Between 2017 and 2022, the NNM or Poshan Abhiyaan targeted an annual 2-percentage-point reduction in the prevalence of low birth weight and child underweight, a 25% fall in the prevalence of child stunting and a 3-percentage-point annual decline in the prevalence of anaemia among women and children under five years of age.

But if the NMM continues to progress at the current pace, relative to the 2022 targets, there will be an 8.9% excess prevalence in low birthweight, 9.6% in stunting, 4.8% in underweight, 11.7% in anemia among children, and 13.8% in anaemia among women, said the paper published on September 17, 2019, in The Lancet Child and Adolescent Health.

Malnutrition was the predominant risk factor for death in children under five years of age in every Indian state in 2017, accounting for 68.2% of the total deaths in that age group, the researchers concluded.

Malnutrition was also the leading risk factor for health loss across all ages, responsible for 17.3% of the total disability-adjusted life years (DALYs) that denotes the years of potential life lost because of disability.

India is not on track to achieve its 2025 nutrition target–to achieve zero hunger–IndiaSpend had reported in December 2018.

The researchers working on the Lancet paper analysed the disease burden due to child and maternal malnutrition, and the trends in malnutrition indicators from 1990 to 2017 in every Indian state. This study was part of India State-Level Disease Burden Initiative Malnutrition  jointly conducted by the Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation in collaboration with the Ministry of Health and Family Welfare, along with experts from over 100 Indian institutions.

The study found widespread malnutrition in India in 2017 in children under five years of age: Four in 10 were stunted (39.3%), three in 10 were underweight (32.7%) and three in five were anaemic (59.7%).

Also, there were signs of a new nutrition problem–one in every 10 children was overweight (11.5%).

The study highlighted the biggest factors that lead to higher malnutrition in children–low birth weight and poor exclusive breastfeeding. One in five children (21.4%) was born with low birth weight or under 2.5 kg, and only half of all children were exclusively breastfed (53.3%).

There is a need to set bold but achievable targets based on the analysis of these data, said the paper.

“This study reports that malnutrition has reduced in India, but continues to be the predominant underlying risk factor for child deaths, underscoring its importance in addressing child mortality,” said Lalit Dandona, director of the India State-Level Disease Burden Initiative, in a statement. Low birthweight needs particular policy attention in India as it is the biggest contributor to child death among all malnutrition indications and its rate of decline is among the lowest, he added.

One in three of the world’s 156 million stunted children under five years of age lives in India. In 2016, it was estimated that undernourishment among India’s children under five years would cost $37.9 billion–Rs 2.7 lakh crore or about three times the Centre’s 2019-20 budget for education–through lost schooling and economic productivity.

Uttar Pradesh, Bihar, Assam and Rajasthan fare worst
The states were divided in terms of the socio-demographic index (SDI)–low, middle and high–calculated on the basis of per capita income, education, and fertility rate in women younger than 25 years.

The malnutrition DALY rate was much higher in low SDI states than in the other groups. It varied from six to eight times across states in 2017, and was highest in Uttar Pradesh, Bihar, Assam, and Rajasthan, as per the study.

The malnutrition rate in low SDI states was 1.8 times higher compared to the middle SDI group and 2-4 times higher than the high SDI group.

The DALYs rate due to malnutrition across all ages varied six times across states. In low SDI states, it was double the rate reported by middle SDI states and two to seven times higher than in high SDI states.

Disability-adjusted life-years rate due to malnutrition in children under five, 2017

Source: The Lancet Child and Adolescent Health

Malnutrition reduced only ‘modestly’
Of the 1.04 million children under five who died in 2017, 706,000 or 68.2% were due to malnutrition as we mentioned earlier. From 1990 to 2017, the mortality of children under five due to malnutrition had reduced “modestly”–from 70.4% to 68.2%–showed the study. Similarly DALYs in children under five due to malnutrition reduced only from 70.1% to 67.1%.

On almost all indicators, the rate of decline when projected for 2022 was not enough to meet the NNM targets.

Stunting prevalence reduced significantly in every state of India during 2010-17 but this decrease was less than the 8.6% annualised reduction needed to reach the NNM 2022 target. Similarly for wasting, underweight and anaemia, at the current rate of progress, the NNM targets are not likely to be met.

As we said earlier, there would be excess prevalence for low birthweight, stunting, underweight and anaemia in children relative to the 2022 targets.

Need ‘bold but achievable’ goals
The malnutrition indicator targets set by NNM for 2022 are “aspirational” and the rate of improvement needed to achieve them is much higher than the rate observed and might be “difficult” to reach in a short time, the study said. “This slow pace of improvement needs to be accelerated, so that future prevalence of malnutrition indicators are better than our projections based on trends so far,” the study said.

Correcting or resetting of targets has been done before at the global level. In 2005, the World Health Organization set its Global Nutrition Targets for six indicators to be achieved by 2025. But it became clear in a 2018 review that these targets were too high and “if the targets are too aspirational, they might be labelled as unrealistic, with the potential that investment and action are demotivated”. So the targets were re-set for 2030.

The paper suggested that NNM could set “bold but potentially achievable targets” for 2030. There could be national and subnational targets for reducing malnutrition based on the analysis of trends, the paper suggested.

India has the highest low birthweight prevalence
Low birthweight and short gestation or premature birth or was the largest contributor to the malnutrition disease burden, the paper found, responsible for 43.6% of DALYs.

South Asia, with India as its largest component, is estimated to have the highest prevalence of low birthweight in any region. It impacts not just the child but increases risk of chronic diseases later in life.

Low birthweight prevalence decreased significantly in 14 states of India during 2010-17, but its decline–1.14% annually–was much lower than the 11.8% annual decline needed for the NNM 2022 target.

Low birthweight depends on various factors: Mother’s nutrition, growth of the baby in the uterus, term at the time of birth and the space between the age of the mother and child.

Since women in India are underweight–one in every five–compared to even sub-Saharan Africa, it is suggested as a reason for low birthweight in India. Chronic undernutrition in mothers results in preterm and low birthweight babies, it is known.

In order to improve children’s health, India will have invest in mother’s nutrition, IndiaSpend had reported here and here. 

(Yadavar is a special correspondent with IndiaSpend.)
 

The post Why India Is Likely To Miss Its Nutrition Targets For 2022 appeared first on SabrangIndia.

Ushasri with her three-month-old son and anganwadi worker T Vijaya. Ushashri’s first son was 2.5 kg at birth, while her younger son was 3 kg, apparently heavier because she was better fed.

The first was 2.5 kg, just above the low birth-weight category, which is linked to long-term health risks, as a fifth of Indian babies are, as are 17.6% in Andhra Pradesh (AP). Ushashri’s second son, born here three months ago, 150 km north of Vijayawada, was a healthy 3 kg.

What changed during her two pregnancies was the universalisation of an AP government programme that began in 2013 in 102 so-called “high risk” blocks to all 676 blocks in 2017 to provide a hot, cooked meal of rice, sambar, milk and eggs to nearly 600,000 pregnant and lactating mothers at local anganwadis or government day-care centres.

Before the programme, YSR Amrutha Hastham–earlier known as Anna Amrutha Hastham and Indiramma Amrutha Hastham–the state provided pregnant and lactating mothers with raw rice, dal, vegetable oil and four eggs at home.

“Now, I eat (cooked food) at the anganwadi,” said Ushasri, dressed in a pink kurta and salwar, her wet hair wrapped in a towel, as she spoke to a visiting anganwadi worker and four visitors at her home in Aryapuram, a Rajahmundry suburb.

“Both ways [of giving food] are fine–but this is better,” said Ushasri, who is a graduate and takes tuition classes at home. Her husband works in a private company and their monthly income is Rs 6,000, above erstwhile undivided AP’s urban poverty line of Rs 1,009. Her only complaint: eating an egg is difficult because she is a vegetarian. At the anganwadi, health workers have told her the egg is good for her. 

“I have the rice and milk, but the egg is a little difficult,” said Ushasri.

There have not been many independent assessments of YSR Amrutha Hastham, and the benefit of such feeding programmes is contested–as we explain later–but a limited 2019 evaluation by the United Nations Children’s Fund (UNICEF) found that it satisfied mothers, boosted their dietary diversity to 57-59%, egg and milk consumption to 74-96% and calcium intake through tablets to 87%.

Our check of the AP programme confirmed some benefits and found logistical shortcomings related to unpaid anganwadi rents and staff salaries and staff shortages. But the data from the UNICEF evaluation have implications for AP’s and India’s future.

Undernourished children: India’s lost opportunity

With over 48 million children malnourished and two of every five Indian children stunted, or short for age, India has the highest number of undernourished children in the world.

For most children, the problem starts before they are born.

Children who received extra nutrition through government-run programmes from the time they were in their mothers’ wombs until age three were 11% more likely to acquire a graduate degree than those who received them between ages three and six, according to a January 2018 study published in the Journal of Nutrition.

Children eat hot meals at the Kothalanka anganwadi centre in Andhra Pradesh’s East Godavari district.

The study offered conclusive evidence that adequate nourishment to unborn babies and infants creates benefits that enhance their education and employment prospects in later life.

With the education benefit of early-life nutrition extending to college, the researchers estimated that such daily exposure could potentially increase India’s college graduates from 7.5% of the country’s 73.8 million Indians aged 20 to 24 to 11.8%. An increase in the college graduation rate, in turn, would deliver economic gains from higher wages.

This would be a significant economic achievement for a country with one in three of the world’s 156 million stunted children under five. In 2016, it was estimated that undernourishment among India’s children under five years would cost $37.9 billion–Rs 27,240 crore or about as much as India’s 2019-20 budget for the National Rural Health Mission–in future, through lost schooling and economic productivity.

YSR Amrutha Hastham is one of five state programmes that aim to reverse current nutrition trends. Healthy children are a prerequisite to take advantage of India’s demographic dividend, the economic benefits of having the world’s second largest working population, which is now in danger, as IndiaSpend reported in August 2019.

Getting to know what’s best for baby

“I breastfed my son within an hour of his birth,” said Ushasri. “At the anganwadi, they explained to me that I have to breastfeed up to six months. So, I am not giving him anything else–like water or other milk.”

The result of the fresh, nutritious meals was that Ushasri gained 12 kg during her second pregnancy, and her second son is healthy.

Most Indian mothers enter pregnancy with poor nutrition: 23% of reproductive-age women are too thin for their height and 58% of pregnant women are anaemic, increasing the risk of death for them and their babies. Additionally, 8% of pregnant women–approximately 4.5 million–are adolescents, according to the National Family Health Survey (2015-16).

This is why improving the nutritional status of mothers is important.

Only 46% of pregnant women and 51% of lactating mothers nationwide received supplementary nutrition services from anganwadi centres under India’s flagship 44-year-old scheme for maternal and child health, the Integrated Child Development Services (ICDS), the world’s largest such effort.

The average birth-weight of children whose mothers are enrolled in the YSR Amrutha Hastham was 2.9 kg in 2019–babies above 2.5 kg are termed normal weight babies. There were about 300,000 each pregnant and lactating mothers enrolled in financial year 2019-20.

The programme in AP runs under the ICDS and the supplementary nutrition programme, with a budget of Rs 2,219 crore, with the state government putting in Rs 17.75 to the central government’s share of Rs 4.75 for each meal.

Five states–Karnataka, Andhra Pradesh, Telangana, Chhattisgarh and Maharashtra–in India offer mothers some form of hot cooked meals in their anganwadi centres. Two states, Madhya Pradesh and Uttar Pradesh, have discontinued the programme, and Odisha is about to begin the programme.

Since the hot-cooked-meals-for-mothers programme replaced take-home rations (THR)–fortified supplementary nutrition for children under six and lactating and pregnant mothers for home use–traditionally distributed by the AP government, experts said it is important to assess the performance of the hot-cooked-meals programme against THR.

In early August 2019, we travelled to urban, rural and tribal areas of AP’s East Godavari district and found widespread acceptance of the hot-cooked-meals programme and satisfaction among beneficiaries. We also found that anganwadi workers who implemented the scheme needed more support from the government and better infrastructure.

More dietary diversity, limited weight gain

While the supplementary nutrition programme already supplied raw rations to mothers, the rationale behind a hot meal at the anganwadi is to ensure the mother consumes the meal (and not someone else at home), receives antenatal services and other nutrition support, such as iron and folic supplements, calcium tablets, deworming tablets and health information.

A hot, cooked meal is served to pregnant and lactating mothers at the Kothlanka anganwadi centre in East Godavari district of Andhra Pradesh.

In AP’s YSR Amrutha Hastham, the hot, cooked meal is served six days a week between 11 am and 2 pm to pregnant and lactating mothers, prepared by anganwadi workers who also prepare it for children who come there in the morning. In addition to what the supplementary nutrition programme provided at home, the state has added on an egg and 200 ml of milk every day. 

Anganwadi workers are expected to keep a record, through a mobile application, of women enrolled in the programme, the services they received, weight gained during pregnancy and birth-weight of the babies.

The 2019 UNICEF evaluation we referred to was carried out in Andhra Pradesh and Telangana, based on interviews with 360 pregnant and lactating mothers and a review of data from the state government’s management information system. It also found:
 

• While on-the-spot consumption of iron folic acid tablets was “poor” (22.6%) because most respondents took the tablets at home (77%), 87% of mothers took calcium and 56% deworming tablets. 
• Most beneficiaries consumed the meal on 21 out of 25 days in a month. 
• The estimated mean weight gain between the second and the ninth month of pregnancy ranged from 8.3 to 9.7 kg

Malnutrition among women was greater in tribal areas as compared to rural areas, according to the evaluation: 19% were wasted compared to 12% in rural areas, and 79% of tribal women using the programme had the minimum nutritional diversity compared to 89% in other rural areas.

While most respondents found the food tasty and the quantity sufficient in the evaluation, most enrolled mothers gained less than 6 kg, while only 6.8% gained more than 9 kg, according to the latest data provided by the state government.

This is within India’s average maternal weight gain–5.1 kg to 8.3 kg but below the global average–8.3 kg to 15.3 kg.

The average weight of the baby born to the women enrolled (between January and July 2019) was 2.9 kg, according to government data, which is within the average birth-weight (2.8 to 3 kg) in India.

In deprived tribal areas, most enthusiasm

Surrounded by verdant hills and paddy fields, Devarapalle is a small tribal village in Maredumilli mandal of East Godavari district. The Devarapalle anganwadi was destroyed in a flood and classes are held in a community centre. There is no toilet or kitchen.

The position of a helper has not been filled for many years and anganwadi worker Ganga Bhawari, 29, does the cooking as well. “There is no anganwadi building, no compound, no power and no water supply,” she said. A teaching assistant, recruited by a nonprofit, who works with children, helps Bhawari.

Loeshwari, 21, is a mother of two–a three-year-old and seven-month-old. The meal she ate at the anganwadi was invaluable, says Loeshwari, who got an egg, milk, sambar and rice. “We can’t afford to eat an egg every day,” she said.

At the Devarapalle anganwadi, we met Loeshwari, 21, a mother of two–a three-year-old and seven-month-old–who looked much younger because she was thin and small. She weighs about 42 kg, and came to the anganwadi every day during pregnancy and till her second child was six months old.

The meal she ate at the anganwadi was invaluable, said Loeshwari. “We can’t afford to eat egg every day,” she said. Tribal communities do not milk their cows, so mothers had limited access to protein.

Life is tough for women here, they have three to five children, work through pregnancy, and they do not go to their maternal homes for delivery–as many in India do–so mothers are back to household chores immediately after birth.

There are two additional programmes for women and children in tribal areas: while anganwadi centres statewide feed children aged three to six, those in tribal areas feed children six months onwards. Lactating mothers receive additional packet of dates, jaggery and peanut chikki–a kind of candy–and ragi malt to improve nutrition.

“Two of my children come to the centre, eat and like the meals,” said Kadavala Sugunavati, 26. “My children fall sick less often since they started the meals.”

There are five pregnant women, three lactating mothers and 33 children, aged seven months to seven years, registered at the Devarapalle anganwadi. Almost all come by for their daily meal.

“Some women come early in the morning, when they leave for work, for eggs and milk, the rest come in the afternoon for rice and sambar,” said Ganga Bhawari, the anganwadi worker.

This enthusiasm was evident in other rural centres we visited, but it was not in urban anganwadis.

More gripes in urban areas

At the Lishbarpeta municipality primary school in Aryapuram, two anganwadi centres have been merged. More than 30 children below six were studying in the classroom, and two anganwadi workers and two helpers were cooking the meals. However, out of the six pregnant and four lactating mothers registered here, only two or three come to the centre every day.

Pregnant and lactating mothers being counselled by child development project officer C H V Narsamma at Lishbarpeta Municipal School, Rajahmundry in Andhra Pradesh’s East Godavari district.

“They say that it is too far off to travel, and there are flights of stairs to climb up and down, which they find difficult,” said anganwadi worker Vijaya. Many mothers prefer their meals to be packed and brought to them by their family members which they eat at home.

“It takes me a whole hour to come here to have the meal and I have a young baby at home and another child,” said a mother who had visited the centre to have the meal that day on the request of the anganwadi worker.

“Beneficiaries feel that it is free food, why to go and eat at the [anganwadi] centre,” said D Sukhajeevan Babu, project director for the ICDS in East Godavari district. He said at least 10-20% of women do not show up for the meals.

“There should be a flexibility (offered) for mothers between getting take-home ration and hot meals,” said Babu.

Does the evidence support hot, cooked meals?

Not everyone is convinced of the benefits of “spot-feeding programmes”, such as YSR Amrutha Hastham.

While maternal malnutrition–a mother’s height, body mass index and anaemia–is a risk factor for poor child outcomes, the impact of one hot-cooked daily meal on child health or other supplementary foods on maternal diets is not evident, said Purnima Menon, senior research fellow, International Food Policy Research Institute. 

“That said, I understand that these programmes also include additional inputs at the time of the meals–provision of iron tablets and behaviour change communications,” said Menon. “This is good, but it also makes it challenging to disentangle the effects of the meals per se from the other components offered alongside.”

Menon had two other reservations:
 

• While programmes such as the YSR Amrutha Hastham may benefit mothers who attend, evidence has shown centre-based feeding programmes exclude those who cannot attend every day. 
• Feeding programmes for pregnant mothers who are already calorie-sufficient may lead to excess weight gain and retention after pregnancy, which is a concern for southern states.

Other experts have said there is enough evidence to support spot-feeding programmes.

The risk of stillborn babies was significantly reduced for women given balanced energy and protein supplementation, according to a 2015 review of several studies. Other reviews and studies (here, here and here) found a significant increase in the mean birth-weight of new-born infants whose mothers were provided nutritional supplements during pregnancy, wrote Prasanta Tripathy, public health researcher and activist and co-founder of Ekjut, a non-profit working in Keonjhar, Odisha in an email response.

Governments should invest in addressing the intergenerational cycle of undernutrition in the first 1,000 days of birth, said Tripathy. States should map “food-insecure regions” and target them with not just supplementary nutrition but also to other determinants of undernutrition, such as drinking water, he said.

Venkat Laxmi, 28, with her seven-month-old son, who was a healthy 3 kg at birth. She is a beneficiary of the Andhra Pradesh government’s hot, cooked meal programme, which offers this meal for 25 days a month.

Without adequate human resources and infrastructure, even the best schemes cannot reach their potential, said experts. While the AP government has been committed to run the YSR Amrutha Hastham, there are some obvious gaps relating to unpaid salaries, rent and staff shortages.

Every anganwadi worker we spoke to admitted to getting her salary after a delay of two to four months. Since many of the anganwadi centres are not in government buildings, rent for some centres had not paid for the last six months. Many anganwadi workers paid for the cost of running the centre from their own pockets. Vacancies at every level affect the efficiency of the programme: the anganwadi in Devarapalle did not have an anganwadi helper; there is 8% vacancy in anganwadi helpers, 23% vacancies in supervisors in the district, government records show.

The vacancy in supervisors affects the effective monitoring of the services. Many centres we went to had weighing scales that were not working.
On the larger front, there are concerns that the most vulnerable mothers may have been left out of the scheme as the percentage of food-insecure beneficiaires in the scheme was much lower than expected, said the UNICEFevaluation.

This report has been supported by ROSHNI-Centre of Women Collectives Led Social Action.

This story was first published here on Healthcheck.

(Yadavar is a special correspondent with IndiaSpend.)

Courtesy: India Spend

The post Feeding Mothers, Fighting Malnutrition: The East Godavari Experience appeared first on SabrangIndia.

Diagnosed with chronic obstructive pulmonary disease in 2008, former consultant Raj Iyer, 69, has seen his once-itinerant life shrink to his bedroom in eastern Bengaluru, where he lives amidst his life-support equipment, including a 24-hour oxygen supply.

His itinerant, fulfilling life changed 11 years ago when he repeatedly felt short of breath and was eventually diagnosed with chronic obstructive pulmonary disease (COPD), which had debilitated his lungs and his ability to breathe.

Smoking 60 cigarettes a day for 40 years was probably the immediate cause, although worsening air pollution may have played a role. “I knew my symptoms were of a respiratory disease but I didn’t know it was COPD,” said Iyer. “I certainly didn’t know how bad it gets or that it is incurable.”

Today, Iyer is 69, and his once expansive life has shrunk to a room in his house in Bengaluru’s eastern Pai Layout, where he lives with his primary caregivers, his 34-year-old son and 27-year-old daughter-in-law, whose lives, as we explain later, are circumscribed by his illness.

“When I first got married (in 2012), his COPD was not as bad, and he didn’t need continuous oxygen support,” said Antara Karthikeyan, Iyer’s daughter-in-law and a kindergarten teacher.

As the COPD progressed, Iyer needed oxygen support, multiple hospitalisations because of breathlessness caused by high levels of carbon dioxide–which is toxic to the body and accumulates when COPD affects ability of the lungs to expel carbon dioxide–and fell frequently due to his weakening bones.

Iyer’s room is taken over by the paraphernalia of his life-support system. A “BiPAP machine”, which is a respirator that steadies his breathing. A portable oxygen concentrator to take along while travelling. A larger oxygen concentrator, a machine that scrubs nitrogen from the air and give him a stream of pure oxygen through a 7-m-long plastic tube that allows him to move around the house. And to keep the life-giving gas flowing even when the electricity cuts out in India’s IT capital, notorious for its shaky power grid, the oxygen concentrator is connected to an inverter.
If Iyer’s professional and personal life followed India’s physical and economic transformation, so did the trajectory of the little-known, ill-managed disease that ravages his body–and is killing more Indians than ever before in a country with growing air pollution, more smoking among young people and an ageing, vulnerable population.

An incurable and progressive disease, COPD moved up from eighth spot to second on the list of leading ways to die in India, over 26 years to 2016 (the year for which the latest data are available). COPD claimed more victims than either road accidents or suicides in 2016. It claimed more lives than diabetes, malaria, tuberculosis and breast cancer combined in 2016. It only trails heart disease in the number of Indians it kills.
COPD is responsible for nearly a million deaths every year, as IndiaSpend reported in March 2019, in the first part of this series. The second part explained the contribution of traditional stoves burning coal, wood and cow-dung to COPD in India. In this, the third part, we bring you the story of a nation’s toxic air, a dangerous habit and a man being slowly claimed by a disease killing more Indians than ever before.

The fourth part will explain how India is unprepared for its COPD crisis.

Air pollution, smoking and ageing

Tobacco smoking is the primary cause of COPD worldwide, and it is responsible for a fourth of all cases in India. But air pollution–including ambient and household pollution due to biomass burning–is the primary cause of COPD in India and is responsible for more than half (53%) of all cases.

The ambient particulate pollution in India rose 12.5% over 27 years to 2017, from 80 μg/m3 (microgram per cubic metre) in 1990 to 90 μg/m3 in 2017, whereas China reduced its ambient particulate pollution from 58 μg/m3 to 53 μg/m3 over the same period.

These are “population weighted annual means” measuring fine particles, either dust or smoke, that penetrate the innermost recesses of the lungs. Averaged across the country, these data give weight to areas in proportion to their population, so that greater weight is given to areas where more people live. But these averages mask local concentrations of toxic air that may be many times more than the average.

In addition, more than 266 million Indians use tobacco, according to a 2018 World Health Organisation factsheet, and while the most common way to die of tobacco is from cardiovascular disease (48%), the next is chronic respiratory disease (23%), which includes COPD.

Although the proportion of any smoking among men aged 15 to 69 in India fell 27% over 12 years to 2010, cigarette smoking rose two fold in that age group and four fold in the 15-29 age group, according to a 2016 paper in BMJ Global Health, a journal.

“Despite modest decreases in smoking prevalence, the absolute numbers of male smokers aged 15-69 years has increased substantially over the last 15 years,” said the paper. Iyer started smoking when he was 17 and did not quit until a year before he was diagnosed with COPD.

A compounding factor in COPD’s rise in India is its ageing population, since there is growing evidence that susceptibility rises with age.

Over 21 years to 2011, the number of Indians above the age of 60 rose 93% from 53.7 million to 103.8 million. The decadal growth in elderly population between 2001 and 2011 was 35.5%, compared to 17.7% growth in the general population.

As the country ages and air pollution rises, COPD is likely to be increasingly common in India, experts told IndiaSpend.

India now accounts for a third (32%) of all disability adjusted life years (DALYs)–an indicator of overall disease burden–for COPD worldwide. Over 26 years to 2016, there was a 54% rise in the share of COPD in India’s total disease burden, as COPD moved up from being the eighth-leading cause of death to the second, according to the 2017 India: Health of the Nation’s States report by the Public Health Foundation of India (PHFI), a think tank, and the Indian Council for Medical Research, a government-run network of research laboratories.

Within this rise of COPD, there are medical nuances that explain why the disease is poorly understood, even by doctors, and poorly managed, claiming more Indian lives than it should.

Why so many Indians die of COPD

When Iyer felt the first shortness of breath, constant cough and tiredness in 2006, he went to a cardiologist who suspected it to be respiratory and cardiac related. The doctor prescribed medicines for both and despite symptoms getting worse, Iyer continued to work and travel. 

Two years later, when he was alone, Iyer’s blood sugar levels dropped and he asked his driver to take him to a hospital. There, a number of tests later, his condition was correctly diagnosed as COPD.

It should not have taken two years for a diagnosis because Iyer has been a smoker since he was 17 and smoked, as we said, up to 60 cigarettes a day for 40 years.

As in Iyer’s case, a classic COPD symptom is shortness of breath, although other symptoms can include fatigue, cough and tightness of the chest. Patients feel short of breath because the tubes carrying oxygen to air sacs in the lungs are inflamed–chronic bronchitis–or because smoke damages these sacs, which is emphysema.

Either way, the lungs do not expel carbon dioxide or absorb oxygen as they should, even as airways are inflamed, making breathing difficult. This is especially difficult for older patients.

“At the age of 25, our lungs are at their optimum efficiency [taking in] around four to six litres [of air with every breath]; from then on, it gradually declines about 25-30 ml per year,” said H B Chandrashekar, director of the Jain Institute of Pulmonology and Sleep Medicine at the Bhagwan Mahaveer Jain Hospital, Bengaluru. “For smokers, this is two or three times faster, so about 80-90 ml decline each year,” said H B Chandrashekar.

So, by the time a smoker reaches the age of 45, the lung capacity is equivalent to a 75-year old’s, he said. Iyer, as we said, was 58 when diagnosed.

All his adult life, Iyer’s mother and friends told him to quit smoking. In 2007, he finally did. A year later, he was diagnosed with COPD. By then, he was in the second stage of the disease, meaning his COPD was moderate with symptoms worsening on exertion.

COPD patients say they are perfectly normal before but the fact is that lung function has been on decline that hey noticed because of aging, said Rajani Bhat, consultant physician, pulmonologist and critical-care-medicine specialist, who treated Iyer for eight years.

“Usually patients come to COPD as an exacerbation of a bad lung infection,” said Rajani Bhat, consultant physician, pulmonologist and critical-care-medicine specialist, who treated Iyer for eight years. “They say that they were perfectly normal before, but the fact is that their lung function has been on a decline for sometime, but they felt it only later because of aging.”

If caught early, ideally in full body health checks that include lung-function tests, COPD can be treated and managed through inhalers, usually bronchodilators, that open airways and make breathing easier, even though there is no direct cure.

There are several reasons why COPD is not diagnosed early by most Indian doctors:
 

• It is often confused with asthma because it has some similar symptoms: shortness of breath, wheezing, cough and chest tightness.
• Diagnosis is confirmed with a test called spirometry–measuring how much and how fast the lungs exhale–which is not commonly available in India.
• Most doctors assume only smokers are at risk, thus underestimating the risk to non-smokers who contract it due to biomass burning and occupational hazards like working in mining, textiles, welding, foundry and farming.
• COPD patients are often misdiagnosed as having asthma and are given inhalers for asthma that is corticosteroid inhalers which do not work.
• COPD often progresses into heart disease, which may be treated but the underlying lung disease remains undiagnosed.

“In our own study, we found that 25% of patients admitted with myocardial infarction [heart attack] had an underlying lung disease which was not known,” said B V Murali Mohan, Consultant, Pulmonology and Internal Medicine, at Narayana Health, Bengaluru.

Unlike heightened general awareness of India’s number one killer–cardiovascular disease–COPD is seldom written about in the popular media.
“It (COPD) is not considered of reader or viewer interest,” said Srinath Reddy, PHFI president. Coupled with poor diagnosis in primary care, confusion with other respiratory diseases and “low self referrals” by patients, COPD is an ill-understood disease, said Reddy.

Living with COPD

Iyer has watched COPD gradually take over his life.

From stage two in 2008, the disease within him has progressed to stage four, which means it is now in very severe stage where hospitalisations are frequent and lung function is limited.

Over the last four years, he has been hospitalised 10 times, mostly with a lung infection or low oxygen saturation in the blood.

In 2019, Iyer has only been hospitalised in January.

“They say if you have not been hospitalised for more than six months, you are doing well,” said Iyer. He has become adept at managing his disease at home, adjusting his BiPAP machine, running his nebuliser, which deliver medication to open his airway in a fine mist, and has avoided going to the hospital.

“Most patients, especially women, do not want to burden their children and family (and) hence wait till it is too late to see a doctor,” said Bhat, Iyer’s doctor. This is being penny wise, pound foolish, she said, since regular follow-ups ensure patients do not need to be hospitalised frequently.

Since most COPD cases in India are detected late and in stage 2 and beyond, they need frequent hospitalisation, especially in winter.

Iyer spends between Rs 10,000-15,000 every month on managing COPD, but each hospitalisation that usually lasts a week can cost between Rs 60,000-100,000.

Apart from the medical paraphernalia that keeps him alive, opposite his bed is a blackboard, on which daughter-in-law Antara Karthikeyan has written a list of medicines he needs to take every day and in case of an emergency.

Raj Iyer’s COPD was first thought to be a cardio-respiratory problem. By the time he was diagnosed with COPD, two years later–a year after he quit smoking–the disease was in its second stage, at which point there were moderate symptoms that worsened on exertion.

Given his research background–he has a master of philosophy degree in social anthropology–Iyer has studied the disease’s mechanism extensively and answered questions on treatment and medicines with ease.

“To treat COPD, doctors prescribed steroids, which in-turn bring on diabetes and osteoporosis,” said Iyer. “Because COPD makes you breathless, you are less active, which further weakens bones and muscles.”

Inhalers do not cause these side-effects; only the oral steroids, said Bhat, his doctor. “Iyer has to take oral steroids for his exacerbations and he has had to take them over a long period of time” she added. “However he wouldn’t be alive, if not for those medications.”

Yet, COPD detected early can be managed, and patients can hope for better quality of life.

Pulmonary rehabilitation

An intervention that works as effectively, if not better, than medication for COPD is pulmonary rehabilitation, which includes a 12-week programme of exercises for chronic lung patients under medical supervision, nutritional counselling and breathing techniques.

Exercise improves a patient’s breathing capacity by working muscles that become deconditioned due to disuse; it “empowers” patients and gives them confidence, so they can be independent, explained pulmonologist H B Chandrashekar of Bhagwan Mahaveer Jain Hospital  who set up Bengaluru’s first, and one of India’s earliest, pulmonary rehabilitation centres in 2012 in the hospital.

“Exercise reduces chance of exacerbation, hospitalisation, improves symptoms and even may reduce mortality,” says pulmonologist H B Chandrashekar of Bhagwan Mahaveer Jain Hospital, Bengaluru. He set up the city’s first, and one of India’s earliest, pulmonary rehabilitation centres in 2012.

“Exercise reduces chance of exacerbation, hospitalisation, improves symptoms and even may reduce mortality,” said Chadrashekar. Most patients are reluctant to go into rehab, as they consider it unnecessary, and most hospitals do not have such a centre, since it does not bring in as much revenue as hospital beds do, he said.

Living in Bengaluru possibly took a greater toll on Iyer’s health. Pulmonologists explained how Bengaluru’s unique weather and geographical conditions make its residents especially prone to respiratory illness.

While air pollution is not as high as in New Delhi or in other northern cities–15 of which rank among 20 of the world’s most-polluted cities–Bengaluru’s altitude of 3,020 ft or 920 m above sea level and equable climate ensure pollutants do not rise, as they would in warmer weather, but stay close to the ground.

“The treeline in the city, with trees on both sides of the road, are the city’s lungs [but] also trap the pollutants close to the breathing zone,” said Bhat. The city’s high pollen concentration makes residents prone to allergies, asthma and COPD.

When Iyer was first recommended pulmonary rehabilitation in 2008, he didn’t take it seriously. In 2015 when his condition worsened, he went to Mahaveer Jain Hospital and accepted the rehabilitation.

He went to the hospital in a wheelchair with oxygen support; slowly he weaned himself off the wheelchair and constant oxygen support. In 2015, he felt better and was physically capable of doing more.

Iyer pointed out that insurance companies do not cover pulmonary rehabilitation. “They are willing to cover COPD and pay tonnes and tonnes of money, if you claim insurance,” he said. “But (they) will not pay for rehab that will prevent hospitalisation and save them money.”

The rehab costs Rs 1,000 a week, during which there are three one-hour sessions. Iyer paid for and continued rehab sessions for a year and was strong enough to achieve important milestones: his son’s wedding, buying property and travelling.

However, after a series of falls and injuries, he was not able to continue rehab after 2017. As his conditioned worsened, a greater burden is apparent on his family.

How families cope with COPD

COPD has altered the way Iyer’s family lives.

His son and daughter-in-law cannot, for instance, travel out of the city at the same time.

Daughter-in-law Antara Karthikeyan was once a retail manager with long working hours, but she was constantly worried about Iyer home alone.
“My number one concern was, what if he trips and falls,” said Antara Karthikeyan. “He cannot get up on his own. How will he call us?”

Her decision to become a kindergarten teacher, so she could return home by afternoon, was a personal choice, she said. She and her husband have hired help to look after their four-year-old daughter, Tanya, and be available in case Iyer needs assistance while Antara Karthikeyan is at work.

COPD does not affect only the lungs but causes wider systemic damage because of inflammation. The disease has brought gastritis, diabetes, oedema, sleep disturbance, anxiety and depression to Iyer, who uses music, reading books, watching documentaries and meditation as a way of making peace with his body’s slow degeneration.

This is the third of a four-part series. You can read the first part here and the second part here. 

Reporting for this article was supported by the REACH Lilly Media Fellowship Programme on Non Communicable Diseases.

This story was first published here on Healthcheck.

(Yadavar is a special correspondent with IndiaSpend.)

Courtesy: India Spend

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Only 23% of children aged 6-23 months received an adequately diversified diet, according to the study by Sutapa Agarwal from Tata Trusts, Rockli Kim and S V Subramanium from the Harvard Center for Population and Development Studies of Harvard University, and others, published in the European Journal of Clinical Nutrition in February 2019.

Among the poorest households, 18% of children had a sufficiently varied diet as compared to 28% of children from the richest households, a difference of 10 percentage points. At the same time, 17% of children of mothers with no education ate an adequately diversified diet as compared to 30% of mothers with a high school or higher education, a difference of 13 percentage points, the study found.

An “adequately diversified diet” entailed consuming at least four items from seven food groups used for the purpose of the study–grains, roots and tubers, legumes and nuts, dairy products, flesh foods (meat), vitamin A-rich fruits and vegetables, and other fruits and vegetables.

Eating a varied diet is as important, if not more, than the quantity and quality of nutrition. In the study, most children had a higher consumption of grains and a poor consumption of fruits and vegetables, nuts and legumes, eggs and meat.

“More than animal versus plant–we need to think of macro nutrients related to the balance between fat, protein and carbohydrates,” said Subramaniam, one of the co-authors of the study, in an email. “And for young children fat intake is critical. There is an emerging recognition to focus on proteins, but not nearly enough for fat intake among very young children. And here is where dairy consumption–including milk–is important for addressing the burden of child undernutrition.”

Wealth and education gap

“For the poorer strata it is affordability and accessibility, while for the better-off strata it could be lack of knowledge,” said Subramaniam, explaining the study’s findings. Food is an industry now, he said, adding that dietary preferences among the well off need to be interpreted in the larger context of global trends towards homogenous food.  

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 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, the National Family Health Survey-4 (NFHS-4) 2015-16 found. Some 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.

The present study on dietary diversity also used NFHS-4 data, in which mothers were asked to choose from a list of 21 food items they had given their children in the preceding 24 hours.

The items were then divided into seven food groups: grains, roots and tubers, legumes and nuts, dairy products, flesh foods, vitamin A-rich fruits and vegetables, and other fruits and vegetables.

The mean score of dietary diversity of Indian children was found to be 2.26, on a 0-7 scale, where 0 means children are not fed any of the 21 food items and 7 means they are fed at least one from all seven groups.

The biggest difference between children of different wealth groups was in consumption of dairy products–children in the richest households were three times more likely to consume dairy products as the poorest households.

Meanwhile, children of mothers with high school or higher education had a greater likelihood of consuming all seven food groups and had twice the odds of eating an adequately diversified diet as those with mothers with no education.

Grains consumed most

Among the seven food groups, children mostly ate grain–74% were reported to have consumed roots and tubers, 55% dairy products, 37% other fruits and vegetables, and 29% vitamin A-rich fruits and vegetables.

Children’s consumption was the lowest for eggs (14% of respondents), legumes and nuts (13%), and flesh foods (10%), the study found.

Between the richest and poorest households, the difference in consumption of dairy products was the highest (39% in poorest households vs 72% in richest households), followed by vitamin A-rich fruits and vegetables (26% vs 33%) and other fruits and vegetables (34% vs 40%).

Consumption of dairy products varied most by mothers’ education level–44% for uneducated vs 73% for educated–followed by vitamin A-rich fruits and vegetables (25% vs 34%), and other fruits and vegetables (32% vs 43%).

Although dietary diversity increased in 2016 as compared to 2006, it was poor throughout and actually reduced in the upper two wealth groups (out of five). Despite the reduced gap, the upper groups consumed 2-4 times more diversified diets than those in lower groups.

Consumption of some food items was influenced more by maternal education than household wealth. These included: pumpkin, carrots, squash, dark green leafy vegetables, liver, heart, organ meat, fish, shellfish, legumes and nuts, and flesh food.

Consumption of packaged items such as canned juices increased with increased wealth and mother’s education, which the researchers called “alarming”. They suggested that food items that are cheap in India such as pumpkin, carrots and dark green leafy vegetables should be encouraged.

Can more meat help?

To improve dietary diversity, children should be eating more animal-sourced foods. Indians consumed 194 gm and 242 gm of protein a day in rural and urban areas, respectively, against the recommended 459 gm, according to an analysis published in Livemint in January 2019.

Although dairy and poultry foods are cheaper in India than in some low- and middle-income countries, they remain beyond the reach of many. Here, cash transfers can play a role, said a study on child feeding practices in 2006 and 2016 conducted by the agriculture research group International Food Policy Research Institute (IFPRI) and published in the journal Maternal and Child Nutrition.

It would also be important to remove cultural barriers to meat consumption among young children, the study said. Among the one-third households that did not consume animal protein,  improving consumption of legumes/nuts and fruit and vegetables could help, said Phuong Nguyen, a co-author of the IFPRI study, on email.

Another study from IFPRI had found that despite health and nutrition education increasing three-fold from 3.2% in 2006 to 21% in 2016, the poorest mothers had the second worst coverage of health and nutrition services (after the richest group), IndiaSpend reported in March 2019.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

The post ‘For Children’s Nutrition, Mother’s Education More Important Than Family Wealth’ appeared first on SabrangIndia.

New Delhi: “One has to be alive to be a patriot,” former Indian health secretary K Sujatha Rao wrote on Twitter on May 13, 2019, referring to election debates that focussed on issues of “nationalism and terror and not health”.

The data back Rao’s assertion of misplaced priorities.

In 2017, terrorism claimed the lives of 766 Indians, or 0.007% of all deaths, while health reasons claimed 6.6 million Indians, or 90% of all deaths.

In 2017, the last year for which comparable data are available, India’s spending on defence was double its health expenditure, according to the 2017-18 budget.

Poor investment in health and education directly impacts the country’s productivity and economic growth. Indians work for six-and-a-half years at peak productivity, compared to 20 years in China, 16 in Brazil and 13 in Sri Lanka, ranking 158th out of 195 countries in an international ranking of human capital, as IndiaSpend reported in September 2018.

8,000 times more deaths from ill-health than terror
There were 9.9 million deaths in India in 2017, with a death rate of 717.79 deaths per 100,000 people, according to the 2018 Global Burden of Disease (GBD), a global estimate of morbidity and mortality published by the University of Washington.

Communicable, maternal, neonatal and nutritious diseases caused 26.6% of all deaths in India, and non-communicable diseases caused 63.4% of all deaths, while injuries accounted for 9.8%.

Deaths by conflict and terrorism fall under the “interpersonal violence” category, accounting for 0.007% of all deaths, or 766, according to GBD data.

Terrorism claimed fewer lives, according to another database: there were 178 terror incidents reported nationwide in 2017, killing 77 and injuring 295, according to the South Asia Terrorism Portal.

Deaths due to diabetes (254,500), suicides (210,800), infectious diseases (2 million) and non-communicable diseases (6.2 million) put together are 8,000 times the deaths caused by terrorism (766).

Defence vs health vs education spending
“… Hlth [Health] & edu [education] need to be top (sic) & [at] least 8% GDP allocated 2 [to] them,” Rao wrote in her tweet.

India’s public health spending is among the world’s lowest. With a fifth of the world’s population, India’s public expenditure was 1.02% of gross domestic product (GDP) in 2015, IndiaSpend reported in June 2018.

While India’s public-health spending was estimated to be 1.4% of GDP in 2017-18, the equivalent proportion of GDP spent on health in the Maldives is 9.4%, in Sri Lanka 1.6%, in Bhutan 2.5% and in Thailand 2.9%.

India is the fifth largest defence spender in the world. The defence budget in 2017-18 was Rs 4.31 lakh crore ($ 72.1 billion, using 2017 rates), or 2.5% of GDP, as per Institute of Defence Studies and Analyses, a think-tank. This is double the health budget that year, according to our analysis.

About a fourth of the defence budget, or 24%, goes towards pensions.
 

Source: Economic Survey 2017-18, Institute of Defence Studies and Analyses

In 2017, India’s school education budget, including central and state spending, was about Rs 4.41 lakh crore ($ 73.8 billion) or 2.6% of GDP, more than defence and health separately. However, almost half of India’s grade V students cannot read a grade II text and more than 70% cannot carry out division, according to the Annual Status of Education Report (ASER) 2018, IndiaSpend reported in January 2019.

India had the second-lowest score for quality of education in South Asia in 2016 (66 out of a possible 100, just ahead of Afghanistan’s 64) and behind group leader Sri Lanka (75), IndiaSpend reported on September 25, 2018.

Health and education need more money
While India’s health budget is rising–in 2018 it was double of what it was in 2010–as IndiaSpend reported in January 2019, it is still inadequate, considering that India is home to a third of the world’s stunted children, has the highest number of tuberculosis patients and reports among the world’s highest out-of-pocket expenditure, an indicator of public healthcare failures.

The National Health Policy of 2017 talked about increasing public-health spending to 2.5% of GDP by 2025, but India has not yet met the 2010 target of 2% of GDP, IndiaSpend reported in April 2017.

The National Policy on Education, which guides India’s approach to education, has since 1968 recommended a minimum spending of 6% GDP on education but that target has never been met. There have been “pervasive and persistent failures in implementation leading to sub-optimal utilisation of the resources provided”, the 2016 document said.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

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Despite the reduction, India’s IMR in 2017 remained higher than the global 29.4, a rate equivalent to that of the West African nation of Senegal and higher than most South Asian neighbours’ except that of Pakistan and Myanmar.

IMR is considered a rough indicator of a country’s overall healthcare scenario. The latest data come from the Sample Registration Survey (SRS) Bulletin, which is released by office of Registrar General and Census Commissioner, Ministry of Home Affairs. The last SRS bulletin was released in September 2017.

In 2017, India’s rural areas had an IMR of 37 and urban areas 23, revealing difference in healthcare quality and access despite implementation of a national programme to bridge this gap, the National Rural Health Mission, since 2005.

Source: Sample Registration Survey 2019, 2007

Among Indian states, Madhya Pradesh recorded the most number of deaths of children younger than one (IMR 47) in 2017, followed by Assam (44) and Arunachal Pradesh (42). Madhya Pradesh’s IMR was equivalent to that of the West African country Niger’s, 80% of whose land area lies in the Sahara Desert and which ranked the very last on the United Nations’ Human Development Index in 2018.

As for the Indian states that performed well, Nagaland recorded the lowest IMR of 7–corresponding to that of Kuwait and Lebanon–followed by Goa (9) and Kerala (10).

Close behind were Puducherry (11), Sikkim (12)  and Manipur (12), all small states (with a population of less than 10 million), except Puducherry, which is a union territory (federally administered area).

Large improvement in some states

When compared to 2006 SRS figures for IMR, among India’s larger states (with a population larger than 10 million), New Delhi and Tamil Nadu both slashed their infant mortality rates by 57%–from 37 in 2006 to 16 in 2017.

Other states which showed similar declines were Jammu and Kashmir (-56%), Himachal Pradesh (-56%) and Punjab (-52%).
Among smaller states, Nagaland showed the most decline of 65% from 20 in 2006 to 7 in 2017, followed by smaller state Sikkim (-64%) and union territories Dadra & Nagar Haveli (-63%) and Puducherry (-61%).

Slow change in others

Similarly, states of Manipur and Arunachal Pradesh are the only ones where the IMR increased between 2006 and 2017, from 11 to 12, and 40 to 42, respectively.

Uttarakhand (-5%), West Bengal (-15.8%) and Tripura (-19.4%) are states showing the slowest decline in IMR between 2006 and 2017.

Source: World Bank

Indian IMR worse than most neighbours’

India’s IMR of 33, as we said before, remained worse than that of Nepal (28), Bangladesh (27), Bhutan (26), Sri Lanka (8) and China (8), but better than that of Pakistan (61) and Myanmar (30).

Household wealth and maternal education play an important role in infant and child mortality, and states with more educated women show better health outcomes for children, IndiaSpend reported on March 20, 2017. Also, a child born in a household on the highest stratum of the wealth index was about three times more likely to survive early childhood compared to a child born in the lowest stratum,  IndiaSpend reported in January 2018.

Only one third of women (35.7%) have more than ten years of schooling in India while there is high inequality where nine individuals own wealth equivalent to 50% of the country.

Indiaspend.org is a data-driven, public-interest journalism non-profit/FactChecker.in is fact-checking initiative, scrutinising for veracity and context statements made by individuals and organisations in public life.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

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Goti Bai with her earthen chulha used for everyday cooking. She received a gas stove, cylinder and regulator under PMUY but cannot afford a refill.

A farmer from Khatlabor village in north Rajasthan’s Pratapgarh district, Bai is one of 80 million poor Indian women to benefit from the scheme titled Pradhan Mantri Ujjwala Yojana (PMUY).

On a scorching April afternoon when we arrived at her home, Goti Bai was busy with a weekly meeting of the local self-help group. How does she cook? we asked. She pointed to the chulha (earthen stove) on the floor of her one-room home. This windowless space serves as the living room, bedroom and kitchen for her family.

The steel gas stove that Goti Bai got as a part of the PMUY package sat on a high wooden beam, smothered in dust and cobwebs. She led us to her cowshed, her lavender odhni (stole) pulled firmly over her face as is the custom among the women of the region when they are in the presence of unknown men.

We were accompanied by volunteers of Prayas, a non-profit working on health, livelihood and gender in Rajasthan, as we investigated why PMUY has been unable to phase out chulhas in rural kitchens, as Factchecker reported on April 22, 2019.

Goti Bai’s LPG cylinder sat behind bales of cattle fodder. “We don’t have the money to buy a refill,” Got Bai explained.

The programme, started in 2016, gives women from below-poverty-line households their first gas cylinder, a regulator and a connecting tube. The government pays the security deposit for the cylinder, the cost of regulator and the installation charges–Rs 1,600 in all–as a kind of “loan” that is later deducted by the gas agencies from the LPG subsidies that beneficiaries get in their bank accounts.

After this, families have to buy their own refill cylinders that cost about Rs 800-850 each upfront. Even though an amount of Rs. 200 is deposited in their accounts after the loan amount is deducted, many beneficiaries cannot afford this price upfront, we found. Most homes in Khatlabor continue to cook on chulhas using firewood, dung and coal, breathing in noxious smoke, said Jawahar Singh, Prayas’ district coordinator in Pratapgarh.

We found this true of many villages we visited in Chittorgarh and Pratapgarh districts. Families that do use LPG to cook, do so sparingly–to brew a cup of tea, for example, or on a rainy day when firewood turns damp. This is despite the fact that Rajasthan ranks third in the number of LPG refill connections as per this December 2018 report from The Hindu BusinessLine.

Apart from the expenses involved in buying refills, there are widespread cultural factors as well: Food cooked on traditional stove is considered “healthier” and “tastier” by many. Also, in a society where gender skews are entrenched, the health risks women face from sustained use of solid fuels tend to be disregarded.

Our findings are supported by other studies as well: 73% of beneficiaries in rural Bihar, Rajasthan, Uttar Pradesh and Madhya Pradesh–where two-fifth of India’s rural population lives–still use solid fuels for cooking due to financial reasons and gender inequality, said a February 2019 study by Research Institute for Compassionate Economics (RICE), a non-profit research organisation. Further, researchers found 85% of Ujjwala beneficiaries still use solid fuels for cooking.

While 76% of households owned a LPG connection by 2018, an increase of one-third from 2014; 98% of household owned both chulha and a gas stove and 36% exclusively cooked on a chulha on the day before the survey.

‘Why buy cylinder when firewood is freely available?’

The scheme’s stated intention is to empower women by sparing them the discomfort of working in “smoky kitchens” or having to “wander in unsafe areas for firewood”, as per the official website. The government has claimed that till January 2019, 80 million households received free cylinders and 60 million received connections.

But these numbers do not reflect the reality of LPG use in the kitchens of beneficiaries, we found by listening to the stories of the women members of a local self-help group gathered in Goti Bai’s courtyard.

“I got a cylinder in 2017 but we had to pay Rs 200 [to middle men for documentation],” said Poorki Bai, 42.  She has got three refills since, about one each year.

How did a single cylinder last that long? “I still cook on the chulha, the cylinder is for cooking in a hurry, to make chai when guests arrive or during the rainy season when the firewood is damp,” she said. Other women nodded their heads in agreement: An LPG cylinder at Rs 800-850 is about 13% of their average monthly earning of Rs 6,345, according to the Rajasthan Economic Survey, 2017-18.

Researchers at RICE found that since most rural households could gather free solid fuels–firewood, dung, agricultural residue–in their neighbourhood, an LPG refill is considered an expensive alternative. This was especially the case for those who live near forests where they could find firewood or owned animals that yielded dung.

At Katlabor village, Kali Bai, 18, with the stack of firewood she and her mother collected. This pile will last her family a year. It is usually the women who collect firewood in the dry season in Rajasthan.

“Why will we buy a cylinder when firewood is available free of cost?” asked Poorki Bai.

The 2019 RICE study asked respondents to name the fuel they used in their kitchens the day before they took the survey: Richest households had higher chances of exclusively using LPG to cook than those with fewer assets, it was found. The richest households also used solid fuels to cook at least one food item a day, as per the study.

Most houses in interior Rajasthan have two chulhas, one in the inner room/kitchen and other parked in the veranda. The outdoors one is used during summers and the indoors during winters and rains.

We found in our visits to local homes that the chulha is usually kept in a windowless room where the ceiling has turned black with soot. Women normally cook squatting in front of the stove, inhaling harmful smoke. During winters, families huddle around the chulha for warmth and this includes infants and small children.

Household air pollution led to 482,000 deaths in 2017

Solid fuel like firewood, cow dung and dry grass are highly damaging to health. Cooking on traditional chulhas leads to incomplete combustion, and emission of particles such as suspended particulate matter, carbon monoxide, polyaromatic hydrocarbons, polyorganic matter and formaldehyde. All these are harmful for respiratory health.

Household air pollution led to 482,000 deaths and 21.3 million disability adjusted life years (DALYs)–years lost due to ill-health, disability or early death–in 2017, according to a study published in The Lancet Planetary Health, a global journal, as IndiaSpend reported in December 2018.

The same study showed that even in 2017 more than half (55.5%) of India still used solid fuels–dung, coal, wood and agricultural residue–for cooking. The numbers were much higher–over 72.1% or about 486 million people–in Bihar, Jharkhand, Odisha, Chhattisgarh, Assam, Madhya Pradesh and Rajasthan. These states together suffered half the deaths caused by household pollution.

Particulate matter, known as PM 2.5, is 30 times smaller than human hair and has the ability to travel through the blood vessels to different organs causing lower respiratory infections, ischaemic heart diseases, stroke, chronic obstructive pulmonary disease, lung cancer and diabetes.

Krishna Bai, 32,  an accredited social health activist from Keshavpura, Pratapgarh district, has not received an LPG connection despite filling the form and requesting the panchayat.

Women, children most vulnerable to household air pollution

Of all premature deaths caused by household air pollution, 44% were due to pneumonia, 54% due to chronic obstructive pulmonary disease (COPD), and 2% due to lung cancer. Women and younger children who spend the most time at home are the most vulnerable.

Exposure to air pollution during pregnancy leads to outcomes such as low birth weight and stillbirth.

COPD, typified by coughing, wheezing and breathlessness, is the second highest killer in Indians, responsible for death of almost 1 million Indians in 2017, IndiaSpend reported in March 2018. It is caused by the inflammation of airways in the lungs and results in the destruction of air sacs that extract oxygen and expel carbon dioxide.

In 2017, Rajasthan had the highest death rate due to air pollution–112.5, meaning 112 people in every 100,000 died due to air pollution impact. The state also ranks second worst after Chhattisgarh with 1,752 DALYS or disability adjusted life years per 100,000.

Switching from solid fuels to LPG cylinder can prevent these deaths and disability but PMUY’s implementation is riddled with many challenges.

Not enough awareness about health hazards

Another study on 550 PMUY households found most of the households lacked knowledge about health hazards of cooking with solid fuels. In their survey in Bikaner, Rajasthan, researchers from Delhi-based Institute for Economic Growth found 13% respondents considered serious health impact of solid fuels exist, 27% perceived no ill effects while 60% thought health effects were temporary like eye irritation, coughing etc. when cooking with solid fuels.

Then, the researchers explained the ill-effects of solid fuel use–from childhood pneumonia to heart disease. They gave the households a discount voucher and found that informed households had a 36% higher rate of using the voucher than the others.

When researchers asked households to quote the maximum price they were willing to pay for an LPG cylinder, the answer was Rs 352. This is 40% of the market price of a cylinder (around Rs 850) and even after subsidy of Rs 200, it would be 50% of the cost.

Medical fraternity too is unaware of air pollution hazards

There were three-to-four COPD patients each in the 50-bed male and female wards at the district hospital in Chittorgarh. Mangal Lal, 70, a farmer from Achalpura village had been hospitalised three days ago after a bout of acute breathlessness. A widower, he has been living alone since his daughter got married. Lal was a beedi smoker all his life but quit three years ago. “I cook my own food on the chulha,” he told IndiaSpend, struggling to breathe.

70-year-old Mangal Lal suffers from chronic obstructive pulmonary disease. He has been beedi smoker all his life but quit three years back. He still cooks his food on a chulha.

“We do get COPD patients but most of them have a history of smoking and most of them are male,” said Madhup Bakshi, principal medical officer at the district hospital, Chittorgarh. Since COPD takes a few decades to develop, most of his patients are older. “There are very few women who come to us with COPD symptoms, they may have a natural resistance to the disease,” he said.

In the female ward, we met Shankari Bai, 70, who sat on her bed unable to breathe. Every word she spoke was followed by a long struggling breath. After a while, her granddaughter started answering the questions for us.

Shankari Bai (right) has been suffering from COPD for the last five to six years and cannot walk long distances. She has not been prescribed inhalers.

Shankari Bai has cooked on the traditional chulha all her life even though she received a cylinder two years ago. About 5-6 years ago, she started complaining of breathlessness.  Under treatment for last 3-4 years, she has never been prescribed inhalers, only tablets.

The best treatment for patients with COPD is inhalation therapy using bronchodilators that relax the muscles around the airways and corticosteroids that prevent the inflammation of airways or a combination. But patients we met were given drugs, injections and syrups.

There was also lack of awareness among chest specialists about the prevalence of COPD in the region. “Smoke from chulha is not a big risk factor for COPD,” said Rakesh Bhatnagar, chest physician, at the hospital. “Women do come for respiratory illness but COPD is not common among them.”

But data show this is not true: COPD was responsible for 8.59% of all deaths in Indian women, almost equal to 8.71% in men in 2016, as per the Global Burden of Disease, 2017 data.

About 90,000 patients died due to air pollution in Rajasthan, about 39,000 were due to household air pollution, stated The Lancet Planetary Health, as we mentioned earlier.

There are cultural and gender-related reasons why the chulha is not disappearing from rural kitchens. Since women do most of the work involved in organising and using solid fuels, families do not even think of the opportunity cost of the time spent collecting firewood or cow dung.

Food cooked on chulha is ‘tastier’, ‘healthier’

Also even though people agreed that cooking on gas was easier and better for the health of cook, most also believe that the use of solid fuels made food “tastier” and “healthier”.

“I remember sitting with a Jain family in Madhya Pradesh and their daughter, who was studying for BSc in biology, explaining to me that wood-smoke improves eyesight because it washes away impurities,” said Aashish Gupta, co-author of the paper and research fellow at RICE.

“Another Brahmin old man explained that carrying loads and cooking with solid fuels involves substantial kasrat (exercise) which improves women’s health. We heard ‘Gas ka khane se gas hoti hai (food cooked with LPG induces stomach gas) in rich as well as poor households.”

Households that owned an LPG thought it is easier to cook using it (77.4%) but food tastes better when cooked on chulha (92.2%). Further, 86.5% thought cooking on chulha is better for health of the person who eats it though 69.8% thought it is worse for the person cooking it in the RICE study.

These findings show how many women knowingly sacrifice their own health and comfort for the comfort of their children, husbands, and other family members.

In Pratapgarh, we found similar barriers. Women weren’t taught how to use LPG cylinders and men were okay with that. “I am afraid of lighting the gas stove, I may burn down the house,” said Kesari Bai, 45, whose husband went to Pratapgarh to get the cylinder. Only her sons were confident about turning on the gas stove.

“I know chulha smoke is bad for us, it leads to burning of eyes, cough and itching but what to do?” said Kesari Bai. She wasn’t alone, three of the other women especially older women in the village express fears about lighting a gas stove. Having heard of such incidents, they were also worried the cylinder would explode.

Not everyone who wants a cylinder gets one

At the anganwadi (childcare) centre in Kesavpura village in Pratapgarh, the sahayika (helper) was cooking sooji halwa (semolina porridge) over a chulha, surrounded by children. The centre did not have an LPG cylinder connection. The local ASHA (accredited social health activist) worker Krishna Bai, 32, had filled a form and put in a request for a cylinder with the panchayat but hadn’t heard back.

Sumitra Bai from Acchoda village has yet to get a gas connection despite many requests.

“Please get me a cylinder,” Sumitra Bai pleaded with us when we were interviewing villagers about Ujjwala. A labourer who works in the mines at Acchoda village in Chittorgarh district, she was tired of cooking on a chulha after an exhausting day at work, she said. “I have gone to the [district] collectorate and to the gas agency but they keep saying that your name is not in the list,” she said, showing us her Aadhaar card and bank account, both required for PMUY benefits.

In a random survey conducted by volunteers and staff of Prayas, the percentage of households without cylinders showed up thus in three villages across Pratapgarh and Chittorgarh districts–42% (12/28) in Khatlabor, 45% (33/72) in Kesarpura and 20% (10/50) Sowani.

60% Ujjwala households claim they did not get subsidies: study

Also there seemed to be a very low awareness about the LPG subsidy that is deposited in bank accounts linked with Aadhaar. “We didn’t get any subsidy in our bank account,” was a common complaint across the villages we visited.

Under PMUY, as we explained, beneficiaries get a gas connection, stove, regulator and one LPG cylinder at a subsidised rate. This is either provided to the beneficiaries as a loan or gas agencies deduct the amount over time from the subsidies that the beneficiaries get.

The RICE study also found 35% of all LPG-owning households, and 60% of households that received LPG through Ujjwala, reported not receiving the subsidy at all.

A substantial portion of these households are likely to be those that have not yet paid the “loan” component of the Ujjwala but “most of these households were not aware that this was the reason”, said the study which added that the Ujjwala guidelines have not been explained to most households. Additionally, some of these households have paid the loan component, and are still not getting the subsidy, for various reasons. Most of these could be due to glitches in the usage of Aadhaar, said Aashish Gupta of RICE.

“We have provided gas connections to over 3,000 beneficiaries since April 2016,” said Rakesh Badala, owner of Priyanka gas agency in Gandhinagar locality of Pratapgarh. He said in Pratapgarh, the gas agencies are recovering the initial Rs 1,600 they waived off from the subsidies. “After the initial 6-7 refills, the subsidy amount reaches the beneficiaries,” he told IndiaSpend.

Acchoda village is populated by Kanjars, a marginalised community branded “criminal” by the British and now denotified later. They still struggle for social acceptance and have few avenues to earn and live with dignity. Most Kanjars here work in the mines and only Salagram Kanjar’s family has bought refills, about six. “I don’t know if I received any subsidy,” he told IndiaSpend. “I can’t read and the bank official said I didn’t receive anything.”

In order to effectively promote the use of LPGs, the government will have to reduce the cost of the cylinders and explain the benefits of cooking with LPG while breaking the myths around it, experts believe. “Larger subsidies for cylinder refills, informational campaigns that educate about the harms of air pollution exposure, and behavioural campaigns that change attitudes:” These are some of the recommendations of the researchers at RICE.

Further, Ujjwala is emphasised as a project for women but if men were encouraged to take on household tasks like cooking through a public campaign, the use of LPG cylinders may accelerate at a faster pace.

Reporting for this article was supported by the REACH Lilly Media Fellowship Programme on Non Communicable Diseases.

(Yadavar is a principal correspondent with IndiaSpend.)

Courtesy: India Spend

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An infectious air-borne bacterial disease that mostly affects the lungs but is preventable and curable, TB kills 421,000 Indians every year. That is the equivalent of passengers dying in 2,100 Boeing 737 MAX (200-seater) crashes, or more than five such crashes a day.

Indian TB deaths represent 32% of global TB mortality, and from current trends the country is not likely to meet its 2025 target of eliminating the disease, said the report, Building a tuberculosis-free world: The Lancet commission on tuberculosis published in the medical journal Lancet on March 21, 2019. The global target for eliminating TB is 2030.

On 12 indicators of its battle against TB, India is on track on two (tobacco taxation and political will), approaching its target on three (children with TB, universal health coverage service score and prevalence of undernourishment), but trailing on seven, namely drug- and multi-drug-resistant TB, national public-health financing, social-protection system, catastrophic health expenditure, anti-retroviral treatment for HIV patients and air pollution.

India needs to provide better diagnostic and treatment services, prioritise private provider engagement, provide universal access to drug susceptibility testing at the time of diagnosis and invest in active case-finding strategies to reduce its TB burden, said the commission report, which was chaired by Eric Goosby, a professor of medicine and infectious diseases expert at the University of California, San Francisco.

The Lancet TB commission involved 37 TB commissioners from 13 countries and mapped out priorities in diagnosis, treatment, prevention and advocacy efforts to end tuberculosis by 2030.

Currently, 10% of India’s TB patients die because they do not go to a doctor or go too late. It takes them an average of 4.1 months to get to a doctor and 57% of patients do not reach a “high-quality treatment provider”, where they are most likely to be diagnosed and treated, said the Lancet report.

Bridging these “care cascade gaps”–or gaps in the steps that a patient takes in order to get cured–will reduce India’s TB incidence by more than a third (38%) between 2018 and 2035. For both TB burden and deaths, the most important factor is patients visiting the private health-care sector in India, said the report.

Improving the state’s engagement with the private sector, where 80% of India’s TB patients seek early care, can save up to 8 million lives by 2045, said the report.

It would cost India an additional $290 million (Rs 1,999 crore) to “engage with” the private sector, said the report. Although that is half the current national TB budget, it is 0.9% of what India’s TB mortality costs: $32 billion.

Each dollar invested in reaching TB targets would provide a return of $16 to $82, said the report.

A quarter of India’s TB budget was spent on addressing the quality of TB care in the private sector, union health minister JP Nadda wrote in the TB commission’s report. This included free diagnosis, including rapid molecular tests, financial incentives to private providers, web- and mobile-based TB notification systems, digital technology for treatment adherence, etc.

Private-sector engagement
As we said earlier, 80% of TB patients first seek care in the private sector, where 46% get all their treatment. However, the quality of treatment in the private sector can vary.

In a sample of TB patients from Mumbai, seeking care from both the public and private sector, the average time taken to diagnose and start drug-resistant TB treatment was 87 days. The shortest time to start treatment was one month and longest around eight months. For drug-sensitive TB, when first-line TB drugs were effective, the duration ranged from 28 to 42 days, depending on the patient’s previous history of TB and treatment, IndiaSpend reported in February 2019.

Before 2009, only 1.5% of state TB spending in India was set aside to engage NGOs and private providers. The National Strategic Plan for Tuberculosis Elimination (NSP 2017-25) promised increased funding and called for a six-fold increase in “notification”–as reporting of TB patients is called–to 2 million patients per year by 2020 from the private sector, which would represent 75% of all estimated TB patients.

In 2017, 1.8 million TB cases–21% from the private sector–were notified in the national electronic system, called Nikshay. In 2018, 2.1 million TB cases were notified, an overall increase of 17%, of which 24% came from the private sector.

However, only 35% TB cases were handled correctly by the private healthcare sector in Mumbai and Patna between November 2014 and August 2015, IndiaSpend reported in October 2018.

Implementation hurdles
Despite the government’s commitments and claims, uneven implementation has slowed progress.

For example, even though the private sector treated about 2.2 million patients, according to this 2016 study in The Lancet, only about 541,000 were notified, as per Nikshay records in 2019. That means 76% of TB patients from the private sector were not reported to the government.

India is still in the process of implementing a universal drug-susceptibility test (DST), which detects drug resistance on all TB samples, as it has committed to under the NSP 2017-2025.  Only 257 of India’s 712 districts offer the universal DST test, according to the India TB Report, 2018, and only about 32% of notified TB patients underwent universal DSTs, IndiaSpend reported in January 2019.

These testing failures could explain why no more than 28% of India’s 135,000 estimated drug-resistant TB patients were diagnosed and only 26% treated in 2017, according to the Global Tuberculosis Report 2018.

Despite 2018 WHO guidelines that make bedaquiline–a new drug for TB–part of the core regimen for 135,000 drug-resistant TB patients in India, only 3,000 received the drug till January 2019, we reported.

(Yadavar is a principal correspondent with IndiaSpend.)

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Courtesy: India Spend

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New Delhi: Despite a four-fold increase in the number of women and children receiving supplementary nutrition under the Integrated Child Development Services (ICDS) programme in the 10 years to 2016, a large proportion of the poorest have not benefited, a new study has found.

Anganwadi worker Madhubala, 47, at a pre-school education class at an anganwadi held in a primary school in Kuiya village, Farrukhabad, Uttar Pradesh.

Women who were uneducated or from the poorest households had lower access to the flagship programme the study found. While the poorest households had the highest utilisation of ICDS services in 2006, their share became the second lowest in 2016, the study says, suggesting that the reasons could include poor delivery, difficulty of accessing remote regions, and social divisions such as caste.

Started in 1975, ICDS, the world’s largest scheme of this kind, provides nutrition and health services to all pregnant and lactating mothers and children under six years of age. In addition to take-home food supplements and hot, cooked meals, the programme provides health and nutrition education; health check-ups; immunisation; and pre-school care services at either government-run anganwadi (childcare) centres or at home.

The study, “India’s Integrated Child Development Services programme; equity and extent of coverage in 2006 and 2016”, co-authored by researchers the International Food Policy Research Institute (IFPRI), a research advocacy based in Washington D.C., and the University of Washington, US, will be published in the World Health Organization’s April 2019 bulletin.

Using data from two rounds of the National Family Health Survey conducted in 2005-06 and 2015-16, the researchers examined equity in ICDS’ expansion and the factors that determine the utilisation of its services.

Low to middle socio-economic brackets were more likely to receive food supplements, nutrition counselling, health check-up and child-specific services than both the poorest and the richest groups, the researchers found. Women with no schooling were also less likely to receive ICDS services than those with primary and secondary education.

“Even though overall utilization has improved and reached many marginalised groups such as historically disadvantaged castes and tribes, the poor are still left behind, with lower utilisation and lower expansion throughout the continuum of care,” said IFPRI research fellow and study co-author, Kalyani Raghunathan, in a statement.

Researchers found these gaps especially pronounced in the largest states of Uttar Pradesh and Bihar, which also carry the highest burden of undernutrition. While both states have shown improvements in 2016, they still fall behind national averages, suggesting that overall poor performance in high-poverty states could lead to major exclusions, the authors said.

Even in better-performing states, exclusion of the poor could be due to the challenges of reaching remote areas despite attempts to close district-wise and caste-based equity gaps, Raghunathan said.

Proportion Of Children (6-35 Months) Who Received Food Supplements In 2016

Source: IFPRI

Coverage improves but the poorest still have less access

The study shows an increase in the number of beneficiaries of ICDS services from 2006 to 2016 in four key areas, along with an eight-percentage-point rise in the frequency of monthly supplementary foods provided to children:
 

• Supplementary food — 9.6% to 37.9%
• Health and nutrition education — 3.2% to 21%
• Health check-up — 4.5% to 28%
• Child-specific services — 10.4% to 22%

With the exception of Tamil Nadu, Chhattisgarh and Jharkhand, the coverage of food supplementation during pregnancy and lactation was less than 25% in most states in 2006 but increased in almost all states by 2016. The greatest expansion was seen in food supplementation during childhood, which reached more than 50% coverage in Jharkhand, Madhya Pradesh, Uttaranchal, Tamil Nadu and Andhra Pradesh.
The coverage of services has improved for the poorest group–from 11.7% to 34.8% for food supplement; 3.4% to 14.8% for nutrition counselling; 5.1% to 21.5% for health check-up; and 11.3 to 20.4% for child-specific services between 2006 to 2016.

However, barring the richest quintile–the top 20% wealth group–the poorest quintile had the lowest share in coverage of the four services in 2016. In 2006, poorest group had reported the highest share.

“Those belonging in the highest quintile may perceive ICDS as a scheme for the poor which is why they may opt out of the service,” said Purnima Menon, senior research fellow at IFPRI and co-author of the study, “It also could point out to the fact that the quality of the services would not be what they expect.”

Exclusion of the poorest could be due to difficulties with complying with programmatic conditions, the authors noted. But the most plausible explanation is poor service delivery in Uttar Pradesh and Bihar.

The two states are home to almost half of the poorest quintile (20%) of the Indian population and also have the lowest coverage of services, which adds up to the overall exclusion of the poorest quintile, said Menon. “Uttar Pradesh and Bihar have high fertility and high population so it’s likely they need more ICDS centres, and more financing to ensure full-scale delivery of all services,” she said.

When the researchers analysed the differences between different caste groups in accessing services, they found that in 2006, scheduled castes and scheduled tribes were twice as likely to receive supplementary nutrition as other groups, but in 2016 the differences were smaller.

Of all castes, Scheduled Castes and Scheduled Tribes utilised ICDS services the most, the study said. In Odisha and Chhattisgarh, with large tribal populations, efforts to strengthen the system seem to have worked, as have efforts to focus on tribal areas as part of the state health mission in Maharashtra, the authors said.

Scheduled Tribes are among India’s poorest with 45.9% falling in the lowest wealth bracket, IndiaSpend had reported in February 2018.

Mothers with no schooling received fewer ICDS services

While only 34.7% of uneducated mothers received food supplements, 43.7% of those with primary education and and 43.8% of those with secondary education did. This trend was visible across services, although those with the highest category of education also had lower access.  

“The women with no education may intersect with the poorest quintile which is predominantly in UP and Bihar, which could explain their poor utilisation but we are yet to analyse this,” Menon said, adding that there is much to be explored in further analyses.

ICDS: From patchy start to universal coverage

ICDS services were patchy throughout the early 2000s. A 2005 World Bank report said that since children in the crucial development age-group of 0-3 years were not getting enough attention, maring the programme’s effectiveness. Also, ground-level staff lacked adequate training, political commitment was missing, and the programme failed to reach out to the poorest households and the lower castes.

Another 2006 study found only 6% girls aged 0-2 years and 14% aged 3-5 years received supplementary nutrition despite 90% of their villages having an ICDS centre. These led to reforms from 2006 to 2009–more funds and provision of supplementary nutrition in a rights-based framework.

In 2006, India’s Supreme Court ruled that the programme was to be offered universally. Soon after, the government expanded its services across India, with a goal of ensuring about 1.4 million centres across the country. Today, ICDS serves about 82 million children younger than 6 years and more than 19 million pregnant women and lactating mothers.

Why ICDS scheme needs more attention and support

Previous studies have shown that greater coverage and utilisation of services leads to improvement in health–for example, this 2015 study showed that girls who received supplementary nutrition grew taller than their peers.

However, there has been a decrease in funding for ICDS in recent years and since it is a demand-based scheme, much of it is blamed on low demand from beneficiaries.

Although the present study shows an overall improvement in access, another story with a shorter time-frame shows the number of children from 6 months to 6 years who received supplementary nutrition fell by 17%  from 2014 to 2019 from 84.9 million to 70.5 million, and of pregnant and lactating mothers reduced by 13% from 19.5 million to 16.9 million, according to a 2019 budget brief by the Accountability Initiative of the Centre for Policy Research, a think-tank.

The number of beneficiaries fell across the country but was noticeably more in poorer states such as Bihar (53%) and Uttar Pradesh (25%). The share of anganwadi services in the overall budget for the ministry of women and child development fell from 89% in 2014-15 to 68% in 2019-20.

“While adequate funding is definitely an issue, the IFPRI study points out the fact that ICDS services are not reaching the poorest quintile and that means poor don’t know about the services or don’t find them convenient to avail [of] due either to access gaps or social norms,” said Avani Kapur, director, Accountability Initiative. “This means there is need for more home visits, behaviour-change communication, filling up [of] vacancies of CDPOs [child development project officers], lady supervisors and training of anganwadi workers,” she added.
The wages of frontline anganwadi workers were increased from Rs 3,000 to Rs 4,500 per month from October 2018, which Kapur said is a good move, adding that providing transport facilities to women supervisors to reach remotes tolas (hamlets) could also help.

(Yadavar is a principal correspondent at IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Courtesy: India Spend

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Farheen Chaudhari, 19, works as a mentor at Apnalaya, a non-profit working in Govandi, one of Mumbai’s largest slums. She was told to stop playing kabaddi by her 21-year-old brother.

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