Unpalatable truths

TWO MALNOURISHED CHILDREN in their flooded tenement on the banks of the Yamuna in New Delhi, a file picture. According to the report, 42.3 per cent of the children in India are underweight.-JOHN MCCONNICO/ASSOCIATED PRESS

The hunger and malnutrition situation in the country has shown marginal improvement, according to the HUNGaMA report.

ONE area that has always bothered policymakers in a growth-obsessed economy is the state of the social sector, in particular figures indicating the numbers of people going hungry or are homeless and children who are out of school, the poor nutritional status of women and children, and the high infant and maternal mortality rates. Recent government surveys such as the National Family Health Survey (NHFS) - 3 and the District Level Household Survey (DLHS-2 in 2002-04) have repeatedly underscored several unpalatable facts relating to the well-being of the majority of the population. The HUNGaMA (Fighting Hunger and Malnutrition) report, a brain child of the Citizens' Alliance against Malnutrition, a broad coalition of young Members of Parliament and non-governmental organisations and coordinated by the Naandi Foundation, is one such effort that has captured, albeit incompletely in a holistic sense, the state of hunger and malnutrition in the country.

The report, which claims to cover 20 per cent of India's children from 73,670 families in 112 rural districts in nine States, received a lot of prominence and media coverage not only because of its catchy title but also because it was released by none other than Prime Minister Manmohan Singh. It claims to be the next best source of information after the publication of the DLHS-2, the last survey to have collected data on the nutritional status of children in the 0-71 months category. According to the report, the number of underweight children in 100 focus districts has decreased to 42.3 per cent from 53.1 per cent at the time of DLHS-2.

The product of a collaboration with some corporate partners, the survey for the report was done in 100 districts categorised as high-focus from the Bimaru States (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh). Twelve more districts were added, the six best from the Bimaru States and six from the high-performing States.

The report points out that the food crisis and the global economic downturn could have contributed to the deterioration in the state of affairs. Whether subsequent government data and surveys are going to corroborate the findings of the report needs to be seen. At the moment, the marginal improvement seems to suit one and all. But it is far from adequate. The Prime Minister's Council on Nutrition Challenges, constituted in October 2008, has met only once in November 2010.

The report has come up with many interesting facets, which need to be analysed in order to make meaningful interventions. It partially busts the myth that people do not access services. In the 100 high-focus districts surveyed, it was found that the immunisation facility for children through anganwadis was accessed by 85.8 per cent of the mothers interviewed; food for the 3-6 age group was also well patronised. In the better districts surveyed, the most accessed service was food. These districts also saw high attendance in the pre-school education for three- to six-year-olds. The report, however, does not venture to analyse these trends.

What these figures essentially mean is that services are accessed by people, provided they are made available and information about them is disseminated aggressively. Immunisation is one such campaign that has grabbed the attention of people in general. And what is more, people access services based on their needs. Food being a primary need, the availability of the same in the anganwadis is a godsend to many impoverished families that may or may not have access to the public distribution system (PDS).

The section on mothers highlights dominant feeding practices, issues relating to diet, hygiene, health care and the use of the Integrated Child Development Services (ICDS). The section looks at some of the issues from the perspective of mothers. It may be path-breaking as an idea, though the responses that have emerged are not exactly something that policymakers have not known for some time. Even journalists have encountered similar responses in their own limited ways.

The section begins with the level of education of the mothers surveyed to highlight one fact: the higher the educational attainment of the woman of the house, the higher the likelihood of her accessing the services. In the 100 focus districts, 66.3 per cent of the mothers had never been to school, though 68.1 per cent said that they had a strong say in decision-making regarding their children.

A small percentage reported that they were able to play a similar role in major household purchases. The report does not elaborate what exactly the decisions that the mothers were allowed to make for their children.

What remains a sad reality is that the majority of women in India today, including educated women, do not have the right to decide who they want to marry, when they can marry and the number of children they will have. Even the sex of their unborn offspring is often predetermined. Therefore, to say that almost 70 per cent of women have the right of decision-making may not be reflecting the true picture.

The problem is that the priorities regarding the kind of services that are required to be disseminated have been lopsided and skewed. For instance, there is no reason why the campaign for immunisation should not be accompanied by an equally aggressive campaign to promote breastfeeding or to provide access to health care and a universal PDS.

But it is precisely here that government policy on these issues comes to play. The report fails to underpin the systemic causes behind the indicators so elaborately studied.

Arun Gupta, the regional coordinator of the International Baby Food Action Network-Asia, pointed out that despite all the discussion in the media and other platforms on the low rates of breastfeeding, as evidenced in the HUNGaMA report, there has barely been any improvement in the existing figures in the past two decades. The ball is in the government's court. Skilled counsellors trained in health and nutrition are needed to advise working women in both the organised and unorganised sector about the benefits of breastfeeding. Simultaneously, the aggressive promotion tactics of the baby food industry has to be strictly dealt with. If they do these things with the help of sufficient funds, breastfeeding rates will go up, he said.

The reasons why women did not breastfeed their children soon after birth ranged from ignorance to poor milk supply. Nearly 58 per cent of mothers in the high-focus districts fed water instead of breast milk to their infants until six months. Fewer than 20 per cent of mothers had heard the word malnutrition in their local language, which also was not surprising. When larger survival issues are at stake and basic nutrition itself is a challenge, it is not surprising that people remain uninformed about malnutrition. While on an assignment on food security in Haryana, this correspondent was told by an anganwadi worker that it was pointless telling the women what to give their newborn and young children. They knew it all, she said; they just could not afford it.

The HUNGaMA report has found that around 70 per cent of women feed solids and semi-solids to their infants in the six to eight month group while a small percentage begin earlier. When mothers were asked why they delayed non-cereal foods such as vegetables, dairy products and fruits, 93.7 per cent of them in the high-focus districts said that those foods were expensive.

On using soap, a criterion for hygiene, almost all women in the three district clusters admitted having it at home though its use seemed to be very frugal. Only 19 per cent in the high-focus districts admitted to using soap after toilet use; the percentage was higher at 49.5 per cent in the better districts. Now this indicates that soap comes under the category of avoidable expenditure. The survey did not enquire what alternatives to soap people used. It is known that soil or ash is commonly used in place of soap. The availability of soap is not the question; it is its affordability. But the report does not explore this issue any further. The best districts from the best States showed higher usage of soap.

Similarly, the usage of health-care facilities was also restricted to those who could afford them. The three main reasons cited by mothers for not taking their children to trained doctors were that it was expensive, it was time-consuming, and that the services were not perceived as useful.

Girls, the report says, started off with a nutritional advantage only to fall behind after reaching four years of age. The pattern was common among children of Scheduled Caste, Scheduled Tribe and Muslim families. As a rule, children from richer families were found to have a better nutritional base. In the chapter Demographics and Nutrition Status, the authors Abhijit Banerjee and Ariel Zucker note that household socio-economic status is by far the most robust predictor of nutritional well-being in the focus States. The effect of village infrastructure on health outcomes was not very poignant.

In the section on anganwadi services, the survey revealed that only 41.7 per cent of anganwadi workers in the 100 high-focus districts said that their payments were up to date; over 20 per cent said they had been paid three months ago or even earlier. The report underscores the poor working conditions of ICDS workers and helpers. In all the three district clusters, the survey found that the number of anganwadi centres with functioning handpumps was low. Dry rations were available only to 61 per cent of the anganwadis in the 100 focus districts.

The report is interesting, well-produced and replete with easy-to-understand graphs and district-level data. However, it should lead to something more productive than vague discussions aimed at raising the existing knowledge levels of mothers about malnutrition or providing better training for the anganwadi worker. It is not correct to pin the prime responsibility for the infant's health and survival on the mother. The state does not seem to have any role here, barring the release of the report.

The assertion that the first and primary custodian and protector of a child's health is her mother... she does the best she can, with information and resources available to her, to nurture her child and that the mother's poor knowledge of what is good for her baby and her poor decision-making skills are responsible for child malnutrition speaks very poorly of the otherwise rich findings of the report. Equally problematic and limited is the understanding that social and economic backwardness is aggravated by inequality in access to information.

The report says that mothers, village-level service providers, panchayat members and village communities have poor access to information on the best practices in childbearing and child-rearing. It recommends an aggressive education-communication campaign using multiple media and formats in order to reach out to rural populations. Herein lies the limitation of this report. It is not enough to have 24x7 information blitzes as suggested in the report; what is needed is information backed by access and affordability.