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Death by drought and more

26 Dec

ANJALI LAL GUPTA IN THE HINDU

In drought-hit Bundelkhand, corruption is not just a tired cliché from a bad Bollywood movie, it is a life-threatening human rights emergency.

Corruption exacerbates poverty in Bundelkhand…the money earmarked for NREGA is being cleverly pocketed by village council leaders and unscrupulous officials.

Sesame shoots in the fields of Bundelkhand make it seem there is no drought. But the crops are stunted and useless.

Bundelkhand, which comprises six districts in Madhya Pradesh and seven in Uttar Pradesh, has had a drought for seven years except the last one. At the peak of farming season this year, rains were half of normal.

In between Mahoba and Chhattarpur districts lies Khajuraho airport. Swanky roads and five-star hotels dot the tourist destination and belie the silent human catastrophe unfolding just kilometres away. Drought may have ravaged the fields but State apathy and the brazenly corrupt officials are more brutal.

Multitudes throng us in every village we visited. Willing to clutch at straws in their desperation, their voices would go: “Have you written about my mentally challenged son?”… “I applied for old age pension long back.” … “I have been anxiously waiting for my widow pension card.” “They haven’t paid my NREGA wages.”

Inaccessible healthcare

Eighty-five-year old Motiya, slumped on a cot, gives out a heartrending cry as we step into his dingy hut. His wife sleeps nearby. Both have had fever for four days. Motiya has bed sores and can barely move. Villagers say that often worms crawl out of his mouth. “The other day my father defecated in bed. I cleaned him up. Where is the money to get them medicines?” asks Motiya’s son Chaniya, a daily-wage labourer in Seelaun village of Chhattarpur. The government hospital is 25 km away, and rarely stocks medicines.

Cattle, abandoned on highways, and the old are among the causalities of this drought as families flee a disaster. In village after village, elders have in vain applied for pension that provides Rs. 275 a month. Often the local officials demand bribes from penniless petitioners. Also, families who own more than five acres of land are not classified as being Below Poverty Line or BPL. It does not bother the officials that the drought has rendered income from land inadequate.

Dalit woman Jhharokhan Paswan in Chandauli village of Mahoba could not complete the last rites of her husband who died of grinding hunger last year. “My blind husband died a slow painful death,” she says. A tattered sari covers her old body. Had the grain bank supported by ActionAid partner organisation Kriti Shodh Sansthan not given her 40 kg of wheat, she would have had to go on begging. Last month, she threw a dried-up chapatti on the district collector’s table. He promised to mark her as BPL. And she is still waiting.

Against the wall

Despair is all too common in Bundelkhand. Rani’s husband Priti Pal Singh jumped into a well in Chandauli three months back. Their three acre land had stopped yielding, and he couldn’t repay a loan of Rs. 80,000 he took for his daughter’s wedding. Rani has asked for a job but the sarpanch argues over how an upper caste woman can go to work! Though only slightly better-off, villagers have been generous enough to offer food. “I dread to think what will happen if they stop. Sometimes I too feel like jumping into the well,” her voice falters. Nights spent listening to her children crying out of hunger are still fresh in her memory.

Corruption exacerbates poverty in Bundelkhand. The running of the National Rural Employment Guarantee Act or NREGA is an example. The scheme that promises 100 days’ work could have been a lifeline for rural families. But the money earmarked for it is being cleverly pocketed by formidable village council leaders and unscrupulous officials.

NREGA wages have not been paid to 200 people of Akauna village in Chhattarpur for eight months. Officials have yet to answer queries posed in March under the Right to Information Act on how many villagers got jobs in Akauna. Eighty villagers in Seelaun are yet to get remuneration. In village after village, inhabitants underline that those who are close to the panchayat leaders get NREGA work or a BPL tag.

Village council heads often refuse to accept written applications. Hence, little evidence remains of how many rural folk sought jobs and how many got them. The Afforestation Mega Campaign in Uttar Pradesh — a scheme worth Rs. 1582 million — was launched last year to boost the NREGA in drought-prone Bundelkhand. Mahoba was supposed to get 10 million saplings. “Only 40 per cent of the saplings have been sown, the rest are on paper,” reveals Manoj Kumar of Kriti Shodh Samsthan.

Six rivers have gone waterless in Mahoba. So, without food, water and jobs, people have no choice but to migrate to metropolises. Chhattarpur Collector E. Ramesh Kumar was quoted in The Hindudated September 5, “This is not distress migration.” He attributed the movement to seeking better opportunities.

“In Delhi we live in plastic huts next to roads. At times we fall from high rises doing construction work. Does that sound like a better opportunity?” asks Ramlal.

Ramesh Kumar, in a telephonic exchange, says he is only a few months old in Chhattarpur. And that “some shortcomings” perhaps do affect some villages.

Great divide

The distance between Bundelkhand’s poor and their political leaders is huge. Asked whether elected representatives have visited them ever since the polls, there are laughs all around in Chandauli.

Even as Finance Minister Pranab Mukherjee has said the country has enough food stored to prevent high inflation, hunger is widespread in Bundelkhand.

Those who are entitled to subsidised grains in Seelaun assert the full quota of 35 kg hardly ever reaches them. Numerous people across villages wryly confess that their meals consist of chapattis and salt. Bangle seller Ramesh Lakhera says, “I remember the taste of dal.” Lakhera’s earnings have plunged, and lentils cost a steep Rs. 90 per kg.

“Nearly 65 per cent of families are malnourished in 500 villages of Mahoba,” says Manoj Kumar.

In Banda district, 48 per cent of the children aged three or less are underfed. Government records reveal there are 130,000 malnourished children in Chhattarpur and 600 in Tikamgarh district. However grim these statistics may be, there’s more.

“We have discovered 40 undernourished children in Kandva village of Tikamgarh who have not been mentioned in anganwadi registers. Ten are severely malnourished,” says Narendra Sharma of ActionAid. Government-supported anganwadis supposedly provide nutritious food to toddlers and pregnant women.

In Mahoba, 165 anganwadis don’t function at all.

Denied rights

Rural families in Bundelkhand are routinely denied their right to health and life as they are often unable to access lifesaving treatment. The health system is seldom held to account. “Lately we rushed a young man bitten by a snake to the nearest health centre. They sent us away. He died on the way to a bigger hospital,” says Lallu Khan of Mahoba. Last year five children died of diarrhoea in Seelaun. Ramkali Ahirwar from Pratappura says bitterly, “We go to doctors when we are about to collapse. We die at home everyday.”

Asked whether the Uttar Pradesh government headed by a Dalit leader has made any difference to their lives, Phulia Rani, a Dalit woman in Chandauli, says “No.”

Meanwhile, the state website proudly announces “the historic decisions including increase in the budget for the welfare of Dalits and tribals by 41per cent”.

The author is a development journalist based in New Delhi and Hyderabad.

http://www.hindu.com/mag/2009/12/27/stories/2009122750130400.htm

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Orissa: Death dances in valley of neglect, apathy

16 Sep

Akshaya Kumar Sahoo in THE ASIAN AGE

Ghasian Majhi, 20, a resident of Miangpadar in the poverty-stricken Kal-ahandi district, looks desperately for someone who can help her to protect her two little daughters — Sumita Majhi and Sumitra Majhi. The one-year-old Sumita and Sumitra, 3, are undernourished and are at present fighting malnutrition.

Ghasian’s neighbour, 20-year-old Laxmi Majhi, died of cholera on September 2, leaving behind her three-month old baby Shanti in the custody of her grandfather Ghasiram Majhi.

At least 10 children in their locality have died in the last four weeks in cholera. A lot many children are at present down with the dreaded disease. Not only children, 50 adults, both male and female, have perished of cholera in the last one month.

Over 5,000 others in 13 panchayats under Lanjigarh and Bhawanipatna blocks, who are cholera-affected, are waging a battle between life and death.

The disease, which is seen more as a fallout of the state government’s alleged failure to provide basic healthcare facilities and civic amenities to the people living in forest areas of the district, appears all set to spread further into the neighbouring villages because of continuous awareness drive either by the state government officials or non-governmental agencies to persuade the affected people to take medicines and pure drinking water. Add to this, the absence of good road communication network to the affected pockets has stood in the way of timely intervention by the health officials.

Miangpadar is a small tribal hamlet located under the foothill of Kirangaghati hills, just 25 km from Bhawanipatna, the district headquarters of Kalahandi district. It is one of several villages where cholera has unleashed its spell of destruction. Villages like Jamchua, Panchbahili, Rukuni Badel, Tenganabahili Bandelguda, Ghatikunduru, Talbora, Tarngel, Bondkali, Jalkrida, Dominijholia, Kenduguda, Chachagoan, Barguda, Pedimguda, Chatabanduguda, Kedndupith, Borpadar, Borakhoje and Merkul are now under the grips of the disease, nakedly exposing the lapses of the state administration in taking precautionary and preventive steps.

Kalahandi Lok Sabha member Bhakta Charan Das, who actually first brought to light the outbreak of the disease in the area, says, contrary to the claim of the state government of providing quality life to the tribals, people in the district are living in abject poverty and deprivation.

“The affected pockets, which come under Lanjigarh constituency, were represented by a ruling BJD member for over 20 years. But it still remains in underdeveloped. Basic healthcare, education and minimum civic amenities are still distant dreams for people living in those villages. Majority of the people do not have purchasing power; they do not get 35 kg rice as entitled under Annapurna Antodoya Yojana. The Union government’s flagship programme — National Rural Employment Guarantee Scheme — is also not properly implemented in the area,” alleges Mr Das.

Purna Majhi, a resident of Miangpadar, says although he had worked for few days in an NRGS work last year, he has not yet received his remuneration.

One can find people in the area are still surviving on traditional, unhygienic mushrooms and Karida (bamboo-roots), thus exposing themselves to food poisoning. Bulging bellies of children adequately makes a statement of undernourishment and malnutrition. Infants are fed with water-rice and forest produces.

“We do not have money to buy cows nor can we afford for milk as we do not have regular income,” says 35-year-old Lalu Majhi, father of four children. The poor condition of the villagers were explicitly visible at Malati Majhi’s house. Her four year daughter Basanti was seen just managing without any clothes while the seven-year-old Shanti was trying to cover her body with torn saree.

According to Bharat Bhusan Bemal, a social worker and former local legislator, the disease broke out because of the carelessness of the authorities.

“Most of the villages do not have tube-wells. People are forced to drink contaminated waters of streams, rivers and rivulets. Although there are some tube-wells and dug wells in the affected villages, they were lying defunct and disinfected. Only after loss of some many lives, the government woke up and repaired them,” adds Mr Bemal.

Niranjan Pradhan, ex-chairman Bhawanipatna Municipality, blames the state administration for not taking preventive steps to check the spread of the disease.

“Much before the present catastrophe, the state administration knew well the wretched condition of the people. But, never did it created infrastructure such as bridges and roads to make the area accessible for mobilisation of doctors and para-medics,” says Mr Pradhan. Mr Pradhan, however, praises district administration headed by collector R. Santhangopalan for his efforts to reach out to the people distress.

“The collector is camping day and night in the affected pockets and trying his best to mobilise medical teams to the affected pockets.

“Things are now under control. At the peak time, we had engaged 30 medical teams and but now the number has been reduced 10. I hope within a very short time, we will get rid over the situation,” informs the collector. The collector puts the death figure at 27.

http://203.197.197.71/presentation/leftnavigation/asian-age-plus/news-plus/orissa-death-dances-in-valley-of-neglect,-apathy.aspx

Women’s health need for gender justice

29 Jul

K.S. Jacobin  The Hindu

The poorer health indices for girls and women mandate a social revolution which not only provides equal opportunities but also focusses on achieving equal outcomes.

There has been significant improvement in the health, education and employment status of women in India over time. Yet, health indices for girls and women compare much less favourably with those for boys and men. Successive governments have recognised the inequalities in health indices and have implemented many schemes to improve women’s health. Many programmes, including the National Rural Health Mission, provide care for women, especially during pregnancy and deliv ery and after childbirth. Family planning programmes offer services related to contraception for women, improving their health. Many programmes aimed at the general population also impact women’s health.

Nevertheless, community programmes have contended and shown that economic development results in greater improvement in women’s health than direct medical interventions alone. Consequently, education and employment for women became core features of such programmes. The national campaigns on education (Sarva Shiksha Abhiyan) and employment (National Rural Employment Guarantee Scheme) have a specific focus on girls and women. Self-help groups and micro-credit initiatives also increase skill levels, provide alternative livelihoods and generate income and assets for women.

Indicators of the status of women: A detailed analysis of national data shows some reduction in maternal deaths and an improvement in many indices related to infant health. However, there are gender differentials in many indices, with data disaggregated by gender, showing far greater improvement for males than for females. The perinatal mortality rate, infant mortality rate and under-5 mortality rate are poorer for girls. There is evidence of foeticide and infanticide of girls. They are often malnourished and brought to hospital later in their course of illnesses than boys. The birth of a girl and failure to conceive a boy are significant risk factors for post-partum depression. The suicide rate among young women is about three times that seen for young men. Violence against women and girls is common.

Women and girls have lower adult literacy rates, school enrolment and attendance figures. The long walk to school with its associated fear for physical safety, lack of toilets at schools, the small number of women teachers and the second class status of the girl child contribute to these lower rates.

Socially devalued

Women’s work at home, because of its invisibility, is rarely recognised, although they work for roughly twice as many hours as men. Technological progress in agriculture and the shift from subsistence to a market economy have had a dramatic negative impact on women, cutting them out of employment as many women are unskilled and lack education. Child labour among girls and unequal wages for women for similar work are common. Working women of all segments of society face various forms of discrimination, including sexual harassment. Women’s work is also socially devalued and autonomy in decision-making related to their life rarely exists for the majority of women.

While gender equality and justice are among the United Nations Millennium Development Goals, their implementation in India has been slow and patchy. Issues related to gender equality are not adequately mainstreamed for India. Discussion of gender is usually confined to Goals 3 and 5, which are gender equality and maternal mortality. Women are cast only in the role of victims, rather than as equal partners in development. The social, economic and cultural contexts, the most significant predictors of women’s health, are barely mentioned.

Health justification for gender justice: Gender injustice is often viewed in the socio-cultural context and usually in terms of social outcomes. However, analysis of health data clearly documents the importance of gender and its impact on women’s health. Women are the largest discriminated group in India. This results not just in adverse social outcomes but also unfavourable health outcomes.

Social determinants have a significant impact on the health of girls and women. Viewing the health of women in general as an individual or medical issue and suggesting individual medical interventions reflects a poor understanding of issues. Reducing public health related to women to a biomedical perspective is a major error of the public health movement. Social interventions should form the core of all health and prevention programmes as individual medical interventions have little impact on population indices which require population interventions.

Barriers to scaling up interventions for women: The major barrier to mainstreaming gender justice and to scaling up effective interventions is gender inequality based on socio-cultural issues. The systematic discrimination of girls and women based on culture and tradition needs to be tackled if interventions have to work. Although the short time-lag between the (absence of) medical intervention and the health outcomes stand out as causal, it is the longer latent period and the more hazy but ubiquitous and dominant relationship between gender and culture which have a major impact on the outcome. Failure to recognise this relationship and refusal to tackle these issues result in poorer health standards of women. Tradition and culture maintain their stranglehold on gender inequality. Debates on gender equality are often reduced to talking about culture, tradition and religion. The prevalent patriarchal framework places an ideological bar on the discussion of alternative approaches to achieve gender justice for girls and women.

The way forward

While the Constitution guarantees equality for women, legal protection has little effect in the face of the prevailing culture. Many researchers and activists are no longer convinced that we can succeed in improving women’s health or status unless society attempts to confront its gender bias openly. For too long we have been refusing to discuss women’s issues explicitly with society. It would appear that nothing short of a social revolution would bring about an improvement in the health of Indian women.

Many approaches have been suggested. They will all need to include approaches which examine, understand and confront gender discrimination in social, cultural and religious spheres. Legal solutions enforcing gender justice are equally necessary, and monitoring the implementation of legislation is mandatory.

The right to health is a fundamental right and the poorer health indices of half the population is a cause for concern. There is an urgent need for a detailed re-examination of public health statistics for India, disaggregated by gender and region. There is an equally vital need to set up policies and programmes to counter adverse trends. The evidence from such disaggregated data should be used to set targets for action. Progress has to be visible and benchmarks have to be set high.

The magnitude of the inequality related to health is often downplayed even within medical circles. The second-class status of women in Indian society persists and women’s perspectives continue to be missing, marginalised or ignored. There is a definite need to engage communities and the population as a whole in a debate to challenge traditional stereotypes and accepted social norms. Programmes to achieve gender equality should not only focus on the provision of equal or greater opportunities for women. They should also concentrate on achieving equality in gender outcomes within a reasonable time frame. Outcomes in general, and health outcomes in particular, are measurable with a much greater degree of accuracy than opportunities.

All plans and projects within community programmes should be assessed using the “gender lens” in order to achieve gender justice for women. These programmes will have to cover the social context of home, school, workplace, law and politics in order to improve women’s health. There is a need to challenge the normalisation of gender discrimination in India. The focus should be on public health approaches to change social and cultural perspectives with the aim of primary prevention of discrimination while continuing medical interventions for early diagnosis and management of the medical consequences. There is a need for aggressive gender justice in order that women in India achieve equal health and social status in the foreseeable future.

(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)

http://www.hindu.com/2009/07/29/stories/2009072956090800.htm

A breathtaking waste

1 Jun
Padma Shastri , Hindustan Times
Email Author Indore, June 01, 2009

It’s a tragic irony in Madhya Pradesh: Labourers dying to produce a product very few people use any more.

Thousands of families work all day in Mandsaur, the sole producer in India of white and red slate, to make those rectangular, chalk-like ‘pencils’ used by primary student in rural government schools.What the labourers don’t know — and the government has so far refused to acknowledge — is that a large chunk of these pencils never even reach the rural markets.

Instead, they are used to conceal opium as it is smuggled across the state border illegally; in addition to slate, Mandsaur is also a large producer of opium.There is no other means of employment here. So the illiterate, landless locals — and often their children as well — risk contracting silicosis, an incurable lung disease, as the silica dust drifts into their lungs.Most of the labourers work in dark, dingy homes, putting entire families at risk.Official records say 569 people have died of silicosis in Mandsaur over the last 24 years. Unofficial estimates suggest that the actual number is at least three times that.

The irony of these deaths has not gone unnoticed.The National Human Rights Commission (NHRC) has been recommendingfor over 18 years that Madhya Pradesh act against the slate pencil manufacturers.In 1991, then NHRC chairperson Justice Rangnath Mishra visited the region and recommended action against these units.As recently as last year, an NHRC report recommended a ban on the production of slate pencils altogether, in the interests of the workers and children employed in the units.

The report also pointed out that slate pencils were no longer in use and their production and distribution was just a cover for the massive illegal trade in opium.Mandsaur, one of the largest producers of legal opium in the world, also has a bustling illicit business. Many of the district’s 109 slate pencil units, the NHRC found, were using crates of their product to smuggle opium.No action has followed this report. Meanwhile, seven more people have died and five others contracted silicosis in Mandsaur.“There are practical problems with banning these units,” says State Labour Commissioner Ashwini Kumar Rai. “Closure will throw large numbers of people out of work. Steps are being taken to prevent child labour.”Government sources, meanwhile, say slate pencils aren’t going away any time soon.

“The nexus between the politician, opium producer, peddler and slate pencil unit owner is too strong,” said a government source, speaking on condition of anonymity.For the impoverished locals, that nexus is a death sentence.“I have trouble breathing and I can’t work any more,” says 40-year-old Manohar Singh Rajput of Ralaita village, a father of five. “I worked at the slate pencil units since I was 15… there is no other work to be had here. A few years ago, doctors said I have silicosis. I get Rs 365 a month as medical assistance, but it’s not enough to feed my five children, so they too work at the quarries. What choice do we have?”

The silent tragedy of hunger

6 Apr

HARSH MANDER

THE HINDU ON SUNDAY http://www.hindu.com/mag/2009/04/05/stories/2009040550100300.htm

It is the State’s responsibility to be proactive about hunger and malnutrition which still survive despite surging economic growth and agricultural production.

 Photo: Ashoke Charabarty 
2009040550100301
Failure of governance…  

 In the dark shadows of this land, a silent tragedy plays out for millions of women and men, boys and girls, who sleep hungry. The experience of chronic hunger in distant villages of India, as much as on its city streets, is one of intense avoidable suffering: of self-denial; of learning to live with far less than the body needs; of minds and bodies stymied in their growth; of the agony of helplessly watching one’s loved ones — most heartbreakingly children — in hopeless torment; of unpaid, arduous devalued work; of shame, humiliation and bondage; of the defeat and the triumph of the human spirit.

Such high levels of hunger and malnutrition are a paradox, because they stubbornly survive surging economic growth and agricultural production which outpaces the growth of population (although it has worryingly stagnated in recent years). The riddle deepens because the State in India runs some of the largest and most ambitious food schemes in the world. The persistence of widespread hunger is the cumulative outcome of public policies that produce and reproduce impoverishment; of failures to invest in agriculture, especially in poorer regions of India and for rain-fed and small farmers; of unacknowledged and unaddressed destitution; of embedded gender, caste, tribe, disability and stigma which construct tall social barriers to accessing food; but, in the last analysis, it is the result of a profound collapse of governance.

The colonial Famine Codes — developed since the 1880s to codify and prescribe State responses to cataclysmic famines which took tens of thousands of lives — continue to cast a long shadow over responses of the State to hunger, even though both the nature of famine and the political economy of the State have been completely transformed in free India. State authorities continue to regard starvation as a temporary aberration caused by rainfall failures rather than as an element of daily lives. The effort remains to craft minimalist responses, to spend as little money as is absolutely necessary to keep people threatened with food shortages alive. And the duties of State officials are not legally binding, in ways that they cannot be punished for letting citizens live with and die of hunger.

Typical response

 

Allegations of starvation deaths are typically met with official denials and the blaming of the victims. Public servants believe mistakenly that death from consuming no food whatsoever is the only “proof” of starvation. But starvation is a condition of not just the dead but the living, and people who have lived with prolonged food denials mostly succumb not directly to starvation, but to health conditions which they would have easily survived had they been adequately nourished. There are seamless lines between dying of and living with starvation, prolonged food denials, malnutrition, and the subjective experience of hunger. Starvation is closely related to the equally neglected phenomenon of destitution, in which people lack even the minimal economic means for bare survival. The State must acknowledge these conditions, identify people threatened by them, and address and prevent the enormous and avoidable toll of suffering, sickness and death that they entail.

Public policy — and even much of civic action and mainstream academia — do not adequately acknowledge or address the unconscionable reality of the unrelentingly precarious, lonely, humiliating and uncertain existence of women and men, boys and girls who grapple with critical hunger, chronic food denials and starvation as a part of their lived everyday experience. If their suffering is admitted, they tend to be blamed for it, as the “undeserving” non-working “unemployable” poor.

Destitute people are those who almost completely lack the resources (financial and material), the employment, assets, access to credit, and social and family support and networks which are required to secure the means for dignified survival. These are men and women, girls and boys who are powerless and disenfranchised, socially isolated and devalued, sometimes stigmatised and even illegalised, and often with special needs born out of disability, illness, social standing and age.

For large numbers of these forgotten people who live routinely and precariously at the edge of survival, each day comes afresh with the danger of one push that will send them hurtling over the precipice. This may come from an external emergency, like a natural disaster, epidemic or riot, but even from local crises: a sickness in the family, a sudden untimely death of a breadwinner, or a brush with the law. These people who live on a regular basis in constant peril of slipping into starvation — or at least chronic, long-term, unaddressed hunger — may be described as destitute.

Excluding the destitute

 

Karl Marx wrote evocatively of the exclusion of destitute populations from what he described as “political economy”: “Political economy does not recognise the unoccupied worker… The beggar, the unemployed, the starving [and] the destitute are figures which exist not for it, but only for the eyes of doctors, judges, gravediggers and beadles. Nebulous… figures which do not belong within the province of political economy.” Incidentally, Marx was right about their exclusion, but not about their being “unoccupied workers”. On the contrary, we have found that the destitute are forced to labour in arduous, low-paid, undignified work in order even to stay barely alive as each new day dawns.

The destitution and helplessness of highly marginalised groups do not arise from low incomes or even from their own intrinsic and irrevocable biological infirmities (such as of age and disability), but from the fact that in many cases these infirmities are externally imposed by social arrangements themselves. People may be barred from access to food even if it is locally available and they have the economic means. These social barriers to food security may include gender, caste, race, disability or stigmatised ailments.

The expulsion of those who most need it from support and succour, from care and rights — often by their own families, by local communities, but most importantly by the State — requires us to identify those classes, social categories and local communities who are destitute and socially expelled. Even in the more intimate context of a village, many of these socially excluded groups are invisible, barely known or acknowledged. In most contemporary cultural contexts, social categories that consistently tend to be highly dispossessed and vulnerable in their access to food include disabled people, both as breadwinners and as dependants; single women and the households that they head; aged people, especially those who are left behind when their families migrate or who are not cared for by their grown children; people with stigmatised and debilitating ailments such as TB, HIV AIDS and leprosy; working and out-of-school children; and bonded workers. In addition, in diverse cultural and socio-economic contexts others may be added, such as certain denotified and nomadic tribes (these are communities who were notified by colonial rulers as “criminal tribes” and often continue to suffer from this stigma, even though they have been officially “denotified” by the government of free India) in one place, some specially disadvantaged dalit groups like Musahars or Madigas in another, weavers, artisans and particularly disadvantaged minority groups in yet another, all designated as “primitive tribal groups”, survivors of conflict and internal displacement, and many other diverse forgotten people. Many of them are of contested citizenship.

On the bridge between the rural and the urban destitute are the distress migrants, at the bottom of the heap, both where they move for work and from where they come. In urban contexts are street children, with or without responsible adult caregivers, urban homeless people, slum-dwellers and a wide range of unorganised workers, both seasonal migrants and settlers, such as rickshaw pullers, porters, loaders, construction workers and small vendors, and people dependent on begging.

Inadequate measures

 

Government programmes are woefully inadequate to address destitution; in fact, they tend to be blind to or in denial of the fact that large numbers of people lack even the elementary means and power to survive with dignity. It is stressed that this is a duty of the State, not to the dead but to the precariously living. It requires public vigilance about individuals, communities and several categories living with starvation and absolute hunger. It requires the State to act, not after there is an emergency like a drought or flood, not even after people die of starvation, but proactively, before people slip into destitution and fail to access, in an assured and reliable manner, with dignity, the nutritious and culturally appropriate food they require to lead healthy lives.

Gandhi offered us a “talisman” to use in moments of doubt and confusion. He asked us to recall the face of the poorest, most defenceless, most powerless man we have encountered. (Today he would have recognised that she would probably have been a woman!) We must ask ourselves whether what we are attempting has meaning for this person: does it touch her life with dignity and worth? Does it augment her power and self-reliance? If it does, it must surely be the right thing to do. It is this talisman that we need to hold up to public policy in the glittering world of vast reservoirs of darkness today.

Lessons in apathy

3 Apr

FRONTLINE

http://www.frontline.in/stories/20090410260701800.htm

R. RAMAKUMAR

The neglect of the public school system and the encouragement of private schools characterise the UPA’s education policy.

V.RAJU

PRIMARY education in India has the history of being an object of neglect by the Indian state through the 60 years of Independence. First, the state has never regarded the provision of education to children as a legal duty, as most modern nations have. In other words, the need for a compulsory education law that would universalise education was never seriously considered. India is one of the few modern nations that has not yet banned all forms of child labour. Secondly, while most modern nations have expanded their educational systems through significant public spending, public financing of education in India has always been inadequate. The share of expenditure on education has only rarely exceeded 3 per cent of the gross domestic product (GDP) in India, while the international average is close to 5 per cent. Thirdly, while in many modern nations educational expansion has gone hand in hand with substantive social transformation, large parts of India are yet to undergo such transformation. Class, caste and gender discriminations have persisted on a mass scale in Indian society, fostering corresponding differentials in educational achievements.

In 2003-04, according to official estimates, about 52 per cent of children were out of school at the elementary education level. The corresponding share was higher at about 59 per cent for Dalits and 70 per cent for Adivasis. Even among children who enrolled, dropout rates were large; in 2003-04, the average dropout rate at the elementary level was about 52 per cent. In the age group of 5-14 years, there were about 13 million child workers as per Census 2001.

The United Progressive Alliance (UPA) government assumed power in 2004, riding on a historic verdict of the people against the neoliberal policies of its predecessor. While there were no illusions of any significant shift of policy, there was the hope that a sincere effort to address some of the concerns in education would begin under the UPA. The Common Minimum Programme of the UPA pledged to “raise public spending in education to at least 6 per cent of the GDP”. In part, this increase was to be financed through an education cess on Central taxes. A legislation that ensured right to education as a fundamental right was also promised. The midday meal scheme was to be made a national scheme for all primary and secondary schools.

Public financing of education

The total public spending on education has been falling sharply as a share of GDP from 1999-2000 onwards (see chart). In 1999-2000, India spent 3.3 per cent of its GDP on education. When the UPA government took over in 2004, educational spending stood at 3 per cent of the GDP. After 2004, this share actually fell for the first three years and then rose to settle at 3 per cent in 2007-08 (the last year for which revised Budget figures are available). Tentative Budget estimates of expenditure and the GDP show a possible fall of public spending in 2009-10 to below 3 per cent. Clearly, in spite of introducing an educational cess, the UPA government was unable to prevent the fall in total public spending on education after 2004.

The increase in public expenditure on education was to be achieved in a phased manner. Economists C.P. Chandrasekhar and Jayati Ghosh have prepared a set of estimates on the annual increase in public educational spending that is required to gradually achieve the target of 6 per cent of the GDP by 2009-10 (Table 1). As per their estimates, the actual expenditure on education in 2007-08 should have been Rs. 2.2 lakh crore, equivalent to a public spending to GDP ratio of 5.5 per cent. As this amount was to be spent by the Centre and States together, a part of this amount should have been devolved to States in some tied fashion. However, for every year after 2004, the actual public spending on education was significantly lower than the required amount. In 2007-08, the total public spending on education in India was only Rs.1.4 lakh crore: a deficit of 36 per cent.

The educational infrastructure is poorly developed: in 2007-08, as many as 27 per cent of schools did not have pucca buildings, 13 per cent did not have drinking water facilities, and 50 per cent did not have separate toilets for girls. Here, a government high school at Dhoolpet in Hyderabad.

It may be argued that the Central government’s spending on education has risen as a share of the GDP. While that may be true, the inability of the UPA government to ensure a rise in States’ spending on education cannot be sidestepped. In fact, in many ways, the UPA government has continued to tie the hands of States in the sphere of spending choices. One of the most important barriers to the States’ spending on the social sector is the Fiscal Responsibility and Budget Management Act. The Act mandates all States to reduce their revenue deficit to zero, and fiscal deficit to 3 per cent, by around 2010. In this situation, States have shied away from spending and have preferred to park surplus funds in the intermediate treasury bills of the Reserve Bank of India. As on March 6 2009, States had an investment outstanding of a whopping Rs.96,182 crore in these treasury bills. The complicity of the UPA government in engendering this situation cannot be missed. In some of the flagship schemes of the Central government, such as the Sarva Shiksha Abhiyan (SSA), there was an absolute fall in expenditure after 2007. The Budget outlay for the SSA, which was Rs.12,020 crore in 2007-08 (Revised Estimate), fell to Rs.11,940 crore in 2008-09 (Revised Estimate) and Rs.11,934 crore in 2009-10 (Budget Estimate). Further, the share of States’ contribution to the SSA has been raised, without corresponding increases in total devolution to States.

Right to Education

The 86th constitutional amendment had established the right to education in India as a fundamental right. The UPA government delayed the tabling of the law that operationalise this amendment in Parliament for about two years. A Draft Model Bill was circulated in 2006. There was strong criticism that the provisions of the Bill undermined the spirit of the constitutional amendment. The Bill placed the onus of ensuring the child’s presence in school on the parents while absolving the state of any responsibility in either ensuring provision or enforcing the law. Also, while a 2005 draft of the Bill contained a provision to reserve 25 per cent of seats in private schools to poor children, the provision was deleted from the 2006 Model Bill. Given its present form, there is little chance of the Bill addressing the issues of enrolment and drop-out in any substantive manner.

Educational backwardness

Contrary to the claims of a section of civil society activists and non-governmental organisations, backwardness in education continues to be acute in India (Table 2). Data compiled by the National University of Educational Planning and Administration (NUEPA) show that the share of girls’ and Dalits’ enrolment in total primary enrolment has remained largely unchanged between 2002-03 and 2007-08. The state of educational infrastructure is poorly developed: in 2007-08, 27 per cent of schools did not have pucca buildings, 13 per cent did not have drinking water facility, and 50 per cent did not have a separate girls’ toilet. Studies show that even while these facilities are available, their quality remains poor.

In a development that undermines the right to free primary education, there has been a growth of private schools; the share of government schools among all schools providing elementary education declined from 86.3 per cent in 2003 to 81.2 in 2007. The neglect of the public school system and the encouragement of the private school system characterise the neoliberal ideological orientation of the UPA’s educational policy.

Reflecting the squeeze on finances, the number of single-teacher schools has risen from 2 per cent in 2002-03 to 10 per cent in 2007-08. Another outcome of the financial squeeze is that almost all the new appointments in primary schools are of a short-term contract nature; these grossly underpaid teachers are known by different names: para-teachers, shiksha-mitras, contract teachers, and so on. The quality of teaching has been the casualty under this cost-cutting policy.

In sum, the task of universalisation of education remains as big a challenge in 2009 as it was in 2004. Experience shows that the success in completing this task is contingent on the degree to which the problem is progressively politicised. To be certain, the UPA government has proved to be a major failure in this regard.•

R. Ramakumar is Assistant Professor, School of Social Sciences, Tata Institute of Social Sciences, Mumbai.

Unhealthy trend

3 Apr

FRONTLINE

http://www.frontline.in/stories/20090410260702100.htm

R. RAMACHANDRAN & T.K. RAJALAKSHMI

The present government and the ones before it have neglected the health sector, as the National Family Health Surveys show.

A.M FARUQUI

WHAT is the state of the nation’s health? The findings of the third National Family Health Survey (NFHS-3), a household survey carried out during 2005-06, should put the political class to shame. The country may be witnessing an 8-9 per cent economic growth and the government may think that India is a world power in the making, but these findings tell the real story of where all that growth is headed.

When the United Progressive Alliance (UPA) came to power in 2004, some of the health-related declarations it made as part of the National Common Minimum Programme (NCMP) are as follows:

The government would increase public expenditure on health services from around 1 per cent of GDP to around 2-3 per cent;

While focussing on primary health care in a substantial manner, all efforts shall be made to provide health insurance to all rural families;

In order to tackle all communicable diseases, the government would increase investment in health services;

The government would make all life-saving drugs affordable to all;

The government would ensure that all sections of the population can afford and avail themselves of health services.

In the context of these promises, how does the national health profile look?

The infant mortality rate (IMR), the number per 1,000 children before one year of age, is 57, which means over one in 18 infants die before they are one year old. While the figure is a marginal improvement over the IMR of 68 of NFHS-2 (1998-99) – about 1 in 14 – this is unacceptably high.

The same is true for children under five, wherein the child mortality rate (CMR) is 74 (one in 13) as compared to 92 of NFHS-2. This is a far cry from the Millennium Development Goal (MDG) of a CMR of 42 by 2015. More tellingly, this is equal to the average of all the Least Developed Countries (LDC), 2.5 times that of China and eight to 10 times higher than that of developed countries. Clearly, the IMR target of 30 by 2010 set by the 2002 National Health Policy (NHP-2002) is unlikely to be achieved.

Immunisation programme

What is particularly disquieting about these figures is that much of these deaths are preventable through childhood immunisation. But the reach of the country’s Universal Immunisation Programme (UIP) continues to remain low, which is the result of a weak public health care system. The NFHS-3 data show no significant improvement in immunisation coverage between 1998-99 and 2005-06 (Figures 1 and 2): 42 per cent coverage in NFHS-2 and 44 per cent now. The coverage has actually worsened in Andhra Pradesh, Gujarat, Maharashtra, Punjab and Tamil Nadu. The objective of introducing the pulse polio programme (PPP) over and above the routine immunisation programme was to make India polio-free. That goal has not been achieved because the PPP is being done at the cost of routine immunisation, in terms of deployed resources. The budgetary allocation for routine immunisation has been roughly a third of that for the PPP. The number of Acute Flaccid Paralysis (AFP) cases, an indicator of the success of polio vaccination, which prevents limb paralysis in children, has actually increased enormously, from 3,047 in 1997 to 31,973 in 2006.

The UIP suffered a major blow during 2008-09 because of the highly misplaced decision to shut down the three vaccine-producing public sector undertakings (PSUs) on grounds of non-compliance with the World Health Organisation (WHO) norms on good manufacturing practice (GMP). With the government unable to ensure adequate supplies from the private sector at affordable prices, vaccine shortage has worsened. While these PSUs never had any problem with their vaccine quality, there have been recent reports of vaccine from GMP-qualified private sector companies failing in quality checks (story on page 114).

Children’s health

India is fast earning the dubious distinction of being the “hunger capital of the world”. The nutritional status of children has not improved over the past five years, which means the Integrated Child Development Services (ICDS) aimed at promoting child health and nutrition is not working.

The outreach and delivery of ICDS is extremely poor. As per NFHS-3 data, the services of an anganwadi are available only to a third of the children and the supplementary food scheme reaches only 26 per cent. As a result, nearly half the children under the age of five are stunted, which reflects their childhood nutritional status. Nearly one-fifth are underweight for their height, an indicator of both chronic and acute undernutrition. These figures are nearly double the levels of undernutrition even in sub-Saharan Africa.

Undernutrition extends to adults as well (Figure 3). Over half the women and nearly one-fourth of the men are anaemic. This is a direct consequence of the continued lack of balanced nutrition from childhood into adulthood, especially among women.

Women are the worst hit in terms of access to health services. According to NFHS-3 data, only 17.3 per cent of women have ever received any service from a health care worker. Only 17.9 per cent of the public health centres (PHCs) have a woman doctor. As a direct consequence, 56.2 per cent of women (aged 15-49) are anaemic, which actually represents an increase from the NFHS-2 data of 51.8 per cent. The percentage of pregnant women who are anaemic has also increased from 49.7 per cent to 57.9 per cent.

Around 52 per cent of childbirths take place in the absence of a qualified health worker. This, coupled with women’s intrinsic poor health and poor nutritional status, causes the death of over 120,000 mothers following childbirth. The maternal mortality rate (MMR), the number of women dying of childbirth-related problems per 100,000 deliveries, is a high 300, according to NFHS-3, still way beyond the NHP-2002 target of 100 by 2010.

Communicable diseases

The burden of disease on the population continues to be high and takes a heavy toll of life. Recent years have witnessed a resurgence of various communicable diseases such as tuberculosis (TB), malaria, chikungunya, dengue, kala-azar, encephalitis and leptospirosis.

India bears one-fifth of the world’s burden of TB. About 3.7 lakh people die of TB in India every year, the highest in the world, and this figure is only likely to go up with increasing evidence of the widespread prevalence of multi drug-resistant TB (Figure 4). Since NFHS-2, the reported cases of TB have declined by 18 per cent, but the level of medically treated cases of TB has not changed (Figure 5).

The number of malaria cases remains at around two million annually, but the disturbing aspect is the increasing trend of drug-resistant falciparum malaria (nearly half the cases), which causes the highly fatal cerebral malaria. Poor surveillance and the lack of access to hygiene, sanitation and drinking water among the poor, coupled with a weakening public health system, have contributed to this.

About six lakh children die of diarrhoea, a disease that is easily preventable by providing access to potable water and sanitation. Infected children can be prevented from dying if they have access to the simple household remedy of Oral Rehydration Solution (ORS). According to NFHS-3, only one-third of urban diarrhoeal cases get ORS, while less than a fourth of rural cases get it (Figure 6). The situation, according to NFHS-3, has actually worsened; only 29 per cent of households have access to improved toilet facilities. Besides, about 200 million people still do not have access to clean drinking water.

Notwithstanding the controversy in the number of Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) cases and the prevalence rate of infection in the country, and the recent downward revision of estimates for these, they are still significant. With the latest estimate of 25-31 lakh cases (depending upon the study and the agency), India has the third largest number, after South Africa and Nigeria. This constitutes a serious threat and a major challenge for the health care system in the country. Though treatment and access to health care facilities for the disease have improved in recent years, these need to improve further.

Having said that, one should bear in mind that the allocation for HIV/AIDS is skewed greatly in its favour because of foreign funding for the National AIDS Control Programme (NACP), from agencies such as the Melinda Gates Foundation. The allocation for the NACP is roughly of the same magnitude as the combined allocation for the control of TB, leprosy, trachoma, blindness and iodine-deficiency disorder. The neglect of the routine immunisation programme for women and children, in terms of inadequate finance, manpower and cold-chains and other infrastructure, only compounds the problem of tackling communicable diseases.

Health infrastructure

In terms of the growth of infrastructure in the public health sector in rural areas, even as per 2001 population norms, there is a shortfall of 21,983 subcentres, 4,436 PHCs and 3,332 community health centres (CHCs). Though the increase in the number of subcentres from the 9th Plan period to the 10th Plan period (6 per cent) has been significantly higher than that from the 8th Plan period to the 9th Plan period (0.8 per cent), this is still insufficient given the population growth.

The PHCs have actually registered a 2 per cent drop between the 9th and 10th Plan periods. There is a substantial increase only in the number of CHCs, but these suffer from staff and resource shortages.

As many as 807 PHCs have no doctor, 1,188 PHCs and 1,647 subcentres function without electricity or without regular water supply. According to the Rural Health Statistics of the Ministry of Health and Family Welfare (MoH&FW), 50 per cent of subcentres, 24 per cent of PHCs and 16 per cent of CHCs function out of rented or temporary premises.

Availability of skilled personnel even for standard medical care is woefully inadequate in the public health system. More than one-fifth of the sanctioned posts for doctors are vacant, while over 40 per cent of the PHCs have no laboratory technicians and nearly one-fifth have no pharmacists. This is a direct fallout of the nature of our medical educational system, which is largely based on the Western model, is urban-centric and does not produce the right kind of health workers. Only 20 per cent of the medical professionals are available for 70 per cent of the country’s population, in rural India.

The nature of hierarchical health governance, administratively, financially and technically, also contributes to the poor state of the public health sector. Further, “public health and sanitation, hospitals and dispensaries” are State subjects. Health should be brought under the “Concurrent List” in the Constitution, which gives a role to both the Centre and the States.

Rural health mission

The National Rural Health Mission (NRHM), which is a flagship programme of the UPA government, has certainly brought in some reforms, but they are not enough. Also, there are several shortcomings in the NRHM, as discussed below.

The NRHM was launched in April 2005 with the objective of providing universal access to equitable, affordable and quality health care. However, the findings of the second Common Review Mission (CRM) of the MoH&FW, released in November 2008, show that much of the NRHM’s focus has been to increase institutional deliveries despite most of the States having poor infrastructure. For instance, in Karnataka, institutional deliveries increased from 60 per cent in 2005 to 79 per cent in 2008-09, while the First Referral Units, the PHCs and the CHCs remained underutilised. It also revealed that the PHCs and the CHCs continued to lack basic facilities and faced a shortage of technicians and doctors.

In 2007-08, the Jan Swasthya Abhiyaan (JSA) and the People’s Rural Health Watch (PRHW), citizens’ fora that raise health issues, conducted a survey in the high-focus States of Uttar Pradesh, Madhya Pradesh, Chhattisgarh, Jharkhand, Orissa, Bihar and Rajasthan to analyse the impact of the NRHM on rural health care.

The survey found that only married women were selected to serve as accredited social health activists (ASHAs), the lynchpin of the NRHM. The ASHAs were found to be trained mainly for reproductive and child health services (read family planning) and not as community health workers, which is what is envisaged under the NRHM.

Nearly 75 per cent of the ASHAs spoken to in the survey said they had received no money. In fact, according to the CRM report, payments for the ASHAs and the Janani Suraksha Yojana (JSY) scheme were poor. It added that introducing incentives for the JSY and sterilisation compensation had “deleterious effects”.

The JSA-PRHW survey concluded that no genuine steps had been taken to recruit doctors at all levels of the public health services, retain them and make the health system functional; that despite a massive shortage of infrastructure, no measures had been taken to address the issue. The incentives under the JSY needed to be reviewed as they were leading to conflict and corruption between auxiliary nurse midwives (ANMs), ASHAs, dais and anganwadi workers.

All of the above are pointers to inadequacies in the public health care system, in terms of resources deployed and hence in its outreach and coverage.

India has the most privatised health care system in the world. According to NFHS-3, for 70 per cent of urban households and 63 per cent of rural households the unregulated private sector is the chief source of health care. Only 5 per cent have any kind of insurance cover for at least one member of the household. As a result, people bear over 80 per cent of medical expenses through “out-of-pocket” expenses, pushing the already poor to below-poverty-line status.

According to the 2004 data of the National Sample Survey Organisation (NSSO), 40 per cent of the respondents did not take treatment for their serious ailments because of financial constraints. According to the Planning Commission’s Steering Committee Report on health, the average cost of private health care is about eight times the cost in the government sector.

Not only does the private sector need to be regulated, it must also be integrated into the public health system where possible and in certain situations be required to perform the role of the public health system. Health care, being predominantly private-sector driven, makes the system urban-oriented with a bias towards tertiary-level health services. Profitability becomes the bottom line, ignoring equity and rationality.

“Medical tourism”

Against the WHO’s recommendation of 10 to 15 per cent Caesarean deliveries, today in urban India 45 to 50 per cent of childbirths are by Caesarean. This situation is attributable to a profit motive, which has also led to an undesirable growth in “medical tourism”, with indirect government support for patients from West Asia and the developed world who have the money to pay.

Even medical education has become private-sector dominated. The Medical Council of India (MCI), responsible for maintaining standards in medical education and in the medical profession, has increasingly become subservient to the interests of private enterprise.

Over the years, with the increase in the number of private medical colleges, the MCI’s powers have grown greatly. In November 2002, the Delhi High Court ordered its president, Ketan Desai, to step down on various charges, including corruption. But, despite the court’s observations, the Centre has done nothing to correct the irregularities within the MCI. Recently, it turned a blind eye to Ketan Desai’s re-election as the MCI’s president.

In an environment of private-sector-dominated health care, irrational treatments abound. It is estimated that in India two-thirds of the money spent on medical treatment goes towards buying unnecessary drugs because of irrational prescriptions by private practitioners. Such an environment has enabled the pharmaceutical industry, which comes under the Ministry of Chemicals and Fertilizers, to thrive. There is a proliferation of brand names in India, with as many as 80,000 brands around. Even so, only 20 to 40 per cent of the people have access to all essential drugs they need.

Many drugs are sold at huge profit margins of 200 to 400 per cent, thus putting essential drugs beyond the reach of the common man. The prices of drugs have grown at a disproportionately high rate when compared with the Wholesale Price Index (WPI). This has actually worsened during the UPA regime. Yet, policymakers are reluctant to impose any price control because of the industry lobby prevailing over politics. The existing price control regime is far from effective as most essential medicines are outside its purview.

There is also the issue of the spurious drug market, which the Drug Controller General of India (DCGI) appears ill-equipped or unwilling to tackle. Therefore, a national drug authority under the Health Ministry becomes necessary.

As regards investment during the past five years, the average spending on health was 0.86 per cent of the gross domestic product (GDP) as against the 2 to 3 per cent that the UPA promised. Even as a fraction of the total expenditure, the spending on health has dropped to 2.9 per cent from 3.4 per cent.


Polio drops being administered in a remote village in Salem district in Tamil Nadu as part of the pulse polio campaign in February. The goal of making India polio-free has not been achieved because the pulse polio programme is being implemented at the cost of the routine immunisation programme.

Public health expenditure in India as a proportion of total health expenditure is only 16 per cent, according to the JSA. This is less than that in Ethiopia (36 per cent), Burkina Faso (31 per cent), Nigeria (28 per cent) and Pakistan (23 per cent). In 1974, around 80 per cent of hospital units and 80 per cent of hospital beds were in the public sector. Post-liberalisation, in the 1990s, the trend reversed and only 38 per cent were in the public sector. The situation now could be far worse.

In addition to this is the fiscal management pressure from the Centre on the States, resulting in massive budgetary cuts in the socio-economic sectors, including the already deprived health services. The overall health expenditure by States declined from 4.5 per cent in 1999-2000 to 3.6 per cent in 2008-09.

Besides, the government subsidy for health also does not reach the poorer sections of the population. According to a WHO report, only 10 per cent of the total subsidy goes towards the benefit of the poorest 20 per cent of the population, whereas the richest 20 per cent avails itself of 33 per cent of the subsidy.

Access to quality health care is a basic human right and should be viewed as a fundamental right of every citizen. A healthy nation is a prerequisite for social and economic development. Mere economic growth measured in gross financial terms, as is evident, does not ensure that. To make the public health care system work requires determined political leadership, adequate investment and appropriate policy instruments rooted in ground realities.

Therefore, in the run-up to the general election, from the perspective of the electorate, people’s health should be accorded top priority along with education and food security. Public health must be brought to the top of the political agenda, which, unfortunately, has not been in evidence in the past 60 years of independence.•

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