasekhar, C P and Jayati Ghosh (2005): ‘The
Unfulfilled Potential of the ICDS’ in
www.macroscan.comi
Dreze, Jean and Amartya Sen (1995): India:
Economic Development and Social Oppor
tunity, Oxford University Press, New Delhi.
Dreze, Jean and Shonali Sen (2004):
‘Universalisation with Quality: An Agenda for
ICDS’, report prepared for the National
Advisory Council, available at www.nac.nic.in.
International Institute for Population Sciences
(2000): NationalFamilyHealth Survey 2: India
1998-99, UPS, Mumbai.
Ramachandran, Vimala (2005): ‘Reflections on
the ICDS Programme’, Seminar, No 546,
February.
The World Health Report (2005): ‘Make Every
Mother and Child Count’, World Health
Organisation, Geneva.
3694
Economic and Political Weekly
August 26, 2006
Perspectives
Nutrition Policy
Shifts and Logical Fallacies
Iffood security is a priority, then foodgrains should remain at the
head of the agenda for policy, especially if the nutritional problems
of the marginalised are to be addressed. Further, the type of
diversification offood baskets that is taking place, apartfrom
being restricted to the better-off, is certainly unhealthy.
Imrana Qadeer, Anju P Priyadarshi
uring the 1970s and 1980s nutriI 1 tionists were intensely engaged in
1
understanding the very nature of
under-nutrition in India, how to control it
ind debated issues of measurement of
poverty. By the mid- 1980s, however, with
the decline in severe forms ofmalnutrition
such as kwashiorkor, marasmus, pellagra
and beriberi, the direction of nutrition
research changed. While the concern with
declining pulse production remained, their
research focus shifted towards the ascen
dancy of nutrition related diseases such as
diabetes, hypertension, coronary heart
disease, micronutrients and obesity.
Supplementation programmes rather than
nutrition policy debates and social plan
ning engaged them, while earlier, the latter
were important areas of interest for most
senior nutritionists.
This movement away from an unfinished
agenda left a vacuum in policy research
that was taken over by liberal economists.
Other than production, pricing and expen
ditures on food, they also started exploring
and explaining consumption demand
based on trends in consumption data. The
National Nutrition Monitoring Bureau
data had shown a decline in energy con
sumption the late 1970s and 1980s. This
was reported as early as 1984 [Rao 1987;
Ramachandran 1987]. The same data had
also provided insights into energy andprotein
consumption declines across income classes
[Gopalan 1992]. An associated trend of
declining consumption of cereals between
1972-73 and 1993-94 was later picked up
in the NS S by a number ofeconomists and
was proclaimed as a “sobering thought
against mind-boggling projections of
demands” for foodgrains [Rao 2000].
358
Over time, several explanations were
offered for this decline and each of them
had a set of assumptions behind it. These
explanations were (a) the increasing wel
fare ofpeople as reflected in the improved
infrastructure in rural areas [Rao 2000],
(b) self sufficiency of the nation reflected
by the increasing foodgrain production
and buffer stocks ofover 60 million tonnes
along with exports ofthe same [Gol 2002],
(c) diversification of the food basket
[Radhakrishna et al 2004] and (d) volun
tary shift away from cereals due to ex
panding and diverse food markets, taste
and lifestyle changes affecting the
behaviour of the poor [Dyson et al 2000].
Dyson predicted a further decline ofcereal
consumption to as low as 11.45 kg per
person per month (38 kg per annum per
person) with a change in the social situ
ation. In short, this set of scholars judged
declining cereal consumption as reflec
ting of improved social conditions and
therefore a positive trend. The nutritionists
not only remained silent, but their preoc
cupation with micronutrients or protective
foods, gave credence to these ideas. This
understanding of nutritional trends has
had a serious impact on nutrition policy.
1993 Policy Document
The nutrition policy document of 1993
did talk of intervention programmes, but
not in isolation. It placed equal emphasis
upon increasing foodgrain production, the
public distribution system to ensure food
security, land reforms, health and educa
tion. Its goal was to reduce further chronic
energy deficiency (CED), low birth weight,
anaemia of pregnancy, to achieve pro
duction targets of 250 MT by 2020, to
have a strategy for horticulture to promote
protective foods and evolve a inter-sectoral
approach to nutrition planning. In contrast,
the Tenth Five-Year Plan proposes a
paradigm shift, with four basic thrust areas:
(i) Shift from household food security and
freedom from hunger to nutrition security
for the family and individuals.
(ii) Shift from untargeted food supple
mentation to screening of all persons from
vulnerable groups for identification of
those with various grades of under-nutri
tion and appropriate management.
(iii) Shift from lack of focused interven
tion on the prevention of over-nutrition to
strategies ofprevention, control and man
agement of obesity.
(iv) Though it mentions the need for en
suring production of cereals, pulses and
seasonal vegetables to meet the nutritional
needs, this comes a poor fourth on the list
of priorities.
An unexpected though critical proposal
is to reduce the recommended dietary al
lowances (RDAs) and set up an expert com
mittee to formalise this suggestion. In other
words, the proposal comes first and the
experts to rationalise it come later - a pro
cedure that hardly befits aplanning exercise.
This paradigm reflects the new under
standing of nutritional issues based on the
explanations for the declines in cereal con
sumption offered by some eminent social
scientists and the current concerns of the
nutritionist. Planning, however, cannot
ignore the majority ofthe people, specially
the underprivileged. The focus on ‘families
and individuals’ and ‘nutrition security’
rather than on ‘food security’ indicates a
beliefthat food shortages and hunger are no
more significant policy issues. Secondly,
identification of individuals through
surveillance and their ‘management’ trans
forms a major public health problem into
a clinical problem that is amenable to
institutional management or targeted
programmes. These interventions are con
sidered effective irrespective of failing
infrastructure of the public distribution
system, and health and welfare services.
The thesis of‘improved welfare in rural
areas’ has already been critiqued by Saha
who not only showed serious methodo
logical flaws in drawing conclusions, but
also questions the basic assumption of suf
ficiency of food and welfare in rural areas
[Saha 2000]. Undermining ofrural welfare
Economic and Political Weekly
January 29, 2005
during the 1990s was evident from the fact and gloss over class differentials or assume massive to be tackled through individual
that investments in rural development over that only the population below the 30th identification and management (Table 2).
this period declined from 14.5 per cent to 6 percentile is significantly calorie deficient. Table 2 gives the proportion of all those
per cent ofGDP [Patnaik2004]. The budget Also, they make no attempt to actually who get less or more than 2,400 calories,
for health declined from 1.5 per cent to 0.9 look at food items other than cereals that i e, 100 per cent of RDA. It shows the real
per cent of the GDP [Gol 2002] and the have been consumed nor pay attention to extent of the under-nourished population
targeted public distribution system failed to some basic principles of nutritional sci that moves from 63.9 per cent to 67.1 per
reach the poor [Swaminathan 2000]. The ences. Re-interpreting the NSS data is thus cent over the four NSS round as against
thesis of improved welfare hardly matches the key to understanding the fallacies of the declining undernourished population
the evidence. Similarly, Dyson’s projection the popular explanations. We are analysing using the new mantra of reduced RDAs
of a persistent decline of cereal consump direct consumption offoods and not overall
Table 2: Distribution of the Total
tion to levels as low as 138 kg per person consumption that also includes foods used
Households by the Identification Criterion
annually under the influence of non-cereal as animal feed and for processing in the
(Rural)
and non-food commodity markets also fails. food industries.
1983- 1987- 1993- 1999For our analysis, data for four rounds of
After 2000-01, when levels of food avail
2000
94
84
88
ability of as little as 151 kg per person per NSS were covered (38th, 43rd, 50th and
To
’
10
11
14
year were reached, a reversal of the declin- 55 th rounds) and the entire sample was Very poor
34
34
29
33
Poor
ing trend took place when programmes of classified using calorie deficiency of less Total
44
44
40
47
poor
44
47
43
47
food-for-work were introduced over the than 90 per cent to define different classes, Middle
12
13
12
6
following two years [Patnaik 2004]. This To make the 55th round comparable to the High
Intake of less
64
67
61
only reaffirms that while the elasticity of earlier rounds we have made adjustments
than 2,400 calories 64
100
100
100
100
demand of cereals is articulated within for the two recall periods used in the 55th Total
complex social conditions and is suscep- round for the consumption survey using Note: The criterion for classification of the groups is
based on level of per capita per day(pcpd)
tible to variations, these variations are the adjustment factors as suggested by Sen
calorie consumption which is lower than
r- sible only after a certain minimum level and Himanshu [Sen et al 2004]. The official
the RDA.
< ereal intake is achieved. According to poverty line of the Planning Commission Source : NSS unit level record data.
the principles of nutritional science, 60-70 fell on the upper side of the range of
per cent of the total energy should come monthly per capita consumption expendi
Table 3: Total Per Capita Per Day Unit
Values Spent on Selected Items
from carbohydrates preferably starch ture (MPCE) of the poor group for each
(Cereals)
[National Institute of Nutrition 2003]. The survey year. Table 1 gives the distribution
(Rs)
tendency to retain minimum levels of cereals of the sample over different years in each
1983- 1987- 1993- 1999- the source of starch - is thus not only eco class as well as the variations in calorie
2000
94
88
84
____ ______________
_ rational. deficiency within classes (ranging from
nomically,
but also nutritionally
20.8
12.5
The current shifts within nutrition policy less than 70 per cent to less than 100 per Very poor
5.4
6.2
25.9
15.2
7.6
6.3
these cent). The value of this classification is Poor
and the main arguments on which
1________
33.4
18.6
9.2
7.2
Middle
uiv
_________
47.9
23.7
8.4 11.9
are based are the
focus of__
this paper. -t
It that it is sensitive to the complex and Well-off
32.8
17.7
8.7
6.7
primarily uses evidence from ruraf India pervasive nature of the problem of under- All
Selected Non-Cereals
to explore some of the myths regarding nutrition. Hence, it brings out the fallacy Very poor
212.9
61.7 95.6 138.1
171.5 267.0
78.1 114.7
of the assumption that there are clearly Poor
contemporary shifts in diets.
104.1 153.5 228.8 362.7
Middle
vulnerable groups that can be managed Well-off
140.0 195.3 292.2 515.9
214.2 353.0
through surveillance and individual iden All
93.4 143.7
Population Averages versus
Total Selected Food
tification. Secondly, by defining under
67.1 101.8 150.6 233.7
Very poor
Class: Issues of Methodology
nutrition as 90 per cent of the recom- Poor
186.7 292.9
84.4 122.3
247.4 396.1
111.3 162.7
'', we are Middle
Most of the analysts ofNational Sample mended dietary allowance (RDA),
148.4 207.2 315.9 563.8
Well-off
100.1 152.4 231.9 385.8
Survey (NSS) data who show declines in able to show that, even when understated, All
'real consumption either look at averages the problem of under-nutrition is too
• able 1
: Identification of Poor and Very Poor on the Basis of Percentage of RDA Per Capita Per Day Calorie Intake Over the Years
(Rural)
1987-88
1983-84
<90
<70
<100
<70
<90
Per cent Per cent Per cent Per cent Percent
Intake
Intake
Intake
Intake
Intake
4988
70
5371
30
10359
50
3898
8
148
2
6762
95
13013
74
19775
84
16075
34
708
7
<100
<70
Per cent Per cent
Intake
Intake
6980
98
15338
87
22318
92
23911
50
1268
13
4005
70
5690
30
9695
50
3189
8
132
2
1993-94
<90
Intake
<100
Per cent
Intake
5450
5609
Per cent
1999-2000
<100
<90
<70
Percent Per cent Per cent
Intake
Intake
Intake
4234
10222
9838
7328
No of Hhlds
70
99
96
98
94
70
Percentage
6708
16687
14154
20097
16834
7282
No of Hhlds
Poor
30
89
76
83
69
30
Percentage
10942
22296
19604
30319
14610 26672
No of Hhlds
Total poor
50
94
86
90
81
50
Percentage
3033
20764
13975
16269
3417 11253
No of Hhlds
Middle
8
55
37
46
32
10
Percentage
117
1207
667
782
550
290
No of Hhlds
High
2
18
10
18
13
7
Percentage
Seventy per cent of RDA is 1,680 calories, 90 per cent of RDA is 2,160 calories and 100 per cent of RDA is 2,400 calories.
Note:
Source: NSS unit record data.
Very Poor
Economic and Political Weekly
January 29, 2005
5787
96
16922
76
22709
86
14025
38
695
11
5937
99
19823
89
25760
94
20781
57
1344
21
359
according to which undemutrition declined
over the four NSS rounds from 47 per cent
to 44 per cent. This is because calorie
deficiency of a lower order is excluded
from the analysis.
Even within our very conservative op
erational definition, the vulnerability of
the poor is evident where those getting less
than 90 per cent of the required energy
ranges from 94 to 96 per cent of the
population in the group. In the middle
classes, using the same criterion, 33 to 38
per cent households are energy deficient.
This proportion goes up to 47-57 per cent
(Table 1), when all those below 100 per
cent of energy requirement in the class are
taken. In other words, this section of the
middle class, under social pressure to keep
up its status (non-food consumption), is
perpetually struggling against hunger. It is
very different from the image of the newly
emerging urban middle class, crowding
the consumer markets and probably over
lapping with those well-off and middle
house holds that fall in the proportions
getting over 100 per cent of calorie RDAs
(Table 2). The following section offers
a brief contextual review of food avail
ability and expenditure on food.
Figure 1: Total Per Capita Per Day Intake of Nutrients
100------------------------80------------------------
x--x—x
*
60—----------------------
1500
--x—x
1000
500
20 g—a—□
0- •O'
CO
•
“
CO
O>
CT)
i
<*)" a
5
O)
O)
CT)
v
O
O
CO
CO
i
CT)
CT)
O>
°?
—
i
co
co
O)
co
co
CT)
O)
O)
CT)
a>
co
?
CO
5
CT)
Patnaik’s work on availability of
foodgrains defined as net output plus net
imports minus net additions to public stock,
shows that, in the 1990s, India lost what
it had achieved after independence.
Foodgrain availability, as five-year aver
age per head per year, came down from
199 kg at the turn of the 19th century to
148.5 kg prior to independence. In the year
1945-46 it was as low as 136.8 kg. It then
rose to a three-year cumulative average,
of 177 kg in the early 1990s and then
declined sharply to 163.2 kg. In 2000-01
it was only 151.06 kg and showed some
recovery over the following years due to the
food-for-work programmes of the govern
ment [Patnaik 2004]. It is important to
recognise that this decline had a differential impact on the consumption ofdifferent
classes as a result of differences in access
due to a household production of food,
quality of food and its prices and wages.
An analysis by Radhakrishna et al shows
that between 1970-71 and 2000-01, the
relative prices of food in rural India that
were comparable to non-food items in the
initial decade increased while the prices
of non-foodgrains declined significantly.
360
o
co
00
O)
•
s s s
O
S 2 5
sM
2 sCT)
O)
2
5
co
O)
O)
a>
O)
All
Well-off
Energy (kcal)
Iron (mg) —— Vitamin A (mg) -
Proteins (gms) —x — Fat (gms)
0
O
I 5■a> “
a>
Middle
Poor
Very Poor
0
°?
-
Note: * All the nutrients corresponds to the primary Y-axis (scale 0-120) on the left side of the graph except
‘Energy(Kcals)’which corresponds to the secondary Y-axis on the right side of the graph.
Figure 2: Proporionate Intake of Energy and Nutrients from Cereals
100r
80
S
60
o
*40
2Q
0.
xr
OO
i
CO
co
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i
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i
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***
o
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oo
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cn
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i
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i
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CO
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. <- - • iron
s
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05
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00
CT)
Well-off”
Middle ”
Poor
Very Poor
o
tt
*■
Calories ----------- Proteins
Food Availability and Consumption
Expenditure Over the Years
4000
3500
3000
2500
2000
1201
co
CO
s
CO
OJ
CO
CT)
CT)
O
-
CT)
CT)
CT)
Total
Mt—Fats —m — Vitamin A
Figure 3: Per Capita Per Day Intake of Groups of Food Item other than Cereals (gms)
-------
SGOi------------------ -------- ----------
—■
-
600
w400
cn
-A
200
A -A
0
3
co
co
O>
co
co
r*
co
a>
sco
a>
o
o
CM
<J>
0>
cn
Very Poor
s
co
oo
a>
co
co
Kco
a>
s
co
a>
cn
“o”
a
a>
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05
CO
CO
CO
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N-
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o
2 2 s
■0
CO
co
co
t'-
co
O0
OS
CO
05
05
05
05
05
i
05
o
CM
Middle
. Milk
Using the NSS percentiles they also show
that while total consumption expenditures
have increased for all classes over three
decades since the 1970s, consumption
expenditure on food shows a negative
growth rate over the 1990s. It is pertinent
to note that for non-cereals, all classes
showed a positive growth rate during the
1970s and 1980s and a negative growth
rate for the 1990s. But, for cereals, negative growth rates were evident from the
1970s itself, except for those below the
30th percentile who held on till the end
of the 1980s [Radhakrishna et al 2004],
This tenacity of the poor to retain their
a>
a>
V
co
CO
co
'T
cn
co
co
a>
t-co
a>
co
o>
a>
05
" “ I
Poor
Cereal
co
co
Well-off
o
o
o
CM
O>
cn
o>
All
----- ■------ Vegetables
cereal intakes are the key to our argument
in favour of foodgrain security at class
level and not nutrition security at the
individual level. Our analysis of the four
rounds of NSS reveals that the quality of
cereal and non-cereals consumed by the
poor and the rich were markedly differ
ent as shown by the higher unit values
of the items for the well-off (Table 3).
Taking the expenditure of the very poor
class for the year 1983-84 as the base, the
total expenditure on selected food andI non
food items across classes shows a uniform
trend of a tripling of expenditures over
time. For each round of NSS, the well-off
Economic and Political Weekly
January 29, 2005
Figure 4: Per Capita Per Day Intake of Groups of Food Item other than Cereals (gms)
100-
80
60
E
05 40
<x
200
4 4 TiCT)
o
4
co
£o>
CO
CT)
CT)
CM
co
CO
CT)
O)
CT)
O)
co
co
co
O)
00
r4 o
4-
CM
co
co
CT)
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CT)
00
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a>
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co
00
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a
o
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4- 4
CO
co
00
CT)
CT)
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co
cr>
CT)
a>
o>
O
a
cn
CT>
a>
All
Milk products*
Meat and fish**
------------- Edible oil
•
CT)
Well-off
Middle
Pulses and pulse product
a.
4
O)
CT)
CT)
CT)
Poor
Very Poor
o
4 -dCO
Poultry, other birds and egg (nos)
- Fresh fruits
Notes: * Butter, ghee, icecream not included here but included in edible oils and processed food group
respectively.
n
•• Poultry and eggs are given in nos and quantity consumed varies between 0.07 for the very poor
to 0.3 for the well-off.
Figure 5: Proportionate Intake of Calories from Food Groups other than Cereals
25
have over time spent five times more
compared to the very poor. The increase
in expenditure on non-food items over
time varied from two and a half times in
the well-off to not even double in the
poorest class. For food items, however, the
rich show an increase of 3.5 times and the
poor of 2.4 times. For non-cereals, both
the extreme groups show a rise of expen
diture by four times, but for cereals the
poorest have an expenditure jump of 3.5
times as compared to the rich who raise
their expenditure only 2.4 times (Table 4).
This again reiterates the pressures in the
1990s on the poor who do not spend much
on non-food items. Even though the ex
penditure of the poor on in non-cereal
foods increases over time in the same
proportion as that of the well-off, their
expenditure on cereals reflects a higher
proportionate increase compared to the
rich. The expenditure gap between the
richest and the poorest for each year also
increases significantly for non-cereals and
non-food items studied, revealing the
advantages and choices available to the
Table 4: Total Per Capita Per Day
Expenditure on Selected Item Groups
20
15
8
1983-84 1987-88 1993-941999-2000
All Selected Food and Non-Food Items
2.94
2.06
1.19
1.00
4.36
2.95
1.68
1.45
7.70
4.97
2.78
2.36
10.58 17.17
6.11
5.42
8.04
5.14
2.94
2.56
10
<5
0-
Very poor
Poor
Middle
Well-off
All
5
-o
0
CO
«O
CO
t*
o>
s
o
<•)
i
r,
co
o>
i
co
CO
CM
cn
•
co
C7>
01
O>
O
o
CO
CO
CO
00
O>
tCO
at
o
O)
o>
O)
T
CO
CO
cn
p
co
co
d s s
o>
O)
*■
CO
O>
o
co
o>
01
m
cn
All
Well-off
Middle
Poor
Very Poor
*
Meat, poultry, fish
Milk and milk products
Sugar
> — Pulses and pulse product
-•----- Vegetables
o— - Fresh and dry fruits
Edible oils
Very poor
Poor
Middle
Well-off
All
Total Non-Food'
0.43
0.41
0.58
0.55
1.06
0.97
2.93
2.81
1.31
1.23
0.58
0.87
1.75
5.01
1.99
0.66
1.05
2.47
7.91
2.74
***lt includes fuel and lighting, clothing and footwear,
Figure 6: Proportionate Intake of Proteins from Food Groups other than Cereals
'20-1
Very poor
Poor
Middle
Well-off
All
16
- 12-
education, medical and rent.
M-
0.59
0.90
1.39
2.61
1.37
Total Food*
0.76
1.10
1.72
3.18
1.69
1.47
2.08
3.22
5.56
3.09
2.28
3.31
5.22
9.26
5.02
* Selected food groups: pulse, milk, meat*, edible
oil, vegetables and fresh fruits.
4-
0
-4
fere*-*4
co
CO
co
cn
CO
o
bCO
**
CO
O)
~
2 2
O
o
CM
i
CT)
O)
CT)
Very Poor
o
O
co
CO
CO
II
2CT) **SS S~ **£
CO
xr
CO
co
<D
o
’r
O)
2
0>
o>
o>
■.
Note:
o>
cA
“
CT)
~
O
O
Q
°
i
a>
CT)
CT)
XT
CO
CT)
—- ----- Milk and milk products
Vegetables
CO
CO
XT
O)
£ 2 2
2
Middle
Poor
Pulses and pulse products
A
C
co
O)
XT
CT)
I
Beverages, snacks, etc
a>
~
Well-off
O
o
o>
o>
a>
s
co
CO
CT)
O
CO
°?
EE
c»
?
g
CT)
CT)
“
CT)
CT)
s S
All
Meat, poultry, fish and egg
Fresh and dry fruits
-----• Sugar group provides 0.05 per cent of proteins for Ve?'Poor groupto OfBper
cent for the welloff^n'lQG^^^OO^nd^^ible^Oils'p'/ovidesO.I "per cent of Proteins for the Poor and 0.08 percent
for the well-off for this period.
Economic and Political Weekly
January 29, 2005
Very poor
Poor
Middle
Well-off
All
Very poor
Poor
Middle
Well-off
All
Cereals
0.43
0.37
0.58
0.52
0.72
0.68
0.96
0.92
0.67
0.62
Non-Cereals*
0.33
0.22
0.52
0.37
1.00
0.71
2.22
1.69
1.02
0.75
0.85
1.07
1.28
1.52
1.18
1.23
1.59
1.88
2.23
1.73
0.63
1.01
1.94
4.05
1.91
1.04
1.72
3.35
7.02
3.28
Note: Base is the total selected expenditure of the
very poor group for the year 1983-84.
361
Figure 7: Proportionate Intake of Fats from Food Groups other than Cereals
601
50
When quantities ofcereals increase in diets
of the poor, it not only leads to increased
and better utilisation of proteins but also
helps lessen some micronutrient deficien
vention programmes, and perhaps ensures
their greater efficiency. Keeping this in
mind we now turn to the issue of diversi
fication of the food basket to examine how
cereal are being replaced and among whom.
The NSS data shows that the maximum
decline in total per capita cereal intake is
40
o
0) 30
O.
20
10
for the affluent,
improvement, except in the 55th Round.
co ’e
o
co co
o>
O
o
Only 15-25 per cent of their total energy
co
co
co ***
-3
co
2
5
5 5 2
co
OJ
£
comes from other foods. The actual intakes
2 2
!
2
of various foods per capita per day show
All
Well-off
Middle
Poor
Very Poor
that despite the slight improvement ofcereal
a— Edible oils
- - ■- - Milk and milk products
—♦— Pulses and pulse products
intake the very poor still get less than
+
Sugar,
---x- -- Vegetables
----------- Meat, poultry, fish and egg
jaggery
400 gm, the poor just about manage the
—o— Fresh and dry fruits
Beverages, snacks, etc
recommended amounts (409 gm) while the
rich. This picture ofavailability, unit prices A intake, though better than that of the other two classes - despite significant
and expenditure patterns, makes it clear poor, is still below the recommended decline over time-still consume sufficient
c
r
....
nnl_________ n____ 1
that there is a vast difference both in the allowances. Thus we find that while the quantities of cereals. Milk and vegetables
diets
of 44 per cent of the sample are show a sharp increase among the middle
■’uantity and quality of food intake and
.aerefore, only household consumption of markedly deficient in all four main nutri and the well-off classes where the current
classes alone can give the real picture of ents and calories, the middle class lack intake levels have reached 200 gm and
mly micronutrients. Since 38 per cent of above. Pulses and milk products again
food basket diversification.
them get less than 90 per cent of required show improved intakes among the better
Shifts in consumption P.ft.tn
™ “
energy.
against milk products. This trend is
be concentrated in this group.
We now examine the quantity and qual- InInproviding
providingthe
thecalories
caloriesand
andthe
thenutrinutn- repeated for food items such as edible oil
play
an important
important role
role in
in the
the meat, fish poultry and eggs and
ity of food baskets and the importanceof ents, cereals
' J
/ an
y
. .
.
. poorr cclasses.
]asses Figure
22 shows
that,
the
fruits. Visible fats are adequate only for the
Figure
shows
that,
the
traditional patterns of mixed cereal and
proportion
of
total
calories
derived
from
well-off(40 mg) and the middle class shows
protein-based Indian diets as against the
•
an improved oil intake only in the 55th
newly emerging low cereal diets. These cereals and cereal substitutes have come round of NSS. The poor on the other hand
mii-o i«iov
shifts
raise questions of adequacy of en- down to 80 and 74 per cent for the two
ergy for the poor and dietetic balance of poor classes, 65 per cent for the middle are still struggling to reach the prescribed
51 7per cent* for the well-off. It is levels of these foods with the singular
the well-off. The shift in energy intakes and
i
balanced
exception
of vegetables
(Figures
3 and 4).
•
’ i a U.
____ 2 diet,
” ,
over time in each class points out that pertinent to note that
in
------x
—
exceot for the poorest who have margin- of
the total
ofthe
total calories,
calories, 60-70
60-70 per
per cent
cent should
should This evidence ofdiversification ofthe food
ally improved their energy consumption, come
i e, cereals basket, hmhed to the rntt^dle ^d the wellcome from
from carbohydrates,
<
all othe^ classes have lowered their energy [National
Nutrition 2003],
[NationalInstitute
Institute of
ofNutrition
2003]. For
For off classes, ’"^bly gete_^ected
intake (Figure 1) and yet, the energy intake the
the two
two classes
classes of
of the
the poor,
poor, 82
82 per
per cent
cent proportions of calories, Prokins and fats
of the poor is clearly below 90 per cent and 73 per cent of the proteins also> come
come and other nutrients provided by dasses of
of the RD A. They also consistently take from
from cereals
cereals for
for these
these classes
classes. While
While the
the foods other than cereals and cereal
amounts that are less than that prescribed proportion
proportion of
of fats,
fats, Vitamin
Vitamin AA and
and iron
iron stitute (Figures 5 6 and 7). For the poor
for one person in one day, of proteins from
of calories from oils and
fromcereal
cerealhave
havedeclined
declinedover
overtime
timeininall
all the proportion
x x
7
classes, for the poor it still provides nearly vegetables, milk and milk products, and
(60 mg), fat (30 mg), iron and Vitamin A
(30 mg and 2400 mg respectively). The 70 per cent of iron and 30 per cent of fat. fruits shows only a marginal increase over
time, while that from pulses declines, and
level of protein intake is sufficient for the Thus, while foods with high protective
value
are
important,
it
is
also
important
to
stagnates from sugars. None ofthese foods
middle class and more than sufficient for
contributed more than
appreciate
that
cereals
are
the
cheapest
food
' 4 per cent of the
the well-off despite a decline over time.
total
calories.
For
the
well-off protein rich
Also, despite a lowering over time, the sources for energy and proteins. “Different
...
fo°
d
mixtures
provide
different
protein
foods
provide
29
per
cent
of energy, which
energy intakes of the middle and the welloff dasses remain more than adequate as energy percentage depending upon the total is twice the required 8-12 per cent, and
therefore unhealthy. Similarly, milk, its
do their intake of fat which shows a sharp calories available” [Sukhatme 1972]. In
fact,
in
absence
of
adequate
quantities
of
products, meat, and poultry as a source of
increase from 1993-94. While the iron
cereals
(energy),
optimum
dietary
protein
proteini are relevant only for the well-off
intake of the middle class is below the
and the middle groups. The fat intake of
o
—
j
utilisation
does
not
take
place
for
which
sufrecommended, the well-off get just about
the poor is under 20 gm per day and 10 gm
sufficient quantities of iron. Their Vitamin ficient energy is necessary [ICMR 1998].
0
CT)
362
O)
CO
CD
CT)
CO
•
O)
CD
CO
O)
00
CO
J
’T
CT)
•
O
O
O
O)
**
«y
CO
CO
00
O)
co
00
xy
CT)
O
O
—
CT)
O)
CT)
XT
00
00
CO
’T
O
O)
CT)
CD
CT)
CT)
O
Tf
00
•
co
00
CT)
CO
CO
i
rCO
~
’T
»
co
CT)
**
O
o
o
pu
,
CD
**
O)
CT)
Economic and Political Weekly
January 29, 2005
composition. The truth is that the lower
BMRs of the healthy Indian in comparison
to that of the healthy European are one
thing and the lowering of BMR due to
falling body weight quite another. With
low energy intakes, “BMR declines over
a three week period by up to 15 per cent
when expressed as per unit ofbody weight.
Thereafter further fall in BMR are achieved
primarily by progressive loss oftissue mass”
[WHO/FAO/UNO 1985]. In other words
Lowering of RDAs
this1Sisnm
notdarac
racial
or genetic feature, rather,
mis
‘ai U1SC1ICUV
There are several aspects of RDA that an outcome of poor socio-economic conrequire serious consideration. The Tenth ditions leading to physiological adaptaPlanhints thatthepresentRDAsareflawed tion. With almost 50 per cent of thepopuas they are based on incorrect assumptions lation being under 18 years of age [Indian
» . . .
r,
x..
j, can
36.7and 48.6 [National Institute of Nutri such as ahigh Basal Metabolic Rate (BMR), Institute for Population Studies 2000}
level of~ physical
activity of the their
growth’ potential be denied by a
______
'
'*
tion 2003]! The methodology ofthe survey a higher
b
.
.■
.
j
inc_____ DTI A cj
Indians
andhence higher Physical Activity
restrictive
standard?
Specially, when RDAs
however, is not spelled out. Neither the
are
not
for
individuals
but for groups
populations selected for the study nor the Ratio (PAR), and the use of a reference
wherein individuals have their own spe
exact BMR levels are set out. According man and woman. It also states, “it is unlikely
to the National Nutrition Monitoring that any extra food at this stage (adoles- cific needs. It is well known that, as weight
Bureau (NNMB), in rural areas obesity is cence) can accelerate or extend the dura- and exercise increase with adequate diet,
BMR also increases [Venkata et al 2004].
a problem among only 6 per cent of men tion ofphysical growth. Additional dietary
Experts who proposed the present RDAs
?-J 8 per cent of women [NNMB 2002]. intake at this period can only lead to
had
gone into the details of its components
i
most probably located in the energy adolescent obesity” [Gol 2002].
and given convincing reasons for assumThese
objections
are
based
on
little
sufficient well-off class that constitutes
evidence and are therefore unconvincing, ing higher PARs that are used to calculate
only 12 per cent of the NSS sample or a
:w recommendations of the expert RDAs [ICMR 1998]. The argument that
section of the middle class and cannot be The new recommendations of the expert
of the —Indian
of Medical physical activity in India has gone down
g
roup
o*.
—— —Council
allowed to overshadow the extreme under
on the BMR can at best be true for the well-off and part
nutrition of 44 per cent or the 67 per cent Research (ICMR) are based
____
factorial
method
where
the
Indian
BMR of the middle class and is not a universal
energy deficient population of rural India.
5 per
cent less than that pre- phenomenon. For instance, it is well known
is
taken
as
i
4
Though vegetables and fruits are impor
—--1 that the introduction of green revolution
the internationally used
tant, horticulture as conceived by the Tenth dieted by equation?
On the other hand technology, by increasing the number of
Plan - unlike the vision ofNutrition Policy Schofield’s < .
crops, raised physical activity levels ini
(1993) —
- van
can hardly reach that half of the the actual BMR data on Indians is varied
populationt'hat needs food the most. In the [Soares M J et al 1991; Shetty P S et al tially - especially of agricultural labour.
*
*
„ T ..nrriainl 100'71 TnpcPAYnAftQ
et al 1997]. These experts Subsequent mechanisation did not reduce
given market driven economy the strategy 1994; Ferro-Luzzi
toS^^Bi^fheShy physical activity, but replaced labour that
to promote horticulture actually promotes
was not reabsorbed [Saha 2000]. Today it
exports and elite markets, and not the local adults can be explained by climatic differ
Also,
differences
in
the
BMR
of
isbeingarguedthatRDAsneedtobebased
consumption ofvegetables and fruits. Also, ences.
the crons it encomages are ~flowers, coco- young and iwomen
healthy men and women with
with on energy expenditure rather than requireSt X nTXZ arimatic Body Mass Index (BMI) of >18.5, mar- ments. This ignores that people are mcashew nuts, mushrooms, aromatic Body Mass Index (BMI) of >18.5, marnlants etc [Gol 2002], which cannot fill ginally
and
ginally undernourished
undernourished with
with BMI
BMI of
of active due to forced unemployment
- .
the reil oan
’
17-18.5,
17-18.5 and
andseverely
severelyundernourished
undernourishedwith
with not
notby
bychoice.
choice.To
Touse
uselow
lowphysical
physicalactivity
activity
Our analysis thus shows that if food BMI
BMI <17,
<17, are
are noted
noted but
but it
it is
is emphasised
emphasised of the middle class as reflective of a umjrity isaapriori^
priority“then,
then,’foodgrains
foodgrainsshould
should that once adjusted for weight and fat free versal shift can be extremely misleading
jrity^is
remainattheheadoftheagendaforpolicy, mass with the analysis.of~ce,^se -nee, given die sc
studies in India, it cannot be simply as
specially if the nutritional problems of the differences become statistically insigni sumed that all inactivity is an outcome of
marginalised sections are to be addressed. ficant or even reverse due to an altered fat
Secondly, the type of diversification of free mass composition. The degree oHoss welfare. It is worth remembering that RDAs
are at best policy guides and not pres
food baskets that is taking place, apart of body weight is therefore a key factor. criptions for individual management. Also,
The Tenth Plan objects to the use of
from being restricted to the better-off, is
icicuvv persons
viomxao ’ (healthy j
oadults t0 shift from a ‘reference’ to an ‘actual’
‘reference
young
certainly
nutritionally
unhealthy.
Thirdly,
wiuivuv
-X- — - witrheTghUoTl^
anYlSl cm and group average requiresjull ^wUdge^of
without undermining the urgency of pulse
levels of energy expenditure, activity lev
production, given the overlapping nature body
body weights
weights of
of60
60 kg
kg and
and 50
50 kg
kg for
for men
els and consumption of each group that we
of calorie, protein and micronutrient de- and women) and proposes to use the average
Indian body
body weight.
weight. At
At the
the same
same time
time itit do not have. Are we then attempting to
ficiencies - that is often ignored when the Indian
normalise CED and heading for multiple
NNMB data is analysed for discrete de- explains lower BMR of the Indians on the
RDAs that are different for the rich and
ficiencies—the importance ofcereals needs basis of low Indian body weights, lower
the poor?
to be realised as it supplies not only energy protein turn over and a different body
of it is from oils. For the well-off the total
fat intake is around 80 gm per capita per
day and 40 gm out of it comes from edible
oils. This again reflects their unhealthy
dietary pattern. On the basis of this analy
sis it is clear that diversification of food
baskets is a reality only for the well-off
and the middle classes, while for the poor
(44 per cent) today, it remains a myth. It
is also apparent that the nature of this
diversification is neither healthy nor
leading towards equity.
The vulnerability of the middle group
was emphasised at the beginning. While
57percentgetlessthantherequiredenergy,
the reported
the
reported urban
urban obesity
obesity (BMI>27)
(BMI>27) is
is
Economic and Political Weekly
but also substantial amounts of proteins
and some small amounts ofmicronutrients.
The paradigm shift conceived of by the
Tenth Plan is premature. In view of the
vulnerability of the poor and half of the
middle class. The present policy needs to
go back to the concerns addressed in the
1993 policy statement and focus on CED
rather than micronutrients and obesity.
January 29, 2005
363
New Delhi-WHO, SEARO, pp 7-18.
The definition of Indians as ‘energy foods are proliferating, the freedom to
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It
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for
by the body where it maintains its input
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mended Dietary Allowances for Indians: A
penalties ranging from metabolic shifts, from the embarrassment of not providing
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slowing of BMR, high morbidity and low sufficient quantities of foodgrain to the
of Medical Research’, New Delhi, pp 11-27.
public
distribution
system
and,
thus,
to
physical activity [WHO 1985]. Which of
UPS (2000): ‘National Family Health Survey,
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these levels of adaptation will be accepted those who need it most. Secondly, lowered
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NIN (2003): ‘Dietary Guidelines for Indians - A
level has its explicit penalties. In most to further lower the poverty lines that have
Manual’, National Institute of Nutrition,
civilised countries only the healthy with already been brought down to single figures!
Hyderabad, pp 3-10.
lowest morbidity rates and a normal BMR Arguing for lowering of RDAs to ensure NNMB (2002): ‘Diet and Nutritional Status of
Rural Population’, National Institute of
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[WHO 1985]. In India, BMR studies
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SAHMAT, New Delhi, pp 12-19.
are few. Even if it is assumed that a large when the poor alone depend upon it.
Radhakrishna, R, Rao, K Hanumantha, C Ravi,
Thirdly,
RDAs
are
the
basis
for
calculating
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B S Reddy (2004): ‘Chronic Poverty and
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K (1987): ‘Food Consumption in
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only
one
earning
member
and
joint
fami
pointed out that, “the term adaptation has
of Foodgrains in Rural India: Causes and
been freely used to buttress statistical con lies. A further lowering of RDAs, there
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The inadequate interpretation of declin Rao, S J Kamala (1987): ‘Seasonal Changes in
sistent with normal physiology”. He argued
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that adaptation, “represents not a stage of ing cereal intake and the not so convincing
Undernutrition: Basic Issues and Practical
Approaches, New Delhi, pp 283-85.
normalcy but one of ‘strategic metabolic arguments to lower RDAs are closely linked
and functional retreat’ in response to stress, to the new paradigm of planning, wherein Saha, Anamitra (2000): ‘Puzzle of Declining
Foodgrains Consumption’, Economic and
a device which may help the victim to ward a dismantling of the food security system
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tunately will not help him to ‘live’ life” fessionals allow themselves to ignore tested
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Poverty_WC.pdf, accessed on September 10,
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2004.
Shetty, P S, M J Soars, W P James (1994): ‘Body
excess calories get deposited as fat and are
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harmful. For a given height, therefore,
Imrana_qadeer@yahoo.co.in
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there is a given weight and, once stunted, a
Journal of Clinical Nutrition, November 48,
person with the right weight for his age can [This work is part of the ongoing European
Suppl:S 28-37.
become obese. It is this logic that is being Commission project, ‘Monitoring Health Policy Soares, M J, L S Piers, P S Shetty, S Robinson,
A A Jackson, J C Waterlow (1991): ‘Basal
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spurts for Indian adolescents is equally Dyson, Tim andHanchate, Amresh (2000): ‘ India’s
Sukhatme, P V (1972): ‘India and the Protein
unsubstantiated as it is well known that
Demographic and Food Prospects: State Level
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growth spurts peak at around 14 years and
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Swaminathan, Madhura (2000): ‘Weakening
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Welfare: The Public Distribution of Food in
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(1997): ‘Basal Metabolic of Weight - Stable
India’, Left Word, New Delhi, pp 101-08.
adolescents of the third world shows that
Chronically Undernourished Men and Women: Venkata, Ramana, Y, M V L Kumari Surya, S Rao
Lack
of
Metabolic
Adaptation
and
Ethnic
despite high levels of stunting and under
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growth spurt after dietary correction Gopalan, C (1987): ‘Measurement of Under
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Basic
Issues
and
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Approaches,
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The unscientific haste with which the
New Delhi, pp 15-16.
Consultation’, Geneva, pp 34-52.
lowering of RDAs is being pushed, points - (1992): ‘Food Production and Consumption
-www.fantaproject.org/downloads/pdfs/
Trends
’
in
C
Gopalan,
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in
Deve
to some interesting connections. In a milieu
adolescents.pdf, accessed on October 7,2004.
lopment Transition in South East Asia,
offree markets where food plazas andjunk
364
Economic and Political Weekly
January 29, 2005
TUF
N
U
T
R I T
N
The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy
FOOD POLICY AND APPLIED NUTRITION PROGRAM
DISCUSSION PAPER NO. 1
Challenges to the Monitoring and Evaluation of Large Nutrition
Programs in Developing Countries: Examples from Bangladesh
Rezaul Karim, Jennifer Coates, Gwenola Desplats, Iqbal Kabir,
Yeakub Patwari, Stephanie Ortolano, Thomas Schaetzel, Lisa Troy,
Beatrice L. Rogers, Robert F Houser, F. James Levinson
February 2002
Corresponding Author: James,Levinson(d)tufts.edu
Discussion papers provide a means for researchers, students and professionals to share
thoughts and findings on a wide range of topics relating to food, hunger, agriculture and
nutrition. They contain preliminary material and are circulated prior to a formal peer
review in order to stimulate discussion and critical comment. Some working papers will
eventually be published and their content may be revised based on feedback received.
The views presented in these papers do not represent official views of the School. The
discussion paper series is available on line at http://nutrition.tufts.edu/publications/fpan.
Please submit drafts for consideration as FPAN Discussion Papers to
Patrick.Webb@Tufts.edu.
1
Introduction
Most large-scale nutrition surveys carried out in developing countries have been
conducted to compile or update national or regional data that are independent of project
activities. At the same time, a growing number of large scale projects are developing
monitoring and evaluation systems that also build on periodic baseline and evaluation
surveys to assess whether project objectives are being met, and whether improvements in
nutritional status observed are indeed attributable to the interventions. Donors and
governments are demanding increasingly rigorous evaluations to assess whether their
operational investments are cost-effective. Such information also guides the direction of
future activities.
One intervention, the Bangladesh Integrated Nutrition Project (BINP), has been using
baseline and evaluative surveys since 1996 to assess its performance and to inform
decision making. The project is widely acknowledged to be one of the most impressive
large-scale, community-based nutrition programs in the world. At the same time, a
careful analysis of its own survey data has revealed problems in collecting, analyzing and
interpreting data—difficulties which are not unique to Bangladesh.
This discussion paper uses the BINP survey experience to explore three data-related
issues: a) the role and validation of control groups; b) problems in interpreting
anthropometric data (specifically, weight-for-height); and c) challenges in the collection
of consistently comparable baseline and evaluation data. It is hoped that this discussion
might inform the design and interpretation of future baseline and evaluative surveys.
Bangladesh Integrated Nutrition Project
The Bangladesh Integrated Nutrition Project, presently covering roughly 15 percent of
the population of rural Bangladesh, is supported by the World Bank and other donors and
is implemented by the Ministry of Health and Family Welfare in partnership with
indigenous and international NGOs. Although community-based nutrition is not the only
BINP activity, it is the most important.
The community-based nutrition component of the project includes growth monitoring of
children under the age of two, counseling for the families of these children, and daily
onsite food supplementation for children who are severely malnourished (below 60
percent of weight-for-age standards), or found to be faltering in their growth. Pregnant
women are also weighed monthly and receive counseling and iron/folate supplements.
Women with BMIs less than 18.5 receive daily food supplements. In addition, all women
receive post-partum vitamin A supplements. Income generation in the form of
homestead garden and poultry activities and participation in women’s’ groups
(responsible for production of the food supplement and other tasks) is targeted to
households designated as low income on the basis of household registration data.
2
The BINP baseline and midterm cross-sectional surveys relate to the first phase of the
project, which was carried out in an initial six thanas1 by the government in collaboration
with the indigenous NGO, BRAG2. The surveys were carried out in each of these six first
phase thanas^ and in two non-project control thanas4. The control thanas were selected
based on comparability with project thanas according to key indicators3. The baseline
and mid-term surveys were carried out by two different contractors and begun in
September/October 1995 and October 1998 respectively.
Both surveys followed a two-stage cluster sampling procedure. In the baseline survey, the
first sampling stage selected 10 sub-geographic areas from each of the eight thanas. The
second stage randomly selected one cluster in each of the 80 selected areas to total 80
clusters. In each cluster, all of the 40-50 households were interviewed for the household
part of the survey, while mothers with children under the age of 5 years were interviewed
in the second part of the survey.6 A total of 3,411 households and 1,647 mothers were
interviewed (Mitra and Associates, 1996).
In the midterm evaluation survey, the primary sampling unit (PSU) in project thanas was
the coverage area of the Community Nutrition Center (the project working area),
covering 1,000 to 1,500 people. A comparable population was selected in control thanas.
The first stage employed a sampling procedure to select 120 PSUs in the project areas
and 40 PSUs in the control areas. In the second stage, 40 households having at least one
child under-two years of age were randomly selected from each PSU. In all, 6,476
households were surveyed (INFS, 1999). The quality of data collection was ensured by:
1) intensive training of enumerators and 2) individual supervision of the data collection
with performance checks. The midterm survey piloted and field-tested the questionnaire
to ensure its accuracy, reliability, and appropriateness.
Initial analysis and reports by the contractors in each of these surveys were necessarily
rushed to accommodate project reporting timetables. The data on children were therefore
reanalyzed at Tufts to permit a more deliberate and systematic examination. In the Tufts
analysis, anthropometric indices were calculated using EpiNut program in EpiInfo
version 6.0. Nutrition indices were calculated and reported using both Z-scores and
percentage of median of the NCHS anthropometric reference (NCHS, 1977). The
analysis included specifically weight-for-age (the measure used in ongoing BINP
1 There are 496 rural thanas or sub-district geographic-political units in Bangladesh, with an average
population of 225,000 persons. Although the term employed by the government at this writing is “upazilla”
we will retain the term “thana” used at the time of these surveys.
2 Formerly the Bangladesh Rural Advancement Committee, this NGO now uses only its previous acronym.
3 Banaripara in Barisal division, Faridpur Sadar in Dhaka division, Gabtali thana in Rajshahi division,
Mahammadpur thana in Khulna division, Rajnagar thana in Sylhet division, and Sharasti thana in
Chittagong division.
4 Haziganj thana in Chittagong division and Sonatal than in Rajshahi division.
$ Literacy rates, availability of drinking water, type of housing, availability of electricity, land ownership,
and population density.
6 Although the project itself focussed on children under the age of two years, the baseline survey,
inexplicably, surveyed children up to the age of five. Data used in this analysis utilized only the under two
population.
3
monitoring utilizing project-generated growth monitoring data), weight-for-height, and
height-for-age (used as indicators of wasting and stunting respectively).
Issues and Challenges
Three major issues arise from analysis of the BINP data:
1. Control groups, their selection, and the extent to which changes in control group
populations actually reflect secular change;
2. Anthropometric measures and their interpretation;
3. Baseline data necessary to assess progress in meeting project objectives.
Each of these is discussed below.
1. Control Groups
Normative evaluative survey methodology requires that pre-post data on a control
population be utilized to approximate the secular change, which would have taken place
in the absence of the project, and then to subtract this change from that observed in
project areas. Experience from the Bangladesh project and from comparable projects
elsewhere indicates, however, the difficulty of employing this procedure and the
difficulty of interpreting results when this is done. Let us begin with the BINP data.
Table 1 summarizes the change in the prevalence of different degrees of malnutrition, as
measured by three different indicators of nutritional status, between baseline and midterm
in both project and control areas. As seen in the case of two of the child anthropometric
indicators, weight for age median and height for age z-score, major improvements were
found in the control population; in only one instance — severe cases of malnutrition as
assessed by weight for age median — did malnutrition prevalence decrease significantly
more in project areas than in controls (p=.008). An examination of other survey and
surveillance data within Bangladesh indicates, however, that the control group
improvements do not reflect secular change in the country as a whole. Data from the
4
Table 1. Nutritional Status of Children (< 2 Years) in BINP Baseline and Midterm
Evaluation Surveys
Project
Midterm
Baseline
N = 4,696
N = 501
N (percent)
N (percent)
Underweight (WAM)*
Normal
Mild
Moderate
Severe
Wasting (WHZ) ±
Normal
Mild
Moderate
Severe
Stunting (HAZ) **
Normal
Mild
Moderate
Severe
Control
Midterm
Baseline
N= 1,582
N = 202
N (percent)
N (percent)
91 (18.2)
196(39.1)
166 (33.1)
48 (9.6)
1,187 (25.3)
1,914 (40.8)
1,489 (31.7)
106 (2.3)
34 (16.8)
82 (40.6)
69 (34.2)
17 (8.4)
355 (22.4)
651 (41.2)
504 (31.9)
72 (4.6)
264 (52.7)
127 (25.3)
74 (14.8)
36 (7.2)
2,553 (54.4)
1,542 (32.8)
513 (10.9)
88 (1.9)
116(57.4)
51 (25.2)
26 (12.9)
9 (4.5)
825 (52.1)
517 (32.7)
212 (13.4)
28 (1.8)
39 (19.3)
51 (25.2)
58 (28.7)
54(26.7)
485 (30.7)
454 (28.7)
389 (24.6)
254(16.1)
123 (24.6)
97 (19.4)
128 (25.5)
153 (30.5)
1A55 (31.0)
1,289 (27.4)
1,130(24.1)
822 (17.5)
Chi2 test was used to test for significant differences between baseline and mid-term values for the project area and the
control area.
♦ PO.OOl for project areas and p<0.01 for control areas
± P<0.01 for control areas
** PO.OOl for project and control areas
5
Bangladesh Bureau of Statistics and the Bangladesh Nutritional Surveillance Project from
the 1990s indicate an average reduction in underweight prevalence of 0.5 percentage
points per year, while the reduction in underweight prevalence in the BINP control group
during the three year period was over four times that (2.1 percent per year), a reduction of
only 0.8 percentage points per year less than the project group (HKI, 1999).
Similarly, the reduction in stunting (height for age) in Bangladesh has been estimated at
1.88 and 1.73 percentage points per year by Child Nutrition Surveys of Bangladesh and
by the Bangladesh Nutritional Surveillance Project, while stunting reduction in BINP
control groups averaged 4.9 percentage points per year, or 2.7 times higher.
A similar phenomenon was observed even more strikingly in the Community Nutrition
Project in Senegal, a project with a similar set of interventions carried out between 1995
and 2000 where, in urban areas, malnutrition rates fell among participants 12-17 months
of age from 33.2 percent to 29.3 percent, but fell even more among controls of the same
age, from 32.3 percent to 25.9 percent (World Bank, 2000). Although it is, of course,
possible that these figures reflect reality, it is unlikely that in a project, considered
successful by both service providers and beneficiaries, control group nutritional status
would improve by more than that of project participants. Most likely, some confounding
factor is at work with the control group population. (No comparable national data for
these years exist for Senegal, making it difficult, to track secular trends.)
In the case of BINP geographic proximity of the control areas to project areas has been
suggested as a partial explanation for the improvement (beyond secular trend) found in
control areas. The hypothesis is that while control children did not receive food
supplements, they may have benefited from some of the counseling taking place in the
project areas (i.e., positive leakage effects). Data from the mid-term evaluation, however,
indicate significantly better knowledge and practices in project as opposed to control
areas, suggesting that movement of counseling messages across thana boundaries was
limited at best. The evaluation found, in project areas, better water and sanitation
practices, better understanding of exclusive breastfeeding, better understanding of the
value of iodized salt, high participation rates in the vitamin A capsule distribution
program, and, in turn, lower reported rates of young child morbidity, than in control
areas.
A second explanation given to explain the larger than expected improvements in control
group children has to do with the proliferation of non-governmental organizations
(NGOs) in Bangladesh, reducing the likelihood of finding “untouched” non-BINP areas
that can be used as pure controls. This suggests, at a minimum, that careful information
should be collected in future evaluations on non-BINP interventions taking place in both
the control and project areas.
If these explanations are at best partial, however, and if these improvements in control
children are not significantly reflective of secular change, what other factors are likely to
explain this phenomenon? Do we attribute them to an exaggerated testing or study effect
with the idea that such an effect may be greater in the measurement of child nutrition?
6
Does the time/attention/sensitization associated with the one time gathering and weighing
of young children in control areas constitute such a powerful intervention? If yes, what
sustains the gains through to the next assessment?
One way of better understanding this problem may be to identify several reasonable wellmatched control areas (well-matched to each other and to the project sites) and to collect
baseline data on only one of these controls but gather “post” data on each of them, thus
assessing the extent to which this testing or study effect is operative. (The “post only”
data for a control group could also serve as baseline data for a new area about to enter the
project.)
In the absence of such an assessment, however, the question posed is whether, in cases
where changes in control group status do not represent secular change, they should be
used to inform the real impact of a project?
Using such controls would lead to an underestimation of the effect of the project. If the
project areas show greater improvement in variables compared to control areas,
researchers can argue that an even greater difference would have been observed in the
absence of confounders (for example, Hawthorne effect of being measured, spillover
effects of behavior change communication (BCC), or non-project organizations working
in control areas). This reasoning is commonly used in epidemiological studies examining
associations between exposures and disease outcomes. Findings of no difference
between project and control areas, or a greater improvement in control areas, makes it
difficult to draw conclusions about the success or failure of the project, largely because it
is difficult to measure, and in turn, statistically adjust for these external influences (for
example, the extent to which Hawthorne effect, spillover effects of BCC or non-project
organizations working in the control areas influence the variables of interest).
The problems noted above are hardly the only problems faced in trying to utilize control
groups in project evaluations. Another problem is that of control group comparability. In
efforts to launch a project quickly, adequate attention often is not given to the
comparability of control and project populations. Although in BINP several socio
demographic variables were used to select comparable control groups, the results
presented here indicate problems that complicate project evaluation. Most notable are the
religious differences noted in Table 2 where the minority Hindu population was more
than twice as large in the control group at baseline (Chi2, p<0.001).
BINP experienced a similar problem in its “newly married couples” study where a
comparison thana had a significantly higher proportion of households with male members
sending remittances from elsewhere in Bangladesh and from the Middle East. Similar
thana-wide experiments in the country’s new National Nutrition Program will seek,
wherever possible, to divide particular homogeneous thanas into two halves. One half
will serve as a control population, and, where appropriate, a strip of the thana dividing the
two halves will be excluded to reduce problems of project related communications from
the project to the control area.
7
Table 2.
Demographic Characteristics: Baseline and Midterm Evaluations of BINP
Baseline
Project
Population
Religion (percent) *
Muslim
Hindu
Christian
For children < 2 years of age
Age (mean ± SD in months)
Gender (percent)
Male
Female
Control
Midterm
Project
Control
501
202
5,197
1,784
91.4
8.6
0.0
79.2
20.8
0.0
92.0
7.8
0.2
89.9
10.1
0.0
12.4 ±6.7
12.5 ±6.9
11.5 ±6.4
11.3 ±6.5
49.3
51.0
50.7
49.0
51.3
48.7
51.3
48.7
*For project versus control at baseline, Chi2, p< 0.001
8
In large-scale nutrition projects in neighboring India, control groups have not been
utilized in project evaluations for other reasons. In the Tamil Nadu Integrated Nutrition
Project that operated in South India from 1980 to the late 1990’s, control groups were
originally identified, but then, for ethical and political reasons, were incorporated into the
project before a major evaluation had taken place. In the Integrated Child Nutrition
Service (ICDS) project, the very scale of the project made control group selection
difficult at that point in the project’s development (the mid 1990s) when the issue was
considered. Given that the project covered, at that time, over 75 percent of the
development blocks in the country, it was considered unlikely that control areas from the
remaining development blocks could be identified which would not be subject to
suspicions of bias simply because they had not chosen or been chosen to participate in the
project earlier.
2. Anthropometric Measures and Their Interpretation
Independent t-tests of equality of means for each anthropometric indicator suggest that, in
project areas, the average weight for age median (WAM), and height for age z- score,
(HAZ), of under-two children increased significantly between the baseline and midterm
(p<.001). Analysis of WHZ, however, showed no significant improvement (see Table 1
and Figure 1).
In control areas, average WAM and HAZ also improved significantly between baseline
and midterm (p<.01 and p<.001 respectively). Yet WHZ-scores were significantly lower
at midterm than at baseline, (p<.01). This is consistent with trends in national data
indicating that, between the mid-1980s and mid-1990s, Bangladesh experienced a 25
percent decrease in stunting and a 20 percent decrease in underweight prevalence but a 12
percent increase in wasting (see Table 3).
Does this phenomenon indicate a shortcoming in the project? An examination of the
BINP data indicates the possibility that the lower weight for height ratio emanates from
the fact that the rate of decline in stunting (height for age) exceeds the rate of decline in
underweight (weight for age.) In other words, both heights and weights for age are
improving, but the former is improving more rapidly than the latter. The question at hand
then, and perhaps worthy of investigation, is whether this statistical decrease in the
weight for height ratio has functional consequences for these children who, on average
are getting taller, are weighing more, but are slightly thinner.
3. Baseline Data Necessary to Assess Progress in Meeting Project Objectives
Often, large-scale projects set numerous objectives but fail to collect baseline data on
indicators for each of them to permit subsequent evaluation. Those indicators most often
missing, as in BINP, relate to biochemical measurements associated with micronutrient
9
Figure X: BINP Weight-for-Height Evaluation Data
WHZ: Project vs. Control
100% -I
80%
60%
® Normal
40% -
H Mild
20% -
□ Moderate
□ Severe
—
0%
BL
Project
MT
BL
Control
MT
10
Table 3. National Trends in Child Anthropometry
Stunting
1985-86
(percent)
68.7
1995-96
(percent)
51.4
Wasting
14.8
16.6
Underweight
71.5
57.4
Source: (Dhaka University, 1986, 1996)
11
deficiencies and to pregnancy outcomes. In the case of biochemical measurements (e.g.
blood samples to assess hemoglobin and serum retinol, urine samples to test urinary
iodine, and, in some cases stool samples to test for parasitic infection) problems are
technical and budgetary. Additionally, individuals are frequently reluctant to submit to
invasive procedures.
In the case of pregnancy indicators, a problem is the length of time necessary to collect
pregnancy weight gain or birthweight data. Perhaps for the first time in a project of this
size, BINP assumed the challenge of collecting birthweight data in its mid-term
evaluation survey - despite the absence of such data at baseline. Like pregnancy weight
gain data, such data cannot be collected in the few days a survey team normally allocates
to a given area. In the case of the BINP mid-term evaluation, teams were posted at thana
headquarters and were informed, through community and NGO networks, when a
delivery had taken place so that weights could be taken. To be fully effective, of course,
such data need to be linked by household number to other data that have been collected
on these households.
An additional challenge posed for the baseline survey of the new National Nutrition
Program is how to collect baseline pregnancy weight gain data (at least two successive
monthly pregnancy weighings per individual) from communities, prior to the
organization and initiation of community-based activities by a community nutrition
promoter.
Complicating Factors
Experience with BINP and other project based surveys indicates that addressing these
major issues may be complicated by multiple contractors, by inconsistencies between
measures used in monitoring and evaluation systems, and by inadequate data cleaning.
These complicating factors are reviewed briefly below.
a. Multiple contractors - It is often the case with projects financed by large donor
organizations, that requests for proposals are issued and proposals considered for one
evaluative survey at a time. This has to do both with donor agency budget cycles and
with a reluctance, for quality control purposes, to issue single long term contracts for
such purposes. The unfortunate result is that different contractors are often selected
for baseline and subsequent surveys, usually leading to serious problems in
subsequent analysis. This was the case in BINP where, despite considerable vigilance
by project management, differences in survey methodologies, and questionnaire
framing resulted in an inability to compare data from the two surveys. This was
particularly costly on data relating to socio-economic status and to the age of
introduction of complementary food.
Based on this experience, the follow-on National Nutrition Program will be hiring a
single contractor with ongoing responsibility for all such surveys. Such a single
ongoing contract has the additional advantage of permitting familiarity with a
12
project’s ongoing monitoring system assessing project implementation and the
delivery of services. Quality control measures often can be incorporated into such
contracts to satisfy donor requirements.
b. Consistency of monitoring and evaluation indicators - From the outset of the
project, BINP’s monitoring system utilized WAM and the Gomez classification in its
management information system7. Accordingly stakeholders in the project became
familiar with the WAM definitions and emerging numbers. Despite the advantages of
z-scores, particularly in project evaluation, z- score percentage figures for severe and
moderate malnutrition are inevitably much higher than WAM percentages as well as
confusing. (Utilizing z-scores and defining severe malnutrition as <-3SD, would be
roughly equivalent to 67 percent of WAM, as opposed to the WAM definition of 60
percent.) As in the case of switches to the metric system, would there be value in
using z- scores and standard deviations for all analysis in the new National Nutrition
Program? It is, in any case, essential that there be consistency within a project in the
indicators used for ongoing monitoring and for evaluation purposes.
c. Data cleaning - Given major time pressures on baseline and evaluative surveys (the
former frequently is necessary before project activities can be initiated), data cleaning
proceedings are sometimes shortchanged. This was the case in BINP. The result was
an overestimate of severe malnutrition at baseline of 30.2 and 35.7 percent in project
and control groups, respectively (see Table 4).
Although the pressure of time constraints is understandable, the resulting exaggerated
estimates were, indeed, the ones utilized for decision-making in the early stages of the
project and for subsequent comparisons with mid-term evaluation data. Some data entry
programs, commonly used by nutrition projects, can hold a limited number of data points,
thus requiring more than one data set for all variables from a survey. When this
happens, it is paramount to clearly label a unique identifier, either as a single variable or
as a series of variables that will allow these data sets to be linked for analyses. Equally
important is to keep a written description of this variable or set of variables for future use
or when sharing datasets with others. Lack of a written description may lead to loss of
valuable data.
Another common problem found in maintenance of project data files, and related to data
cleaning, is lack of a data dictionary, a document providing a clear description and exact
location in the data files of each variable. A data dictionary can also present acceptable
ranges for each variable. Any observation outside this range warrants further
examination by cross-tabulation with other variables, by returning to the original
questionnaire, by extrapolation of an acceptable variable, or, when a reasonable
adjustment cannot be made, eliminating the data point from the set. In cases where a
considerable number of observations lie outside of an acceptable range for a given
variable, data collection methods should be reassessed.
7 Management information systems are often computer based systems located at project headquarters.
They serve as a data base for project analyses and, in turn, are used to inform management actions to
improve the efficiency of project activities.
13
Table 4: Comparison of Tufts Analysis with Originally Reported Baseline Data
Initial Analysis
Project
Control
Underweight (WAM)
Normal
Mild
Moderate
Severe
Tufts Analysis
Project
Control
(percent)
(percent)
(percent)
(percent)
20.3
35.6
31.6
12.5
17.5
39.8
31.3
11.4
18.2
39.1
33.1
9.6
16.8
40.6
34.2
8.4
14
At a minimum, before releasing results, data should be cleaned by checking ranges and
cross checking for consistency between variables by means of cross-tabulations.
Conclusions
The analysis of data from the Bangladesh Integrated Nutrition Project has uncovered a
number of challenges which need to be faced as projects of similar magnitude are
launched in developing countries. In some cases solutions are readily apparent. In others
further assessment is necessary. This appears to be the case where researchers need to
control for child growth (when this exceeds secular trends); where weight-for-height
measurements can be confounded by more rapid changes in other anthropometric indices,
as in Bangladesh; and where consistency needs to be established in the standards used for
monitoring and evaluation.
15
References
Beaton G.H (1990). “Design of Nutrition Monitoring and Surveillance Systems:
Questions to Be Answered,” Journal of the Canadian Dietetic Association. 51 (4):
472-4.
Dhaka University (1986, 1996). “Child Nutrition Surveys of Bangladesh.” Mimeo.
Gorstein J, Sullivan K, Yip R, de Onis M, Trowbridge F, Fajans P, and Clugston G
(1994). “Issues in the Assessment of Nutritional Status Using Anthropometry,”
Bulletin ofthe World Health Organization. 72 (2): 273-83.
Helen Keller International and Institute of Public Health Nutrition (1999). “The
Nutritional Surveillance Project in Bangladesh in 1999.” Mimeo.
Institute of Nutrition and Food Science, Dhaka University (1999) “BINP Midterm
Evaluation Report — Final Report”. Dhaka, Bangladesh. Mimeo.
Mitra and Associates. (1996) “The Baseline Survey for Bangladesh Integrated Nutrition
Project, Final Report” Dhaka, Bangladesh. Mimeo.
National Center for Health Statistics (1977) “NCHS Growth Curves for Children Birth18 years”. United States: Vital Health Statistics. 165, 11-74.
Sahn DE, Lockwood R, and Scrimshaw N (1984). “Methods for the Evaluation of the
Impact of Food and Nutrition Programmes: Report of a Workshop on the
Evaluation of Food and Nutrition Programmes, September 1981.” Tokyo: United
Nations University.
UNICEF (1999). The State of the World's Children. New York: Oxford University Press.
World Bank (2000). “Community Nutrition Project, Senegal: Project Completion
Report.” Washington DC: Africa Regional Office.
Working Paper 27
March 2000
Online Version
November 2002
Ines Reinhard
K.B.S. Wijayaratne
The Use of Stunting and Wasting as
Indicators for Food Insecurity and Poverty
PIMU Open Forum
INTEGRATED FOOD SECURITY PROGRAMMME
TRINCOMALEE
42 Huskison Street
31000 Trincomalee
Sri Lanka
phone 026-22023
22687
fax 026-22296
e-mail ifspsl@sri.lanka.net
internet www.ifsp-srilanka.org
1
Introduction
1.1
Outline of the Paper
Poverty alleviation has become a target of many development programmes world-wide. Food
security, an important element of poverty alleviation, is a priority focus of German co-operation with
developing countries.
Definitions of poverty as well as appropriate indicators to measure the dimensions of poverty have
been widely discussed and the concept of food and nutrition security (FNS) has evolved
dramatically during the last decades in theory and practice.
This paper will provide some basic information about the current understanding on food security,
nutrition security and poverty. A brief overview is given on existing definitions and the evolution of
food and nutrition security concerns is described.
The concepts of food security, nutrition security and poverty will be presented, showing that
malnutrition arises from various nutritional, biological, social and economic deprivations, and thus
implies more than inadequate energy and nutrient intake. Malnutrition is the outcome of various
factors in a broad development context.
Nutritional well-being is not only a basic human right, but in addition an important input for
development through the creation of human capital with sufficient capacities to provide factors
such as labour, finance, education and care. Consequently, nutritional status, as an outcome of all
these factors, is highly recommended to be used as an indicator for poverty and sustainable
development.
The different indicators for chronic and acute malnutrition of children under five (stunting, wasting,
and underweight) as well as adults (BMI) are explained and the advantages and disadvantages for
the application, use and interpretation of the various indicators discussed.
A brief overview on the world nutrition situation will be given and a literature review will present the
available data on nutritional status in Sri Lanka.
The paper intends to initiate a discussion on the advantages and disadvantages of the various
indicators presented, their application for different prospects, their reliability, use for monitoring
purposes, practicability etc. and furthermore on the issue whether stunting and/or wasting could be
recommended as indicators for poverty.
1.2
The Evolution of Food and Nutrition Security Concerns
The idea of food as a human right might be as old as human history, since food and nutrition
security is a primary concern in any society. In 1948 the United Nations incorporated for the first
time the freedom from hunger and malnutrition into the Universal Declaration on Human Rights,
Art. 25:
In addition the “International Covenant on Economics, Social and Cultural Rights44 (Art. 11) as well
as the “Convention of the Rights of the Child44 (Article 24) included aspects of food and nutrition
security. Amongst those were: adequate food, physical and mental health, medical services,
disease treatment, hygiene, sanitation, sustainable environment and care.
Nevertheless, although accepted nation-wide, the right to adequate food and to be free from
hunger has not yet been given sufficient attention in the context of operational development
concepts.
2
Global FNS has a more than 50 years history and a sequence of definitions and paradigms.
In the 1950s food insecurity was faced with bilateral food aid only. After the historic Hot Spring
Conference of Food and Agriculture in 1943, in which the concept of a “secure, adequate, and
suitable supply of food for everyone’’ was accepted internationally, bilateral agencies of donor
countries such as the USA or Canada, which were created in the 1950s, started to dispose of their
agriculural surplus commodities overseas.
In the 1960s it was acknowledged that food aid might be a barrier to development for selfsufficiency. Assistance mainly aimed on economic development, but focussed on food security on
a national level, or even with the global goal to reach “world food security” (FAO 1983). The idea
was labelled “trickle-down-effect“, thus all members of society should automatically profit from the
global economic growth.
The concept of food for development was introduced and institutionalized. The creation of the
World Food Program (WFP) in 1963 is one prominent example.
As a result of massive food shortages in the early 1970s, the so called “World Food Crisis ,
marked a dramatic turning point from the past area of food abundancy of donor countries to highly
unstable food supplies and prices. As a result, food security insurance schemes, which assured
international access to physical food supplies, were developed in the 1970s. Improved food
security assurance was to be achieved through better coordination between donor organizations
and agencies and food availability surveillance in recipient countries. Policies aimed at increasing
agricultural production (food availability), but did not face the problem of unequal distribution.
National self-sufficiency did not translate into a sufficient food supply on the regional level.
At the first World Food Conference in 1974 in the “Universal Declaration on the Eradication of
Hunger and Malnutrition'' it was adopted that “Every man, women and child has the inalienable
right to be free from hunger and malnutrition...” (cited by FAO 1996, p.26).
Nevertheless, although world-wide per capita food supply for direct human consumption increased,
the official number of people suffering from hunger decreased only slightly from 898 million in 1979
to 809 million in 1991.
In the 1980s it was recognized that food emergencies and even famines were not caused as much
by catastrophic shortfalls in food production as by sharp declines in the purchasing power of
specific social groups. Therefore, food security was broadened to include both physical and
economic access to food supply. The orientation shifted from the global and national level to the
household and individual level. In this decade, poverty alleviation and the role of women in
development was promoted.
In the 1990s, detailed plans were defined to eradicate or at least reduce hunger and malnutrition
drastically. UNICEF (1990) presented a new development concept, focusing on the individual and
household level and including aspects of social services, particularly education and health. The
first International Conference on Nutrition, held in Rome in 1992, was based on this concept.
Nutrition began to be conceptualised in its relation to a broad economic, social and cultural
development context, including individual living conditions, well-being and the freedom from hunger
and disease (FAO/WHO 1992)
During the preparation of World Food Summit, which was held in Rome in November 1996, the
human right to adequate food and nutrition was internationally reafirmed and committed national
governments to a more proactive role. Finally, reduced international public support by donor
agencies reduced food aid to crisis management and prevention.
2
Food Security, Nutrition Security and Poverty
Just as malnutrition and poverty have over the years been subject of often intense conceptual
debate, so by extension has the nature of their relationship. Over time spans poverty contributes to
malnutrition and malnutrition contributes to poverty.
In the following, the concepts of food security, nutrition security and poverty will be presented,
showing that malnutrition arises from various nutritional, biological, social and economic
3
deprivations, and thus implies more than inadequate energy and nutrient intake. Malnutrition is the
outcome of various factors in a broad development context.
2.1
Definitions
2.1.1
Food and Nutrition Security
In several documents and at several occasions the difference between food security and nutrition
security was discussed.
The definition of food and nutrition security has evolved considerably over time. The starting point
of ‘food security1 was food availability to balance unequal food distribution regionally and
nationally. However, it was rapidly accepted that availability, though a necessary element, is not
sufficient for food security, because food may be physically existent but inaccessible for those most
in need. Therefore commonly food security is considering the dimensions access and availability of
food on global, national, regional or household level.
Nutrition security goes beyond the concept of access and availability and includes aspects of use
and utilisation of food in quality and quantity as well as intra-household food distribution. Anyway,
the term “nutrition security” is hardly found in any documents and therefore rarely used, whereas
food security is commonly applied, but not all users imply the seam meaning by using this term.
Among the various existing definitions for food security, the following definition suggested by the
WORLD BANK (1986) is most commonly used and internationally accepted: "access by all peopje
at all times to the food needed for an active and healthy life" (WORLD BANK 1986, p. 1).
This definition is highly generalised through the term “food needed11 .The FAO/WHO (1992a) came
up with a more specific description, which should be added to the above mentioned World Bank
definition of food security.
. r t
, .
. ■ . M
“Food should be sufficient in terms of energy, but also in protein, fat and micronutrients. It should
be adequate with regard to quantity, quality, safety and it should be culturally accepted. .
At the household level, food security refers to the ability of the household to secure, either from its
own production or through purchases, adequate food for meeting the dietary needs of its members.
Nevertheless, a household might be food secure, but some household members may still suffer
from malnutrition. Consequently, household food security is only a precondition, but not sufficient
for an adequate nutritional status of the individual.
Considering the combination of the World Bank and FAO definition of food security as the most
commonly used definition, this goes beyond food availability and access. Aspects such on the use
and utilisation of food are also incorporated in this definition, such as diet quality and food safety,
provision of health services as well as cultural aspects and intra household food distribution, thus
dimensions of nutrition security
.
It is rather depending on what is meant by food security when applying this term. Various
development projects highlight their activities to improve food insecurity, but many of them are
limited to aspects of food availability and access (food security in the narrow sense), but do not
include any interventions to improve the use and utilisation of food (food security according to
above mentioned definition, thus: nutrition security)
Nevertheless, it is suggested not to differentiate between food and nutrition security, but to define
food security in a broader sense as presented above, thus as more than purely availability of and
access to food.
UNICEF (1990) presented a conceptual framework for the analysis of food and nutrition security
in which malnutrition is considered the outcome of food and nutrition insecurity. Its various
determinants are grouped on different causality levels. Consequently, malnutrition is a result of
immediate, underlying, and basic causes (UNICEF 1990) (Figure 1).
4
Figure 1:
Multiple causes of malnutrition and death - the concept of food and nutrition security
| manifestation
malnutrition and death
inadequate dietary
intake
disease
insufficient household^ inadequate maternal^
and child care
\
food security
insufficient health
services and an
unhealthy environmeni
I immediate
I causes
underlying
causes
r
inadequate education
resources and control
human, economic,
organizational
—t
political and ideological superstructure
basic
causes
economic structure
_______
potential
resources
Source:
Adopted from UNICEF 1990, p.22.
5
Immediate causes of malnutrition:
Inadequate dietary intake:
includes both food availability and access to food. In
addition to that it implies the household or individual’s
desire to obtain the available food and their knowledge of
appropriate food preparation, composition and distribution
among the household members.
Disease
Underlying causes of malnutrition:
inadequate household food security
inadequate maternal and child care: provision of time, attention, and support to meet the
physical, mental, emotional and social needs. It includes
care for the child in general, such as child feeding and
protection from infection as well as care for the sick child
or other vulnerable household or community members
(e.g. elderly, disabled)
(immunisation, oral rehydration, growth monitoring,
insufficient health services:
nutrition education and advice on breastfeeding)
drinking water and sanitary facilities.
unhealthy environment:
Basic causes of malnutrition
-
Inadequate education (e.g. through insufficient knowledge to provide adequate care)
-
human, economic and organisational resources
socio-cultural, socio-political and socio-economical factors
inadequate potential resources in the individual’s area of living
Women have multiple roles in the context of food and nutrition security. They are highly
responsible for food production, procurement, preservation, storage, preparation, consumption,
and food distribution among the family members. In addition to that, they are caretakers of family
welfare and are highly involved in collecting fuel and firewood. Therefore, their labour burden is
enormous.
Women’s nutrition and health status has an important impact on child development, especially
during pregnancy and lactation. Reduced energy and nutrient intake during pregnancy is likely to
cause growth retardation in the embryo leading to low birth weight and burdening the child with a
physical disadvantage that it often cannot compensate later. Large parts of women’s income
contribute to basic family maintenance, such as child health and but in most societies women are
traditionally responsible for food crop production, whereas cash crop cultivation is dominated by
men, and in consequence income from cash crop trading is considered theirs.
Women often lack access to health care, education, land, property rights, extension services and
credit A more equal distribution of existing resources and rights between women and men, as well
as the provision of adequate education and training, could have great impact on food and nutrition
security on the household and individual level. However, attention has to be paid to women’s
conflicting demands between domestic responsibilities and their own need to maintain health and
nutrition security. Further conflicts exist between income-earning activities and care.
6
2.1.2
Poverty
Another widely applied term in the context of development goals and concepts is poverty.
According to WORLD BANK 1990, 1.1 billion people live in poverty 70 % of them in Asia, mainly in
rural areas where farming is the main occupation.
Successful poverty alleviation strategies cannot be designed, without an appropriate understanding
of poverty itself.
In the 1970’s poverty was defined in financial terms only. Accordingly weak purchasing power, or
low per capita income was conventionally widely accepted as the main indicator for poverty. As a
result of experience and world-wide discussion, the WORLD BANK (1990) included social aspects
in their definition of poverty, defining it as the inability to achieve a minimum standard of living.
In spite of this, world-wide poverty lines were still defined as monetary poverty lines, leading to a
discrepancy between definition of poverty and related indicators for monitoring purposes. The
guestion arises whether poverty can be understood as a deficiency in the standard of living, when
only monetary indicators are used to measure its deficit.
As one possible solution to this dilemma, the concept of “basic needs" was suggested. Basic
needs include food, health, primary education, favourable environmental conditions, and a social
and cultural life, which all are reguired in sufficient quality and quantity (GROSS, 1997). A broader
definition of “ human poverty’’ has been proposed wherein poverty is seen primarily as relating to
peoples capabilities and opportunities (UNDP, 1997)
Basic needs are achievable through adequate means, such as finance, time, skills, and social or
cultural position (MAXWELL and SMITH 1992).
CHAMBERS (1983; 1991) emphasises in that context the necessity to listen to the poor people’s
preferences related to their needs, thus include participation in social, political and economic
decisions and enable the target group to participate in all phases of development co-operation:
planning, monitoring and evaluation.
Efforts to achieve one basic need may limit the access to another, e.g. temporary food security is
often in conflict with long-term sustainability. Referring to this conflict, the concept of jivelihood
security was implemented. Similar to the concept of basic needs, it also considers the aspect that
in addition to food, people need shelter, health, care, basic education, employment and an
adequate environment, but the food insecure poor have to weigh various livelihood and food
security objectives (MAXWELL 1992).
Achieving short-term food security (e.g. through disposing of livestock, tools or land) often leads to
increased vulnerability in the future. Since locations inhabited by the food insecure poor are often
environmentally vulnerable or degraded, such as erosion-prone hillsides, intensive cultivation often
degrades this vulnerable environment. People lack the means to avoid impacts of environmental
degradation resulting in decreased productivity of those natural resources. Consequently labour
burden of routine household tasks such as clearing the fields, planting, and firewood collection
increases. Hence, food insecurity leads to productivity losses in the short and in the long run.
If poverty could be defined as:
“individuals or groups are not able to satisfy their basic needs adequately.
The achievement of a minimum standard of living that fulfils these basic needs should be the
overall goal in the process of poverty alleviation. Food security (in terms of accessibility and
availability) alone is a necessary condition for that, but not sufficient. Nevertheless, in the concept
of nutrition security, basic needs are taken into consideration, therefore, the improvement of any
single determinant among the concepts of food and nutrition security is simultaneously an
important contribution to alleviate poverty.
7
The conceptual framework of nutrition security published by UNICEF (1990) is already widely
accepted, therefore, it could lay the foundation for inter-sectoral communication with the aim of
achieving a common understanding of nutrition in its broad economic, social, and cultural
development context.
A frequently formulated goal of development programmes is to reach food security, although
applied instruments often focus on determinants of availability and access only.
Consequently, the assessment of the impact of these programmes, using indicators which refer to
determinants of nutrition security (including use and utilisation of food), frequently leads to
unsatisfactory results. It is necessary that development programmes clearly define their goals and
levels of intervention, and indicators are applied appropriately to assess impact on food and
nutrition security at respective levels of intervention.
3
Indicators
In the discussion on the identification and selection of adequate indicators numerous aspects have
to be taken into consideration, such as measurability, sensitivity, reliability, efficiency, and cost
effectiveness. Additional attention requires their ease of interpretation, level of disaggregation,
credibility, and political as well as cultural acceptability. The time gap between data assessment
and the presentation of results of analysis and recommendations is another important issue. In this
context CHAMBERS (1992) presented the principle of “optimal ignorance" (not trying to find out
more than is needed) and "appropriate imprecision" (not measuring more accurately than is
necessary for practical purposes). Therefore, qualitative data can complete (and under certain
circumstances even replace) quantitative data.
The selection of appropriate indicators, according to the aspects mentioned above, depends
mainly on the purpose of its use. Consequently the "optimal" set of indicators (if this exists) mig
be very different for targeting the vulnerable poor, for development planning and policy design or
impact monitoring. Aside from this, it depends highly on the level of assessment, i.e., whether it is
global, national, regional, community, household or individual.
3.1
Food and Nutrition Security Indicators
3.1.1
Overview
On national or regional level the most common indicator for sufficiency of food supply is
kcal/capita/day above the minimum requirement of kcal/capita/day recommended by the FAO
(1985). Access to food is commonly described in terms of income, such as annual per capita
income. Both indicators do not take into consideration the problem of spatial, political and culture
distance, which often exists between people in need, and the food producers, and lead to unequal
distribution between nations, regions, households or even individuals. Within countries with a per
capita food supply of 100 % or above, it was common that 20-30 % of the population consumed
less than 80 % of the energy requirements (WORLD BANK 1986). Even if food is available on local
or regional markets, the poor often lack adequate means or entitlements to secure their access to
it.
Considering the multi-causality of malnutrition, it is unlikely that one indicator alone can provide
sufficient information. For example, a given level of income is an insufficient indicator for. the
degree to which persons fulfil their basic needs since it is unlikely that poverty could be alleviated
through income alone, where basic needs remain poor.
The tables in Annex 1 and 2 give and overview on possible indicators to describe different
dimensions of food and nutrition security.
8
Given the diverse nature of the determinant factors of human nutritional status, and the different
levels of society in which they interact, FNS will necessarily have to involve aspects of both the
natural sciences as well as social sciences. As a result, the relevance of FNS at all socioorganizational levels and the interaction between these levels stresses the importance of an
interdisciplinary approach of FNS.
Table 1 shows examples of the most commonly used FNS indicators at different social levels.
•
•
•
the individual and the household (micro level)
the community (sub-district, district and province) representing the meso level
the nation and the global level (macro level).
Social
Level
Macro
Meso
Micro
Availabiliy
Accessability
■
■
■
Fertility rate
Food production
Population flows
■
■
■
■
■
Harvest timing
Staple food
production
■
■
■
Food storage
Consumption of
wild foods
■
■
■
Food price
Wages
Per capita food
consuption_____
Market and retail
food prices
Meal frequency
Food frequency
employment
Use and
Utilization
■ Stunting rate
■ Wasting rate
■ Low borth
weight rate
■ Latrine
coverage
■ Diarrhoea
disease
■ Wasting
■ Goiter
■ anaemia
Stability
■
■
■
■
Food price
fluctuation
Regional
gaps_______
Pre-/post
harvest food
Womens BMI
Pre-harvest
food practices
migration
National food availability depends on supply and demand. Therefore, data on the production of
different food commodities, fertility rate and the trends in internal population should be reviewed to
determine the national situation of food availability. Food prices and per oap'ta food
are indicators for national food accessibility. The rates of stunting, wasting in ch Idren and adults
and low birth weight (LBW) are FNS impact indicators that designate the extent to which food is
adequately utilized and converted into an satisfactory national nutrition situation Fluctuations in
food prices and regional gaps of food availability or accessibility are sensitive indicators for national
food and nutrition instability.
At the meso level delayed harvest time and reduced staple food production are indications of
reduced food availability. Food prices are sensitive indicators for accessibility. Types of sewage
utnizaton.'The^comparison^e^wee^preacceSVas well
as wasting (low BMI) of women indicates temporal food and nutrition insecurity.
The lack of food storage and the consumption of wild foods are indicators for reduced food
availability of the household. A reduced number of meals per day and increased rate of under or
unemployment may indicate low food accessibility. Appearances of wasting goiter or anemia
among household members are outcome indicators of reduced food utilization at micro level.
Finally, changes in pre-harvest food consumption practices and migration may be sensitive
indicators for temporal food insecurity
9
3.1.2
Indicators on Nutritional Status
Table 2 shows the most common indicators for the nutritional status of children < 5 and adults
Table 2: Most common indicators for nutritional status
Children < 5
stunting
wasting
crisis,
growth retardation poverty, low socio-economic level,
chronic diseases
weight-for-height hunger, insufficient food intake,
underweight
and
weight-for-age
MUAC
mid upper arm
circumference
hunger, food crisis, emergency
because of malnutrition of mother
Vitamin A deficiency
low birth weight
night blindness
Adults
BMI
TGR
food shortages
no differentiation between chronic
acute
body mass index
total goiter rate
Women and
children
Anaemia
low food intake, hunger
Iodine deficiency
Iron deficiency
Anthropometric Indicators (stunting, wasting, underweight, MUAC, BMI)
• stunting
=
• wasting
=
• underweight
=
height-for-age Z-scores below -2 SD of reference population
Indicator for long-term nutritional deprivation.
weight-for-height Z-scores below -2 SD of reference population
Indicator for acute malnutrition.
weight-for-age Z-scores below -2 SD of reference population
Commonly used for national and regional statistics.
The weight and height measurements of the children is usually guoted in terms of Z-score, based
on the standard deviations (SDs) above or below the median reference value for a person of a
given age (FAO/WHO 1992). Z-score using the US National Centre for Health Statistics (NCHS).
The level of median minus 2 SD is usually taken as the cut-off point or threshold, below which
malnutrition exists (FAO/WHO 1992).
Another common classification is the deviation from the median. Commonly children below 70
the median ar classified as malnourished, below 60% as severelty malnourished.
•
of
The Body-Mass-lndex (BMI) is a measure for fatness/thinness in adults.
BMI =
Weight in kg
.2
(Height in metres)'
Normally body weight is proportional to body height and the BMI of well nourished adult ranges
from 18.5 to 25. A BMI higher than 25 indicates obesity and a BMI lower than 18.5 is considered to
be an indicator of energy deficiency. Women are considered severely malnourished if the BMI is
lower than 17.
10
MUAC (low mid upper arm circumference ) describes a substantial weight loss in children,
usually due to acute starvation and/or severe disease. Due to the simplier and faster
assessment procedure than for wasting, this indicator is usefull marker for under nutrition in
emergency situations.
Low birth weight (LBW) indicates that the pregnant woman is severely malnourished (quantity
and quality of food) and/or in poor health and predicts future undernutrition for the child.
Vitamin A, iron and iodine deficiencies are the most common and most severe micronutrient
deficiencies in developing countries. Vitamin A deficiency (VAD) causes night blindness, a
simple functional indicator for this condition. Iron deficiency induces anemia, which can be
measured by the hemoglobin concentration in blood. The most visible form of iodine deficiency
is goiter. The total goiter rate (TRG) is an indicator of the duration and severity of iodine
deficiency. However, a more accurate indicator of iodine deficiency in the community is the
measurement of urinary iodine excretion (UIE) in schoolchildren.
•
•
•
Poverty Indicators
3.2
•
Poverty has conventionally been measured as he number of proportion of people in a
population who earn less than the required standard for minimum subsistence, however the
latter is defined. Poverty as such thus implicitly an economic concept with income considered
as the main determinant of the persons well being. Income poverty may be absolute with
respect to subsistence poverty and relative with respect to what others learn or own.
•
Human poverty has been proposed by UNDP (1997) in relation to people’s capabilities and
opportunities. Without opportunity people can not develop their capabilities, e.g. a child without
accessibility to health services may have little opportunity to be immunised and thus to develop
the capability to be healthy.
UNDP (1996) recommended the use of CPM (Capability Poverty Measure) to reflect a lack of
basic capabilities:
•
-
Prevalence of underweight
Proportion of unattended birth deliveries
Female illiteracy
•
The better known HDI (Human Development Index) focuses on the average level of capacities,
not the lack of capacities.
•
The HPI (Human Poverty Index) is a composition of five indices (UNDP, 1997):
-
•
The HDM (Human Deprivation Measure) is also a composite of deprivations in
-
•
•
Life expectancy
Literacy
Access to safe water
Access to health services
Child nutrition
Health
Education
Income
Self-perception of the poor is a very important aspect, therefore poverty can also be related to
disempowerment in mainly three dimensions: social, political and psychological (Friedmann,
1996)
If poverty relates to lack of capabilities, women often suffer most. The GEM (Gender
Empowerment Measure) measures female participation in political, economic an social spheres
of life and their decision making power. (UNDP, 1996)
11
Anthropometric indices in growing children have been recommended repeatedly as a suitable
key indicator for absolute poverty in communities. Firstly it is generally accepted, that women
and children are the most vulnerable groups in communities, compared to the rest of the
population. Secondly in numerous studies it has been consistently observed, that
anthropometric indicators of growing children who are repeatedly ill do not reflect the
•
attainment of their genetic potential.
Consequently, nutritional status, as an outcome of inadequate food availability, caring capacity,
basic education, health systems housing and environment conditions as underlying causes of
inadequate food intake and repeated episodes of diseases, is suggested as an alternative indicator
for the existence of absolute poverty .
Especially low-height for age amongst children < 5 years of age (stunting) is an appropriate
indicator for poverty in a population, since it reflects the dissatisfaction of basic needs during the
first years of life.
Poverty Situation in South Asia/Sri Lanka
4
Table 3 shows that according to the applied indicator the percentage of the population classified as
poor varies a lot. The percentage of Sri Lankans found to be suffering from Human Deprivation
(health, education and income) is with 31% far higher than those who only experience income
deprivation (22%).
Table 3’.Human Deprivation in South Asia
(Haq 1997, modified by the author)
Country
Population Health1 Education2 Income3 Human4 Stunting5
%
%
%
%
%
(Mil.)
Bangladesh
115
31
India
902
32
Pakistan
133
58
Sri Lanka
18
44
South Asia
1168
35
73
53
65
27
56
48
25
34
22
28
61
40
57
31
44
55
52
18
52
1 lack of access to safe drinking water and prevalence of underweight <5 children
2 adult illiteracy and out-of school children
3 World Bank 1995, based on national poverty lines
4 deprivations in health education and income (HDM)
5 prevalence of low height-for-age, Situation of Worlds Children 2000, UNICEF
(referring to most recent data between 1990-98)
5
World Nutrition and Poverty Situation
According to World Bank presently 1,3 Mio. People live in absolute poverty and 800 Mio. people
are malnourished and suffer from hunger. Inequality is worsening. Whereas in 1960 the poorest
20% had 2.3% of the world’s income, in 1997 this reduced to 1.1%.
Figure 2 shows the trend in terms of prevalence of malnutrition and the absolute number of
undernourished pre-school children in the developing countries of Africa, Asia, and Latin America.
By the year 2000 it is estimated that about one third of the children under five years of age in
developing countries will suffer from growth retardation (stunting) due to inadequate feeding and
12
poor health. Although prevalence rates in all three regions are decreasing, the absolute number of
stunted children is growing in Africa because of the high rate of population growth. However, within
these regions there are considerable differences. For example, in Eastern Africa the percentage of
stunting is increasing. Furthermore, despite improvements in Latin America, the total number of
stunted children has remained constant in Central America in the period of 1980-1990.
Figure 2: Estimated Prevalences (%) and Number (106) of
Stunted Preschool Children from 1980-2005 (ACC/SCN 2000)
(%) Children
(106) Children
60 q----------
200 -i—
50
-
40
^11
30
20
'A ,
“A ,
10
1990
Year
R Gross
•
Africa
Asia
- a - Latin
America
o 1—
o 4—
1980
180 sar- <
-M
160-_______
140-120-100-80-60-40
20
2000
1980
1990
2000
Year
2
Inadequate food and poor health are two direct factors contributing to undernutrition Major
achievements have been reached that most of the people in the world receive sufficient food to
meet their energy requirements. However, energy is not sufficient to ensure good nutrition.
Adequate micronutrients must also be available.
Among the most important micronutrients are: iron, vitamin A, and iodine. Indisputably, iron
deficiency is a major public health nutrition problem. According to the estimation of WHO about 5
billion people suffer currently from iron deficiency - about 80% of the world s population In a
recent evaluation (1999), a MI/UNICEF/Tulane University research team concluded that. neary two
third of 78 studied countries have VAD of public health importance. In a joint effort WHO UNICEF
and ICCIDD recently updated the statistics on iodine deficiency diseases (IDD). Out of 191
countries that were classified, 130 had IDD as a public health problem. In 1999, about one third of
the world’s population is at risk for IDD.
Undernutrition has severe consequences in the economic and social development of people and
countries. According to the ACC/SCN, at least 50% of diseases are caused by malnutrition and the
economic growth of the world economy is reduced by more than one percent due to malnutrition.
13
Use of Stunting, Wasting and Underweight in available Data on Sri Lanka
6
presented by Mr. K.B.S. Wijeratne, Sewa Lanka Foundation, Colombo
Points for Discussion
7
Is it necessary to differentiate between food and nutrition security?
Basic needs concept acceptable as definition of poverty?
Should poverty indicators describe exclusively long-term or also short term deprivations of
basic needs?
Why monetary indicators to measure poverty are still predominant?
How far are poverty indicators considered for development policy and development programs
(formulation, implementation and evaluation)?
Advantages and disadvantages in the application of stunting as poverty indicator
(measurability, reliability, cost-effectiveness)
•
•
•
•
•
•
8
Synthesis
Poverty is multi-dimensional. Poverty exists, where basic needs are not fulfilled, where there is little
power, little choice and where there is serious deficiencies in the amount and control of resources.
Poverty is not static, it is constantly generated by structures and processes in society.
We should talk about “human poverty as poverty means poor people. Poor people should be
recognised as key actors in development - subjects, not objects-and outsiders thus need to learn
to listen more, and to play a catalytic role.
Development programmes often define poverty alleviation and the satisfaction of basic needs as
their overall goals, whereas activities often only focus on improved access or availability of food in
a certain region - only one dimension of food security. The availability of food on household and
individual level, as well as the economical and physical access of households and individuals are
often neglected.
Poverty affects nutrition. The relationship is best understood when poverty is defined in a broader
sense, in relation to human capabilities.
Nutrition affects poverty. Malnutrition has damaging physical and mental consequences for
individuals, households and communities. It reduces a persons productivity and a childs cognitive
development. Ultimately malnutrition hinders the economic and human development of a nation.
Poverty is more than a lack of income and assets. While income poverty is important for nutrition it
is not necessarily strongly related. For human beings to fulfil the many aspects of their potential
(physical, mental, social, economic, etc.) they require basic needs, to which they have their rights.
Nutrition is more than food. Health, care and a healthy environment are equally necessary
conditions for good nutrition. Food is not merely an aggregation of calories - micronutrients are
important components which need more attention.
Present policy is often neglecting the need of a multi-sectoral approach as well as community
involvement in all phases of development co-operation: planning, implementation and monitoring of
programmes. This needs to be improved urgently to tackle the problem of food and nutrition
insecurity, thus to overcome malnutrition and poverty and to meet the populations basic needs.
14
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xz .
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