By Maheen Mirza
Dehla finally admitted her severely malnourished son in the Nutrition Rehabilitation Centre of the district hospital in Bhopal which is about 5 kms from where she lives. Dehla belongs to the Gond adivasi community and resides in the Ganga Nagar basti in Kotra in Bhopal. Not confident about her ability to speak in Hindi and generally shy in her interactions with people, she had put off admitting her son to the hospital.
As she had feared, the hospital experience was not a pleasant one. She felt harassed by the demands of the doctors, was unsure of going to the medical store and of talking to the hospital staff. She said she was made to feel responsible in some way for her child’s condition. Her husband and her elder son were of no help and never came to the hospital. Three days later, she brought her son home before the full treatment was completed. While her son continued to just about survive, her older daughter died suddenly one morning.
Dehla says that while she was at the hospital, she was told that her daughter also needed care but there was no urgency about it. She was too scared of the staff and unsure of herself to mention that her daughter, who was able to walk when she was a year old, now, at the age of three, just caught at her pallu and dragged herself along. Dehla said she could see that her daughter was getting worse, but with so many other worries, she did not give it her full attention. Everyone just assumed that the little girl would start walking again as she grew up.
There is an anganwadi (outreach health centre for the poor) in the basti not more than eight houses away. It is managed by a woman belonging to another caste. The staff there find Dehla’s unkempt hair, her inability to feed her children and her constant demand for nutritional supplements, annoying. They treat her and people like her as beggars and not as rightful beneficiaries of welfare schemes like the ICDS.
The Integrated Child Development Scheme
The Integrated Child Development Scheme (ICDS) begun in 1975 was meant to serve people like Dehla and her children. It is one of the largest social programmes in the country to address issues of malnutrition amongst children below the age of six years and of pregnant and lactating women. The programme has been running for over three decades, yet based on re-analysis of the National Family Health Survey II (1998-99) data by Standard of Living Index, 56.8% of children under the age of three (about 4.5 million), among the urban poor are underweight. In urban Madhya Pradesh the situation is much worse. Here, 72.4% of urban poor children are underweight, 60.4% are undernourished and almost nine out of 10 children are anaemic.
Initially the ICDS programme was intended only for the poor sections of the population primarily in rural areas where populations living below the poverty line (BPL) were eligible for supplementary nutrition through the anganwadi. In 2001, the Supreme Court ordered the universalisation of ICDS to cover all children below six years of age, pregnant and nursing mothers and adolescent girls. They were to receive the full range of ICDS services. In 2004, the Supreme Court, while qualifying the norms and number of anganwadis, clearly ordered that all slums were to have anganwadi centres.
Unfortunately, ICDS coverage in urban areas has been poor. According to data from the Department of Women and Child Development, Government of India, in 2005 there were only 360 urban ICDS projects catering to a little over one-third of the urban poor (90 million). In 2004, the National Advisory Council had estimated that at least 2,970 ICDS projects were required if the scheme was to achieve universal coverage. It is obvious that the number of current projects is way below the requirement.
Not only are there too few anganwadi centres in urban settlements, they are also selective in their coverage and difficult to access for the vulnerable populations that most need them.
An anganwadi centre is supposed to cover a population of 750 in the gas-affected areas of Bhopal, and 1,000 in other areas. Food to anganwadis is supplied on the basis of number of beneficiaries. It has been noted that once the mandatory number of beneficiaries is provided for, listing of children/families also ceases as there is officially no space to provide for them. It is the socially more powerful, resourceful and vocal sections of the population that get listed first while the marginalised, needy populations get left out of the coverage of these services. In most lists, including the slum lists and the BPL lists, several of the most vulnerable households like pavement-dwellers, construction workers or new migrants are never counted as they do not fall in the ‘notified’ category nor do they have the political force or other clout required to get included in these lists. Having no ‘valid’ identification document, they are refused most services and end up buying them at market rates which are much higher and often unaffordable. In Bhopal, about 30-40% of slums or slum-like settlements remain excluded from the official slum and ICDS lists.
The basti of 60 families in Gautam Nagar is located on a 2,500-3,000 square foot private plot of land. The people of this basti are Ojha Gond adivasis. Over 80% of the children are underweight with very high levels of anaemia among both women and children. Several of them suffer from sickle-cell anaemia, a condition that needs constant care, attention, and most importantly, adequate and special nutrition. Several children in the basti have succumbed to hunger. The closest anganwadi centre is located less that a kilometre away and should ideally be covering this population. However, when people from the basti go to the centre to ask for supplementary nutrition, they are turned away as they are not included in the ICDS list and therefore are not eligible for the nutrition that is provided there. Since they live on a private piece of land, the reach of government services is even more restricted.
The condition of vulnerable populations living in officially recognised bastis is not necessarily better. Here, the problem is social exclusion. Like in Dehla’s case (she lives in Ganga Nagar basti) several marginalised communities are unable to access anganwadis even when they are located a few houses away.
Batis are not homogeneous unless they are very small. Larger bastis have a mix of people from various communities residing in small pockets. Communities that are a social, cultural, economic or religious minority do not have access to anganwadis that are located in the better-off areas within the slum. In Bapu Nagar, for example, the Jharawalle, a community that makes and mends iron implements and tools, has one of the worst nutritional records in the basti. Even though they know that they are eligible to access anganwadi services, they don’t because it is located in a pocket where people of another caste reside and they do not feel confident to go and ask for nutrition supplements from there.
When a slum is relocated – usually to the remote outskirts of the city – the government social services (and other services like water and electricity) do not automatically follow. Gehu Kheda is a relocated slum. Some 2,000 households were moved here from Depo Chauraha, 15 km away. Six years later it still has no government services in the form of anganwadis , fair price shops, or primary schools.
Malnutrition and under-nutrition are mostly invisible conditions until they get really critical. So detecting the condition on time, especially among children, is crucial if any intervention is to succeed. Had Dehla’s daughter’s condition been observed and acted upon by health workers, she would not have died.
Once malnutrition has been established and treatment started, it must be closely monitored over a period of time. The underlying cause of illness and disease is often malnutrition; address the latter and you avoid the former. Currently there is no robust mechanism in urban areas to adequately detect, address and manage malnutrition. Poorly trained and uncaring health providers and the insensitive and irresponsible attitude of the administration through which all these services are delivered are squarely to blame for the appalling malnutrition among children countrywide.
The public distribution system
The public distribution system (PDS) is the other crucial and big government programme that is supposed to provide adequate food to the poor in the form of subsidised rations. The leakages in the programme at the implementation level, and also some policy glitches, have rendered it much less effective than it could be. A programme that could have been a lifeline for the poor, especially in times of frequent food crises has, for reasons we shall see below, been rendered less than effective.
A common complaint of new migrants in Bhopal is that ration cards can only be used in the place where they have been issued. “The purview of the ration card is limited to just one fair-price shop. If it has to provide us with food, it has to be universally valid. It must work in every part of the country,” says a resident from Gautam Nagar. Leave aside the country it doesn’t even work in every part of the same city. “We moved to Indra Nagar recently because my father runs a kabad (junk) shop in this area, but our ration comes from Sargam where we stayed earlier. It is difficult to lug the rations all the way here,” says Deepa, an adolescent girl.
Getting a new ration card or making any changes in the existing one is, as everyone who has tried it knows, a monumental and exhausting task. The Madhya Pradesh government website promises a ration card in 15 days. “It took me a whole year and more trips than the hair on my head to different offices to get my ration card separate from my son,” states Kochai Aji of Ganga Nagar.
An applicant must provide proof of residence but there is a large shifting population among the urban poor and they can hardly provide ‘proof of residence’ for the temporary shelters cobbled together with pieces of scrap that constitute their ‘residence’. Not surprising, then, that the ‘Report on Socio-Economic Disparities in Madhya Pradesh’ prepared by the Poverty Monitoring and Policy Support Unit of Madhya Pradesh’s State Planning Commission (based on data of the NSS 61st round) shows that there are more ration cards among the rural population than the urban: 73% of urban households had a ration card compared to 83% of rural households. Scheduled Tribe households have the lowest number of ration cards in urban areas.
Currently three kinds of ration cards are issued in Madhya Pradesh – Antodaya (yellow card), Below Poverty Line (blue) and Others (white). According to the NSS 61st round, the Antodaya card which is meant for the poorest section of the population, accounts for merely 1.3% of ration card holders while BPL card holders accounted for 25.2%.
The amount of ration allowed is the same irrespective of the number of family members. “In Rinku’s house there are three people and in Ramrati’s house there are seven. They both get the same amount of ration. The only option is to get a new card made when the son marries, so you can show a separate household,” explains Pushpa from Gautam Nagar.
People do not necessarily get all the commodities they are entitled to or in the quantities they are entitled to. It depends on how much is sent to the fair-price shops that are the officially designated sales outlets, or so they are told. Kalpana tries to recall when she last got sugar from the ration shop. “They gave us sugar at Diwali. Before that they gave it once in May just before the rains.” Antodaya card holders faced less of a problem of this nature.
People cannot choose the kind of foodgrains they want. A fixed amount of wheat and rice are disbursed. In the Gond pocket of Ganga Nagar, the people are rice eaters. The 3 kg of rice they get on the ration card lasts them for two or three days. After that, they have to buy rice from the open market at Rs 20 a kilo. None of the people encountered during the course of this research used the kerosene available on the ration card. They either used LPG or firewood for cooking, and a few used electric heaters, usually in an emergency. They sold the kerosene to roadside tea stalls at double the price. The same was the case with sugar. Wheat, too, was sold to the atta chakkis. “If we are given more rice of a little better quality, we won’t have to run mini ration shops,” chuckles Chandrakala.
Another problem is that all the rations have to be bought at one time. They cannot be bought in instalments. If there is not enough money to get the entire ration, people take a loan to get the whole amount because if only a few kilos are bought at a time, the rest stands cancelled. This also causes problems of storage. When people have no space to store the rations, they end up selling it.
People also have a problem with the fact that the ration doesn’t get carried over to the next month. This is a problem for seasonal migrants who go to their villages during the soyabean cutting or sowing season. They cannot claim their ration when they return. So for the period that they are in transit, they cannot claim the rations there or here. A way around this is to leave the card with relatives or friends and ask them to collect the ration. If the entire community moves together, though, this is not an option. In most cases they lose their rations for three to four months in a year.
The most pertinent issue with regard to nutrition is the lack of policy reinforcement. The role of both the ICDS and the PDS in curbing rising malnutrition in the country is critical, but over time, there has been a clear impetus to reduce the population that is covered by these services. The PDS has undergone several shrinking exercises. In the case of the ICDS, where the Supreme Court has stressed on universalisation, once the targets are met the provision requirements are considered to be fulfilled and any additional requirements are ignored leaving a large number of vulnerable households without services.
When hunger is an ever present spectre, these programmes have become the only lifeline that people have. But the lifeline is frail at best. The least that can be done to strengthen these interventions is to make them more community-centric and sensitive to people’s needs. Otherwise, they will continue to remain ineffective in addressing one of the most serious problems facing the country today.
By dispossessing people of their land, traditional occupations and natural resources, the government has pushed them into becoming dependent on such schemes. Leave alone equality and dignity, these schemes are unable to provide people even with basic minimum nutrition requirements, which is their primary aim. This clearly indicates the intent and commitment of the government to its poorest populations.