On the ninth of every month, pregnant women visit the primary health centre at Wazirabad, Gurugram district, Haryana, to receive antenatal care under the Pradhan Mantri Surakshit Matritva Abhiyan (Safe Motherhood Programme)

Wazirabad, Haryana: Rajvanti Devi, 38, stood in a long queue of pregnant women, braving the bright midday sun, at a primary health centre in Wazirabad block of Gurugram district, Haryana. This queue is usual on the ninth of every month, when the health centre provides services to pregnant women, particularly those identified with high-risk pregnancies, under India’s Pradhan Mantri Surakshit Matritva Abhiyan (Prime Minister’s Safe Motherhood Programme, PMSMA).

Rajvanti Devi, a mother of two girls, was pregnant for the third time, but she did not know how far into her pregnancy she was. This was her first visit to a health centre, and she was surprised when told she was six months pregnant. Further, the pregnancy was risky, the health centre staff told her, because with a haemoglobin level of 8.8 gm/dL, she was mildly anaemic–the normal range is 12-16 gm/dL for women. The risk was greater as her second child had been born through a caesarean section.

Her pregnancy will be tracked through Haryana’s high-risk pregnancy portal–the only one run by a state government, launched in November 2017–to make sure she receives all required antenatal check-ups, supplements, and referrals to specialists in community health centres or district hospitals. Under this system, Gurugram has recorded 2,750 high-risk pregnancies, and Jhajjar district 3,526.

This is part of Haryana’s ongoing efforts to reduce its maternal mortality ratio (MMR)–past efforts have made the state’s MMR the 12th lowest in the country, having cut it down from 101 deaths per 100,000 live births in 2014-16 to 98 in 2015-17, according to Sample Registration System (SRS) data. The Indian average was 122 in 2015-17.

Haryana’s health ministry has set a target to reduce its maternal mortality ratio to 70 per 100,000 births by 2030. The high-risk pregnancy portal helps register and better track high-risk pregnancy cases, to make sure the women never miss a check-up and their progress is monitored closely.

“The goal is to reduce the maternal mortality rate, infant mortality rate and stillbirth because morbidity and mortality is particularly high in high-risk pregnant cases,” said Alka Garg, deputy director for maternal health in the National Health Mission (NHM), Haryana.

Haryana’s experience with its portal would be instructive for all Indian states, which together detected half a million women with high-risk pregnancies under PMSMA between 2016 and 2018. High-risk pregnancies have a greater possibility of complications during labour and delivery, birth defects, premature delivery, stillbirth and, in worst cases, the death of the infant and mother. “Timely detection of risk factors during pregnancy can prevent deaths due to life-threatening complications during childbirth,” PMSMA guidelines note.

As IndiaSpend’s visit to Gurugram district showed, the programme is already showing results. The proportion of high-risk cases identified during antenatal check-ups increased from 6.91% in 2013-14 to 14.35% in 2017-18, data from NHM Haryana show.

Earlier, grassroots health workers would check up on pregnant women but there was no focus on high-risk cases. Now, if a woman with a high-risk pregnancy misses her monthly check-up, it is flagged within the system, and health workers go to her house and bring her to the health centre, said Sheela Devi, 57, a health supervisor at the Wazirabad primary health centre.

The Niti Aayog identified Haryana’s policy for managing high-risk pregnancies, including the portal, as a ‘best practice’ in antenatal care in January 2018.

However, frontline workers, beneficiaries and doctors said the quality of care must be improved, and services made available not only on the ninth but throughout the month.

Tracking high-risk pregnancies

High-risk pregnancy cases include women who have severe anaemia with hemoglobin levels below 7 gm/dl, hypertensive disorder in pregnancy (with blood pressure higher than 140/90 mmHg), Human Immunodeficiency Virus (HIV) or syphilis, gestational diabetes, previous history of caesarean section, stillbirth, abortion, premature birth, obstructed labour, and twin pregnancy.

On being found to be at risk, Rajvanti Devi was given a red card signifying high-risk pregnancy, and will now be closely monitored by grassroots health workers–accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs)–along with counselling sessions and regular follow-ups until the birth of her child.

A woman detected with a high-risk pregnancy is given a red antenatal card with a ‘High Risk’ stamp. She is closely monitored through Haryana’s high-risk pregnancy portal.

The PMSMA is an expansion of the Vande Mataram programme, first launched in the early 2000s. “In the past couple of years there has been an expansion of maternal and outreach health services and more recruitment of ANMs, so things have really improved,” said Sulakshana Nandi, national joint convener of the Jan Swasthya Abhiyan, the Indian branch of the global People’s Health Movement (PHM).

More than 10 million women received antenatal care under PMSMA between July 2016 and January 2018, according to the central Ministry of Health and Family Welfare.

“All government hospitals collate data on the number of high-risk pregnancies in the district, and the portal is updated once every month with all case details,” said Neelam Chaudhari, 44, an ANM in the Islampur health centre of Haryana’s Gurugram district.

“The portal was an innovation of the state to identify high-risk pregnancy cases,” said Garg of the National Health Mission, Haryana. “We have a 100% name-based portal where each woman’s journey through her pregnancy will be closely monitored until the birth of her child.” 

Of all the high-risk pregnancy cases recorded in Gurugram, 647 were due to previous caesarean section deliveries, 179 because of severe anaemia, 187 due to hypertension and 211 due to multiple pregnancies, according to the portal.

IndiaSpend obtained district-level data for Gurugram and Jhajjar from the high-risk pregnancy portal. Haryana’s National Health Mission did not share data for the entire state despite repeated emails and phone calls in the month of October. This story will be updated if we receive the data.

Counselling

A crucial component of PMSMA is counselling of expecting mothers. “We tell them to practice spacing between births,” said Sheela Devi. “If it’s a high-risk case or a caesarean, we counsel them to at least have a gap of three years until the next baby.” 

“If at any given point they miss their monthly check-up, ASHAs are sent to their homes or we call them to find out why they didnt come,” she added. “The high-risk pregnancy portal is extremely helpful to keep a track record of every woman.” 

For delivery or conditions requiring urgent medical attention, high-risk pregnancy cases are referred to district hospitals or community health centres that provide specialist services. “Just last month on PMSMA day, we found a case of hypertension,” said Chaudhari. “A woman had 220/190 mmHg blood pressure, she was immediately sent to the civil hospital along with an ASHA worker.” 

Antenatal care

Like Rajvanti Devi, most women do not receive proper antenatal care during their pregnancy. In 2015-16, only half (51%) of the women aged 15-49 years who were surveyed had the World Health Organization-recommended four antenatal care visits for the last birth before the survey, according to data from the National Family Health Survey 4 (NFHS 4). About 17% of women received no antenatal care during pregnancy.

Not everyone agrees that the PMSMA is the ideal way to provide antenatal care. Women have to wait in queues, some of them do not get to see a doctor, and the quality of care is poor as there are many women waiting on one single day, said Nandi of the Jan Swasthya Abhiyan.

“This programme is just another campaign,” she added. “The actual high-risk cases are not being prioritised due to herding of all pregnant women on one day of the month to increase footfall… I have seen cases in which the services that should be provided everyday are not being given because the priority is to gather as many women as you can on the 9th of every month.” 

Low intake of iron and folic acid tablets

When Rajvanti Devi’s high-risk pregnancy was detected, she was recommended to get an ultrasound, and start regular doses of iron and folic acid tablets. During pregnancy, anaemia increases the risk for maternal mortality, preterm birth and infant mortality, as IndiaSpend reported in September 2019.

“I have iron tablets but I do not eat them,” said Rajvanti Devi. “It makes me feel nauseous and I can’t do any of my chores later.”

“Women do not eat the prescribed iron tablets,” said Chandan Kachroo, 58, a gynaecologist in a private hospital in Gurugram, who has volunteered to see patients one day a month under the PMSMA. “I have mostly seen this in patients coming to government hospitals. Patients in the private hospital eat the iron tablets regularly.”

Only 14.4% of the poorest women took iron and folic acid tablets for more than 100 days, as compared to 48.2% of women in the highest wealth bracket, according to data from the 2015-16 NFHS 4.

Chandan Kachroo, 58, a private gynaecologist and volunteer under the government’s safe motherhood programme, with Rajvanti Devi, 38. Her pregnancy is high-risk as she is mildly anaemic and had a caesarean section previously. Haryana tracks high-risk pregnancy cases through an online portal, the only state to do so.

Caesarean sections

Previous caesarean sections make up for a large chunk of high-risk pregnancy cases: 24% in Gurugram and 13% in Jhajjar, based on data from the high-risk pregnancy portal.

The rate of caesarean sections has doubled from 9% in 2005-06 to 17 % in 2015-16. Caesareans are particularly common in private sector health facilities (41% of deliveries), an increase from 28% in 2005-06, according to NFHS 4.

Private sector involvement 

Doctors working in the private sector are encouraged to volunteer for PMSMA and provide voluntary services at nearby government health facilities on the ninth of every month. About 5,799 such volunteer doctors have registered to participate under the programme since July 2016, according to a reply in the Lok Sabha (lower house of the parliament).

“There was an appeal made to all the gynaecologists part of the Federation of Obstetric and Gynaecological Societies of India (FOGSI) to participate in PMSMA,” said Kachroo. “I have volunteered for this scheme as a way to give back to the society.”

Kachroo examined a total of 50 patients in the four hours of her volunteering service at the primary health centre in Wazirabad. She said she found 12 cases of high-risk pregnancies.

“Maternal health services being available to every woman is a part of universal health coverage, rather than a charity, which the PMSMA makes it out to be,” said Nandi of the Jan Swasthya Abhiyan. “Remote areas do not have as many private gynaecologists. But most private gynaecologists volunteer in bigger cities where there are already enough practitioners available.”

This story was first published here on Healthcheck.

(Ali is a reporting fellow with IndiaSpend.)

Courtesy: India Spend

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Poor urban migrants are more undernourished than the rest of the population, but are unable to access subsidised food benefits when they migrate for work. The forthcoming programme aims at making food rations available to them everywhere through the public distribution system. 

Indian interstate and intrastate migrants make for about 37% of the country’s total population, according to the 2011 Census. But the government does not have accurate state-wise numbers for migrants. More than a quarter of fair price shops (28%) do not have PoS machines, showed data submitted in the Lok Sabha (lower house of the parliament). 

Presently, the central government supplies subsidised food grains under the National Food Security Act, 2013, at Rs 1-3/kg, to more than 800 million people through 500,000 ‘ration’ shops. The allocation to each family depends on the number of members, and is marked in the ration card issued by the state government to the head of the family. This card is digitally linked to Aadhaar, a 12-digit unique identification number used to verify the identity of Indian citizens.

Under the existing system, once a beneficiary of the food ration scheme migrates, he or she has to apply for a fresh ration card at the new place. But the ‘One Nation, One Ration Card’ system — also linked to Aadhaar — would eliminate the need for a new card. This way, it aims to deliver the promise of Aadhaar–portability of government benefits without the need for any other proof of identity.

After the government made it mandatory for welfare beneficiaries to link their Aadhaar with their ration cards, several people were reportedly denied food grains due to malfunctioning of the biometric authentication system, IndiaSpend reported on August 11, 2018. Experts said the same could happen with the new scheme. 

“All the problems that are faced by beneficiaries in Aadhaar authentication will be faced in the ‘One Nation, One Ration Card’ scheme as well,” said Sameet Panda, state convener, Odisha, Right to Food Campaign, (RTF), an advocacy group. “If one’s Aadhaar is not seeded or the biometric authentication fails due to any of several possible reasons, one will not receive ration no matter where [they are].”

Pilot schemes show up challenges

The Odisha government began implementing a pilot of the ‘One Nation One Ration’ system on September 1, 2019, for its intrastate migrants. Out of 32 million beneficiaries, 1.8 million (6%) could not get their Aadhaar linked with their ration card before September 15, 2019, the deadline mandated by the Odisha government, The New Indian Express reported on September 17, 2019.

Up to 35% of households did not have Aadhaar-seeded ration cards, an October 2019 study of 348 households in Nabarangpur, Nuapada and Malkangiri districts of Odisha had found. Of these, 31% had children under 10 years of age. Upto 12.42% individuals did not have an Aadhaar number while 19% submitted it but could not not get it linked to their ration card, the study by the Khadya Adhikar Abhiyan (Odisha chapter of the RTF) had found.

Earlier, in August 2019, the central government had trialled interstate portability of ration cards as a pilot project in two state groups: Andhra Pradesh-Telangana and Gujarat-Maharashtra. This would have enabled migrants in each cluster to avail of ration from the partner state.

“Gujarat has both intrastate migrants from the eastern tribal belt and interstate migrants from Maharashtra working in the diamond cutting industry,” said Sejal Dand, state convener, Annasuraksha Adhikar Abhiyan, an advocacy group working on food security in Gujarat. “We have not seen a single  beneficiary who has migrated to Gujarat and been able to procure ration in the state.”

Tribal communities in Gujarat have reported not being able to get ration due to poor internet connectivity even in their own villages, Dand said. “The government should make the data public as to how many people availed the ration,” she added.

Seasonal migrant workers not tracked

The exact number of mig­rant workers within India is not easy to establish, especially at the state level, as we mentioned earlier. The latest publically available data comes from the 2011 Census.

“Migration patterns across the country will have to be studied as the fair price shops–both in the home state as well as in the state he/she has migrated to–will need information on the inflow and outflow of migrants,” said Panda of the Right to Food Campaign. “Allocation of ration to each state will have to be made much more dynamically depending on the migration patterns.”

The central government allots food grains to the state, according to the district-wise requirement based on the number of ration card holders and previous year’s allocation.

“As per our understanding, [the cost of] providing subsidised ration to seasonal migrants will be borne by the states. We are yet to get any clarity about how a particular state subsidy will be implemented in another state,” said A S S Ramarao, the south zone (Chennai) general manager of sales and procurement at the Food Corporation of India.

Electronic PoS machines

For the ‘One Nation, One Ration Card’ programme, all fair price shops offering subsidised grains would have to install electronic PoS machines and all ration cards would have to be linked with the beneficiary’s Aadhaar number, as we said earlier.

Source: Lok Sabha

By February 2019, 72% of fair price shops (388,012 of 533,165) across the country had installed electronic PoS machines, data from the Lok Sabha showed.

Bihar, which had the least number of devices installed, had the second highest number of immigrants in the country after Uttar Pradesh, according to the 2011 Census.

“The transactions based on electronic PoS machines are beneficial as the dealers at the fair price shops do not have to manually keep the records of every beneficiary anymore. The device also checks for duplication of ration card holders,” adds Ramarao.

(Ali is a reporting fellow with IndiaSpend.)

Courtesy: India Spend

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The Protection of Children from Sexual Offences (Amendment) Bill of 2019 actually weakens the POCSO Act, Shailabh Kumar, lawyer and co-director of Haq: Centre for Child Rights, said.  Including death penalty as punishment could reduce the number of cases reported and might lead to murder of the victim. Further, there has been no amendment to provide for compensation of victims, and no strong solution for reducing pendency of cases.

Most members of parliament across political parties welcomed the amendments, and the bill–though debated in the house for nearly four hours–was passed without being referred to any parliamentary standing committee. In this monsoon session of the Lok Sabha, 34 other bills were passed, each receiving little attention from lawmakers. This is the fourth story in our series analysing the most significant of these 35 bills.

The POCSO Act was amended with five new clauses, including extending punishment from 10 to 20 years for penetrative sexual assault with children below the age of 16 and death sentence for aggravated penetrative sexual assault by a person in a position of authority–which includes police officers, members of the armed forces and public servants. It also includes cases where the offender is a relative of the child, or if the assault injures the sexual organs of the child. 

The death penalty can also be given in case of aggravated sexual assault which results in the death of a child or for assault during a natural calamity or in any situation of violence, the amendment says, replacing the words ‘communal or sectarian violence’ in the original bill.

Other provisions change the length of prison sentences for certain kinds of crimes, and would not have an impact on the rate of crime against children, activists said.

Death penalty not a deterrent
“Introducing death penalty was nothing but a populist move,” said Kumar.

Activists are concerned, as we said, that the introduction of death penalty will reduce the number of reported cases of sexual offence against children. As many as “94% of the accused are known to the victims in cases of child sexual abuse”, said Mohd Ikram, manager, child safeguarding policy at Breakthrough, a women’s rights organisation in Delhi. “When most accused are personally known to the victims and their families, the possibility of death may deter the victims to file a complaint.”

There is also a higher likelihood that the accused would rape and murder a victim to avoid getting caught, Ikram said.

Further, no empirical evidence exists to suggest that death penalty has a deterrent effect over and above life imprisonment, according to the Law Commission’s 2015 report on death penalty. The report suggested abolishing death penalty for all cases except terrorism.

In 28.9% of the cases where a trial court awarded the death sentence, the case ended in acquittal by a higher court. The death sentence was conclusively given in only 4.3% of cases–trial courts erroneously imposed the death penalty in 95.7% cases, according to the report.

“If we look at the timeline, the ordinance introducing death penalty was brought right after the Unnao and Kathua rape cases in early 2018 because of a huge uproar,” said Kumar. “PM [Narendra] Modi went to the World Trade Organization meeting where India was criticised for its policy on women and child safety, and the ordinance was brought in immediately after.”

In the Kathua case, an eight-year-old girl was abducted, raped and murdered in a village near Kathua in Jammu and Kashmir in January 2018. Six of the seven accused were convicted in the case, of which three were imprisoned for life and three sentenced to five years in jail.

In the Unnao case, a 17-year-old girl was gang-raped in April 2017, and the accused is a member of the Uttar Pradesh legislative assembly from Unnao, and was a member of the Bharatiya Janata Party, in power in the state and at the Centre. The case is still going on.

Instead of acting in haste, the government should have studied how people would react to the changes, and understood the problems in implementation of the Act, Kumar added.

“In addition, the bill is silent when it comes to protecting the victim and their family in cases where the accused is in a position of authority,” Ikram said. “Merely increasing the punishment for aggravated sexual assault is not enough.”

Trials pending for most cases
The police recorded 106,958 crimes against children in 2016, the latest year for which data are available, from the National Crime Records Bureau (NCRB). Of these, 36,022 cases were recorded under the POCSO Act. But 89% of the cases that were registered in 2016 were pending trial. Over 90% of cases registered in 2014 and 2015 were pending trial, according to NCRB data. Courts convicted the accused in only 29.6% of cases in 2016.

From January to June 2019, 24,212 cases of child sexual assault or abuse were registered under POCSO, of which 27% cases went on trial, as was noted during the parliamentary debate during the amendment of the Act; 4% cases were completed.

The Supreme Court issued directions to districts with more than 100 pending cases under the POCSO Act to set up fast-track courts with a resolution deadline of 60 days. As many as 1,023 fast-track special courts for POCSO cases would be set up, Minister of Women and Child Development Smriti Irani, who introduced the bill in the Rajya Sabha, said.

But an increase in the number of special courts would not necessarily lead to a reduction in pendency of cases, said Kumar.

For instance, fast-track courts do not address the problem of vacancies in courts. Special courts constituted under the POCSO Act will have judges not below the rank of a sessions judge and will be appointed from the same pool of judges.

With 28.7 million cases pending in district and subordinate courts, there are currently 17,891 judges against the required strength of 22,750, according to the 2018-19 Economic Survey. There are over 4 million cases pending in the country’s high courts, which would need 8,152 more judges to resolve. High courts have 62% of the sanctioned judges, with only 671 out of 1,079 judges’ positions filled, according to the economic survey.

Activists said that creating a child-friendly environment in courts is important so that the judicial and administrative process does not add to the trauma of the child. In the Indian judicial system, both judges and special public prosecutors need more training to handle sensitive cases, Kumar said. For instance, the Juvenile Justice Board is headed by a principal magistrate who hears cases only related to children, which helps them be more sensitive and give all their time to such cases.

Further, the bill should have tried to lay down rules to improve police investigation into these cases. For instance, the Supreme Court, in response to a public interest litigation on the alarming rise in reported child rape incidents, slow investigations and time in receiving lab reports, suggested designated forensic science laboratories in every district of the country for the POCSO Act.

One-stop centres
The amended POCSO Act provides for the setting up of one-stop centres where child victims can get shelter, medical assistance, counselling and legal aid, all under one roof. Activists welcomed this provision.

However, these shelter homes would need to be monitored. For instance, 100 complaints of child sexual abuse were made at a single one-stop centre in Haryana, according to a response to a Right to Information (RTI) request filed by Aseem Takyar, an activist, the Times of India reported on June 6, 2019.

Activists said the child support system should be further strengthened and victims should be provided with counselling and financial compensation for their mental and physical well-being while the case is underway.

Lack of process for compensation
The National Legal Services Authority (NALSA) compensation scheme for survivors and victims of rape will work as a guideline for special courts to award compensation, a Supreme Court bench had ruled in 2018, and had asked the government to make compensation rules under the POCSO Act itself.

But even after the amendment, no rules have been framed by the women and child development ministry. Further, the bill does not say who gets the compensation if the child dies.

Gaps remain in the implementation of the compensation scheme. For instance, from 2013 to 2018, 3,153 cases were registered under POCSO in 25 districts of Tamil Nadu. In only 95 of these cases was the victim given interim compensation, according to the response to an RTI request filed by a non-governmental organisation, as reported by The New Indian Express on February 3, 2019.

Antiquated view of consensual sex
The legislation takes an antiquated view in the treatment of consensual sex between young adults. POCSO Act does not consider adolescents from 16-18 years of age as consenting adults who can indulge in sexual activities and fails to distinguish between consensual sex and sexual abuse. This is often misused by families to cover up cases of elopement and inter-caste marriages.

In a recent case, the Madras High Court suggested that the age defining a ‘child’ should be reduced from 18 to 16. The court also noticed that the POCSO Act needs to take into account the age-gap between the abuser and the victim to differentiate between teenage consensual relationships and sexual abuse. 

(Ali is an IndiaSpend reporting fellow.)

Courtesy: India Spend
 

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A gram sabha (village committee) meeting organised in the Chasagurjang panchayat of Pallahara block of Odisha. The panchayat has a population of 5,000 and has asked the state government to open mini anganwadi centres for distant hamlets that do not have a full-fledged anganwadi.

“Our child’s nutrition has been compromised because we don’t have an anganwadi centre in the village,” said Munda, who lives in a small hamlet in the Pallahara block of Odisha’s Angul district. “We have to cross a river to get to the nearest anganwadi. How am I supposed to send my four-year-old son to the centre every day?”

The poorest people–those in the “lowest wealth quintile” or the 20% with the least amount of wealth–and other disadvantaged social groups such as the scheduled castes (SCs) and scheduled tribes (ST) living in small hamlets such as in Pallahara have the least access to anganwadi services, data from the fourth National Family Health Survey (NFHS) show. Living in remote areas, as many from STs do, exacerbates this inaccessibility.

STs comprise 8% of India’s population (104 million) but 45.9% of those from STs were in the lowest wealth bracket, more than any other social group, as IndiaSpend reported in February 2018. In 2015-16, as many as 19.7% of ST children under five years were stunted–had short height for age–and 19.0% of SC children, as compared to 16.4% of other backward castes and 11.9% of ‘general’ castes, NFHS data show.

Mini anganwadis for vulnerable populations

Low- to middle-income social groups are more likely to get food supplements, health check-ups and other ICDS services, NFHS-4 data show. In 2015-16, 63.3% of the poorest children did not get a health check-up as against 54.9% children from the second wealth quintile (poorest 21% to 40% of the population). Those better off prefer private services and hence have a low utilisation of ICDS services.

In 2015-16, a higher proportion of ST children received food supplements, health check-ups and pre-school education than other social groups, but this is low as compared to the proportion of poor people belonging to STs that need these services. For instance, even though almost half of the ST population (45.9%) belongs to the poorest quintile (poorest 20%), and 24.8% to the second lowest quintile, 60.4% of their children received food supplements under ICDS, NFHS data show.

Compare this to other backward castes: 18.3% of their population belongs to the lowest wealth bracket, and 19.3% to the second lowest, while 45.6% of children received food supplements under ICDS, data show.

Administrative shortcomings

The meeting that Munda attended was organised by members of the gram panchayat (elected village committee) and community leaders to hear people’s concerns and educate them about the need for a mini anganwadi.

“We are proposing two mini anganwadi centres in distant hamlets,” said Sashank Shekhar Naik, 47, sarpanch (village head) of Chasagurujang. “Our priority is to make mini-anganwadi centres available to children from the scheduled tribes who live in faraway villages. Children from here never get their take-home rations. It is impossible for parents to take them to the anganwadi centre every day and lose their wages.”

Since 1975, the government has run a supplementary nutrition programme under ICDS, which provides take-home rations–chhatua (powdered grain), eggs and pulses in the case of Odisha–for pregnant women, lactating mothers and children. It also provides hot, cooked meals for children, as well as pre-school education for children aged three to six, at anganwadi centres, as IndiaSpend reported in August 2019.

This helps support a child’s first 1,000 days–a window of opportunity in early childhood when a child’s growth and cognitive development are the fastest.

ICDS was universalised in 1995-96 to cover all community development blocks, and now reaches remote corners of the country. However, the poor, especially those from disadvantaged groups, are still left behind, as IndiaSpend reported in February 2018. Even in better-performing states such as Odisha, the lowest on the social ladder are excluded as they often live in remote areas.

“Anganwadi workers are not from our village, even if our children go to the centres, they are the last ones to be fed,” said Munda Saunto, 44, a panchayat member. “Auxiliary nurse midwives and ASHAs (grassroot health workers) hardly ever visit our village because of the rough terrain.”
“Children from distant hamlets are supposed to come to my anganwadi centre, but their attendance is the lowest,” said Nirupama Nayak, 31, an anganwadi worker in Udayapur village, which also covers Jayapur village. “They cannot travel 3 km every day, alone, to visit the centre. As a result, they miss out on their hot cooked meals, neither do they get pre-school education.”

The government sanctioned 116,848 mini anganwadi centres in 23 states and union territories in 2007, data from the National Institute of Public Cooperation and Child Development show. There are no data on how many mini anganwadis are currently operational.

Until 2005, only one of the six services–hot cooked meals–were provided in a mini anganwadi under the ICDS. In 2007, norms were revised so that all six services were to be provided, ICDS guidelines show.

Even though the villagers in Pallahara want an anganwadi, there is an administrative issue: Kuna Munda’s village, Jayapur, overlaps with another gram panchayat; half the population comes under that panchayat, which means that Jayapur does not have the minimum 150 people to make it  eligible for a mini anganwadi centre. The villagers have proposed two mini anganwadis, one in each gram panchayat.

Even the panchayat members were unsure whether Munda’s village belonged to the panchayat of Chasagurujang, where the meeting was taking place, or if he should have gone to the other panchayat that Jayapur is also a part of.

“We have submitted proposals to the government for a mini anganwadi centre especially in the hamlets without an anganwadi, where children cannot reach the nearest centre by foot. It is under consideration and the government will sanction it soon,” said Manoj Mohanty, district collector of Angul.

Renu Pati, the child development project officer for Angul district who oversees ICDS services, and should have been involved in sending the proposal, said she had not received any proposals yet for a mini anganwadi. She refused to answer any other questions.

Reduced government burden, improved health
The lack of access to nutrition could be felt most acutely in disadvantaged communities. For instance, in 2013, 19 infants died due to malnutrition when the Odisha government ran a special project for the development of vulnerable tribal groups–the most disadvantaged among STs. Under the project, 216 children were identified as severely underweight and suffering from severe acute malnourishment, but 60 of these were not referred to any hospital, found the 2017 Comptroller and Auditor General report, the latest on particularly vulnerable groups. “No remedial measures were taken by micro-projects to eradicate malnutrition,” the report said.

In addition to helping children and families, mini anganwadi centres would also reduce the burden on the government. Currently, nutritional rehabilitation centres support highly malnourished children and mothers, spending Rs 125 a day per child and mother in Odisha. A malnourished child, along with their mother, is kept for a minimum of 15 days at the nutritional rehabilitation centre under close observation, while focusing on their nutrition.

In January 2019, Nayak, the anganwadi worker, sent three children to the nutritional rehabilitation centre in Pallahara block’s community health centre, 40 km from the village. Two of the children were in the red zone–signifying severe malnourishment with very low weight for height–and the third child was in the orange zone, showing moderate malnourishment. A closer anganwadi centre could have helped these mothers and children supplement their nutrition and avoid severe malnourishment. 

(Ali is an IndiaSpend reporting fellow.)

Courtesy: India Spend

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These gaps “represent risks for the achievement of the key objectives of the 2030 Agenda”, the CAG said in a July 8, 2019, report.

While the health ministry proposed to increase India’s public health expenditure to 2.5% of its gross domestic product (GDP) by 2025, “it has remained within a narrow band of 1.02-1.28% of GDP”, the report said.

For this report, the CAG audited the NITI Aayog, the health ministry, the ministry of statistics and programme implementation, and 14 other ministries for preparedness to achieve SDGs. To analyse states’ performance, seven states–Assam, Chhatitsgarh, Haryana, Kerala, Maharashtra, Uttar Pradesh (UP) and West Bengal–were chosen based on their ranking on various health indices for 2015-16.

The NITI Aayog’s three-year action agenda (2017-2020) envisaged a rise in the Centre’s health budget to Rs 1 lakh crore ($14.5 billion) by 2019-20. But, the allocations have fallen short: India allocated Rs 53,294 crore ($7.7 billion) in 2017-18, Rs 56,045 crore ($8.1 billion) in 2018-19 and Rs 65,038 crore ($9.4 billion) in 2019-20, the report noted.

India’s National Health Policy 2017, framed in line with the SDGs, prescribes increasing the health expenditure of states to more than 8% of their annual budgets by the year 2020, but the seven states evaluated spent between 3.29% and 5.32% for the period of 2012-2017, according to the report.

The National Health Mission–which provides for universal access to equitable, affordable and quality health care services–was conceived as the primary tool to reach health targets: maternal mortality ratio (MMR) of less than 70 deaths per 100,000 live births, neonatal mortality rate (NMR) of 12 deaths per 1,000 live births and under-five mortality rate (U5MR) of 25 deaths per 1,000 live births.

In 2017, India’s MMR was 130 deaths per 100,000 live births, according to Census data, while its NMR was 24 deaths per 1,000 live births and U5MR was 39 deaths per 1,000 live births, as IndiaSpend reported on September 20, 2018.

Yet, allocations to the National Health Mission fell short by 13.6% in 2018-19 compared to the budget projections, according to the CAG’s report.

Source: Report of the Parliamentary Standing Committee, cited in the Comptroller & Auditor General’s report

The standing committee of parliament on health, while examining the allocations, had observed that these shortfalls would affect the strengthening of health facilities.

India’s neonatal mortality rate (24 deaths per 1,000 live births) is higher than the global average (18). Sri Lanka (8), Bangladesh (18) and Nepal (21) are better off despite having lower per capita incomes, as IndiaSpend reported on September 20, 2018.

In 2015, India spend 1% of its GDP on public health, second-lowest in the south east Asia region, according to data cited in the National Health Profile 2018. That same year, Maldives spent 9.4%, Sri Lanka 1.6%, Bhutan 2.5% and Thailand 2.9%.

State spending on health yet to increase
To reach the 2025 target of spending 2.5% of GDP on health, the National Health Policy mandated states to increase their health spending on primary care by at least 10% every year. In addition, a 4% health and education cess was also proposed which was not implemented.

The Policy, as we said, also prescribes increasing states’ health spending to more than 8% of their annual budgets by the year 2020. Yet, none of the seven states studied for this report by the CAG spent that amount by 2017.

Further, 29% of NHM funds with states were not spent over five years to 2016, as IndiaSpend reported on August 20, 2018.

Health shortages affect progress
Rural India has a shortfall of between 24% and 38% in the number of sub-centres, primary health centres (PHC) and community health centres in 28 states and union territories, data from the CAG’s 2017 audit report on reproductive and child health under the National Rural Health Mission, which seeks to strengthen the delivery of public health services in rural India, showed.

Each PHC with a load of more than 20 deliveries per month needs at least two medical officers, according to Indian Public Health Standards set in 2006. Chhattisgarh has a total of 341 doctors in PHCs, which makes for 0.43 doctor per PHC, lower than required, according to the data cited in the CAG’s report. There were “considerable” human resource shortages in Chhattisgarh and UP, the report said.

UP is one of the worst-performing states in infant and under-five mortality rankings, as IndiaSpend reported on March 16, 2017. While UP has a 30% shortage of PHCs, West Bengal has a shortage of 69%.

With a rural population of 62 million, West Bengal has one PHC for every 68,000 people–less than half the prescribed number of one PHC per 30,000 people.
 

Source: Report of CAG (No. 25 of 2017)

The population-doctor ratio in India was 11,082:1 in 2017 in government hospitals, 25 times higher than the World Health Organization recommendation of 25 professionals per 10,000 population, as IndiaSpend reported on January 28, 2019.

Dearth of data
The NITI Aayog, the government’s policy think tank and the body responsible for overseeing implementation of SDGs, and the statistics ministry in consultation with the state governments, were to prepare the National Indicator Framework, the backbone for monitoring of SDGs.

However, data for 137 of 306 national indicators were not available for 13 SDG goals, the CAG’s report said.

The framework includes 50 indicators related to health, but data for 23 of these–such as screening for cervical cancer among women and incidence of viral hepatitis–were not available, according to the report.

At both the Centre and the state levels, there was “evidence of insufficient efforts at putting in place a comprehensive indicator framework, identification of data sources, production of disaggregated data” for Goal 3 (good health and well-being), the report said.

“Better measurement, greater evidence and more informed reporting are expanding voter awareness and deepening policy debates,” as IndiaSpend reported on May 15, 2019. “This makes it imperative for central and state governments to improve the quality of public health data.”

(Ali is a reporter with IndiaSpend.)

First published on https://www.indiaspend.com/

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Afsana Bano studied to class 12, among only 16% of women with more than 10 years of education in Uttar Pradesh’s Sitapur district. Yet, she is an underweight mother with an underweight child, ignorant of the health needs of both. Bano and her 2.6-kg child represent the failure of government adolescent, sexual health services in the state.

Bano’s situation is representative of a cycle that keeps millions of Indian mothers and children, particularly in the most populous, poorest states, undernourished and incapable of learning and earning enough, thus holding back Indian economic progress, according to several research studies.

Bano was 18 when she married and was underweight when she conceived, weighing 51 kg in the eighth month of pregnancy, gaining no more than 200 gm by the ninth. She did not think much of it because she was unaware of the consequences of an underweight child.

Studying till class 12, Bano had an above-average education in rural Sitapur, where no more than 16.4% of women have had 10 years of education, compared to 32.9% in UP and 35.7% nationwide. But she never got the attention or counselling that the government health system was supposed to give her.

This is particularly important in Sitapur, where 36% of married women are adolescents, according to the 2015-16 National Family Health Survey (NFHS)–or NFHS-4–data, compared to an average of 21% in Uttar Pradesh (UP), India’s most populous and third-poorest state, by per capita income, and 27% nationwide.

With 4.4 million people, Sitapur is classified as one of 25 “high priority districts” across Uttar Pradesh and 184 across India identified for special attention to pare child marriage and adolescent pregnancies.

But the programme to address early marriage and teenage pregnancy, the Rashtriya Kishor Swasthya Karyakram (RKSK), a five-year-old national youth health programme, was given 1% of National Health Mission (NHM) funding in Sitapur, falling over a year from 3% in 2016-17.

Of this money a third was never spent, according to a 2019 analysis of NHM finances by Accountability Initiative, a think tank based in New Delhi, although there has been some improvement, as we explain later.

Source: Accountability Initiative, 2019 ((Data shared with IndiaSpend)

The failure of the RKSK to meet its ambitions of widening attention to adolescent sexual health and incorporating those needs into wider health programmes and effect change was acknowledged by a government spokesperson.

“The inherent problem with the programme is that the RKSK is seen as a low-priority component in NHM,” Sujit Verma, NHM’s district programme manager in Sitapur, told IndiaSpend. “The kind of demand institutional deliveries, leprosy, tuberculosis programmes have is not felt by RKSK.” The community does not consider adolescent health issues as important enough to be discussed in a hospital, he added.

“Handholding of ASHAs (accredited social health activists) and peer educators is required to develop a demand that stems from the community,” said Verma.

Developing the ‘demand’

With Bano and Sitapur, that demand has obviously not materialised. Developing the demand, as Verma put it, has wider implications.

Preventing malnutrition of children and women in what experts call a “crucial” 1,000-day window–from the start of a woman’s pregnancy to her child’s second birthday–could boost India’s gross domestic product by between $15-46 billion (Rs 1.03 lakh crore to Rs 3.17 lakh crore), according to 2013 report by Save the Children, a global advocacy. That is six times the size of India’s 2018-19 health budget.

Bano’s situation is representative of many women in Sitapur, where child marriage and early pregnancy are endemic, said experts: 7.3% of women in Sitapur between 15-19 years already are mothers, according to NFHS-4 data. Even though teenage childbearing in UP is half (3.8%) India’s average (7.9%), in Sitapur 35.5% of women are married before they turn 18, higher than the UP average of 21% and the Indian average of 27%.

It took India 19 years to bring down child marriages by 51%, according to the Global Childhood Report by Save the Children. If those numbers to fall further, adolescent health in rural areas requires immediate attention. That may be difficult without adequate data.

“Not enough information is available on younger adolescents (10-14 years), and both younger and older adolescents’ needs to be assessed differently,” said Niranjan Saggurti, India country director, Population Council, a global research organisation. “One can then get more clarity as to which adolescents are most at risk as regards reproductive health.”

Bano’s education did not prepare her for knowledge of sexual or health issues. She studied at  a madrasa, or Islamic seminary, and no health worker or health programme reached her mud-and-straw home in Parsendi village, 90 km north of the state capital Lucknow, as they were supposed to–and indeed do in India’s more prosperous states, such as Kerala. 

Bano’s husband, Mohammed Karim, 21, was in no position to advise her: he studied till class five and worked for awhile in a “tablet-making company”, as he put it.

Before pregnancy, Afsana visited the anganwadi–or government creche-cum-health centre–only once. The first time she visited was in the sixth month of pregnancy, which is three months later than recommended and only got one tetanus vaccination instead of the two she should have. She was given iron and calcium tablets, but they made her sick with diarrhoea, she said.

Bano never visited the anganwadi again.

The malnourishment cycle

There is every chance Bano’s child will grow up malnourished, as children of underweight mothers tend to be, and be less educated and productive than he might be.

Malnutrition is one of the leading causes of about half of India’s childhood deaths, and if they are affected at an early age, there can be long-term consequences, affecting motor, sensory, cognitive, social and emotional development. States with more educated women had healthier children, according to a March 2017 IndiaSpend analysis of NFHS-4 data.

While India’s burden of disease due to child and maternal malnutrition has been decreasing since 1990, malnutrition was responsible for 15% of the total disease burden in India in 2016, according to India: Health of the Nation’s States, a report produced by independent medical agencies, nonprofits and the government.

Nationally, there was a 9.6-percentage-point reduction in the stunting rate of children in 2015-16 compared to a decade before that. UP’s improvement rate was 10.5 percentage points, according to our analysis of NFHS data.

Home to almost a third of the world’s stunted children under five (46.6 million), India is not on track to reach the World Health Organization’s (WHO) 2025 global nutrition targets, IndiaSpend reported in January 2019.

Of Indian children under two years of age, 90.4% did not receive an adequate diet, according to NFHS-4 data. About 18% of children aged 6-23 months ate iron-rich foods, and more than half the children in this age group were anaemic. About 54% consumed vitamin A-rich foods, the lack of which can lead to childhood blindness and poor immunity.

To address this situation, government health services must go to the root of the problem: the mothers. That is not easy to address, said experts, when the mothers are adolescents.

Why adolescent health matters

Adolescent health is the most critical stage in life for health interventions, according to expert advice.

“More than 33% of the disease burden and almost 60% of premature deaths among adults can be associated with behaviours or conditions that begin or occur during adolescence,” said a 2002 WHO statement.

The health of adolescent girls and young women is linked to the birth weight of the children and to child survival. Adolescent mothers become more vulnerable to problems related to pregnancy and childbearing and are more likely to have premature and underweight babies.

High maternal and child mortality in adolescent mothers and a smaller but significant contribution of adolescents to the total fertility rate (TFR) or the number of children that a woman has. UP’s TFR is 3.1, compared to 1.8 in Kerala, 1.6 in Tamil Nadu and 1.6 in West Bengal, compared to the replacement rate of 2.1, at which point population stays the same.

These data illustrate the need to make adolescent health a part of overall maternal and child health, according to a 2014 adolescent-health strategy paper from India’s ministry of health and family welfare.

RKSK in UP: Noble aims, slow spending

Launched in 2014, the RKSK was the first programme to place adolescent health at the centrestage of government health priorities.

The RKSK subsequently widened its scope from sexual and reproductive health to include nutrition, non-communicable diseases and substance abuse and has since shifted its focus from curative to preventive and aims to reach adolescents in their own environment.

These aims have not yet been met in Sitapur, where the training of what are called “peer educators”, specially trained teens aged 15 to 19 from every village, was envisaged as in the other 24 “high-priority districts”. Each of these districts was also supposed to have an adolescent friendly health centre and a counsellor.

In reality, both the RKSK and the NHM struggle to even spend the money they get.

A little more than half (55%) of NHM funds were used in UP in 2017-18, although this is an improvement from 45% in 2016-17, and, as we said, RKSK expenditure as a proportion of NMH spending fell from 3% in 2016-17 to 1% in 2017-18.

Sitapur was given Rs 1.72 crore in 2018-19 for RKSK, up from Rs 1.42 crore in 2017-18, an increase of 21%. The use of these funds increased from 41% in 2017-18 to 45% in 2018-19. 

Source: Accountability Initiative, 2019 (Data shared with IndiaSpend)

“Sitapur reflects a clear low utilisation story; despite the money allocated, districts are not receiving the full amount that’s being allocated to them,” said a researcher who has worked on sexual health issues but requested anonymity because she worked with the government. “Funds are normally released only in the last two quarters, which is also why most of the funds go unused.”

On the issue of a lack of demand for adolescent health services, the researcher said that most of the expenditure in RKSK is not based on demand and was spent on training frontline workers, such as the ASHAs and peer educators.

Back in Parsendi, Bano said she lived a happy life with her husband, with whom she had fallen in love, a rare culmination to a teenage romance in a society where arranged marriages are the norm. She wanted to study further. How would she do it now that she had a child? Bano only smiled. 

Correction: The story has been corrected to reflect that the estimated boost to India’s gross domestic product due to prevention of malnutrition is six times the 2018-19 health budget. We regret the error.

(Ali is a reporter with IndiaSpend.)

Courtesy: India Spend

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The index evaluates countries on eight indicators to determine the wellbeing of children and teenagers (0-19 years): mortality among children under five years of age, malnutrition that stunts growth, lack of education, child labour, early marriage, adolescent births, displacement by conflict and child homicide. A final score out of 1,000 is derived, and countries are ranked accordingly.

Between 2000 and 2019, India’s score rose from 632 to 769. India also improved its rank from 116 of 172 countries in 2018 to, as we said, 113 of 176 countries this year.

In the year 2000, an estimated 970 million children around the world were deprived of their childhood because of these causes. By 2019, that number fell 29% to 690 million.

An increase in public investments, and intervention through programmes targeted at marginalised children to ensure universal healthcare and education are needed to help improve the wellbeing of children, the report suggests.

A minimum financial security for all children through child-sensitive social protection needs to be on governments’ agenda, the report says, adding that adopting a national action plan to reduce and eliminate child poverty, together with dedicated budgets and monitoring systems that track improvements in poverty-related deprivations, will help achieve better childhood outcomes.

Infectious diseases cause most deaths of Indian children under five
India has reduced its child mortality rate by 55% in the last two decades, from 88 deaths per 1,000 live births in 2000 to 39 deaths per 1,000 live births in 2017, according to data from this 2018 report. Yet, it lags the Millennium Development Goal of 25 or fewer deaths per 1,000 live births.

These deaths are mostly attributed to preventable infectious diseases, followed by injuries, meningitis, measles and malaria.

Among neighbouring countries, India’s performance on under-five mortality was better only than that of Pakistan (74.9). Sri Lanka (8.8), China (9.3), Bhutan (30.8), Nepal (33.7) and Bangladesh (32.4) have all outperformed India.

38.4% Indian children are stunted
Between 2000 and 2019, the prevalence of stunting–low height for age–among children below age five fell 25% globally–from 198 million children to 149 million. More than 50% of this reduction was in China and India alone, the reports says.

As of 2018, 38.4% Indian children under five were stunted, the second worst performance compared to its neighbours after Pakistan (40.8%). China (6%) had the lowest rate in the region, followed by Nepal (13.8%), Sri Lanka (17.3%), Bangladesh (17.4%) and Bhutan (19.1%), the report says.

There are wide disparities between states in India–while 48.3% children are stunted in Bihar, 45.3% in Jharkhand and 37.6% in Chhattisgarh, Kerala has the least at 19%, followed by Tamil Nadu (27.1%), according to data from the National Family Health Survey, 2015-16.

1 in 5 Indian children is out of school
Despite India’s advances at giving free universal education to its children, 20.2% of them (aged 8-16) were still out of school as of 2018, according to data cited in the report. Compared to its neighbors, India performed better only than Pakistan (40.8%), while Sri Lanka (6.4%), Nepal (13.8%), Bangladesh (17.4%), Bhutan (19.1%) and China (7.6%) did better.

As of 2018, 152 million children were still engaged in child labour around the world, the report says, adding that a hypothetical country made up only of these child labourers would rank as the world’s ninth largest by population.

India has the most child labourers globally, as IndiaSpend reported in June 2017, depriving them of education and exposing them to unsafe and toxic environment–leading to irrecoverable health damage.

Between 2000 and 2018, child marriage in India fell 51%
India halved its number of child marriages in 18 years to 2018, while marriage rates for the poorest girls fell at least as much as for everyone else, data from the report show. The decline has been fastest among girls younger than 15.

In 1978, India raised the minimum age of marriage from 15 to 18 for girls and from 18 to 21 for boys. In the last two decades, India has worked to curb child marriage through legislation such as the Prohibition of Child Marriage Act, 2006, and schemes such as the Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (called ‘SABLA’), Kishori Shakti Yojana and Nutrition Programme for Adolescent Girls.

The decline is attributed to economic growth, rising rates of girls’ education and proactive investments by government, the report says. Community-based interventions such as empowerment counseling, sexual and reproductive health information, vocational training and life-skills development for girls have also been important factors. Schemes such as conditional cash transfers to educate the girl child have also helped reduce child marriage, the report notes.

Adolescent births in India fell 63% in 20 years
India has managed to reduce adolescent births by 63% since 2000, which has resulted in 2 million fewer young mothers. Progress in India alone accounts for nearly three-quarters of the global reduction in adolescent births–from 16 million to 13 million.

Child-bearing at a young age not only has fatal consequences for the baby but also for the mother, and makes for the leading cause of death for girls between 14 and 19 years of age.

Much of India’s progress has been the result of its social welfare programmes that have enabled more girls to stay in school, and increased access to sexual and reproductive health services.

As of 2018, adolescent birth rate–that is, births per 1,000 girls aged 15-19 years–in India was 24.5, higher than that in China (6.5), Sri Lanka (14.8) and Bhutan (22.1), and better than that in Pakistan (37.7), Nepal (62.1) and Bangladesh (84.4).

(Sana Ali is a reporter with IndiaSpend.)

Courtesy: India Spend

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