In the first week of the ongoing Lok Sabha session, a few questions were asked about child health and the central theme of these questions centred around malnutrition. A recent UNICEF report has found that India ranks highest in annual number of deaths of children under the age of 5. Here’s a brief look at the findings of the report that also examines how India’s heath care policies have been able to cope with the issue of malnutrition, which is the cause of 68.2% deathsof children under 5 years of age.

About the report

The UNICEF report titled “The State of World’s Children 2019-Children Food and Nutrition” is being annually published by the UNICEF since 1980. The aim of publishing this report is to spread awareness and knowledge about issues affecting children and it advocates solutions that can improve children’s lives. This report is one of the many initiatives of the UNICEF. The report states that the triple burden of malnutrition – under nutrition, hidden hunger and overweight – threatens the survival, growth and development of children, young people, economies and nations. The overall findings of the report are that, at least 1 in 3 children under 5 is undernourished or overweight and 1 in 2 suffers from hidden hunger, undermining the capacity of millions of children to grow and develop to their full potential.

The UNICEF report may be read here:

India findings

According to UNICEF, 38% of children under the age of 5 in India suffer from stunting. In the worst affected state, almost 50% children suffer from stunting: in the least affected state 1/5th of the children suffer from stunting. Stunting is a clear sign that children in a country are not developing well – is both a symptom of past deprivation and a predictor of future poverty. The report also explains the triple burden of malnutrition, being – under nutrition, hidden hunger and overweight – which undermines children’s health and physical and cognitive development. Analysis of 2011-12 data suggest that in India 5% of rural and 8% of urban population bears the triple burden of malnutrition.

The report states that although India stands a chance of a good demographic dividend in the coming years, the same can only be realized with improvement in human capital, by investing in people’s education, training, skills and health and malnutrition stands as a hurdle in the path of a good demographic dividend in the future.

The report also mentioned that India’s health system provides curative care and foster positive family practices such as breast-feeding. In India, national and state governments implemented a multi-pronged strategy to support breastfeeding, including large-scale programmes, effective capacity-building initiatives, strong partnerships, community-based action, and communications campaigns. As a result, early initiation of breastfeeding rose from 24.5 per cent in 2006 to 44.6 per cent in 2014.

There was also a detailed mention of how India’s Comprehensive National Nutrition Survey (CNNS), which ran from 2016 to 2018 across all states captured the nutritional status of pre-school, school going children and adolescents up to 19 years of age.

Yet, India topped the list of countries with highest annual number of under-5 deaths in 2018, at 8,82,000 such deaths.

Malnutrition

India’s struggle with the malnutrition among children under the age of 5 (U-5) has been a long one. Malnutrition refers to a pathological state of deficiency or excess of nutrients. Under nutrition is known to be one of the most common causes of morbidity and mortality among children <5 years of age.

India’s policies tackling malnutrition

India has multiple health schemes many of which promote maternal care and nutrition as well child care and nutrition and there is a lot of awareness about the same among the masses that need it the most, i.e. the poor (urban as well as rural) and the rural population at large. One of the most successful models of child health and nutrition is the Integrated Child Development Scheme (ICDS) which was originally launched in 1975 but gained traction much later. ICDS was providing ineffective in tackling the issue of malnutrition as providing primary health care and nutrition is not the only provision in the scheme.

The government later launched Nutrition Rehabilitation Centres (NRCs) at public health centres to treat Severely Acute Malnutrition (SAM) cases. A recent study of these NRCs revealed that shortage of human resources was one of the major issues faced by them. The study was carried out in 4 NRCs and it was observed that only 70% of doctors, 7.4% of nursing staff, and 30% of attendants and cleaners were available across the four NRCs. NRCs provide life-saving care for children with SAM; however, the protocols and therapeutic foods currently used need to be improved to ensure the full recovery of all children admitted. To sustain the benefits and prevent relapse, there is a need to integrate the services at NRC with the community-based therapeutic care to deliver a continuum of care from facility to doorstep and vice versa.[1]

By the insertion of Article 21A in the Constitution, the right to education, hitherto an obligation on the State under the Directive Principles of State Policy became a justiciable right: through this, the 86th amendment to the Constitution in 2002, the State must provide free and compulsory education to all children of the age 6 to 14 years. The 86^th amendement also went further. It replaced Article 45 that comes under the Directive Principles of State Policy and was previously the only provision related to the right to education with a renewed pledge to read (amended Article 45): “The State shall endeavour to provide early childhood care and education for all children until they complete the age of six years.”

CNNS (Comprehensive National Nutrition Survey)

In the data provided on the Lok Sabha recently mentioned that CNNS results highlighted improvement in the U-5 category stating that in comparison to NFHS -4 (National Family Health Survey) which was carried out in 2015-16 there was reduction in cases of stunting from 38.4% to 34.7%, in cases of wasting from 21% to 17.3% and in cases of underweight children from 35.7% to 33.4%.

POSHAN (Prime Minister Overarching Scheme for Holistic Nourishment)

Under POSHAN, the government aims to attain a malnutrition free India by 2022. It was launched in 201 by Prime Minister Modi and it targets to tackle malnutrition by ensuring convergence of various nutrition related schemes. Its large component involves gradual scaling-up of interventions supported by on-going World Bank assisted Integrated Child Development Services (ICDS) Systems Strengthening and Nutrition Improvement Project (ISSNIP) to all districts in the country by 2022.

Since POSHAN is the foremost policy for tackling malnutrition and has such an ambitious target of eliminating completely, the menace of malnutrition that has plagued India’s health care for years now, it is important to study how well and effectively has this ambitious policy been implemented.

The government had planned to release a “Status of India Nutrition” report in March 2019 to rank states according tot heir performance under the POSHAN Abhiyaan. The report however, has not yet been released.

An opinion piece in Livemint argued that Anganwadi centres are supposed to be the point of delivery of all health related schemes and these centres are themselves struggling with infrastructure problems. Around 24% of them lacked their own building and operated from small rented premises, and around 14% lacked pucca buildings. Only 86%, 67% and 68% of AWCs had drinking water facilities, electricity connections and toilets respectively, some of which are either dysfunctional or could not be used due to conditions imposed by landlords. There is also lot of room for improvement in terms of achieving universalization of coverage and advanced service delivery in health care. When the cogs that POSHAN scheme depends are only not functioning at their best output, how can a scheme like POSHAN with such a behemoth task achieve its target completely.

It was reported in September 2019 that a recent study conducted by Indian Council of Medical Research (ICMR) estimated that many Indian states are running behind and may not be able to reach their targets under the POSHAN Abhiyaan.

Way forward

This indicates that India has still a long way to go in achieving its goal of eradicating malnutrition and thus malnutrition related deaths. What India needs is one integrated health plan for children below the age of 6 where all current elements of health care are firstly provided with the infrastructure they need and ensuring maintenance and periodic monitoring of records and data (for ease of assessment of performance) and regular and timely follow-ups. While awareness already exists, multiplicity of schemes makes the task convoluted.

Related:

Most states won’t meet Poshan Abhiyaan targets to curb child malnutrition: Study

Karnataka gov’t delays malnutrition alleviation report, HC warns of contempt proceedings

Gates Foundation study: Child malnutrition reduction targets impossible to achieve

38% Of Indian Children Under 4–Poor And Rich Alike–Are Stunted: Study

Mini Anganwadis Could Help The Poorest And Most Disadvantaged

Why India Is Likely To Miss Its Nutrition Targets For 2022

Budget for Children in #NewIndia in 2018-19

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Migrants often provide essential services in cities, working as drivers, gardeners, and domestic help, boosting cities’ economies. Yet, of a migrant population of 62.6 million in Mumbai, Kolkata, Hyderabad, Chennai, Bengaluru and Delhi in 2011, 33.4 million went to the urban fringes, found the analysis by India Migration Now, a Mumbai-based nonprofit.

These urban fringes have limited civic infrastructure and municipal facilities, prevent migrants from accessing all the opportunities of the main city, and make them susceptible to poor health and living conditions.

Internal migration, both within a state and across states in India, improves households’ socioeconomic status, and benefits both the region that people migrate to and where they migrate from, as IndiaSpend reported in August 2019. Remittances can help reduce poverty in the migrants’ places of origin.

Migration of socio-economically backward people to cities is one of the best ways of promoting inclusive development by providing infrastructure in city centres at lower costs, generating employment, and facilitating the movement of the population from remote and inaccessible areas.

Yet, interstate migration in India is less than in other countries at a similar stage of economic development, studies show. A 2016 World Bank study attributed this partly to the migrant-unfriendly policies in many parts of the country, which also force migrants to the outskirts of cities.

Urban agglomerations

Urban agglomerations such as Mumbai and Delhi include a continuous urban spread of a town and its adjoining outgrowths–such as Central Railway Colony in Mumbai–or, two or more physically contiguous towns–such as Noida in the case of Delhi–according to the Census.

India’s urban agglomerations often spread over several districts, have a population above 7 million, cover various municipal corporations, and have an urban core and an urban periphery (peri-urban area).

The India Migration Now analysis categorised areas as urban and peri-urban based on distance to the urban core, population, presence of a municipal corporation, the proportion of workers engaged in non-agricultural activities and the nature of urbanisation of the area, based on the 2011 census.

For example, in the Kolkata Metropolitan Area, the districts of Kolkata and Howrah were categorised as urban cores as they have municipal corporations, high percentages of built-up area and low rural populations. The districts of North 24 Parganas, South 24 Parganas, Nadia, and Hugli, with low percentages of built-up area, high rural population and no municipal corporation, were categorised as peri-urban.

Saturated cities

In 2001 and 2011, the proportion of migrants who settled in the urban periphery versus those who settled in the urban core was greater for the urban agglomerations of Hyderabad, Chennai, Kolkata and Mumbai.

In only two urban agglomerations, Delhi (12.5 million in the city, 1.3 million peri-urban) and Bengaluru (5.1 million in the city and 859,030 in the outskirts), did more migrants settle in the urban core, rather than the peri-urban.

The Bengaluru urban agglomeration is a relatively nascent phenomenon, and has only recently spilled beyond Bengaluru Urban into the Bengaluru Rural and Ramanagara districts. This could explain why the city is yet to reach its saturation point in terms of attracting migrants.

The National Capital Region (NCR) includes the National Capital Territory (NCT) of Delhi as well as 23 other towns in Haryana, Uttar Pradesh, and Rajasthan, as per the NCR Planning Board. In this analysis, the Delhi urban agglomeration includes only the NCT of Delhi and its immediately bordering districts. Movement from NCT of Delhi itself to various urban hubs (Gurugram, Ghaziabad, Gautam Budhh Nagar) of NCR accounts for 6.3% (783,474) of the migration into the urban parts of NCR.

Migration to Mumbai’s core stayed mostly constant between 2001 and 2011 (going from 5.2 million to 5.5 million), but migration to its peri-urban areas increased from 5.6 million in 2001 to 8.9 million in 2011. For no other urban agglomeration did migration to the core city increase so little over the decade.

Mumbai’s massive growth and urbanisation has been driven by migration since the 1800s, according to the 2009 Mumbai Human Development Report by the Ministry of Housing and Urban Affairs. In recent years, however, the landmass-to-population ratio has been inching towards tipping point in the main city, leading to growing slums and overcrowding, the report said.

Source: India Migration Now

This dashboard by India Migration Now shows migration into the urban and peri-urban areas of Mumbai, Delhi, Kolkata, Hyderabad, Chennai and Bengaluru in 2001 and 2011.

Discrimination against migrants

One of the reasons driving more and more migrants (and some locals) to the peri-urban areas is the cost of living in the urban core, especially of housing, according to a 2019 paper by the Observer Research Foundation, a Delhi-based public policy think-tank.

In addition to the high cost of living, government schemes for temporary and permanent housing exclude interstate migrants, according to the Interstate Migrant Policy Index 2019 (IMPEX 2019) by India Migration Now, which analyses state-level policies for the integration of out-of-state migrants.

Migrants often stay in slums and temporary habitations, and forced evictions without rehabilitation, compensation or notice push them to the fringes.

For instance, a tussle over prime city property and the perception that the urban poor are illegal and encroach upon land prompted state response in the form of large-scale “city beautification” drives and slum rehabilitation projects, according to this 2018 report by the Human Rights Law Network, a Delhi-based legal aid organisation. Evictions took place in major cities such as Delhi, Mumbai, Chennai, Bengaluru and Hyderabad.

Caste- and religion-based residential segregation, often connected to migratory status, also forces migrants to move to the peri-urban areas where the price of exclusion is at least lower, found a study published in the Economic and Political Weekly in 2012, and a 2018 working paper by the Indian Institute of Management, Bengaluru.

Migration trends among Muslims and Hindu Dalit (historically disadvantaged communities believed to be ‘lower’ castes) communities reveals diminishing access to urban space, because of several factors such as discrimination by housing societies, according to a 2019 analysis published in the journal Area Development and Policy.

Governments of several large states have had anti-migrant policies, through domicile reservation in employment, education and service delivery. For instance, the Andhra Pradesh (AP) government passed the AP Employment of Local Candidates in Industries/Factories Bill in July 2019 reserving 75% of private industrial jobs for locals.

In Maharashtra, where 80% of non-supervisory jobs and 50% of supervisory ones are reserved for state residents since 2008, the governing Bharatiya Janata Party-Shiv Sena alliance announced the possibility of a law monitoring better implementation of the quotas and extension of the law to contract-based jobs, according to this report in The Times of India published in August 2019.

The Aam Aadmi Party in Delhi wrote in its manifesto for the 2019 elections that it would reserve 85% of jobs for locals. The Karnataka government said it would implement 100% domicile reservation in private companies, according to a report in The Times of India in February 2019. All these states are home to many migrants who live and work in the periphery of their urban agglomerations.

Unequal access to health, sanitation 

Migrants have inadequate access to health facilities with regard to state-level health schemes, and central government health programmes implemented by state governments–which do not account for incoming migrants–found the 2019 IMPEX analysis.

Internal female migrants in Mumbai made lesser use of health facilities for childbirth, with less than a third receiving antenatal care, according to a 2016 study.

Migrant families are also the most vulnerable and nutritionally insecure because of lack of subsidised food, and children are the worst affected due to the unavailability of the government’s Integrated Child Development Services available to them, found a 2019 study of migrants at a construction site in Ahmedabad.

Access to infrastructural services–water supply, waste management, sanitation and transport facilities–reduces as one moves away from the urban core, according to a 2013 report by the World Bank. Those living in the peripheries bear the ecological, psychological and economic fallout of this lack of infrastructure.

For example, in Bengaluru, access to network services such as piped water is concentrated in the core with access levels rapidly dropping off toward the periphery, the report said.

“In Hyderabad, despite peri-urban areas being richer in water resources, the residents of these areas lose out to a wealthier urban core population with higher purchasing power when it comes to water access,” according to a research study by the South Asia Consortium for Interdisciplinary Water Resources Studies, a policy research institute based in Hyderabad.

Similar issues exist in the peri-urban areas of Chennai, particularly with regard to solid waste management, groundwater depletion and salinity, according to a 2014 study conducted by the United States East-West Centre, a non-profit based in Hawaii, USA.

Policing and traffic administration is also poor in peri-urban areas, according to a 2019 report by the Observer Research Foundation.

Neglected peri-urban areas

In peri-urban areas, which are largely neglected by both the urban and rural administrations, there is often confusion about who is responsible for public services: the panchayat or the municipal government, found a 2015 paper published in the International Journal of Engineering Research and Technology.

Master plans for Indian cities often legitimise the peripheries, but leave them unregulated, according to a 2018 working paper by Mrinalini Goswami of the Institute of Social and Economic Change in Bengaluru. One of the reasons for this is the lack of congruence between urban planning and the realities of local governance.

For example, under the 1985 Model Regional and Town Planning and Development Law, the elected officials of the Metropolitan Planning Committees (MPC) should draw up regional development plans for urban areas. The 74th Amendment to the Constitution mandates that at least two-thirds of the MPC should be elected or should have elected members of the municipalities and panchayats in the area.

Yet, the unelected bureaucracy of the Bengaluru Development Authority continues to be in charge of drawing up the master plans. As a result, planning remains static and top-down, without public participation, and unable to adequately account for the dynamic way in which the peripheries of cities, and the needs of people, change. Inadequate coordination between different government bodies also impacts the delivery of services to citizens, according to a 2013 World Bank study.

Social discrimination

Often, peri-urban areas have heightened caste or religious discrimination, even as the urban core becomes more diverse.

For instance, Raigarh district, in Mumbai’s periphery, has been the site of caste-based conflict and discrimination, according to an India Today report, published in April 2019.

Similarly, in Thane district, also a part of peri-urban Mumbai, caste outweighs all other parameters for political parties when choosing candidates, according to a Times of India report published in April 2019.

Interstate migration increasing slower than it should

Between 1991 and 2011, more Indians migrated than in the decade before, data show. In 2011, 453.6 million migrated, almost 1.4 times of the 314.5 million who migrated in 2001.

Still, interstate migration in India grew slower in the past two decades, increasing 32% from 41 million in 2001 to 54 million in 2011. In comparison, it increased by 55% between 1991 and 2001, data show.

The choice of the city people move to depends on factors such as proximity to their hometown, perceived availability and accessibility of work. For example, Gulbarga, in Karnataka, is close to Maharashtra and Telangana and sends migrants to Mumbai, Pune, Hyderabad and Bengaluru.
Historical migration trends, migrant networks and city infrastructure also impact the destination cities of migrants.

Many from the neighbouring states of Haryana and Uttar Pradesh migrate to Delhi, those from Uttar Pradesh and Bihar to Mumbai, and those from Rajasthan to Chennai and Kolkata, Census 2011 data show.

Need for new government policies

With migrant-unfriendly policies, it has become increasingly difficult for the poor to shift to urban centres in pursuit of survival. Only long-term inclusive policy-making which addresses the multiple exclusions faced by migrants in cities and peri-urban areas can help India capitalise on the opportunities of migration.

Provision of rental housing services, improvement of the service delivery system both in the urban and peri-urban areas, and better coordination between urban governance bodies could help urban agglomerations grow faster economically and provide more support to the migrant population.

(Mitra, Damle and Varshney are researchers at Mumbai-based nonprofit India Migration Now.)

Courtesy: India Spend

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When Narendra Modi became India’s prime minister in spring 2014 the Indian economy was in the doldrums. There was a clear policy paralysis in India’s central government, in large part due to the high profile corruption cases that involved the central government bureaucracy and politicians at the time. Modi promised Indians that “acche din” (good days) were coming. And there was expectation that the Indian economy would do well under a pro-business political regime, headed by a politician known for acting strongly and decisively.

India’s new ₹2,000 note. Shutterstock / Santhosh Varghese

Modi has had mixed successes in delivering on his promises. Here’s a breakdown of some of Modi’s key policies and how he has performed.

1. Demonetisation

India’s economic growth has not recovered to the high levels that were witnessed in the first decade of the 2000s. One important reason for the slow recovery was to do with the Modi government’s demonetisation policy. On November 8 2016, the government withdrew all 500 and 1000 rupee notes from circulation, announcing the issuance of new 500 and 2,000 rupee banknotes in exchange for the now-defunct old ones.

The aim of demonetisation was to deal a death blow to the black economy by reducing the perceived use of illicit cash to fund terrorism and illegal activities. Instead, the policy led to a contraction of the Indian economy, and economic growth slowed down to a four-year low in 2018.

Further, by 2018, around 99% of the bank notes that were made invalid had been deposited with the banking system, suggesting that a large proportion of the 500 and 1000 rupee notes in circulation were not counterfeit notes or black money, as the government thought. Thus, demonetisation led to a large economic loss without any clear benefits in terms of reducing the role of the black economy or corruption.

2. Goods and services tax (GST)

The Modi government’s second bold policy step was to launch the goods and services tax (GST) in July 2017. The aim of the GST policy was to create a common market in India, as opposed to the many different sales taxes that existed in different Indian states. The initial effect of the introduction of the GST was negative on the economy. This was especially the case for India’s large informal sector – which employs the vast majority of people outside of agriculture.

The initial implementation of the GST was not handled well – small businesses in particular were confused about onerous reporting requirements, which placed a large compliance burden on them. At the same time, the GST policy could be seen as one of the most important policy initiatives since the country’s landmark 1991 economic reforms and as the one of the most significant constitutional innovations since 1950. While the initial effect of the GST policy on the Indian economy was a negative shock, the long-term impact is likely to be strongly positive.
 

3. Delivery of public goods

Modi delivered on a large number of important public goods schemes, which built on the initiatives of the previous government. For example, toilet coverage in rural India increased from 47% of all households in 2015 to 74% in 2017, in large part due to the Modi government’s sanitation programme.

Modi’s modernisation plan has included building more than 90m toilets. Radiokafka / Shutterstock.com

As part of the Pradhan Mantri Awaz Yojana initiative, the number of rural houses built increased threefold from 2014 to 2016. There was also a large push on rural electrification to ensure all villages had an electricity connection by 2018.

4. Agriculture

Around 50-60% of India’s population have some form of economic reliance on agriculture. This sector has experienced a prolonged period of decline in rural incomes since 2011, leading to what may has been termed an agrarian crisis.

While the roots of this crisis are deep seated, it could also be attributed to the Modi government’s reluctance to increase minimum support prices for staple crops such as rice, wheat and pulses – something he promised to do in his 2014 campaign. This would have prevented the return of food price inflation, which was a major source of discontent with the previous government.

Tens of thousands of farmers protest in Mumbai. EPA-EFE/Divyakant Solanki

5. Jobs

Perhaps the most disappointing feature of the Modi government has been its lack of success in creating jobs for the large proportion of India’s labour force who are unskilled and poor. Unemployment rose to a 45-year high, according to a leaked report from India’s National Sample Survey Organisation.

The Modi government’s weak record in job creation was particularly surprising, given its original intention to rejuvenate the manufacturing sector as a source of job creation, with the much-heralded Make in India programme. Here, as in the case of agriculture, the roots of India’s manufacturing malaise run deep. They can be linked to India’s inability to foster the kind of labour-intensive industrialisation that has taken place in China and other East Asian countries.

The reasons for why this has been the case is complex, and can be linked to the low levels of skills among India’s workers, poor infrastructure and India’s antiquated labour laws. But, for all its reformist credentials, the Modi government made little headway in providing the jobs that India’s aspirational youth so desperately seek. This could prove crucial in the country’s 2019 national elections.

Courtesy: The Conversation

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