Beginnings of a Public Debate

Economic and Political Weekly August 26, 2006

and support structures to make them possible, do not exist.

Creating a New Social Environment

Any programme that aims at improving the health of women and children must begin by addressing the lack of norms. In the absence of a supportive environment, even the best of services (such as antenatal care or supplementary nutrition or micronutrient supplementation) do not reach the target group. This acts as a significant barrier against women’s access to what is due to them. It is the responsibility of the government, through the anganwadi centres, to work towards creating new norms that support mothers’ and childrens’ rights. To change norms, the entire community has to be mobilised to protect the rights of women and children. Everyone in the community, men and women, old and young have to be involved in a process of debate and discussion on what is best for the health of the mother and the child. The gram panchayat and local bodies must review the functioning of the anganwadi centres and also the status of mother and child health in the village regularly.

An environment should be created where the village appreciates a man who brings water, fetches firewood or helps his wife with cooking, bathing and feeding the child. Such assistance often invites derision, as the man is seen to be womanly. If a girl is married off very young, then the community must react and get together to stop the marriage. A malnourished child or an infant death must become the concern of the entire village. It is only when this happens that there will be some meaning to the food given in the anganwadi centre and the colourful posters telling the woman what she should eat. If it is accepted that the woman has a right to a safe delivery, and that it is the government’s duty to protect her right, then the ICDS programme needs to address the social norms that undermine women’s rights.

Strengthening ICDS

Given that women and children have a right to health and nutrition, it becomes the responsibility of the government to create, through ICDS, a norm where these rights are not violated. For ICDS to play such a role, the following are some issues that need to be considered. Community involvement in ICDS: To ensure the involvement of the community, every anganwadi centre should have a mothers’ committee that meets regularly to review and monitor the functioning of the centre. In Andhra Pradesh, this committee consists of two pregnant women, two lactating mothers, two mothers of children in the age-group of 0-6 years, and two mothers of adolescent girls. It is usually women who are in the neighbourhood of the anganwadi centre who are chosen to be members of this committee. The meetings are rarely held. These women have not been trained, and do not know what their role is supposed to be as members of the mothers’ committee. The anganwadi worker (AWW) too is not clear about the role of such a committee. As there is little respect for this committee in the village, it often remains on paper, and makes little difference on the ground. There are names listed only because the AWW has to report every month to her supervisors. Since there is no public debate and discussion in the community on the anganwadi centre, its function and purpose, mothers’ committees become substitutes for a meaningful community involvement.

The ICDS programme reaches out to only a small section of the village population, giving the impression that it is a “project” and not a universal entitlement. The number of beneficiaries gets fixed on an arbitrary basis and there is no flexibility to change it. For instance, supplementary nutrition in Ranga Reddy district is to be provided to six pregnant women, six nursing mothers, 16 children in the age group of 6 months to 35 months, and 30 children in the age group of 3-6 years. As the programme excludes a majority of women and children, the active involvement of the community is difficult to achieve. The ICDS programme is seen not as a rightsbased institution, but a ‘podi’ (powder) centre where, once in a while, some white powder is distributed on the basis of the AWW’s likes and dislikes.

This lack of public ownership of the programme also opens the door to large scale and blatant corruption. It is no secret that in many places the supplementary nutrition powder is sold by the AWW to farmers as feed for buffaloes. In other instances, the powder is strained to extract the sugar. So much so that during ‘Ugadi’ in Andhra Pradesh, people ask for the anganwadi ‘jaggery’ to make the festival sweets because it is of good quality! There is more public discussion of how good the jaggery is, and how one should try and get it for the Ugadi celebration, than there is on why so many children are malnourished, why there has been an infant death in the village, or why a woman has not been able to go to the hospital for delivery.

Involving the community in ICDS is important so that the village feels a sense of ownership of the centre. It would also render the AWW more accountable and acceptable to the community. Responsibilities of AWWs: The AWW, in many instances, is the only available government servant in the village and is responsible for the most vulnerable groups in the community. Yet she does not get the recognition she deserves. At the village level, the AWW is not involved in any of the village meetings concerning discussions on children, adolescent girls and women, even those where say, the schoolteachers are involved. She is not consulted on any agenda. At the mandal6 level too, it is seen that although those in the revenue, social welfare, education and health departments sometimes coordinate with each other, the members of the ICDS project such as the community development programme officers (CDPOs) are not participants. Even at public functions, for instance, the CDPO never gets invited in the way that a mandal revenue officer (MRO) or a mandal development officer (MDO) are. Right from the beginning, the design of the ICDS programme has been such that it works in isolation from other departments, and is also poorly integrated with the community. This has resulted in the entire programme receiving little importance.

In the village, the AWW is viewed as just a “social worker” paid by the government and not as a functionary of the government. She gets paid only Rs 1,000 a month (less than the minimum wage), and even this amount is not paid regularly. On the other hand, the number of tasks that the AWW is expected to perform is impossible for most workers to complete.

The AWW, as mentioned earlier, is supposed to cater to the needs of pregnant and nursing mothers, adolescent girls and children below six years of age. She also has other responsibilities in the context of other programmes such as family planning, DOTs follow-up for tuberculosis, and girl child protection schemes. Each of these is a major task in itself, requiring a lot of effort. Although the needs of the three target groups under ICDS (children under six, adolescent girls, and pregnant and nursing mothers) are linked to each other, each group’s well-being raises

Economic and Political Weekly August 26, 2006 independent issues. While it is true that in the long-term today’s children are the adolescents of tomorrow and the parents of the day after, right now they are three different groups with specific needs, calling for immediate attention. Each of these is a specialised task requiring professional skills.

To begin with therefore, as many have suggested, there has to be a separation of the 0-3 year old, adolescent girls and women’s programme from the pre-school education programme for 3-6 year old children [Ramachandran 2005]. The pre-school education programme for the 3-6 year olds could be linked to the primary school, with the mid-day meal as supplementary nutrition. In some villages of Andhra Pradesh where the centres are linked to the primary school, it is seen that the attendance at the anganwadi centre is greater because the younger children come to the centre along with their siblings who are in school. Further, the AWW feels part of the larger institution and is therefore motivated to work. The children also like having a proper meal along with the older children in the afternoon. A kindergarten section in the school, open to all children in the age-group of 3-6 years, can be visualised, with the number of teachers being decided according to the number of students.

There is a need for a separate full time trained professional worker to carry out the other tasks of providing nutrition for the under-3s, ante- and post-natal care, immunisation and adolescent health. This person could also be responsible for conducting meetings in the village with the different groups such as women, youth, gram panchayat and so on, working towards creating a norm in favour of children and their rights. This person will have to work closely with the auxiliary nurse midwife (ANM) and the health department. Comprehensive planning and decentralisation: Many of the functions of the ICDS programme depend on the health department for their success. For instance immunisation, ante-natal care, family planning and referral services are all provided by the health department. The role of the AWW is to act as a motivator and a link person between the community and these services. At present there is no institutionalised mechanism for this coordination beyond the village level. At the village level the ANM liaises with the AWW as a contact person in the village and gets data from her on who is pregnant and whether any deliveries or deaths have taken place. Some times, basic first-aid material is also left with the AWW, e g, oral rehydration solution (ORS) packets and paracetamol tablets.

This kind of coordination is not the result of a careful plan of action worked out by the concerned departments at the higher level. Since all the activities are linked, there is a need to understand the significance of this kind of convergence. Two small examples, drawn from the M V Foundation’s experience (see next section), may help to illustrate the point. In the first case, a meeting was held with all the AWWs in one mandal in Ranga Reddy district and their help was sought in motivating women for institutional delivery. The AWWs said that they had given up doing that because when they did take women along to the PHC, there was nobody there to provide the service, and if they dared to ask, they were shouted at by the ANMs. The ANMs, for their part, do not see why the AWWs should have anything to say about the PHC. Coordination at a higher level, along with informing the ANMs that this is part of the role of the AWW, would have been helpful.

Another instance was a meeting in one mandal, held at the PHC, with the ANMs and the medical officer and all the AWWs. The PHC had been given orders that the entire population should be immunised for filaria within two days. The dates had already been fixed for the entire state. The medical officer therefore called the AWWs for a meeting to instruct them to carry out this job under the supervision of the ANMs. It would be impossible for the ANMs to do it alone, as each of them was looking after 5-6 villages. The AWWs however refused to cooperate, saying that it was the last week of the month and that they had to finish all their records in time for their monthly meeting, failing which they would be pulled up by their superiors. There was a long fight between the AWWs and the PHC staff. Ultimately, some of the AWWs agreed to cooperate, while others said they would have nothing to do with the programme. In this case too it was felt that it would have been better for the medical officer to have a meeting with the CDPO and for the two of them, to plan the entire programme together. Smooth coordination between different departments is extremely important for effective implementation of such programmes.

Closely related to lack of coordination is the problem of haphazard and top-down planning. Most programmes are ad hoc, suddenly launched without any preparation or follow up, highly centralised and without involvement of the community. There is, out of the blue, a rally with school children on institutional delivery, a meeting with adolescent girls on HIV/AIDS, or a week to celebrate breastfeeding with no information to the community. Usually it happens this way because it is planned at the state or central level and suddenly passed down to the AWWs as a task to be completed. This makes it very difficult for the AWW, who is the frontline worker facing the community, to implement the programme in a meaningful manner.

Economic and Political Weekly August 26, 2006

concern for anyone in the village – the gram panchayat, the anganwadi centre and the community evaded the issue. At best, people sympathised with the family. Invariably, it was seen as a personal issue, not something that required any social action.

Rallies and marches were organised in the village on the issue of children’s right to health. Meetings were held at the village and mandal level, where this information was shared with the entire community to discuss how each of these deaths could have been prevented. This entire exercise was also to help create an environment where the community felt responsible for the well-being of the children born in the village. It was then decided that the gram panchayat should review the condition of all children in the village every month along with all the concerned government functionaries such as the AWW, the ANM and the school headmaster.

Members of youth groups and mothers’ committees, among others, also attended these meetings in the village. Consequently, in about 50 villages, each month the ANM and AWW, along with the sarpanch and the ward members, now review the number of children who have been immunised; whether supplementary food was reaching the children; details on whether any children died during the month, and so on. They even discuss cases where families did not cooperate or refused to get children immunised, or were unwilling to take the supplementary nutrition provided at the anganwadi centre. The gram panchayat, along with others, then visits these families and motivates them to access the services.

Some changes have already taken place through this process. The gram panchayat in many villages now feels responsible for the children in the village. The ANM and AWW discuss with the gram panchayat the obstacles in delivering services. For instance, in Sheriguda, the ANM explained that she was not doing ante-natal checkups because there was not enough space with privacy in the village. In response the gram panchayat decided to convert a godown into a centre for the ANM and the material stored in the godown was shifted to the gram panchayat office.

In some villages the AWW was caught red-handed while she was trying to sell the supplementary food, and action was taken against her. At the same time, should the AWW require any support from the village, it is provided. In many villages, there were complaints that the ANM was not available. She, in turn, claimed to be making the requisite number of visits. To resolve this problem, a public announcement (with drum beats – ‘dappu’) is now made the previous evening, informing everyone about the ANM’s visit and asking parents to send their children for immunisation and health check-ups. Such issues are now being tackled at the village level, with government departments and the community coming together.

More importantly, as a result of this process of public mobilisation on child health, what was so far seen as a private issue confined to the family (and even within the family, primarily the mother’s concern) has now become an issue for the entire village. In village after village, ceremonies are held where the sarpanch gives out birth certificates to all children below the age of two. Once the backlog is covered in an institutionalised manner, all children in the village are given birth certificates as soon as they are named. For the sake of the certificate, families are naming their children within the first month itself. Through this exercise of giving birth certificates, the panchayat and the community now celebrate the birth of every child

– a significant shift from the earlier position where the death of a child was considered as the mother’s fate.

It is in such an environment that the specific issues of each child are taken up. The families are informed and motivated to avail the services available to them from the ICDS and health departments. At the same time, there is also a discussion on giving children time, and sharing of responsibilities within the family. Through regular review meetings, the community exercises pressure to ensure that the ANM comes regularly and that the anganwadi centre functions.

The community is thus being sensitised to the well-being of pregnant women, mothers and children. With increasing community interest in the anganwadi centre, the AWW is empowered and ICDS is beginning to have a presence in the village. Issues that cannot be resolved at the village level are being taken up by the gram panchayat to higher authorities. For instance, a number of petitions have been submitted to the CDPO asking for better buildings for the anganwadi centres, sanction of additional centres, and steps to activate non-functional centres. The rights of mothers and children are becoming a public concern, with the community demanding from the state what is due to mothers and children.

Conclusion

ICDS is one of the most important public programmes in India, reaching out to the most neglected sections of the population. It can go a long way towards protecting the rights of mothers and children. India cannot dream of progressing with high rates of maternal and child mortality and extremely high levels of malnutrition.

However, a lot needs to be done to enable ICDS to reach its objectives. The coverage of ICDS has to be expanded to reach out to every child, pregnant or nursing mother, and adolescent girl. It is important to demand universal coverage of mothers, children and adolescent girls, dealing with the issue from a rights-based perspective. This involves a clear commitment to the protection of children’s rights on the part of the state, and public mobilisation to ensure that rhetoric translates into action.

Secondly, the functions of ICDS have to be separated, with a specialised person to provide pre-school education and another trained worker to take charge of the health and nutrition aspects of the programme. Active steps should be taken to implement widely-supported recommendations such as keeping anganwadi centres open for the whole day, setting up crèches for younger children, providing take-home rations for those under three years of age, etc. Further, there must be coordination between the health and education departments to provide these services efficiently. Also, the National Rural Health Mission’s plan to post community health workers in each village should be integrated with the ICDS programme, to avoid creating a parallel system and to ensure better coordination between ICDS and the health system.

Thirdly, it must be recognised that the anganwadi centre is expected to perform multiple functions, each of which is equally important and needs to be carefully thought out. There is a need to first have a vision of what is best for the protection of the rights of mothers, children and adolescents, and of the state’s responsibilities in this regard. Based on such a vision one could then estimate the required resources, how these resources can be mobilised and how they should be spent. It is important to set clear goals, so that achievements can be assessed and work given direction. As things stand, the process works the other way round. There is first an

Economic and Political Weekly August 26, 2006 estimate of the resources available, and then“realistic”demands and plans are made, contingent on these pre-specified resource commitments.

The health and well-being of mothers and children must be recognised as an overwhelming priority, and all efforts made to realise this goal. Children are the future of the country and cannot wait any longer. There has to be a serious debate on this issue, involving all sections of society, leading to a vision of what we aspire to be. Backed by a clear vision as well as political commitment to the rights of mothers and children, the ICDS programme and the AWW could play a key role towards the development of the country.

EPW

Email: dipasinha@gmail.com

Notes

References