NREGA and the New Deal

http://www.nytimes.com/2009/08/28/world/asia/28iht-letter.html



I'm encouraged that a variety of news outlets have been covering government poverty alleviation schemes in India. I'd like to highlight another article from the New York Times, "Smart Step to Help India's Rural Poor." I agree with the author, Akash Kapur who observes that there's something different about the National Rural Employment Guarantee Act (NREGA) as compared to other poverty alleviation programs in India's past and present.



NREGA is a government work scheme that's been around since 2005. It promises 60 inr per day of work and 100 days of work a year for men and women below the poverty line (same wage for men and women). In order to qualify for the scheme, all candidates must register with their panchayat (village counsel) who administer the program at the local level. Qualified workers each receive a card which they need to keep to record days worked and wages received. The type of work is unskilled manual labor in projects deemed important for rural development - roads, wells, school buildings, etc.


I view NREGA as India's Works Progress Administration (WPA), the New Deal institution which employed millions of Americans in the 1930s. During the Great Depression, the WPA, an act of Congress, was the country's largest employer and used its millions of dollars and its massive labor force to bring about many public improvements such as roads, bridges and important buildings. It brought millions of Americans through the unemployment and the hardship of the depression and also, according to some economists, helped the economy on the way to by spurring consumer spending.

WPA employed most of America until the economy recovered by the early 1940s and America entered into World War II, spurring an industrial boom. In the late years of WPA, the program focused on providing vocational training to WPA employees to make them eligible for factory work.




In the ideal world NREGA would function somewhat the same way (without the war), by employing rural India until the rural economy catches up with the rest of India and the private sector can take over. Looking forward, NREGA should start to focus on providing job skills to its workers and not just a wage they become dependent on. Authorities and civil society should work to ensure that all BPL populations have access to NREGA and they they're given their promised amount of work days (which all too often doesn't happen in very rural areas). NREGA, like all public schemes, should be monitored extremely closely to ensure that corruption is limited and jobs and funds reach the people who are in the most need and that the projects truly benefit the community.

NREGA has potential to outdo its 1930's counterpart. With some of the best minds in government being put in charge of implementation, with the impressive reporting and accountibility systems being developed, and taking into account results we've already seen, NREGA just might change rural India. NREGA will be nothing short of revolutionary if it can start providing workers job skills, filling the gap of skilled labor that many analysts claim is retarding growth in India.

Take a look at NREGA's website and you'll already see something different. http://nrega.nic.in/
has an impressive amount of information and data for a government website, even down to the panchayat level and individual card holder level! You can see how many hours an individual worked, when, and how much they were paid. All accounts are published (at least in theory). There's even a section for reporting irregularities and for conducting social audits. And a step further, they've published the results of corruption investigations: http://nrega.nic.in/State_details.pdf

NREGA isn't and won't be without the flaws of any program being implemented on a large scale through the India bureaucracy, but it is an encouraging step to help the rural poor.

Paper Rations

http://www.tehelka.com/story_main42.asp?filename=Ne290809the_paper.asp

Tehelka gives a great analysis of the challenges of India's Public Distribution System (PDS). Despite the many criticisms of this system (and they will come up in this blog), it still amazes me every time I think of the shear scale of this system that it actually works. The PDS system is the largest food distrubution scheme in the world, serving more than 320million people - more people than the whole the US.

Even with its problems, the PDS system is crucial for many of the families that I've come in contact with. It tides many families over through hard times and cushions the blows of bad crops or sickness.

That said, the system does clearly need an overhaul. I've met countless poor families with malnourished children who don't have ration cards. I've seen PDS shops that never open. I've seen PDS rations being sold on local store shelves. There are set quotas of 28kg, regardless of family size. Spandan, an NGO in Khandwa, MP, has calculated based on surveys with hundreds of families, that the 28kg rations given to a once a month family usually only feeds the family for a fortnight.

More strigent accountability structures are needed. Rations should be doubled or tripled, especially for tribal families. PDS shops should be well-stocked and open everyday to increase accessibility to families like those outlined in this story. PDS should also include essential nutritrients like vitamins and fruits and vedgetables. And we must recognized that while PDS is an important social safety net, it is not a cure for malnutrition. Other social systems are neccessary to make sure there is education given to communities to prevent malnutrition and that services for identification and treatment of malnutrition are easily accessible

While corruption and logistical problems abound in the PDS scheme, I think its right that Tehelka and civil society approach any type of cash transfer scheme with caution. Cash disappears easily - either to government pockets or the hands of debt collectors. I agree with Biraj Patnaik, who "says replacing the PDS with cash transfers is like “throwing the baby out with the bathwater""

The Women's Crusade

http://www.nytimes.com/2009/08/23/magazine/23Women-t.html


Nicholos Kristof and Sheryll WuDunn write a great article on how the empowerment of women can be the silver bullet we've all been looking for in development.


One of the most relavent points the authors bring out in relation to nutrition is the spending habits of poor men versus poor women:

"Our interviews and perusal of the data available suggest that the poorest families in the world spend approximately 10 times as much (20 percent of their incomes on average) on a combination of alcohol, prostitution, candy, sugary drinks and lavish feasts as they do on educating their children (2 percent). If poor families spent only as much on educating their children as they do on beer and prostitutes, there would be a breakthrough in the prospects of poor countries. Girls, since they are the ones kept home from school now, would be the biggest beneficiaries. Moreover, one way to reallocate family expenditures in this way is to put more money in the hands of women. A series of studies has found that when women hold assets or gain incomes, family money is more likely to be spent on nutrition, medicine and housing, and consequently children are healthier."

Hard to admit, but its the truth we've seen too often in the field. Bad spending choices are often a contributing factor to malnutrition. I've seen huts with a malnourished child and a DVD player. Families will often opt for a satellite dish, even if that means less nutritious food for the children. The tribal areas of MP are especially hard hit by alcoholism, which often leads to domestic violence, depression, and less money for nutrition and education. Less sinister, busy parents will often buy a few packets of biscuits a week to feed their child - not realizing that while they are providing calories, they're not providing nutrition. Biscuits cost a lot more than making a nutritious dal and roti.

With money in the hands of women, I'm sure, as the authors observe, more resources will be spent on nutrition, medicine, and education. The resourcesfulness of poor women to provide for their families is inspiring. Of course the solution is not that simple. Men cannot be left out of development. A change in long-engrained mindsets against women is required. Age-old prejudice's and customs must be overcome. Alcoholism must be addressed. Financial education should be given and fiscal responsibility needs to be taught. Women need to believe in themselves and men in women. But at least we know where the focus should be.

Check out the rest of the articles in this series which all give great insights into the power of women in development.

Posts from realmedicineblog.org

Below you'll find a series of entries from my blog posts on Real Medicine Foundation's blog, realmedicineblog.com.

Since the beginning of my work in malnutrition I posted from time to time on the RMF blog on my findings and the developments of RMF's Malnutrition Eradication Program. I include these posts for your reference as a lot of this serves as a good background to my work and my process learning about malnutrition in India. I decided to start a blog specific to malnutrition, in addition to blogging on RMF's blog about my programmatic work, in order to share my learning experiences and observations from the field. While I still might crosspost on some items, this blog will serve as more of an unbiased reference for those who want to learn more about malnutrition from someone who is figuring it out.

Malnutrition in MP in the news

http://www.ndtv.com/news/india/madhya_pradesh_epicentre_of_hunger.php

NDTV recently covered the state of malnutrition in the districts where RMF is working in Madhya Pradesh. They give a great overview of the challenges we are facing.

Field Report from Southwest MP, June 2009

Widespread malnutrition in Madhya Pradesh, India – A note from the field
Jhabua, Alirajpur, Khandwa, Khargone June 2009

Malnutrition is one of the most serious and large scale health problems facing the Indian state today:
· 46% of children under 5 in India are malnourished
· Over 60% of the children under 5 in Madhya Pradesh are malnourished – the country’s highest malnutrition rate
o Out of these 6 million malnourished children in MP, 1.3 have severe acute malnutrition (SAM) and another 1 million have moderate acute malnutrition (MAM) [1]
o MP’s tribal districts are the worst hit in the country because of their cultural, geographical, and economical isolation with up to 100% malnutrition in some villages.

Children with severe acute malnutrition have extremely high mortality rates – between 20-30%[2] - a rate of death approximately 20 times higher than well-nourished children. Malnutrition is closely tied to MP’s infant mortality: one of the highest in India, with 72 out of 1000 children dying every year. This rate translates into an estimated 130,000 children who will die every year. Malnutrition is one of the largest contributors to this alarming rate, constitutes 22% of the country’s disease burden because it severely weakens a child’s immune system, raising their mortality rates from common diseases such as pneumonia, malaria, and diarrhea.

The millions of children who do survive childhood will be forever affected by malnutrition: children who have been malnourished in the first 5 years of life will have limited mental and physical growth capacity as compared to a well-nourished child. There is evidence that a malnourished child will someday have children with low birth weights, perpetuating the cycle of malnutrition

Malnutrition is rampant throughout almost every town in southwestern MP. While traveling through the districts of Jhabua, Alirajpur, Khandwa, and Khargone this June we found malnourished children in every other household at best, in every household at worst.

Southwest MP has been one of the states worst affected by malnutrition in India for decades. While Madhya Pradesh’s state malnutrition average of 60% malnutrition in children under 5 is already “extremely alarming” according to the Global Hunger Index, malnutrition in the southwestern tribal areas of the state is even more concerning. According to Rural Health Commission the proportion of underweight children in these districts can range from 61-96%.

Madhya Pradesh not only has the highest rates of malnutrition in the nation, but also the accompanying highest rates of severe acute malnutrition (SAM). The District Family Household Survey (DFHS-III) estimates that nearly 12% of children under 5 in MP have SAM. This amounts to nearly 1.3 million children who are dangerously underweight. Considering that the medium case fatality for SAM in India is 23.5% (IAP 2006), over 300,000 children are in danger of death this year. There are also another 1 million children in MP who have moderate acute malnutrition (MAM) and who can become severe after just one bout of illness.

The field reality in Southwest Madhya Pradesh matches the statistics. In many villages we visited, 9 out of every 10 children we screened had some degree of malnutrition, with roughly 2-3 out of 10 children presenting with severe acute malnutrition.

Looking forward, a cause for great concern:

The current situation right now in Southwestern MP is alarming, especially in the context of the deaths reported last year during the monsoon season. We can only expect this year to be worse. Seasonal migration, the economic effects of the delayed monsoon, a particularly bad harvest last year, and higher food prices this year all will compound the already dire situation.

Local NGO workers in Khandwa give the season between June and October the dramatic but not inaccurate title, “the season of death.” Each year the monsoon comes at the time when families are the most food insecure, running towards the end of their stocks from the last harvest. The monsoon brings back migrants who were away from their villages for seasonal labor where they often become malnourished because of the higher food prices and unsanitary conditions in the major cities where they migrate. The monsoon brings with it the yearly bout of waterborne diseases, diarrhea, and pneumonia. Entire families are required to work during this period, leaving young children the most vulnerable to improper feeding and care.

According to data collected by the NGO Spandan in Khandwa, last year over 55 children died in just 22 blocks that were monitored and recorded in the Khalwa block of Khandwa. There is nothing unique about the Khalwa block besides the fact that it was closely monitored. Similar conditions are found throughout tribal MP and similar death tolls can be expected throughout Southwestern MP.

Last year child deaths started in June, continued increasing throughout July and August, and peaked in September.











The monsoon and all the waterborne diseases that it brings will cause a massive spike in malnutrition cases like it does every year. This year the monsoon will also bring with it, economic woes that will further limit individuals’ ability to prevent and treat malnutrition. The monsoon is already a week late and isn’t expected until the end of June. This late monsoon has the potential to cause an economic crisis for some families. I observed while driving through many of the states in Southwest MP that many farmers have already planted their seeds, anticipating a timely monsoon. Even with a week to 10 day monsoon delay and with the current heat wave, there is a good chance that those farmers without irrigation (the majority) may lose their seeds before the monsoon comes. If this occurs, these farmers will have to take out loans to get new seeds, putting them further into debt.

Little improvement since last year

Despite a renewed focus on malnutrition by government, media, and NGOs in Southwest MP, there has been little improvement from this year to last year.

In a study conducted by the Bhil Rural Community Health Centre in Jhabua[3], it was found that only 10% of the children screened for malnutrition recovered from May 2008 to May 2009 (not all children could be relocated in 2009, but the majority revisited, see Annex 1). In only 14 villages we found 609 malnourished children out of 3,115. This 20% malnutrition rate is low for the region, but these are all urban villages located fairly close to the Jhabua market, are somewhat more prosperous than other areas of Jhabua, and are villages who receive access to Real Medicine Foundation and Bhil Health and Literacy Society resources (the RMF malnutrition eradication initiative just launched last month, so improvement who this initiative is still hard to measure). The Jhabua NRC is currently filled over capacity with 21 severely malnourished cases.

In Khargone we’ve seen similar lack of improvement. The Spandan organization did a rapid assessment of 177 children in the Jhirniya block of Khargone in December of 2008 (see annex 2)
- Out of 177 children, 107 (60%) were found malnourished
- 30% were in grade III and IV alone.
- 100% of families surveyed answered that they did not have enough food to carry them through the year, with 60% taking out loans.
- 50% of the families do not attend anganwadis for a variety of reasons

When we visited 3 out of 8 of these villages this June we were only able to track down 15 of the children because the majority of the families had migrated or were out in the fields. Out of those 15 children, only one had improved, the majority stayed the same, and 4 got worse.

Spandan also reports that even after all the interventions last summer in Khandwa, child deaths due to malnutrition carried on until November. They report that 6 children died between October and November and that the malnutrition rate remained at above 62% of children under 5 (see annex 2).

Other districts in the area as equally as alarming. Spandan reports that out of 8 villages surveyed in Burhanpur, 12 children had died between June and November of 2009. These villages saw malnutrition rates of 75%, with the overwhelming majority (83%) of families choosing to pay private doctors instead of seeking government help.

Current capacity to identify, treat, and prevent malnutrition is low in Southwest MP
The high rates of malnutrition in this region are especially concerning because of the weak treatment and preventative care infrastructure and services available at the community level. Right to Food estimates that Integrated Child Development Scheme (ICDS) currently only covers 36% of MP’s 0-6 population and 30% of the pregnant women. The Anganwadi workers – village health workers who the corner stones to the ICDS scheme - are absent, officially and unofficially, from many towns. Anganwadi workers we were able to track down were insufficiently trained, had irregular attendance records, and rarely made home visits. Adequate supervision of anganwadi centers appears to be lacking. None of the anganwadi helpers, who spend considerable amount of time with the children had been trained.

The anganwadi centers in Khandwa did not help prevent the deaths of children. In fact, 80% percent of the children who died in Khandwa were registered at the anganwadi center.









This figure is not surprising, given the state of many of the anganwadi centers that we saw throughout Khandwa and the other districts. Anganwadi centers we viewed were dark and poorly ventilated. They most often lacked sufficient stock of essential medicines such as oral rehydration solution (ORS) and rarely had scales. The quality of the food served at Anganwadi centers was extremely poor during the feeding times we observed. The packaged foods served were often broken rice with a few bits of broken daal. Mostly children over two years old would show up alone for food and leave. Pregnant and nursing mothers and their babies were visibly missing from the anganwadi centers.

Anganwadi workers face huge challenges to carrying out all the tasks required of them with limited resources and limited time. In the village of Dhabia in the Khalwa block of Khandwa, the anganwadi center caters to over 90 children on average who come for feeding everyday. With this large number, about the only part of her job the anganwadi worker has time for is to prepare and distribute food. The scale at this center was buried in a back room and brought out for our benefit.

The anganwadi center in Damkheda, Khargone was even more alarming. We visited this village twice in two weeks. The first day, the anganwadi worker never showed up. The anganwadi assistant, who had no idea how many children were registered, said the anganwadi worker lived in a few villages away along with all the records and the scales. In this village we found 4 severely malnourished children and almost no immunizations or knowledge about ORS. When we met the anganwadi she claimed that no children in the village are malnourished, when in fact 2 children sitting in the same room were.

Nutrition Rehabilitation Centers – absence of F-100, F-75 and patient reluctance to attend
NRCs are already filling to capacity. It is most alarming that out of all the NRCs we visited, only Khandwa’s NRC is using F100 and F75. In all the other centers throughout the country, only milk and some vitamin supplements are being provided. Most children are given mixed diets, with little to no, measurement of caloric intake. We have no way to be sure that the children are receiving the most appropriate diet as outlined by the WHO and IAP.

Many families refuse to go to NRCs because of a whole range of issues; they miss essential house and field work, have to leave their other children at home, and are uncomfortable at these centers. Many families will check their child out before treatment is finished, leaving the child at risk for relapsing and further deterioration. Out of at least 20 families I have personally referred to the NRCs, only 1 had decided to stay to receive treatment.

NRCs also lack the capacity to treat the overwhelming volume of children who require care. Currently there are roughly 160 NRCs which spread across the state with approximately 2500 beds to treat 1.3 million children.

“Bengali doctors” and “quacks” are making the problem worse

For a variety of reasons, many families are resorting to paying money to private doctors for treatment of severe acute malnutrition and related diseases. The principal reason is that these centers don’t require patients to be an inpatient, so parents prefer one day treatment to 14 days in one place. Many of these families have also been failed by the NRC before. There are countless stories about children who go in and out to the NRCs with no results (currently conducting a survey to measure this). Spandan found that in Burhanpur, 83% of families took their kids to private practioners. Not all of these are bad, but some can be dangerous.

Ramnaray, below, was brought to the NRC 4 times according to his parents. When he kept getting worse and contracting respiratory infections his parents finally took him to a “Bengali doctor.” This doctor burned him with an iron to get right of the infection. His parents and the local villagers believe that it worked.

What can be done?

The problem in Southwest MP is overwhelming, but there is plenty of scope to change the situation. Some activities will need to be large scale and coordinated by the government and large NGOs. Even before the official launch of our malnutrition program, RMF and the Bhil Health and Literacy Society have been working actively in a few villages. In Umri, where we’ve been most engaged, we’ve seen a dramatic decline in malnutrition of 37%. This type of pattern can be expected as RMF and other NGOs engage local communities.

- Community level involvement in all planning processes for identification, treatment, and prevention of malnutrition.

- Immediate emergency response team to address the problem: This should be a consortium of all government departments and NGOs that relate to these malnourished children and their families so that relief efforts can be coordinated based on capacity and core competencies of each organization involved

- Provide on the ground job training to both Anganwadis and Anganwadi helpers on malnutrition identification, treatment, and prevention

- Increased AWC, NRC, PDS, and block hospital supervision and conduct random spot check. Will hold AWW and other government officials accountable

- Make AWCs child friendly - with just a donation of second hand toys and some paint, a local anganwadi center can be transformed into a place where children want to attend and will stay longer.

- Mobile clinics for remote tribal areas

- Production of local supplements for moderate malnutrition by village level self-help groups and social businesses

- Create long-term community-based therapeutic care program to continue on throughout the year to decentralize malnutrition care and treatment and make it more accessible to children residing in interior villages.

The Hidden Hunger

May 31, 2009 in Africa, In the news, India by Caitlin McQuilling

http://www.nytimes.com/2009/05/24/opinion/24kristof.html
Nicholas Kristof writes about malnutrition in Africa, but touches on some of the same issues we face with our malnutrition eradication program in India. Malnutrition in India is most often not a result of the lack of food, but a lack of proper nutrition compounded by a lack of education about what constitutes proper nutrition and young child feeding practices.

Malnutrition eradication approaches in India over the past 30 years have focused on food security, trying to ensure that families across the country have access to staple foods. This has resulted in a well developed food distribution system, even in emergency circumstances, but has not achieved reduction in malnutrition – there actually have been increases in some areas.

I’ve included two maps below, the first which maps malnutrition for children under 5 years old, and the second which maps food insecurity in India – rating households’ access to food. You’ll see that there is a close connection between food insecurity and malnutrition, but this isn’t the only element at play. Madhya Pradesh, the state with the highest, “extremely alarming” malnutrition rate is not the state with the highest level of food insecurity.

The causes for malnutrition are extremely complicated in India and vary district by district. Diseases such as tuberculosis and HIV are drivers of malnutrition for many children, and seasonal diseases such as diarrhea and pneumonia exacerbate malnutrition in other children. Issues of sanitation, hygiene and access to clean water are closely tied to malnutrition.
The majority of children and pregnant women in MP, 70%, are anemic. Protein deficiencies are rampant. Most children do not have access to vitamin A or basic vaccinations. Fruits, vegetables, and proteins rarely compliment meals of rice and pulses.

And there are other, more complicated factors at play. I met one family a few weeks ago whose three children were malnourished, the baby severely malnourished. Our village nurse tried to convince them to take the child to the Nutrition Rehabilitation Centre, but they refused to go until a wedding in the village was over. Tribal weddings in MP last for days and nights. They are high energy and intense. I attended the last day of the wedding, which consisted of the entire village of about 200 people singing, dancing, and waiting in the sweltering sun from 10am to 6pm. Many of the families carried snacks with them to get them through the day until dinner was served. This family didn’t. I kept an eye on them all day, watching the baby lull around in lethargy, without being breastfed. He didn’t cry, or laugh, once. The older girls were weak and didn’t play with the other children. Finally dinner – fresh goat, rice, and dal – was served by the groom’s family. I was looking forward to seeing the family eat. As I stealthily observed from across the crowd, the family had a bite or two of the food and then packed the food neatly away in a plastic bag along with empty bottles they had collected during the day. It was heart breaking, perplexing, and probably unjustly on my part, angering. The baby perked up and started to giggle even after receiving just a few bits of rice. The family was starving in the presence of abundant nutrition. They could have easily gotten seconds just as many of the other families did.

I asked my local colleagues right away for an explanation of what I saw and an intervention. They pointed out to me that the husband was not present at the gathering and that often amongst people in this particular tribe women will not eat before their husbands. They would follow up with the husband later, but couldn’t do anything then.

The situation became even more baffling, when my colleague who knows the family told me that the husband and father is a chef at the local school. Clearly he has sufficient access to enough nutrition to bring home to his family.

This colleague spoke to the father later that night and convinced the father to bring the child to the nutrition rehabilitation center the next day. The baby will get treatment and gain enough weight to be back on a normal growth pattern – but what then? How can we guarantee that the baby will not just fall back into malnutrition?

The only thing we can do now is to stay close to the family, visit often and counsel both the mother and father (who seems to be the one making decisions about food in the household) about proper nutrition. While we spend time with them, we’ll also try to understand the root causes of malnutrition in the family. This is not going to be easy or immediate. Our local health workers need to gain the trust of this family in order to understand the problem and solve malnutrition at its core.

And this is what RMF and our partners in the field will have to do in every case to identify, treat, and prevent malnutrition. We will work with groups who are on the ground and who know the local populations the best. We realize that to cure malnutrition in India, food isn’t the only answer. We can pour all the money in the world into the problem and that won’t break the cycle. Sensitive, micro approaches are needed to ensure that our program is effective, efficient and will create long-term change.