The problem

IN both the public and media discourse, the likelihood that we discuss and vocalize only problems is much higher. Hardly surprising, as the problem is invariably more sensational and hence easily grabs headlines; the solutions, even when right before us, are more likely to go unnoticed, unacknowledged and unarticulated.

That the children of central India’s tribal belt are nutritionally amongst the most deprived is an often talked about problem and so are the reasons – household income and food insecurity, maternal undernutrition, poor feeding and care practices, poor access to water, health and sanitation and governance issues related to land alienation, displacement and forest rights. The September 2014 issue of Seminar, The Malnourished Tribal, brought together a range of contributors on the plight of the tribals, as did the UNICEF 2014 report that compiled an extensive analysis of existing data on the determinants of stunting among tribal children and the reach of affirmative actions. However, in the practitioner’s world, this ‘problem voicing approach’ has a short shelf life and is soon forgotten once the problem is acknowledged. Only then does a search begin on what can be done and who are the people doing what and how.

The evidence generated in-house by Unicef (2014) on the nutrition situation of tribal children was translated into action as the Unicef #Icommit campaign. This campaign helped us travel to distant, dry and muddy corners of central India in search of solution seekers and solutions for improving the nutrition status of the tribals and supporting state governments in implementing them.

Unfortunately, there are few alliances and organizations focusing on issues related to nutrition of tribal peoples. Also, forums in which scheduled castes and scheduled tribes are represented together invariably favour the former, possibly because of their larger numbers and stronger collective voice. Overall, the number and geographical coverage of NGOs and faith-based organizations working in tribal areas too is small, a figure which further reduces in civil strife (particularly Naxal) affected areas. Nevertheless, solutions that work and translate into promising practice exist. This note hopes to highlight a few promising solutions to the problem of undernourished tribal children.

The issue of household food and livelihood insecurity needs to be addressed first as the critical step that can reduce undernutrition in tribal areas. Since income security has been adversely affected by loss in productive resources (rights to forest or agricultural lands coupled with low levels of compensation), contracting debt becomes one of the main coping strategies. Expectedly, this far too often ends up in bondage, resulting in a hand-to-mouth existence for those affected. Access to the entitlements of the public distribution system is equally important, but is often constrained by a faulty definition of who falls in the ‘below poverty line’ category, alongside a limited awareness on where and how to access ration cards and entitlements. Moreover, the foodgrains (normally cereals) stocked in the public distribution system (PDS) are rarely part of the tribal people’s diet. The forest is not recognized as a food producing habitat, and if trees are planted, they are usually not fruit/food producing. To make matters worse, tribal foods, uncultivated yet nutritious, are considered unfashionable by communities themselves. Finally, there is heavy reliance on rain fed agriculture, which is increasingly becoming unpredictable due to climate change.

Efforts have, however, been made to link nutrition, food security and livelihood support. The ‘one hot cooked meal scheme’ introduced by the Department of Social Welfare in Andhra Pradesh and Telangana, ensures that pregnant and lactating women receive one free hot cooked afternoon meal each day using raw materials which are purchased by village organizations under the poverty alleviation programme. There are examples of crèches run through women’s groups with funds routed through local panchayats (Chhattisgarh) to support tribal women who engage in productive work outside their homes. Pradan, a non-government organization working across seven states including Chhattisgarh, has helped improve the productivity of land, water and agriculture through organization of women-led self-help groups. It has helped build their capacities in soil health improvement and stabilization of paddy yields by incorporating nutritious crops in the overall cropping plan of vegetables, millets and pulses to ensure food sufficiency for 9-12 months.

Samagra, an online portal of the Government of Madhya Pradesh, supports identification, verification, updating and categorization of all individuals/families by respective local bodies and electronically links households to their respective fair price shops (FPS). The BAIF working in central India has long promoted a farming systems based approach combining agri-horti-forestry with in-situ soil and water conservation practices. Their technique of marrying/integrating practices of crop diversification and intensification with animal husbandry and skills oriented training for food production systems is now being implemented in plots as small as 0.4 ha.

Usually, access to government health outreach and referral services is constrained by geographical, language, cultural and social barriers and high opportunity costs (loss of wages, cost of travel time to the facility and medicines). This may explain the continued reliance on traditional medicine and spiritual healers. Shortage of skilled human resource, high staff turnover and absenteeism remain major problems in tribal areas, particularly in areas of conflict. Community health services managed by nurses are still untapped. And while tribal candidates are preferred, it is difficult to find those who meet the qualification criteria.

Assignments in tribal areas are generally perceived as a ‘punishment’ posting for non-performers or the ‘unconnected’. With poor housing and recreational facilities, endemic road, power and electricity problems, centralized human resource policies that rarely specify the duration of such postings, and inadequate hardship allowances for serving in difficult conditions (such as transportation, board and lodging and promotions/dual degree incentives), few professionals want to work in these areas, thereby negatively impacting outcomes. Tuberculosis, malaria and sickle cell anaemia are major health problems, as are illnesses resulting from an excessive use of tobacco and alcohol. Matters become worse as habitual drinkers (male or female) spend most of their earnings and cash benefits received from government schemes on satisfying their addiction.

There are a couple of promising practices to improve access to care in tribal areas. A judicious mix of professionals like doctors, nurses and a social work team complementing each other could work in community clinics. The efficacy of clinics managed by nurses with periodic doctor supervision and supplementary activities (clinic, community mobilization, home counselling and crèches for nutrition support) has been demonstrated in difficult and dispersed tribal catchment areas of Udaipur in Rajasthan by the NGO, Basic Health Services. Further, that these community clinics led by nurses engaged in nutrition security activities with ambulances capable of going the last mile, work best under a PPP (Public Private Partnership) model. An example worth emulating is that of the Christian Hospital in Bissam Cuttack, Odisha which is a school of nursing attached to the hospital.

Some other promising practices of addressing the problem of access are partnerships with NGOs (under Ministry of Tribal Affairs) for setting up Nutrition Resource Centres in block hospitals run by them in high malnutrition zones (Jharkhand); young professionals encouraged to support the district collector in tribal districts and work on special projects under the Gujarat CM’s fellowship scheme; the tribal coordination cell in district hospitals in tribal districts of Maharashtra with a focus on hospital infrastructure upgradation; and context specific cash transfers to patients to avail primary health care facilities are a few practices that can be replicated in other states of the country. The RIDHI Foundation, working in collaboration with National Health Mission in Palakkad, Kerala, has enabled real time monitoring of data by developing the computer app, Jatak, currently being used at the Attappady Nutrition Resource Centre. Various autonomous councils for social audits of nutrition programmes in tribal areas, such as the Citizen’s Alliance against Malnutrition in Schedule V states, have also been established.

The difficulties faced by the Integrated Child Development Services in tribal areas are well known. There are tribal villages where no government officer may have ever visited an anganwadi centre, even in non-civil strife affected areas. There is also the issue of non-tribal workers looking down upon tribal workers. Even if take home food rations are given for children, these are mostly not availed. The implementation plan for the government run ICDS programmes has no separate chapter on the running of the scheme in tribal areas. No wonder data coverage, allocations and expenditures for tribal pockets are still not available separately.

However, in Odisha, this problem has been partly resolved by involving decentralized women groups to run the ICDS supplementary nutrition programme, thereby improving both the coverage of the scheme and availability of information. Self-help groups provide hot cooked meals and a morning snack to children at the anganwadi centre with the support of an anganwadi worker and ward member. From procuring grains from the Food Corporation of India to selecting the self-help groups and ensuring quality checks and accounting, the entire process is well managed. Menus are also locally contextualized.

Similarly in Chhattisgarh, the Jan Swasthya Sahyog has set up hamlet-based crèches for children between 6-36 months in fringe areas and forest villages of rural Bilaspur. It has also developed the operational requirements, costing, training materials and stationery needs, and a troubleshooting guide for running such a programme at scale by government. Using the lessons of the Bilaspur crèches, a group of researchers under the AAM (Action Against Malnutrition) project has tried to generate operational evidence of how crèches work in Maharashtra, Madhya Pradesh, Bihar and Jharkhand. These experiments show that hamlet-based crèches in tribal areas are both needed and feasible.

Another problem relates to improvement of drinking water and sanitation services. A water crisis is endemic in the tribal and desert-prone areas. The few toilets that exist are rarely used, in part because many don’t have doors and/or water. Infections, particularly in health centres, are a menace, with poor access to safe water and sanitation. Many anganwadis do not even have the facility for hand washing with soap, forget child friendly toilets. Thus, even as community based models are promoted, fund flow mechanisms and appropriate arrangements rarely match the requirements.

There are a couple of promising practices which include ‘unbundling’ of water supply chains, collecting rainwater and promoting water harvesting in hilly areas along with installing mini-pipelines, training local youth on basic geo-hydrology and water resource engineering to support development of village water security plans as demonstrated by WASMO in Gujarat, to list a few. There is also a community group led and managed total sanitation scheme wherein credit for toilet construction has been arranged from banks, MFIs and SHGs. Women self-help groups have set up systems of waste management in rural areas of Tiruchirappalli in Tamil Nadu. Finally, government-NGO partnership models, viz. with PRIA and Gram Vikas, have helped communities and gram panchayats to work together in Chhattisgarh, Odisha and Jharkhand for setting up and maintaining water and sanitation structures.

Unfortunately, inadequate budgeting for tribal sub-plan (TSP) and the special central assistance to the TSP remains a major concern. Fortunately, however, Andhra Pradesh has significantly improved accountability by introducing decentralized and inclusive planning. National Rural Livelihood Mission (Aajeevika) of MoRD works with 10 crore poor households organized into 70-90 lakh self-help groups and their federations at village and cluster level. It provides handholding support to enable them to come out of abject poverty and strengthens existing livelihoods. Also, programmes like the vulnerability reduction fund, food security and health risk fund in the Aajeevika programme of the National Rural Livelihood Mission provide opportunity to layer nutrition interventions while addressing finances. The intention of these efforts is to improve nutrition security while addressing livelihood issues.

The Nutrition Missions across states offer a platform for coordinating inter-sectoral action for nutrition of tribal children. Maharashtra has initiated specific pro-poor and pro-tribal strategies, e.g. filling up supply and payment backlogs at AWCs in tribal areas with special drives for: (i) filling vacant posts; (ii) relaxing recruitment norms for special drives to improve institutional delivery and training of functionaries; (iii) regular government visits to remote and unvisited villages; (iv) pre-monsoon camps; (v) nutrition resource centres at block and primary health care centres; and (vi) doorstep delivery of PDS directly from block level godowns to villages. Recently, Maharashtra has also started a tribal mission with various nutrition programmes. In addition, Gujarat has introduced e-coupons in the PDS system in partnership with cooperatives and NGOs for smoother delivery of services through an autonomous body, D-SAG, under the Vanbandhu Kalyan Yojana.

In brief, a range of attempts are being made to overcome the endemic problem of undernutrition in tribal children. It is important to recognize that both opportunities and promising practices exist, as do the champions that are implementing them. In an environment of cynicism, one needs to look at the opportunities, solutions and the champions before us, providing solutions to nourish India’s tribal children.

VANI SETHI and AKANKSHA DUTTA