MORE than half of the adivasi adults, unlike 35% of all Indians, have a BMI (body mass index) below 18.5, which makes them chronically undernourished.¹ The figures for women and children are far more dismal. For instance 71% of tribal women in Jharkhand suffer from various degrees of malnutrition. This increases the risk of delivering low birth weight babies and having other pregnancy complications. Some of the reasons for undernutrition among tribal women are inadequate diet intake, early marriage, poor access to health services, and high morbidity due to unhygienic practices and surroundings. Undernutrition of mothers is usually passed on to children.

A Unicef report² reveals that only 2% adivasi children in the age group 6 to 11 months were fed complementary foods in recommended quality and frequency. Of the 634 children surveyed in Akkalkuwa block of Nandurbar district³ of the state of Maharashtra, 378 were found to be malnourished and the number of girls among them was as high as 60%. More than 98 children died in three months of 2005, of these 71 were found to be severely malnourished. The human rights groups working on the right to food also witness that tribal children do not have access to the facilities provided by the anganwadi centres (AWCs) under the Integrated Child Development Scheme (ICDS), and the chances of survival of a tribal child are low, with 71.4% being malnourished and 82.5% anaemic.

The Supreme Court order issued in 2004 recommends that all new AWCs should be located in habitations with high Scheduled Caste and Scheduled Tribe populations. Yet, many villages in Khandwa district of Madhya Pradesh do not have AWCs in their villages despite being highly populated with the Korku tribe.

The studies quoted above, and many more, amply demonstrate that widespread poverty, illiteracy, absence of safe drinking water and sanitary conditions, poor maternal and child health services, and ineffective coverage of national health and nutritional programmes are the major contributing factors for dismal malnutrition indicators of tribal communities in central India. They also suffer from many communicable, non-communicable and silent killer genetic diseases.⁵ Their geographical isolation and remoteness further affects the developmental process, as qualified health workers do not wish to work in such areas.

 

It is not only in the tribal regions, but also in so-called mainstream India, that progress on nutrition indicators is disappointing. Given below are some practical suggestions on how to reduce malnutrition among tribal children by improving the delivery through ICDS. First, the commonly held belief that food insecurity is the primary or even sole cause of malnutrition is inapt. However, the focus in India is still on food, and not on health and care related interventions. More nutrition rehabilitation centres (NRCs) should be established in tribal areas. The challenge is to reduce a relapse of discharged cases from NRCs by building the capacity of mothers and other caregivers regarding appropriate home based feeding and caring practices. Moreover, sanitation is one of many factors that importantly limit the growth of adivasi children. Open defecation in India in tribal areas has remained stubbornly resistant and needs urgent attention.

 

Second, the ICDS design needs a change. At present it targets children mostly after the age of three when malnutrition has already set in. The Planning Commission documents reflect that very little of the ICDS resources, in terms of funds and staff time, are spent on the under-3 child, and this low priority must be reversed focusing more on improving mothers’ feeding and caring behaviour, improving household water and sanitation, strengthening referrals to the health system and providing micronutrients. The basic nature of the programme should be changed from centre-based to outreach-based, as a child less than three years cannot walk to the centre and has to be reached at his/her home. Another advantage of visiting homes is that it is not just the mother but the entire family that is sensitized and counselled.

Third, ICDS faces substantial operational challenges, such as lack of accountability due to lack of oversight and an irresponsible reporting system. Even the resources devoted to ICDS are very limited. It appears that state governments actively encourage reporting of inflated figures from the districts, which renders monitoring ineffective and accountability meaningless. An objective evaluation by NFHS-3 shows that 40.4% of children were underweight in 2005-06, 15.8% of whom were severely malnourished. However, in 2009 the state governments reported 13% of children as underweight and only 0.4% as severely malnourished. Where is the problem then? India seems to be as good as Denmark or Norway!

 

Although reporting has somewhat improved since then, yet GOI’s website shows that the percentage of severely malnourished children (reported as grade 3 and grade 4 children in the state data) in March 2014 was only 1.6%. Some states, such as Uttar Pradesh and Rajasthan, reported less than 0.5% children as severely malnourished, clearly reflecting a fudging of data by the ground staff with collusion and backing of their seniors. The district administration also sees reporting correct data as a high risk and low reward activity. The situation can easily be corrected by greater transparency in the district and centre records that can be put on a website, and by frequent field inspections by an independent team of experts, nutritionists, and grassroots workers. Hence, it is important to hold the system accountable by correcting the data and facilitating objective evaluation.

Fourth, there are large-scale irregularities in the supply of supplementary nutrition provisioning (SNP) in violation of the Supreme Court orders by resorting to the engagement of contractors in ICDS in many states such as Maharashtra, Karnataka, Uttar Pradesh and Gujarat. A recent evaluation of ICDS in Gorakhpur by the National Human Rights Commission showed that despite a Supreme Court directive to provide hot cooked meals, all centres supplied only packaged ready-to-eat food, containing a low 100 calories as against a norm of 500 calories, and 63% of the food and funds were misappropriated. The food being unpalatable, half of it ends up as cattle feed. The ready-to-eat food is produced in poor hygienic conditions.

The distribution of manufactured ‘ready-to-eat’ food should be discouraged at all levels as it leads to grand corruption at the ministerial level. Unfortunately, the Government of India has actively encouraged such tendering by laying down the minimum nutritional norms for ‘take home rations’ (a permissible alternative to cooked meals for young children), including micronutrient fortification, thus providing a dangerous foothold for food manufacturers and contractors who are constantly trying to invade child nutrition programmes for profit making purposes. When ICDS centres are not doing well throughout the country, one can only expect more dismal results in tribal regions.

 

Fifth, adivasis have also suffered because of the poor quality of governance. Programme delivery has deteriorated everywhere in India, but more so in tribal areas, where government servants are reluctant to work, and are mostly absent from their official duties. Massive vacancies exist in tribal regions in the face of acute educated unemployment in the country. A study by Unicef in Jharkhand revealed that one of the main constraints that the NRHM in the state faces is lack of skilled manpower. In the two districts of Jharkhand visited, Sahibganj has less than 50% positions in place, while in East Singbhum, with its better infrastructure, it is just around 54%. The Ministry of Tribal Affairs (MoTA) needs to regularly study the state of governance in tribal regions, and put pressure on other ministries and state governments to show improvement. The people, theoretically, can pressure the system to make it more functional but the tribals, when exploited and oppressed, either suffer silently or choose aggressive agitation. Empowerment of tribals, in real terms, can be realized only when the tribals themselves are bestowed with the right to participate in decision making, besides being equipped to find answers to their own problems.

 

Last, we must learn from examples where emerging economies have demonstrated that child undernutrition can be drastically reduced. Thailand has been one of the most outstanding success stories of reducing child malnutrition in the period 1980-1988 during which child malnutrition (underweight) rate was effectively reduced from 50% to 25%.⁶ This was achieved through a mix of interventions, including intensive growth monitoring and nutrition education, strong supplementary feeding provision, community participation, iron and vitamin supplementation and salt iodization along with primary health care.

Similarly, Brazil reduced child undernutrition by 75% (from 20% to 5%) between 1990 to 2006, and China by 68% (from 25% to 8%) between 1990 and 2002.⁷ Even Vietnam, a country poorer than India, has seen a reduction in underweight children from 41% in 1996 to 25% in 2006.⁸ Therefore, nutrition improvement at national scale is possible. However, economic growth is not enough; it needs to be coupled with effective policy and budgetary action, particularly for the most vulnerable – the youngest, the poorest, and the excluded.

 

It is unfortunate that the Ministry of Tribal Affairs (MoTA) pays insufficient attention to the important problems of the tribal, hiding behind the plea that the subject of malnutrition and ICDS does not fall under its jurisdiction. Rather, the ministry should play a more activist role in addressing these issues by pursuing adivasi concerns with the concerned ministries.

MoTA needs to expand its work and improve coordination with other ministries that deal with the subjects impinging on its work. Also it needs to take more responsibility besides dealing only with schemes (such as distribution of scholarships and grants to NGOs) that fall totally outside the purview of the existing ministries. Such an ostrich-like attitude defeats the purpose for which the ministry was created.

Therefore, a systemic change is needed in the way MoTA and state tribal departments function; their approach must change from simply spending their own budget through narrow departmental schemes to knowledge based advocacy with other concerned ministries/departments. MoTA should also highlight the failure of governance that deprives the poor adivasis from accessing elementary services, and put pressure on the concerned ministries and state governments to ensure better policies and delivery in tribal regions. The newly created Niti Ayog should also regularly monitor the impact of existing nutrition policies on the tribal population and engage with the concerned sectoral ministries.

 

Footnotes:

1. Subal Das and Kaushik Bose, ‘Nutritional Deprivation Among Indian Tribals: A Cause for Concern’, Anthropological Notebooks 18(2), 2012, pp. 5-16; and Amaresh Dubey, ‘Poverty and Undernutrition Among Scheduled Tribes in India: A Disaggregated Analysis.’ IGIDR Proceedings/Project Reports Series, PP-062-132009, Mumbai, 2009.

2. Nutrition and Adivasis, Unicef, New Delhi.

3. http://infochangeindia.org/agriculture/books-a-reports/malnutrition-amongst-maharashtras-tribals-how-bad-is-it.html

4. http://www.alrc.net/doc/mainfile.php/alrc_st2010/591/?print=yes

5. R.S. Balgir,Tribal Health Problems, Disease Burden and Ameliorative Challenges in Tribal Communities with Special Emphasis on Tribes of Orissa, accessed at http://www. rmrct.org/files_rmrc_web/centre’s_ publications/NSTH_06/NSTH06_22.RS.Balgir.pdf

6. http://www.righttofoodindia.org/data/garg-nandi07thailand-reducing-child-malnutrition.pdf

7. http://www.unicef.org/india/reallives_ 5901.htm

8. http://www.unsystem.org/scn/Publications/SCNNews/scnnews36.pdf