Ending malnutrition by 2030 - Is India on target?

Malnutrition is the most alarming and persistent health problem faced by the world today as per a recent report of the International Food Policy Research Institute. The frightening statistics of infant mortality and retardation raises serious questions about the development models pursued by governments across the globe.

Nearly half of all deaths of children under the age of five are attributable to malnutrition; 155 million children under the age of five are afflicted by stunting caused because they did not get adequate nutrition in the first 1,000 days of their lives (UNICEF). Apart from physical retardation, brain development is also severely affected. Attention and memory deficit, slowness in learning language and social skills and reduced problem-solving ability are likely consequences of malnutrition (WHO).

The retardation caused in the first two years of a child's life prevents the development of his full potential for the rest of his life and the process cannot be reversed by adequate food and nutrition later. Studies have found that pregnancy at too early an age and maternal anaemia results in increased health risks for the mother and the child.

As per the report placed by the UN before the Global Nutrition Summit 2017, half a billion women of reproductive age and four out of 10 pregnant women worldwide suffer from anaemia. Anaemia is estimated to contribute to 20% of maternal deaths, and increase in risk of stillbirth, premature delivery, low birth weight and neonatal mortality (death within 28 days of birth). Iodine deficiency in mothers may cause brain damage and physical retardation in the child.

Though lack of food is the most common cause, ignorance and improper food habits also play a role in malnutrition. As Nobel laureate Angus Deaton pointed out, consumption of carbohydrate-based diet with low protein and fat content is one of the reasons for malnutrition in India. Unhygienic sanitation can cause frequent incidence of diarrhoea and other infections which, too, may result in malnutrition.

India ranks 97 among 118 developing countries in the Global Hunger Index. About 39% of children under the age of five - about 20 million - suffer from chronic malnourishment and India has the highest number of stunted children (48.2 million) in the world (Save the Children Report, May 2017). If this is the case with the sixth largest economy in the world, it is obvious that we have been following a lopsided growth path for decades.

The success achieved in fighting malnutrition by countries like Malawi, Madagascar Guatemala and Bangladesh which are way behind us in economic development and the examples of states like Kerala, Goa, Tripura and Chattisgarh in our own country show that it is possible to accelerate the process of reducing malnutrition by persistent efforts.

The success of persistent efforts is seen at the national level also. Between 2005 and 2014, there was a 20% decline in malnutrition. The number of stunted children under the age of five has come down from 48% in 2005 to 38% in 2016. This reduction was possible mainly due to the Integrated Child Development Services (ICDS). But instead of feeling elated at this success, we should be concerned that children in such large numbers are still undernourished.

The Lancet, one of the world's best known and widely read medical journals, has worked out a package of proven nutrition interventions which, if implemented earnestly, could eliminate malnutrition at an accelerated pace. The first intervention is to ensure improved nutrition to women during pre-conception, pregnancy and post-partum periods.

Secondly, exclusive breastfeeding should be encouraged for the first six months. This could save up to 1.3 million children each year worldwide, ensuring optimal growth and protection from infections. Spreading awareness about the importance of breastfeeding and countering the misleading propaganda of companies selling formula milk products is the need of the hour.

Increasing investment

As the lives and health of millions of children are at stake, investment on schemes for women and child welfare need to be hiked urgently and drastically. Instead, the Union government is on a reduction spree. The budget allocation for ICDS in 2016-17 was reduced by 9.6% from the allocation of 2015-16. Further, the allocation for Mid-Day Meal Scheme, which was 0.74% of the total Union Budget in 2014-15, was reduced to 0.49% for 2016-17.

Those who grudge government spending on welfare schemes, including on healthcare, terming it a relic of time-worn Socialist philosophy, are perhaps not aware that even in the United Kingdom, the citadel of Laissez-faire Capitalism, a fully public-funded National Health Service ensures that patients don't have to spend anything from their pocket.

The same is the case with other European countries. Even in Qatar, a here ­ditary monarchy which is yet to see the dawn of democracy, patients are assured of heavily subsidised but world-class healthcare provided by the Hamad Medical Corporation, the government-run, non-profit healthcare provider. In contrast
to this, India spends a paltry 1% of GDP on healthcare, well below the world average of 5.99%, as per the Economic Survey tabled in Parliament in January 2017.

Policymakers want to substitute government schemes with contributory insurance schemes. But as social activist Aruna Roy asked, when jobs and incomes are shrinking, how will the poor contribute to the insurance schemes?

India, along with 193 member countries of the UN, adopted Sustainable Development Goals in September 2015 and committed itself to end undernutrition by 2030. Health activists are sceptical about India meeting the deadline, going by the progress achieved so far. It is for all to see that the sense of urgency which is necessary to create a tangible impact is sadly lacking.

(the article was published in DECCAN HERALD on 15.12.2017

Labour laws- Reforms for the few

Labour laws- Reforms for the few

At a time when labour law reforms are being debated, it is important to remember that only 6-7% of the total workforce in the country, that is, workers employed in the formal sector — by the government, state-owned enterprises and private companies — come under the labour laws. The other 93-94% — the vast majority of the country’s nearly 500 million workforce — working in the informal or unorganised sector are outside the purview of these laws.

Landless agricultural labourers, construction workers, beedi workers, sanitary workers, coolies, workers in brick kilns and stone quarries, workers in garment, leather, agarbatti and transport industries, contract and casual labourers are the major constituents of the informal sector, apart from weavers, artisans, hand-cart operators, small traders, pavement vendors, etc.

These workers have no access to basic rights such as fixed working hours, minimum wages, provident fund, gratuity, ESI, paid leave, pension, medical, accident and life insurance coverage, job security, etc., enjoyed by workers in the organised sector.

Unorganised workers are the worst sufferers in unforeseen circumstances like natural calamities or economic crises. For instance, after demonetisation, thousands of workers returned to their native villages as jobs and earnings ceased abruptly and they had nothing to fall back on.

Wages in the informal sector are determined by market forces in the absence of proper regulation. As per data released recently by the National Sample Survey Office (NSSO), the average wage earned by a worker in the unorganised sector is just Rs 6,688 per month. Even the highest average wage of Rs 10,468, earned by unorganised workers in Kerala, cannot be considered a decent wage today and at the current inflation level.

Surveys covering the last two decades have shown that the wages of many categories of workers in the informal sector has not increased at all, and when inflation is taken into account it has decreased in many cases. This is unfair, as the unorganised sector contributes about 51% of the GDP, according to the National Commission for Enterprises in the Unorganised Sector (NCEUS).

As the unorganised workers are spread across a wide spectrum of occupations and as the temporary nature of work takes them from place to place, it is difficult for them to organise themselves and benefit from collective bargaining. Hence, their welfare can be ensured in the immediate future only by introducing universally applicable social security measures. The task is daunting, not only because of the magnitude and complexity of the problem but also because the data available on their living and working conditions is scanty and unreliable.

The National Labour Commission and NCEUS have repeatedly drawn attention to the arbitrary and unjust working conditions and lack of social security and have suggested remedial measures.

Over a period of time, schemes such as old-age pension, widow pension, and MGNREGA were introduced for the benefit of unorganised workers. Due to scanty allocations, delayed release of funds, inefficient delivery mechanism, improper targeting and lack of awareness about the existence of the schemes among workers, a large number of intended beneficiaries have not been able to benefit from them.

Some schemes were formulated without taking into account the nature of their employment and income. For instance, the much publicised Atal Pension Yojana is a contributory pension scheme under which the Government of India will add either 50% of the subscriber’s monthly contribution or Rs 1,000 for the first five years of the scheme, that is from 2015 to 2020. If a subscriber fails to pay the monthly subscription any time during the tenure of the scheme, the GOI contribution and the interest earned on it will be forfeited.

A contributory scheme with such penal provisions does not suit workers who do not have an assured job or income. As per the scheme, an 18-year-old worker contributing Rs 42 per month for 42 years will get a pension of Rs 1,000 beginning at age 60. Experts have calculated that the value of Rs 1,000 will be only Rs. 129 when the worker starts receiving the pension.

Initiatives for reform

As labour falls in the Concurrent List, 44 labour laws relating to wages, employment, industrial relations, social security, etc., have evolved over a period of time. The Centre and states went on legislating, without any coordination between them. The second National Commission on Labour, constituted 72 years after the first NCL, submitted its report in the year 2002, recommending amalgamation of these laws that overlap and override each other, leading to a lot of confusion. But successive governments have failed to implement the recommendations.

The NCEUS released the report “Social Security for Unorganised Workers” in 2006 with a 13-point Action Programme to ensure minimum conditions of work and social security. The Unorganised Workers Social Security Act was passed in 2008 and The National Social Security Board was constituted in 2009. But the board only has an advisory role and no powers to enforce the Act.

In April 2017, the Draft Labour Code on Social Security and Welfare was released, which seeks to introduce a universal social security scheme by way of a single labour code by merging all the existing labour laws. But the move, supposed to be a reform measure, has turned regressive for the workers as the draft code blocks democratic participation by keeping out the trade unions. The code will be governed by a ‘national council’ consisting of 21 members out of whom only three will be workers’ representatives. Even these three will be nominated by the government.

Formulating welfare schemes that are easy to access, doing away with procedural complexities, raising the awareness level of workers, allowing participation of trade unions, and support of media and public opinion are necessary for improving the lot of the unorganised workers.

(The article was published in DECCAN HERALD on Oct 14 2017)

The link between poverty and health

The Indian healthcare market is growing at an astounding pace of 22.9%. Its present worth is around $ 100 billion and is expected to grow to $ 280 billion by 2020. The Indian pharmaceutical industry is the third largest in the world and accounts for 20% of global exports in generic drugs.
India is a prominent centre of medical tourism with about 1.27 million patients from countries such as Sri Lanka, Bangladesh, China and even from developed countries such as Canada, the US and UK flocking the super-speciality hospitals in the country. But this impressive growth story does not mean anything to millions of Indians for whom even primary healthcare is neither accessible nor affordable.

According to a study published in September 2016 by “International Collaboration on the Global Burden of Disease,” India ranks 143 in the list of 188 countries on a range of health indicators.
Though successive governments introduced various schemes and spent hundreds of crores, ‘Health for All’ remains a distant dream. What is preventing the achievement of this much-cherished goal?
Addressing the 54th World Health Assembly in 2001, Kofi Annan, the then UN secretary general, said, “The biggest enemy of health in the developing world is poverty”. The policymakers would do well to remember this stark reality while trying to achieve the goal of Health for All. It is necessary to take a hard look not only within the health sector but beyond it.

According to “The People’s Health Movement”, a global network of grassroots health activists, civil society organisations and academic institutions which are relentlessly campaigning for Health For All, the main cause of poor health of millions across the world is poverty. Poverty is both a cause and a consequence of poor health.

Apart from an accessible and affordable public healthcare, proper living and working conditions, safe drinking water, adequate nutrition and hygienic sanitation are essential for good health.

But poverty and discriminatory customs and practices prevent millions in India from accessing these essential services and resources.

Another major consequence of poverty is malnutrition. Though our GDP has increased 50% since 1991, one-third of the world’s malnourished children live in India. Malnutrition affects the immune system, increases the incidence and severity of diseases and results in poorer cognitive function and learning ability in children. Though “Integrated Child Development Services” started in 1975 has succeeded in reducing malnutrition to some extent, much more needs to be done.

It is reported that almost 2,000 Indians die every day due to diarrhoeal diseases. Non-availability of safe drinking water and poor sanitation are the major issues. Most rural households have no latrines.

Emphasis on hygiene
Swachh Bharat mission of the present government is a big initiative and has raised high hopes for hygienic sanitation. It needs to be extended to more villages and slums and complaints like lack of provision for water, lack of proper arrangements for maintenance etc., should be addressed.

Poor people often live in overcrowded, ill-ventilated houses in unhygienic neighbourhoods, exposing them to indoor and outdoor air pollution. They either do not have or have limited access to safe water and sanitation. Infections and contagious diseases spread faster in such an environment.
A large number of poor work in hazardous occupations such as textiles, dyeing, foundry, chemical, mining, agarbatthi, leather and cracker industries where they are exposed to grave health risks.

Improving the staff strength, cleanliness and availability of medicines in Primary Health Centres and government hospitals, timely immunisation and vaccination, creating awareness about health and illness are necessary to ensure Health for All.

Expert studies have shown that the increase in life expectancy and general health in European countries in the late 19th and early 20th century have more to do with a raise in standard of living, clean water, better sanitation and nutrition than with the advances in medical science.

Eradication of poverty should be seen not merely as a welfare measure but also as a means for progress as healthier workers will contribute more to the economy.

Will be back with the dawn of wisdom

Greenery lost in darkness

Will return for sure with sunrise

Nature’s sheen lost in man’s greed

Will be back with the dawn of wisdom.

Poverty and academic outcomes - THE CRIPPLING EFFECT

Narayanan N Jan 23 , 2017

Family and social environment of children have a greater impact on their performance than the quality of teaching at school.
India has made appreciable progress in primary education in recent decades as for as enrolment of children in school is concerned. But drop-out rate and poor performance of children in government schools, where most of the poor students study, are problems evading solution.

Studies have shown that even after 4-5 years of schooling, children fail in simple tests of reading, addition and subtraction. Inadequate infrastructure, high student–teacher ratio and poor quality of teaching are the reasons traditionally attributed for this situation. While these reasons are valid enough, there is increasing realisation across the world that poverty is the major factor affecting educational outcomes especially at the primary stage.

It is now recognised in many countries that family and social environment of the children have a greater impact on the performance of children than the quality of teaching at school (Unicef). Children from poor families score significantly lower in vocabulary, communication skills, simple arithmetic and the ability to concentrate compared to children from higher income households.

The differences start showing up at the age of 3-4, even before the start of schooling and are found to last even in later years as shown by the Programme for International Student Assessment (PISA) which assessed reading, math and science scores of 15-year old children in 43 countries. The traditional misconception that underperformance is due to genetic or hereditary factors was challenged by child psychologists in the second half of the 20th century who came to the conclusion that intelligence is shaped more by the environment in which the children grow up.

A study by World Health Organisation has shown that maternal health during pregnancy and the quality of antenatal and postnatal care she receives are important factors affecting child’s physical and mental development. Lack of adequate nutrition for the pregnant mother can affect normal brain development of the child. Most women and children from poor families are deprived of medical care and nourishing food when it is most needed.

As a result, premature birth and low birth weight are more common among the poor which in turn leads to disabilities like attention and memory deficit (Commission on the Social Determinants of Health-Early Child Development of the WHO). As the development of brain occurs mainly during the early phase of life, nutritional deficiency at this stage has a lasting effect on the psychological and intellectual growth of the child.

Early years are crucial for the development of cognitive and social skills in children. Along with nutrition and medical care, nurturing relationships and inspiring role models also play a vital role in the early phase of a child’s life. But being over worked and over stressed, poor parents are unable to show warmth and sensitivity and tend to be harsh and high-handed with their children. The consequent emotional disturbance affects the child’s social adaptability and learning capability. Hence, poor parents need to be helped to learn parenting skills so that their frustrations are not passed on to the children.

Playing with toys, reading and listening to stories, reciting rhymes etc develop curiosity, imagination and a sense of exploration in children. But having been deprived of these joys in their childhood, the poor parents don’t realise its importance. Even the few who realise its value, find themselves helpless for want of money and time.

A number of countries have carried out extensive research for finding ways to mitigate the negative effects of poverty on child development and at least two worthwhile approaches have emerged out of this quest. One of these approaches adopted by countries like Mexico and Nicaragua is the Conditional Cash Transfer programme which is linked to immunisation, nutrition and school attendance. This approach has resulted in significant improvements in educational outcomes of poor children. Another approach which is found equally effective is the Early Childhood Intervention programme (ECIP) adopted in countries like Canada and USA.

Comprehensive development
Apart from improving the school performance of children, the implementation of ECIP has also contributed, over a period, to general prosperity according to researchers who monitored the project on a continual basis. The National Head Start Programme of USA is one of the earliest and most successful Early Childhood Intervention programmes. The NHSP aims at comprehensive development of preschool children (3-5 years) of poor parents.

The programme designed by paediatrician Dr Robert Cooke and professor of psychology Dr Edward Zigler prepares children for school while also focussing on involving parents in the education of children. It also focuses on prenatal and postnatal care of mother and nutritional needs and immunisation of children. The programme tries to develop cognitive and social skills in children by a combination of play and instruction.

In course of time, many countries adopted similar programmes although with some variations. But the focus everywhere was to provide support to children in the form of learning activities and training the parents to enhance their capacity for providing a care giving environment at home.

The International Association for the Evaluation of Educational Achievement studied the Early Childhood Intervention Programmes of eight countries and published the findings in February 2016. Chile, the Czech Republic, Denmark, Estonia, Italy, Poland, the Russian Federation and the United States participated in the programme and submitted data on their early childhood development programmes. The study of the data proves conclusively that well designed interventions can advance child development and education in the early years and a successful adult life later.

India needs to replicate such interventions much more vigorously as the severity of poverty here is more acute in the absence of comparable social security measures. While it is worthwhile to replicate interventions whose efficacy has already been proved elsewhere, it is necessary to adopt the interventions to suit the local conditions. First generation learners, whose parents and forefathers were denied education for economic, religious and cultural reasons, need special care and attention to ensure that they don’t lag behind others.

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The never-ending ordeal of migrant workers

Narayanan N Nov 22, 2016,

Every year, hundreds of young people from villages arrive in cities in search of jobs with hopes of freedom from poverty and indebtedness, leaving behind their families, friends and homes. Uneconomic land holdings, decline of cottage industries and handicraft, erratic monsoon, lack of irrigation facilities, degradation of the environment, lack of protection from natural calamities, increasing indebtedness etc are the main reasons for rural to urban migration.

A large majority of rural population are landless labourers. Agriculture provides them only seasonal work of six to seven months in a year. Even when they get work, wages are abysmally low. They have nothing to fall back upon when work is not available. Many of them including those with small land holdings are forced to borrow from money lenders as they find procedures of banks complex and daunting.

People from remote, backward villages and those belonging to socially and economically backward communities are the most affected by rural destitution. Migration to the city is an attempt to escape from poverty and in many a case from the tyranny of the unjust, oppressive and hierarchical caste system.

Most of the migrants retain their links with the village and return when seasonal work is available and again go back to the cities when there is no work in the village.
Earlier, migration of labourers was mainly to cities in their own home states. Now, with the spread of communication and information, they have begun to explore their fortunes beyond their own home states. Agents and contractors have sprung up who recruit workers in large groups to work in distant cities.

Large number of people from states like Bihar, Rajasthan and Uttar Pradesh, which have the largest number of landless labourers are now working in Haryana, Punjab, Delhi, Maharashtra, Karnataka and Gujarat (UNESCO/ UNICEF, 2012b). Even Kerala which was traditionally known for outward migration is now attracting workers from Bengal, Odisha, Assam and Uttar Pradesh. Migrants now constitute 10% of the state’s population (Labour and Rehabilitation Department, Kerala).

The workers soon realise that the ordeal does not end with migration to the city. Even in the period of much flaunted high economic growth, the only sector which opened up noteworthy employment opportunities was the service sector. It has not made any difference to the 287 million illiterate adults of employable age in India (Global Monitoring Report-UNESCO 2014).

As the present model of development is not able to stimulate growth in manufacturing and agriculture sectors — which employ the illiterate, the unskilled and the semi-skilled — they have been left in the lurch. This kind of progress is best described as the engine steaming ahead leaving behind the coaches.

Construction sector is the only one which has absorbed such workers in significant numbers. Construction Workers Welfare Boards (CWWB) set up in all states levy 1% cess on the construction cost of buildings. The fund is meant to be used for providing financial assistance to the families of beneficiaries in case of accident, for old age pension, housing loans, payment of insurance premium, education of children, medical and maternity benefits etc.

Unregistered workers
As per the latest figures, the amount collected so far has grown into a huge corpus fund of Rs 27000 crore (Union Ministry of Labour) and this amount is lying idle. The rules for disbursement stipulate that only workers who register with the CWWB are eligible to claim the benefits under the scheme. Only 2.2 crore of the estimated 4.46 crore workers in the construction industry (Report of Lok Sabha’s Standing Committee on Labour 2013-14) are registered. Large number of applications are kept pending for long periods on flimsy technical reasons. The indifference of bureaucracy together with the ignorance of workers has resulted in the amount remaining unutilised.

Inter-state Migrant Workmen (Regulation of Employment and Conditions of Service) Act was passed in 1979 to regulate the working conditions of migrant workers. The important features of this Act are elimination of middlemen, listing the responsibilities of employers and contractors, ensuring wages equal to those of local employees, right to return home periodically without loss of wages, right to medical care and housing at the employment site.

But these stipulations are rarely implemented by the states as there is no mechanism to ensure monitoring and enforcement of them. Lack of organisational support to protect the interest of migrant workers is also a reason for this situation. Even in a state like Kerala with high level of awareness of workers’ rights, unions have failed to integrate migrant workers into the mainstream, the ostensible reason being language barrier.

Migrant workers live and work in degrading conditions. They are made to work more and paid less than local workers. They live in makeshift shelters where there is no provision of safe drinking water and hygienic sanitation. They are deprived of the benefits of welfare schemes like subsidised food grains and healthcare due to identity issues. As workers have to move from place to place in search of work, schooling of their children poses a big problem.

Though internal migrants now constitute 35% of the country’s population and contribute 10% to GDP (NSSO 2007-08), politicians have ignored them as they don’t have voting rights at their place of work. The issues are not insurmountable if politicians and the administration become proactive. For example, as Aadhar serves as an identity document across states, it can be used for introducing portability of ration cards and health cards.

Activists and NGOs have suggested setting up of help lines, dormitories, daycare centres to take care of children while women labourers are away at work, adequate number of public toilets, mobile schools etc to reduce the ordeal of migrant workers. These issues need to be addressed on a war-footing to ensure that migrant workers lead a life of dignity and not as second-class citizens in their own country.

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