eccd in india
TRANSCRIPT
Learning from Models of ECCD Provision in India
Dipa Sinha & Vandana Bhatia (presented to Kusuma Foundation) June 2009
Contents Acknowledgements .................................................................................................................... 2
Acronyms ................................................................................................................................... 3
Abstract ...................................................................................................................................... 5
1. Early Childhood Care and Development in India .................................................................. 6
Background ........................................................................................................................ 6
Importance of ECCD ......................................................................................................... 7
Status of Young Children in India ..................................................................................... 9
Policies and Programmes for Children under Six ............................................................ 11
2. Models of Provision of ECCD in the Government .............................................................. 16
Good Governance and Political Priority – ICDS in Tamil Nadu ..................................... 20
Maharashtra’s Mission against Malnutrition ................................................................... 29
3. Non-government models of ECCD provision...................................................................... 38
Towards Better Health and Nutrition – CINI .................................................................. 39
Every Child in School and Learning Well - Pratham ...................................................... 46
Child Care for ALL – Mobile Crèches ............................................................................ 54
Child Care for Working Mothers – SEWA...................................................................... 62
4. Lessons Learnt and Moving Forward .................................................................................. 69
Gaps in ICDS and Government Experiences ................................................................... 69
Learning from NGO Programmes ................................................................................... 72
Recommendations for Funding Support .......................................................................... 77
References ................................................................................................................................ 79
1
Acknowledgements This report would not have been possible without the support of the organisations whose work has been documented here. All of them generously hosted us by arranging for our field visits and sharing their experiences and documents with us. We thank the staff of all the organisations for helping us in this endeavour and also for all the wonderful work that they are doing for the rights of young children. The report is informed by our work with the Right to Food Campaign and the Commissioners to the Supreme Court of India in the last few years and learning from the various individuals involved in these two places. We would also like to thank the Kusuma Foundation for giving us this opportunity and Dr. Jean-Paul Faguet, Prof. Jean Dreze and Biraj Patnaik for their help and advice at different stages of the project. Dipa Sinha & Vandana Bhatia
2
June 2009
Acronyms ABC: Achievement of Babies and Children ANM: Auxiliary Nurse Midwife ARI: Acute Respiratory Illnesses ASAT: Anchal Se Angan Tak ASHA: Accredited Social Health Activist AWH: Anganwadi Helper AWW: Anganwadi Worker BPNI: Breastfeeding Promotion Network of India BVS: Bal Vikas Samiti CBO: Community Based Organisation CDC: Child Development Centre CDPO: Child Development Project Officer CINI: Child in Need Institute CRC: Convention on the Rights of the Child ECCD: Early Child Care and Development ECCE: Early Childhood Care and Education ECE: Early Childhood Education FOCUS: Focus on Children Under Six FORCES: Forum for Crèches and Child Care Services GDP: Gross Domestic Product GHI: Global Hunger Index HBNC: Home Based New born Care HDI: Human Development Index HDR: Human Development Report IDA: International Development Association IFPRI: International Food Policy Research Institute IMNCI: Integrated Management of Neonatal and Childhood Illnesses IMR: Infant Mortality Rate INHP: Integrated Nutrition and Health Programme ISHI: India State Hunger Index JSY: Janini Suraksha Yojana MMR: Maternal Mortality Rate MO: Medical Officer MOHFW: Ministry of Health and Family Welfare NACP: National AIDS Control Programme NCAER: National Council of Applied Economic Research NCERT: National Council of Educational Research and Training
3
NFHS: National Family Health Survey NGO: Non Government Organisation NHD: Nutrition and Health Days
NHP: National Health Policy
NIPCCD: National Institute of Public Cooperation and Child Development NNM: National Nutrition Mission NNMB: National Nutrition Monitoring Bureau NPA: National Plan of Action NPE: National Policy on Education NRC: Nutrition Rehabilitation Centre NRHM: National Rural Health Mission NSS: National Sample Survey PHC: Primary Health Centre PT MGR NMP: Puratchi Talaivar M.G.R.Nutritious Meal Program RACHNA: Reproductive and Child Health Nutrition and HIV AIDS Programme RCH: Reproductive and Child Health SEWA: Self Employed Women’s Association SHG: Self Help Group SPAC: State Plan of Action for Children SPOA: Special Plan of Action SSA: Sarva Shiksha Abhiyaan TINP: Tamil Nadu Integrated Nutrition Programme UIP: Universal Immunisation Programme UNICEF: United Nations Children’s Fund UPA: United Progressive Alliance USAID: United States Agency for International Development WFP: World Food Programme WHO: World Health Organisation
4
Abstract
Young children require care and nurture to grow into healthy and productive citizens. While there is extensive research showing the critical importance of interventions for children under six years, they are still a neglected group in public policy and action in India. In spite of unprecedented economic growth in the last two decades, India’s record in the provision of education and health in general, and especially early childhood care and development, is quite poor. Almost half the children under three years of age are underweight and more than 70% are anaemic. The infant mortality rate stands at 62 per 1000 live births in rural areas.
Based on documenting successful efforts towards improving early childhood care and development (ECCD), the present paper builds a case for funding initiatives in the field of early childhood care and development (ECCD) in India. This paper documents six ‘models’ of intervention for ECCD in India. While two of these ‘models’, that of Integrated Child Development Services (ICDS) in Tamil Nadu and the Rajmata Jijau Mother Child Health and Nutrition Mission in Maharashtra are government programmes, the rest – Pratham, Mumbai; Mobile Crèches, Delhi; SEWA, Gujarat and CINI, West Bengal are NGO programmes.
The paper also analyses the status of the ICDS, which is the single largest programme for ECCD in India. It is seen that although it has great potential, the ICDS programme is currently not very effective because of low coverage and poor implementation. However, the experiences of the ICDS in Tamil Nadu and Maharashtra show that the ICDS can be made to deliver, with political commitment and better investments. The NGO models show that for high quality, along with the right investments a programme that is providing early child care and development services must include community involvement, have a strong component of workers’ training, sufficient number of workers, a strong and supportive system of monitoring and supervision, understand mothers’ needs and be sufficiently decentralised and flexible to take into account different contexts.
Finally, the report recommends that there is a need for further investments in the field of ECCD in India. This funding could be directed towards strengthening the ICDS, enhancing community participation, supporting local monitoring, building ‘models’ of child care, including models of crèches and investing in further research and documentation.
5
1. Early Childhood Care and Development in India
Background Young children require care and nurture to grow into healthy and productive citizens. While there is extensive research showing the critical importance of interventions for children under six years, they are still a neglected group in public policy and action in developing countries like India. With high and stagnant levels of malnutrition in South Asia, including India, there is now an increasing focus among researchers, policy makers and development professionals across the world on what needs to be done for children of this age group in a country like India.
The present paper builds a case for funding initiatives in the field of early childhood care and development (ECCD) in India. It is seen that India has an extensive network of public programmes to address ECCD needs in the country. However these are largely ineffective and need major overhauling. An analysis of the strengths and weaknesses of the existing programmes and studying successful experiences both within the government and the non-government sectors in India, can throw some light on the strategies that need to be undertaken to ensure ECCD for all children in the country.
This paper begins with an introduction on the importance of ECCD and current status of young children in India. The next sections are case studies of six ‘models’ of intervention for ECCD in the country. While two of these ‘models’, that of Integrated Child Development Services (ICDS) in Tamil Nadu and the Rajmata Jijau Mother Child Health and Nutrition Mission, Maharashtra are government programmes, the rest – Pratham, Mumbai; Mobile Crèches, Delhi; SEWA, Gujarat and CINI, West Bengal are NGO programmes. The case studies are followed by an analysis of the different models and an attempt to present the key components for any strategy for children under six. The final section makes some recommendations for what a funding agency can invest in; in the field of ECCD, in order to maximise benefits.
The case studies are based on short field visits to the organisations, interviews with staff at various levels and documents of the organisation such as annual reports, impact evaluations, and research studies. Where available, reports or case studies by others and newspaper reports were also used. At the end of each case study, we have listed all the documents related to the organisation’s work, which have been looked at.
6
The analysis and the recommendations made in this report are based on the lessons learnt from reviewing the work of the different organisations whose work has been documented here and also the authors’ experience of working with the working group of children under six of the Right to Food Campaign and Jan Swasthya Abhiyan1. Some sections of this paper
1 The Right to Food campaign and the Jan Swasthya Abhiyan are both networks of a large number of civil society groups including NGOs, trade unions, activists etc. raising issues related to the right to food and health respectively.
draw from reports of this group such as the FOCUS Report (FOCUS, 2006)2, Strategies for Children Under Six (Working Group, 2007) and various reports of the Commissioners of the Supreme Court on Right to Food (all available at www.righttofoodindia.org and/or www.sccommissioners.org).
Importance of ECCD The first six years of life are the most crucial in laying the foundation for a healthy and productive life. The foundations for cognitive, social, emotional, physical/ motor development, language and communication, inculcation of social values and personal habits are laid in these years, all of which last a lifetime.
“If a child falters in one or more of the development milestones -- health and nutrition outcomes, or learning opportunities and capacities -- the child carries, in either latent or cumulative terms, the burden of failure to the next stage” (World Bank, 2004).
“The first 6 to 8 years of a child’s life are globally acknowledged to be the most critical years for lifelong development since the pace of development in these years is extremely rapid.” (NCERT, 2006)
Neuroscientists have found that it is during this period that important synaptic connections are formed in the brain and 85 percent of the child’s core brain structure is already complete by the time she is three (Doherty G, 1997). Research has further established that a stimulating and enriching physical and psychosocial environment is necessary during these early years for the child’s brain to develop to its full potential. The absence of such an environment considerably (and often irreversibly) reduces the chances of this happening (NCERT, 2006 and World Bank, 2004)3.
In fact, the first two years after birth is the period when the child grows most rapidly both physically and mentally. For instance, by the time a child is two years old, she is more than three times her body weight. By the age of three, a child’s brain is twice as active as that of an adult. A child who is malnourished by the age of two has very little chances of ever being fully healthy; a child who has attended pre-school is more likely to learn better in school and so on. Investing in young children’s well being and development is therefore not only in the interest of the child having a strong foundation for rest of her life but also contributes to a more productive population and therefore higher growth and national income. This is the justification often given for investments in ECCD, especially for nutrition programmes (Sridhar D, 2008).
7
2 The “Focus On Children Under Six” (FOCUS) survey was conducted in May-June 2004 in six states: Chhattisgarh, Himachal Pradesh, Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh. It involved unannounced visits in a random sample of about 200 anganwadis as well as detailed interviews with about 500 mothers of children under six. The FOCUS report presents the findings of this survey.
3 See NCERT (2006) and World Bank (2004) for further references of literature on brain development during early childhood.
There is therefore convincing evidence in support of investments in ECCD programmes. The National Focus Group on Early Childhood Education of the National Council of Educational Research and Training (NCERT), Government of India, in its report identifies the following three important principles of child development that the planning and provision of early childhood and primary education programmes need to take account for in order to maximise benefits:
“(a) Child development is a continuous and cumulative process, so that what precedes influences what follows. Therefore, in terms of programmatic interventions, it is important to address the entire childhood continuum, from the prenatal stage to the end of the primary stage, as opposed to intervening during any one sub-stage exclusively;
(b) Health, nutrition, and educational/psychosocial development are all synergistically interrelated, which makes a case for the importance of addressing all the needs of children through a holistic approach; and
(c) The child’s development will be optimised if the programmes address not only the child but also the child’s overall context.”
While child development needs to be seen in such a comprehensive framework addressing the health, nutrition and development needs of children from birth (or even prenatal stages) to the age of six4, each sub stage during these years has its own needs and requirements. The development objectives and priorities of each sub stage of the child development continuum therefore have to be identified, as shown in the figure below:
The Child Development Continuum - Sub-stage Priorities
Source: World Bank, 2004
8
4 Some literature also extends “early childhood” up to the age of 8 and even 11. In this report we restrict ourselves to children under six as this is the most commonly used classification for defining “early childhood” and also programmatically, in India, early childhood programmes are programmes for children under six years of age.
In this paper we consider all initiatives addressing the health, nutrition and/or development needs of children under six as part of ECCD programmes
Status of Young Children in India Children under six are one of the most vulnerable groups in the population, especially in a country like India. Young children are vulnerable because they are physically fragile, with poor immune systems. In spite of high mortality and malnutrition rates, until recently, the rights of children under six got very little attention in the media, political debates or even civil society movements. Even within the community, they are the most invisible, with very little public concern for their well-being. All children, especially the very young, are completely voiceless and their issues are heard only when somebody else takes it up. In a patriarchal society like in India, the responsibility for the well-being of children rests solely with women, who are themselves voiceless. The absence of concerted public action for children under six has resulted in a state that has been described “permanent humanitarian emergency”5, with India now being host to the largest number of malnourished children in the world.
In spite of unprecedented economic growth in the last two decades, India’s record in the provision of education and health in general, and especially early childhood care and development, is quite poor.
National Family Health Survey
9
According to the most recent National Family Health Survey (2005-06), one third of the children are born with a low birth weight. 46% of children under three are underweight which is an improvement of only one percentage point compared to NFHS-2 which was carried out eight years back. The percent of children under three who are anaemic has actually increased from 74.2% to 79.2% and immunisation coverage has decreased slightly from 26.9% to 26.2%. A recent survey of the National Nutrition Monitoring Bureau (NNMB 2007) shows that there is a deficit of over 500
calories in the intakes of children 1-3 years old and about 700 calorie among those 3-6 years
5 National Advisory Council (2004)
Status of children under six ‐ NFHS NFHS 2 NFHS 3
Infant Mortality Rate 68 57Children under three years who are wasted (i.e. low weight for height) (%)
45.9 47.0
Children under three years who are underweight (%)
42.0 43.5
% of children 12-23 months who received all recommended vaccines
26.9 26.2
Children with diarrhoea in the last two weeks who received ORS (%)
15.5 19.1
Children age 0-5 months exclusively breastfed (%)
46.3
Children age 6 – 35 months who are anaemic
74.2 79.2
Children age 3 -5 years who are attending a pre- school (%)*
34.4
Source: National Family Health Survey (NFHS 3) 2005-06: National Fact Sheet India, available at www.nfhsindia.org *National Sample Survey, 61st round (2004-05)
old. Therefore there is clearly a gap in access to food (quality and quantity) and health services for children.
National Sample Survey
According to the National Sample Survey, only about one-third of the children in the age group of 3 to 5 are currently enrolled in any pre-school, public or private (30.5% in rural areas and 49.5% in urban areas).
NCERT
According to the 2001 Census there are 12 crore working women. 90 per cent of working women in the country are in the unorganised sector, and most of them are poor and in the need for crèches and day-care services. While about 2 to 2.5 crore working women and their 5.5 crore children below age 6 may be in need of crèches and day care, only 4.33 lakh have access to these facilities (NCERT, 2006).
Global (and India) Hunger Index
In terms of the Global Hunger Index (GHI) recently released by the International Food Policy Research Institute (IFPRI) India’s performance is very poor. India’s GHI 2008 score is 23.7, which gives it a rank of 66th out of 88 countries. According to the India Hunger Index report this score indicates “continued poor performance at reducing hunger in India”. India ranks below several countries in Sub-Saharan Africa, such as Cameroon, Kenya, Nigeria, and Sudan, even though per capita income in these Sub-Saharan African countries is much lower than in India. Looking at the India State Hunger Index (ISHI), which is constructed using the same method and indicators as the GHI6, it is seen that not a single state in India falls in the “low hunger” or “moderate hunger” category defined by the GHI 2008. Most states fall in the “alarming” category, with one state—Madhya Pradesh—falling in the “extremely alarming” category. Four states fall in the “serious” category (see map above) (Menon et. al. 2009). Two of the three indicators (child mortality and child
10
6 The GHI ranks countries based on three indicators and combines them into one. The three indicators are: proportion of people who are calorie deficient, child malnutrition prevalence, and child mortality rate. The proportion of people who are calorie deficient is a key indicator of hunger. The Index also includes child undernutrition, because children are the most vulnerable to the effects of hunger. Since half of all child deaths are related to undernutrition, child mortality rates are an important measure of the impact of hunger.
India State Hunger Index 2008 (IFPRI)
underweight) used to construct the Hunger Index are related to young children. The India State Hunger Index Report, therefore suggests, “Child underweight contributes more than either of the other two underlying variables to the GHI score for India and to the ISHI scores for almost all states in India. Tackling child undernutrition, therefore, is crucially important for all states in India. Achieving rapid reductions in child underweight, however, will require scaling up delivery of evidence-based nutrition and health interventions to all women of reproductive age, pregnant and lactating women, and children under the age of two years” (ibid.)
Human Development Index
India has fallen to 132 in the new rankings of the United Nations Human Development Index (HDI) for 179 nations. In the HDI of 2007-08, India ranked a dismal 128. India’s position on the human development index ranking is worse than other ‘developing’ countries such as Bhutan (131), Congo (130), Botswana (126), Bolivia (111), Sri Lanka (104), Vietnam (114) and China (94) (Human Development Report,2008; Sainath, 2009)7. The Human Development Index is “a summary composite index that measures a country's average achievements in three basic aspects of human development: health, knowledge, and a decent standard of living. Health is measured by life expectancy at birth; knowledge is measured by a combination of the adult literacy rate and the combined primary, secondary, and tertiary gross enrolment ratio; and standard of living by GDP per capita (PPP US$)” (HDR, 2008).
Policies and Programmes for Children under Six The 86th Amendment to the Constitution introduced education as a fundamental right for children in the age group of six to fourteen. While this is a welcome step forward, children under six have been left out of the Right to Education Bill and there is currently no law that explicitly protects the health, nutrition and/or development rights of children under six8. However, the Directive Principles of State Policy was also amended to mention, “The state shall endeavour to provide early childhood care and education for all children until they complete the age of six years (Article 45 of the Constitution of India).”
While programmes for poverty alleviation, food security, rural development, women’s empowerment, drinking water and sanitation etc. all have an impact on the well-being of children, in this report we are concerned only with those programmes that are directly meant to address the needs of young children. A number of policies govern the provision of ECCD services in India as seen in the table below.
11
7For the HDI rankings of all the countries see http://hdr.undp.org/en/statistics/
8 Earlier the Directive Principles of State Policy mentioned ‘all children until they complete the age of fourteen years’.
Policies Governing Provision of ECCD Services in India
The National Policy on Education (NPE), 1986
Views ECCE as a crucial input in the strategy of human resource development, as a feeder and support programme for primary education and also as a support service for working women. The Policy especially emphasises investment in the development of young children, particularly children from sections of the population in which first-generation learners predominate. Recognising the holistic nature of child development, ECCE programmes were to be expanded and were to be child oriented, with a focus around play and the individuality of the child. The aim was to bring about a full integration of childcare and pre-primary education, to both feed and strengthen primary education.
National Policy for the Child, 1974 and National Plan of Action: A Commitment to the Child, 1992
“It shall be the policy of the State to provide adequate services to children, both before and after birth and throughout the period of growth . . . The State progressively increases the scope of such services so that, within a reasonable time, all children in the country enjoy optimum conditions for their balanced development.”
National Plan of Action (NPA), 1992
The NPA was followed by the formulation of the State Plan of Action for Children (SPAC), aimed at the protection, survival, development, and growth of children. For each of the areas covered under NPA and SPAC, time-bound goals and strategies were laid down.
National Nutrition Policy, 1993
Recognises that children below 6 years are nutritionally vulnerable and constitute one of the ‘high-risk’ groups, and thus accords highest priority to them through policy articulations and programmatic interventions for especially vulnerable groups; the National Nutrition Mission (NNM) has been launched to address this problem.
National Population Policy, 2000
Sees the health of children as a step towards population stabilisation.
National Policy for theEmpowerment of Women, 2001
The provision of support services for women, like childcare facilities, including crèches at work places, educational institutions, homes . . . will be expanded and improved to create an enabling environment and to ensure full participation of women in social, political and economic life.
National Health Policy (NHP), 2002
The 0–6-year-olds comprise a vital segment vis-à-vis the targets of theNHP for reducing IMR to 30/1,000 live births and MMR to 100/ 100,000 by the year 2010. Separate schemes, tailor-made to suit the health needs of children, in tribal and other socio-economically underserved sections have been proposed.
Convention on the Rights of the Child (CRC), 1992
The ratification of CRC (1992) by India has further affirmed the country’s commitment to children, and has resulted in the formulation of a policy framework to prepare a National Charter for Children that ensures that no child remains illiterate, hungry, or lacks medical care. A National Commission for Protection of Child Rights has been set up.
Source: NCERT (2006)
12
As far as young children are concerned the following are the programmes of the Government of India that address their health, education and nutrition needs:
Reproductive and Child Health (RCH) Component of the National Rural Health Mission (NRHM) 9
The National Rural Health Mission was launched in 2005 with the aim of providing accessible, affordable and accountable quality health services to the ‘poorest households in the remotest rural regions.’ The thrust of the mission was on establishing a fully functional, community owned, decentralised health delivery system with inter-sectoral convergence at all levels, to ensure simultaneous action on a wide range of determinants of health like water, sanitation, education, nutrition, social and gender equality. The goals of the NRHM include reduction in infant mortality to 30 by 2012 with a corresponding reduction in neonatal mortality to about 20. The various activities being undertaken under the RCH component of the NRHM which relate child health are: (1) Integrated Management of Neonatal and Childhood Illnesses (IMNCI); (2) Home Based New born Care (HBNC); (3) Promotion of breastfeeding and complementary feeding; (4) Control of deaths due Acute Respiratory Illnesses (ARI); (5) Control of deaths due to diarrhoeal diseases; (6) Supplementation with micronutrients: Iron and Vitamin A and (7) Universal Immunisation Programme (UIP). One of the central features of the NRHM is to introduce a cadre of community health workers (ASHAs) in every village who will establish the link between the people and the health system. The main tasks of ASHA are the reproductive and child health activities. Further, the NRHM has also introduced a scheme of cash incentives or institutional deliveries (Janani Suraksha Yojana) to address the problem of maternal and neo-natal mortality.
Integrated Child Development Services (ICDS)10
The Integrated Child Development Services (ICDS) aims to provide comprehensive services to address the health, nutrition and development needs of children under six. The ICDS
programme is therefore the most important as far as provision of services for children under six is concerned. ICDS works through a network of anganwadi centres (AWC) that are run by anganwadi workers (AWW) and helpers (AWH).
13
The ICDS provides the following six services: (1) Pre-school education; (2) Nutrition and Health Education; (3) Supplementary Nutrition; (4) Referral Services; (5) Immunisation and (6) Health Check Up.
ICDS is a centrally sponsored programme with the Government of India contributing towards 90% of all the programme costs and 50% of the cost of supplementary nutrition. The state
9 For further information see the website of Ministry of Health and Family Welfare http://mohfw.nic.in 10 For further information on ICDS see website of Ministry of Women and Child Development http://wcd.nic.in
Utilisation of ICDS services (in the 12 months preceding the survey)
Percentage of children under age six who:
Received food supplements
26.3
Received immunisation s
20
Received health check-ups
15.8
Went for early childhood care/pre-school
22.8
Were weighed 18.2Source: NFHS-3 (IIPS 2006)
governments contribute to the remaining 10% of the programme costs and a matching grant of 50% towards supplementary nutrition. Some states invest more from their own funds to provide a better quality supplementary nutrition and/or increased salaries, better infrastructure etc.
There has been a massive expansion in the number of anganwadi centres in the country, and very soon there is going to be a sanctioned anganwadi in every habitation. However, the outreach is still low with the last round of NFHS showing a coverage of less than 30%. According to the official figures of the Government of India, the supplementary nutrition programme of the ICDS reaches about 42% of children under six in the country (Supreme Court Commissioners Report, 2009). Considering that almost 50% of children in the country are malnourished, this coverage is indeed very low.
Rajiv Gandhi National Crèche Scheme for the Children of Working Mothers11
Rajiv Gandhi National Crèche Scheme for the Children of Working Mothers was launched with effect from 1st January, 2006 by merging the National Crèche Fund with the Scheme of Assistance to Voluntary Organisations for Crèches/Day Care Centres for the Children of Working and Ailing Women. The scheme is being implemented through Central Social Welfare Board and two national level voluntary organisations, namely, Indian Council for Child Welfare and Bharatiya Adim Jati Sevak Sangh. The Scheme provides crèche services to the children in age group of 0-6 years, which includes supplementary nutrition, emergency medicines and contingencies. In the year 2007-08, 31,737 crèches had been sanctioned to the implementing agencies with a coverage of 7,93,425 children (Ministry of Women and Child Development, 2008).
The Rajiv Gandhi Scheme, while suitable for certain sections of the population, is limited as it is NGO dependent, the unflexible pattern and norms of the scheme do not respond to the diversity of situations in the country especially to the needs of women engaged in occupations as varied as fisheries, forestry, seasonal agricultural occupations etc. Further, the eligibility criterion of the scheme is limiting and the terms “ working women” and “income criteria”, need to be revised. (Gupta A et. al. 2007)
Private/NGO Sector Provision of ECCD
14
Although there are many private sector commercial institutions providing pre-school and day care services, there is no estimate of the number of these institutions or the number of children covered by them. These initiatives are mainly in urban areas and gradually spreading to semi-urban areas and even villages. Summarising the role of private sector in provision of ECCD, the NCERT report states, “Within the private sector, too, there is wide variability—ranging from a handful of well-established elite schools of high quality offering excellence, to the great mass of poorly managed, overcrowded, and under-equipped ‘garage’ schools, which squeeze children into tiny unhygienic spaces and attempt to force-feed them with the
11 See http://wcd.nic.in for details
Three Rs at an unsuitably early age. A recent entry has been the ‘franchised’, imported, and highly expensive model catering to the new urban upper class” (NCERT 2006). The private sector is also completely unregulated.
Different models of provision of early child care and development services are also available in the non-government and voluntary sectors. Again there is no estimate of how many children these initiatives reach out to. These are of varying quality and based on different models. Some of them could provide very important insights into what any programme for young children should have. While this sector is small and can in no way be an alternative to the government in filling the existing gaps, some of the best and innovative work has happened here and a study of these can be of great value.
Documenting Models of ECCD Provision
In this context it becomes important to study existing successful models of provision of ECCD in the country, the lessons from which can inform policy and action on scaling up ECCD programmes across the country. ECCD programmes are those that are primarily focussed at children under six, including provision of education, nutrition, care, health etc. They aim at addressing the all round development of the child. However, in practice not all programmes have all the components.
For the purposes of this paper, two government programmes and four non-government programmes were chosen from a list of “well-known” (based on existing literature and advice from experts) models of early child care provision in the non-government sector in the country. The four non- government organisations (Pratham, CINI, Mobile Crèches and SEWA) were chosen to try and get a mix of strategies, approaches and contexts of work – therefore while Pratham is basically an organisation working on universal education with its work on ECCD having a focus on children in the age group of 3 to 6 and pre-school education; CINI is an organisation that works on a wide range of issues related to reproductive and child health, and among young children is primarily working with children under 2 and their access to health and nutrition. Mobile Crèches and SEWA on the other hand started from the perspective of providing child care services for working mothers and are working on the care, health, nutrition and pre-school aspects for all children under six. Pratham and Mobile Crèches are primarily urban-based while CINI works mostly in rural areas and SEWA’s crèches run in both urban and rural areas.
15
On the other hand, the Maharashtra Mission and the Tamil Nadu ICDS were chosen from among government programme because they are large-scale (covering the whole state), have made innovations primarily within the common framework of ICDS and the reforms have basically been initiated by the state governments themselves. There have been other innovations in ICDS varying in scale, design and impact and these have been listed in the next section.
2. Models of Provision of ECCD in the Government
Introduction
The ICDS is the only major programme in the country that is dedicated to the needs of children under six. The ICDS programme in its vision provides a comprehensive set of services meeting the health, nutrition and development needs of children.
One of the most important interventions on the ICDS in the recent past has been by the Supreme Court. The Supreme Court in the case PUCL vs. Union of India (CWP 196/2001; known as the ‘Right to Food’ case) has issued a series of orders that convert the benefits of the ICDS programmes into legal entitlements. With the first order beginning in 2001, followed by other orders in the years 2004, 2006 and 2007 the Supreme Court has clearly stated that all services of the ICDS must be provided for all children under six, all pregnant and lactating women and all adolescent girls. Further, under this case the Supreme Court has also appointed Commissioners to monitor the status of the food and employment schemes in the country. The Commissioners through their interventions in the Court and directly with the state and central governments have been continuously applying pressure for ensuring compliance of the Supreme Court orders.
While there was almost no improvement after the first order of 2001, after a series of hearings in the year 2004 resulting in detailed directions in relation to the ICDS there has been a tremendous expansion in the programme. While there were about 6 lakh anganwadi centres in the country when the case began, today there are almost 14 lakh anganwadi centres sanctioned in the country. While the norm for supplementary nutrition was 0.95p per beneficiary per day until 2005 (unchanged from 1993), it was increased Rs. 2 per beneficiary per day and more recently to Rs. 4 per beneficiary per day (from April 2009 onwards). While most states used centralised procurement systems for supply of supplementary nutrition, following the orders of the Court, now many have made the shift to decentralised procurement without the use of private contractors. The budget for ICDS too, although still very low, has been consistently rising and has more than doubled since 200412.
16
Over the last few years the focus on ICDS has also increased in the public sphere – in the media, in civil society and among policy makers. The UPA government included the universalisation of ICDS in its Common Minimum Programme. The National Advisory Council13 also made detailed recommendations on the ICDS, including calling for ‘universalisation with quality’ of ICDS. There has been increased media coverage on the issue, including sustained campaigns by the media such as the ‘Republic of Hunger’ series by the NDTV. The issue of ICDS and rights of children under six has also been taken up by groups such as the Right to Food campaign and Jan Swasthya Abhiyan. Across the country events such as the Convention on Children’s Right to Food, celebration of anganwadi diwas
12 See www.righttofoodindia.org and www.sccommissioners.org for details of the Supreme Court case and Commissioners’ Reports
13 The National Advisory Council (NAC) was set up by the previous UPA government as an interface with Civil Society in regard to the implementation of the National Common Minimum Programme (NCMP) of the Government of India.
in different states, conducting Bal Adhikar Yatra etc. have been conducted by many different organisations, campaigns and networks. Communities have made demands for anganwadis to be set up using the order of the Supreme Court of December 200614.
Although the track record of the ICDS has been quite poor both in terms of coverage and quality of services of provided, there is a wide variation in the way the programme functions in different states in the country.
International Organisations’ Support to ICDS15
In some states, there have been innovative strategies adopted covering a few districts/blocks in each state within the ICDS in partnership with international organisations such as CARE, UNICEF, World Food Programme and World Bank.
UNICEF has been providing technical support to the ICDS every since its being set up. UNICEF has also given material support to ICDS in terms of supplies such as jeeps, weighing scales, photocopying machines, typewriters, growth charts, IFA tablets etc. UNICEF’s focus is now on strengthening the ICDS system by contributing to improvement of supply chain management, technical support and innovations to improve the quality of growth monitoring and promotion.
The International Development Association (IDA) of the World Bank has extended support to the ICDS, under the ICDS IV project. The proposed ICDS-IV Project has two major components viz., Nutrition and Early Childhood Education (ECE). The key reform principles of the ICDS-IV Project are (1)A simplified evidence and outcome-focused programme design that is likely to make an impact on Nutrition and Early Childhood Education outcomes; (2) flexibility in ICDS design from central level; (3)stronger convergence at the operational level with health (RCH & NRHM) for nutrition and Sarva Shiksha Abhiyan/primary schools for the Early Childhood Education component; (4) stronger Monitoring and Evaluation linked to a funds disbursement strategy; and (5) more intensive efforts and resources targeted to the high burden States/districts (MoWCD, 2008).
The Integrated Nutrition and Health Programme (INHP) of CARE for instance has worked in different parts of the country to improve the ICDS. INHP is in operation in the states of Andhra Pradesh, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal covering a total of 711 blocks. The best practices that have emerged from the INHP experience include fixed day, fixed site service delivery at monthly Nutrition and Health days (NHD), appointment of community volunteer change agents and Reproductive Health Change Agents, Community-Based Monitoring Systems and Block-Level Resource Mapping.
17
14 Campaign material related to the ICDS are available at www.righttofoodindia.org
15 This section is based on the material available in the website of Ministry of Women and Child Development and Annual Reports of the Ministry (http://wcd.nic.in)
The World Food Programme (WFP), has been extending technical assistance in the fortification of supplementary nutrition in 11 districts in the States of Madhya Pradesh (2 districts), Orissa (3 districts), Rajasthan (3 districts) and Uttarakhand (3 districts).
Innovations in ICDS16
The following are some of the innovations in ICDS by the government or in partnership that have been documented:
1. Special Plan of Action, Rajasthan: The Department of Women and Child Development (DWCD) is implementing the ‘Special Plan of Action’ (SPOA) strategy, in collaboration with UNICEF Rajasthan, to target child malnutrition in seven districts across the state. This programme was initiated in November 2004.
2. RACHNA – A joint USAID and CARE Initiative: The Reproductive and Child Health, Nutrition and HIV/AIDS Programme (RACHNA) was a five year programme of CARE India, supported by USAID that was started in 2001. CARE implemented RACHNA in partnership with and in support of the ICDS scheme, the Ministry of Health and Family Welfare (MOHFW) Reproductive and Child Health Programme (RCH) and the National AIDS Control Organisation’s National AIDS Control Programme (NACP). Through RACHNA, CARE worked to demonstrate and replicate improved service delivery and behaviour change approaches for a set of interventions of proven clinical efficacy through strengthening GoI systems and programmes and empowering communities (some of the best practices that emerged out of this programme have been mentioned above).
3. ‘Dular’ Project, Bihar: The Dular project started in 2001 in selected districts of Bihar and Jharkhand to combat malnutrition, infant mortality and poor maternal health by the ICDS in partnership with UNICEF. The Dular strategy focuses on changing care behaviours of caregivers so as to improve the survival, growth and development of the child. This is done through strengthening of the existing ICDS by providing new tools, incorporating new training, enhancing the structure and focussing on changing care behaviours at the family level. Dular also enhances programme impact by empowering families and communities to initiate actions to achieve the goal of ICDS – reduction in malnutrition and enhance child development. At its core was the strategy of getting the people to be responsible for their own welfare, where community members, acting as volunteers and ‘peer educators’ within their locality, brought about a change in their own socio-economic environment, characterised by poverty and lack of education.
18
4. Anchal Se Angan Tak, Rajasthan: The Rajasthan Department for Women and Child Development and UNICEF jointly initiated the Anchal Se Angan Tak (ASAT) strategy as a community-based care model in seven districts. Under ASAT, a special plan of action for the management of severe child malnutrition was initiated in 2005 in 14 blocks of these seven districts using WHO standards based on a two-pronged strategy—hospital based and community based.
16 This section is based primarily on information available in Ramachandran (2008) and our own experience with the ‘Right to Food’ campaign.
5. Bal Sanjeevani, Madhya Pradesh: The Madhya Pradesh government started a massive campaign through out the state in partnership with UNICEF in the year 2001 for scaling up growth promotion. The strategies included intensive drive for growth monitoring, weighing every child below 5 yrs, categorization of their nutritional status, vitamin A supplementation, health camps for malnourished children and increasing awareness among families as well as communities about malnutrition.
6. Mitanin Programme, Chhattisgarh: The Government of Chhattisgarh initiated a community health volunteer (called the “Mitanin”) programme in 2001. One of the tasks of the Mitanin has also been tackling malnutrition in the area. They do this by providing support to the anganwadi, mobilising the community to monitor the anganwadi, ensuring that the supplementary nutrition and other services of ICDS reaches people and providing health and nutrition counselling to poor families.
7. Rajmata Jijau Mother Child Malnutrition Mission, Maharashtra: This mission was set up by the Government of Maharashtra in 2005 with the primary objective of reducing Grade-III and Grade-IV malnutrition in children in the 0-6 years age group in the state of Maharashtra (See detailed case study below).
8. Tamil Nadu ICDS: The Tamil Nadu government has been constantly making innovations in the services for young children in the state since the introduction of the Tamil Nadu Integrated Nutrition Programme (TINP) in the 1970s. The anganwadis in Tamil Nadu, like its public health system, are known to better functioning compared to most other states in the country. ICDS services, especially the food component also constitute one of the core priorities of all the major political formations in the state (See detailed case study below).
19
The above innovations in ICDS vary in scale, design and impact and all of them need to be studied. For the purposes of this paper, the models of the Maharashtra Mission and the Tamil Nadu ICDS are chosen. These have been chosen because they are large in scale (covering the whole state), have made innovations primarily within the common framework of ICDS and the reforms have basically been initiated by the state governments themselves.
Good Governance and Political Priority – ICDS in Tamil Nadu
One of the first things that one notices on a visit to Tamil Nadu is the efficiency with which public services seem to be working there. Talking to women, one sees that the various health and nutrition services of the government have reached most of them. There is an anganwadi centre in every village. All of them are housed in a decent building. All of them are open and the teacher or helper is present, although the number of children is varying. Food is cooked in the centre regularly and mothers can easily report on what is given and the days of the week on which egg is distributed. There are also complaints about quality of food or of the pre-school education, but relative to the kind of response one gets when asked about anganwadi centres anywhere in North India, Tamil Nadu is refreshing17.
Tamil Nadu has a history of publicly funded nutrition programmes. From the 1950s onwards there have been a variety of public feeding programmes in the state. The ICDS started in Tamil Nadu at the same time as in the rest of the country in 1975. In 1980, the Tamil Nadu Integrated Nutrition Project (TINP) was started with World Bank funding and in 1982 Tamil Nadu universalised the provision of mid day meals to school children (including pre-schoolers). At the same time health and education have also received high priority in the state. There have been innovations made in each of these sectors and the state government has allocated large budgets to the social sector over the last few decades.
20
These initiatives by the state government are reflected in the human development outcomes of Tamil Nadu. On most indicators the state ranks in the top 5 in country and is better than the average outcomes for the country as a whole. The FOCUS report developed an “Achievements of Babies and Children” (ABC) Index based on indicators for survival,
17 Impressions based on visits to several anganwadi centres and villages in Villupuram and Dindigul districts of Tamil Nadu in 2008
immunisation, nutrition and schooling to rank the states in India on how well they are doing with respect to child development (FOCUS, 2006). In the table below this index is presented, with the figures updated for 2005-06. Tamil Nadu stands only second to Kerala in the ranking on child development based on the ABC index.
‘ABC’ Index Based On Selected Child Development Indicators
Survival Immunisation Nutrition Schooling Rank State (% of
children who survive to age 5)*
(% of children who are fully immunized)*
(% of children who are not underweight)*
(% of children who attend school)**
“Achievements of Babies and Children” (ABC) index
1 Kerala 98.4 75.3 77.1 98.4 87.3 2 Tamil Nadu 96.4 80.9 70.2 96.3 85.9 3 Himachal
Pradesh 95.8 74.2 64.5 97.2 82.9
4 Jammu & Kashmir
94.9 66.7 74.4 91.5 81.9
5 Punjab 94.8 60.1 75.1 90.2 80.1 6 Haryana 94.8 65.3 60.4 88.1 77.1 7 Maharashtra 95.3 58.8 63 90.1 76.8 8 Uttaranchal 94.3 60 62 89.7 76.5 9 West Bengal 94 64.3 61.3 85.3 76.2 10 Karnataka 94.5 55 62.4 88.3 75.0 11 Andhra Pradesh 93.7 46 67.5 86.5 73.4 12 Orissa 90.9 51.8 59.3 81.5 70.9 13 Gujarat 93.9 45.2 55.4 84.8 69.8 14 Assam 91.5 31.4 63.6 90.7 69.3 INDIA 92.6 43.5 57 83.8 69.2 15 Chhatisgarh 90.9 48.7 52.9 84.2 69.2 16 Rajasthan 91.5 26.5 60.1 80.4 64.6 17 Uttar Pradesh 90.4 23 57.6 81.9 63.2 18 Madhya
Pradesh 90.6 40.3 40 80.7 62.9
19 Jharkhand 90.7 34.2 43.5 76.9 61.3 20 Bihar 91.5 32.8 44.1 69.5 59.5 *Source: NFHS-3, **Source: NSS, 61st RoundAge groups: “12-23 months” for immunisation ; “below 3 years” for nutrition; “6-14 years” for schooling. Note: The “ABC Index” is an unweighted average of the four indicators. States are ranked in descending order of this Index. This index was developed in the FOCUS (Focus on Children Under Six) Report that was released in 2006. In the present paper we have used the same indicators with updated figures.
21
This is clearly not because of economic growth alone (as states such as Punjab and Gujarat are economically more prosperous but stand below Tamil Nadu on this index), but a result of sustained public action both by the state and the people. The story of focus on children and their rights in Tamil Nadu has to be told in the context of major social change in the state
over the last 50 years, with the inequities among castes and genders decreasing and the state playing the role of a welfare state that delivers on its promises. The reasons for these are many including the role of the Self-Respect Movement in the 1920s, competitive politics since Independence onwards, reservations for the backward castes in higher education and government jobs, major initiatives for women’s education and so on. These are not looked into in detail here; suffice to say that all of this forms the important background which cannot be ignored (Rajivan AK 2006, Viswanthan B 2003, FOCUS 2006).
The major programme in Tamil Nadu for early child care and development is the ICDS, like in the rest of the country. ICDS is a centrally sponsored scheme with some basic guidelines on design and implementation being set centrally by the Ministry of Women and Child Development, Government of India. However, as mentioned earlier the implementation and impact of the ICDS has been very different in different parts of the country. This partly has to do with the general level of governance in a state but also the political priority given to this issue.
Nutrition Programmes in Tamil Nadu18
Tamil Nadu had as many as 25 nutrition programmes in operation in the early 1980s. The focus of these schemes was mainly to combat hunger among children, old people and pregnant women and nursing mothers. Since the beginning of 1980 the various nutrition programmes were reorganised and combined basically into three programmes- Puratchi Talaivar M.G.R.Nutritious Meal Programme (PT MGR NMP), Tamil Nadu Integrated Nutrition Project (TINP) and the ICDS. The TINP (ICDS III) programme was completed in 2003 with the withdrawal of the World Bank, (World Bank shifted its focus to states with a high burden of malnutrition) and integrated into the ICDS. The Noon Meal Programme for children in the age group of 2 to 5 is implemented through the ICDS (Rajivan A K, 2006 and Viswanathan B, 2003).
Tamil Nadu Integrated Nutrition Project (TINP)
The TINP funded by the World Bank started in the year 1980, with a focus on tackling malnutrition in children under three years of age. The basic components of this programme were regular growth monitoring, targeted supplementary feeding and nutrition counselling. Nutrition counsellors were appointed in each village who went house to house to explain to mothers the importance of breastfeeding, introduction of complementary feeding at the right time of the right variety and so on. At the same time the weights of children were regularly taken and those identified as being malnourished were given special nutritional therapeutic food.
22
This project was based on the understanding that malnutrition is the result of not just low incomes and/or lack of access to food but also of inappropriate child care practices. Growth monitoring was therefore a central component of the programme to determine who the
18 The following sections are based on material from Viswanthan B (2003), Rajivan AK (2006), Sridhar D (2008) GoTN (2003), various material available on the website of the Government of Tamil Nadu, www.tn.gov.in and observations and interviews during field visits.
services should be targeted to. Growth monitoring was also a tool to explain to mothers why one child was receiving food and another not, and to explain to them how their children were growing. The supplementary feeding component was targeted to the malnourished children for a fixed period of time to help them recover their growth.
The TINP in its second phase from 1991 onwards, expanded its focus to include immunisation , micronutrient supplementation and education for preschool children (3-6 years). In this phase along with the nutrition workers who worked with children under three and pregnant and lactating mothers, a second worker was appointed at the anganwadi centre focusing on pre-school education. Finally, in the third phase (from 1998 onwards, when it was part of the World Bank – ICDS III project) nutrition and health education, health services by health personnel, referral services and training to adolescent girls for self development and skill formation were additional services that were included.
Noon Meal Programme
The Puratchi Talaivar M.G.R. Nutritious Meal Programme (PT-MGR- NMP) or Noon Meal Programme (NMP), was started in 1982. This was a feeding programme for children in the age group of 2 onwards, up to 9 years initially and later expanded to cover all school going children and pre-school children from the age group of 2+ to 15. The meal consists of rice, dal (or sambar) and green leafy vegetables. Eggs were added to the meal from 1989 onwards and over the years the number of eggs provided per week has increased to 3 eggs per week. Children in the age group of 1 to 2 are given one egg a week. The state government contributes almost Rs. 200 crores towards the costs of providing eggs to children in the anganwadi centres. The component of NMP for pre-school children comes under the ICDS and the food is cooked by the anganwadi helper. In the schools, the government has appointed a noon meal organiser, a cook and an assistant. Currently, about 12 lakh children in the 2-5 age group are beneficiaries of the noon meal programme through the anganwadi centres. The following table gives the feeding scale for children in the 2-5 age-group under this programme:
Norms for Nutrition for 2-5 year age group children S.No Commodity Quantity 1 Rice 80g 2 Dal 10g 3 Oil 2g 4 Salt 1.9g 5 Vegetables, Condiments and Fuel 44 paise* 6 Egg (Monday, Wednesday and Thursday) 46g
* vegetables (20 paise), condiments (9 paise) and fuel (15 paise) Source: GoTN (2003)
23
For children under two the supplementary nutrition provided by the ICDS consists of ‘sattu mavu’, a nutritious mix, which is mixed in boiled hot water and made into ‘laddus’ first thing in the morning. Parents are expected to bring the children under 2 years of age to the centre around 8 in the morning and feed the child the “urundai” made of the nutritious mix, which
the anganwadi helper keeps ready every morning as soon as she opens the centre. A sample ‘laddu’ is kept in a box each day for testing in case of any complaints of food poisoning. This was available in almost every centre during the field visits. However in some villages mothers reported that they did not visit the centre everyday and were instead given their quota of nutritious mix once a month. Some indicated that this practice also made things more convenient for them. The disadvantage with this system however was that the food was shared by other members of the family, especially older children, whereas with spot feeding it could be ensured that the child who the mix was meant for was the one eating it. In spite of these small deviations it was seen from the field visits that the supply of supplementary nutrition was fairly regular, with few complaints.
Pre-school education
While there is definitely a greater focus on the feeding and nutrition components in Tamil Nadu, the pre-school component of the ICDS is also better than in most other states. In almost all the centres visited, there were colourful posters on the walls – many made by the anganwadi workers themselves. There were beads and stones and other such local material which teachers were using to teach the children numbers and so on. The centres would have about 20 children, who usually were able to recite poems, answer some simple questions and so on. The teachers had been trained to teach using a play-way method to develop children’s motor and cognitive skills. We heard from the teachers and the parents that many were now sending their children to private schools because they had English medium there. The child centres19 in Tamil Nadu are also open longer hours and in the afternoon session children who stay back have a nap in the centre before their parents come to take them.
Convergence with health services
The child centre or the anganwadi centre in the village is also the focal point for the provision of health services. The anganwadi worker supports the Auxillary Nurse Mid-wife (ANM) in immunisation. There is a slight change in this in the last one year because all immunisation has now been shifted to the primary health centres following the death of some children due to improper measles vaccination. There are also other ways in which there is a convergence between the ANM and the anganwadi worker, the ICDS and the health department compared to other states. The anganwadi worker organises meetings with women on nutrition and health education in which the technical support of the ANM is sought. Records are maintained together. The monthly meetings of the anganwadi workers are held in the PHC premises. Regular joint review meetings are held at the Primary Health Centre, Block and District level20.
Nutrition counselling
24
Nutrition and health education takes place more actively than in other states. The NFHS-3 report shows that more than 75% of the children who are weighed are also counselled after
19 The anganwadi centres in Tamil Nadu are also known as child centres.
20 TN FORCES (2008)
the growth monitoring. Many women in the villages mention that they were counselled by the ANM or the anganwadi worker about breastfeeding and also about what to give children as complementary feeding. Many women told us that once the child completes six months old they should be given “mashed rice, dal, beetroots and carrots”, in a manner where it seemed that the source of information for all was the same. Although this might not be practiced in many households due to time and resource constraints, we found that most women had the knowledge on what is to be fed and they even reported that they were informed by the ANM or the anganwadi worker.
Monitoring
To enhance community monitoring of the anganwadi centres Village Level Management Committees have been formed in all the districts. This Committee consists of 15 members from the same village. The responsibility of this Committee is to monitor the functions carried out by the Child Centre and to help the Anganwadi Workers in the smooth functioning and implementation of project activities at their village level. For improving the quality in the services of Anganwadi Workers, reliability checks are conducted every month by the Statistical Inspectors in the districts by random selection of Child Centres.
For rating the Child Centres, indicators are selected under 10 different categories and marks are assigned to the indicators which are detailed below:-Malnutrition Free, Health, Growth Monitoring, Supplementary feeding & NMP, Cleanliness & Maintenance, Adolescent Girls, Maintenance of Registers, Quality of service, Community participation and Convergence. Based on the marks obtained, the Child Centres are classified as “A”, “B”, “C” or “D” Grade Child Centres. If the Child Centre is “Malnutrition Free”, straightaway “A”-Grade is given. The best three Child Centres among “A”-Grade are recommended for National and State Awards (GoTN, 2003).
During field visits, the anganwadi workers were also quite willing to let us examine their records. The data that is usually recorded in some ten different registers in other states and even more was neatly organised in one register which had two pages each for a mother and child. These two pages had all the information from the time the mother’s pregnancy was registered until the child turned 5 years old. Therefore from this register one could see whether the mother had her ante-natal check ups, whether the delivery was normal and where it took place, date of birth of the child, whether the child was given colostrum feeding, birth weight, growth chart of the child, immunisation details and so on. This simple innovation greatly reduced the record-keeping burden of the anganwadi workers and also made more information available in a friendly format to ensure proper follow up of every mother and child.
Training and Other HR issues
25
The ICDS programme in Tamil Nadu has also laid a lot of stress on the training of the anganwadi worker. Tamil Nadu has also developed sophisticated training programmes, involving the formation of active “training teams” at the Block level, joint trainings of ICDS
and Health Department staff, regular refresher courses for anganwadi workers, inter-district “exposure tours” for ICDS functionaries, and more (FOCUS, 2006).
Other than training and supervision support, the anganwadi workers and helpers are also given other incentives to work. Tamil Nadu government contributes from its own budget to pay the anganwadi workers higher wages. The anganwadi workers are paid Rs.2,792 per month and anganwadi helpers are paid Rs.1360 per month (compared to about Rs. 1500 per month for anganwadi workers and Rs. 750 per month for anganwadi helpers in most parts of the country, based on central government contributions). They are also entitled to other benefits such as Standard Time Scale, D.A, HRA, increment, bonus and Pongal Gift. They are further entitled 12 days casual leave, three months maternity leave and regular monthly pension. The increments are based on number of years of experience with a separate pay scale being applicable for those with more than10 years of experience.
Infrastructure
What is also striking in the visits to the child centres in Tamil Nadu is the physical infrastructure. Although modest, the infrastructure is better than in most other states in the country. Every anganwadi centre that we visited had a separate designated building. Each building had at least two rooms, one large hall for the children to learn and play in – this hall was usually well decorated with charts and posters, had floor mats for children and a cupboard for the registers and files. On the wall was also some basic statistics of children and women such as number of children in different age groups (6 months – 36 months, 36 months to 60 months), in different caste groups, number of pregnant and lactating mothers and the grade classification of children’s weights – so from the wall one could see how many children in the village were in the Normal grade and how many in Grade I, II, III and IV each. The Government of Tamil Nadu has also begun a process of modernizing the kitchens of the anganwadi centres by supplying LPG connection, Stove and Pressure Cooker along with Electrification (GoTN, 2003).
Dr.Muthulakshmi Reddy Maternity Benefit Scheme
Tamil Nadu is the only state in the country to have a maternity benefit scheme for women in the unorganised sector. Under this scheme the Government gives financial assistance of Rs.1, 000 per month for six months to pregnant women - three months ahead of delivery and three months after, so as to provide them rest and good nutrition. This assistance is given to compensate for the loss of wages during delivery time to each poor woman during pregnancy and the lactating period with the objective of increasing their intake of nutritious food so that they give birth to healthy babies and avoid becoming anemic themselves (GoTN 2003).
‘Tamil Nadu is Different’ – FOCUS Study
26
The FOCUS study also found that ICDS in Tamil Nadu was way different from what was seen in the rest of the states in which the survey was conducted. A table from the FOCUS report is presented here, which shows that in all aspects the functioning of anganwadis in Tamil Nadu is much better than in other states. The infrastructure is better with a larger
number of centres having their own buildings, kitchen and storage facilities, etc. The anganwadi centres are open for a longer duration and the number of children attending the centre is higher. A larger proportion of mothers in Tamil Nadu report that pre-school activities are conducted, anganwadi workers are motivated and that they make home visits. Health services such as immunisation and ante-natal care have a better coverage. Training of anganwadi workers seems to be taking place fairly regularly and the workers are also paid in time. This independent study therefore confirms the field experiences and the general perception that the ICDS in Tamil Nadu is different.
Results from FOCUS survey Tamil Nadu Other FOCUS states Proportion of anganwadis that have: Own building 88 22 Kitchen 85 29 Storage facilities 88 50 Medicine kit 81 23 Toilet 44 15 Average opening hours of the Anganwadi (according to the mothers)
6½ hours a day 3½ hours a day
Proportion (%) who attend "regularly": Age 0 – 3 59 19 Age 3 – 6 87 60 Proportion of mothers who report that: Pre-school education activities are taking place at the anganwadi
89 42
The motivation of the anganwadi worker is "high"
67 45
The anganwadi worker ever visited them at home
58 26
Proportion (%) of women who had at least one pre-natal health checkup before their last pregnancy
100 65
Proportion (%) of children who are "fully immunised"
71 43
Average number of months that have passes since anganwadi worker attended a training programme
6 30
Proportion of anganwadi workers who have not been paid during the last 3 months
0 17
Source: FOCUS (2006)
27
Conclusion
28
The Tamil Nadu experience shows that in the context of strong political will, sustained public pressure and a well-oiled administrative system the ICDS can deliver to a large extent. The Government of Tamil Nadu has made many innovations in the programme and these efforts have paid off. However, the closure of the system of having two anganwadi workers in each anganwadi centre has increased the work load on the anganwadi workers and there is a danger of some of the tasks being neglected. Further, the anganwadis in Tamil Nadu are still not playing the role of a crèche, especially for children under three. Poor working mothers still do not have any institutional options for the care of their young children. The involvement of the local bodies such as the panchayats also seemed to be low. Further, the influence of the kindergartens in the private sector seemed to be spreading fast with no monitoring on the quality of education provided in these places.
Maharashtra’s Mission against Malnutrition (Rajmata Jijau Mother Child Health and Nutrition Mission)
Background
Maharashtra, despite being one of the more prosperous states of India, is home to severe malnutrition. The media has over the years regularly published stories of the high prevalence of malnutrition related deaths especially in the tribal districts of the state. In 2005, the Bombay High Court took suo motu cognisance of one such press report and heard petitions on malnutrition and child deaths. In the course of the case, the State Government admitted that 2,675 children of 0 to 6 years died between April and July 2005 in the tribal dominated districts of Thane, Nandurbar, Nasik, Amravati and Gadchiroli (The Hindu, 2005). This established the need to put into place an effective system of coverage of all children by the ICDS and health programmes on a war footing in order to tackle severe malnutrition.
The Government of Maharashtra set up the Rajmata Jijau Mother Child Health and Nutrition Mission to work towards reduction and removal of malnutrition in all the districts of the state. Set up for five years in April 2005, the mission was envisaged to work in the tribal and rural areas of the state. The Mission was constituted by the Government Resolution dated 11th March 2005 issued by the Department of Women and Child Development, Government of Maharashtra. The primary objective of the mission is to reduce the level of grade III and grade IV malnutrition among the children between 0 to 6 years of age in the state.
29
Malnutrition Removal Campaign21
The Mission was based on the lessons learnt from the Kuposhan Nirmulan Abhiyaan (Malnutrition Removal Campaign) initiated by Mr. V. Ramani, Divisional Commissioner, in the Aurangabad division of Maharashtra in March 2002. There were fourteen child deaths in 2000-01 due to malnutrition, all reported from Bhadali village in Vaijapur taluka of Aurangabad district. In the investigations that followed, it was found that there was no anganwadi or health care system in the village, because the village size and population was small and there was no separate anganwadi sanctioned in the area. The Malnutrition Removal Campaign was then launched in the Aurangabad Division with the principal focus of the campaign being 100% survey, registration and weighing of children in the 0 to 6 age group. Each anganwadi worker, in addition to her own jurisdiction, was asked to cover an extra population of 500 in order to cover the areas where there was no anganwadi.
Initially, according to the ICDS records 1.2 million children under six were identified in the eight districts of the Aurangabad division. With greater emphasis on complete coverage, 1.7 to 1.8 million children were reported. These children were weighed and classified according to their nutrition status. In July 2002, 7867 children were reported in grades III and IV stages of malnutrition in the ICDS records. The survey conducted in the same period, with greater emphasis on complete coverage, showed that the number of children with severe malnutrition in the division was 10705.
The campaign ensured that all the children in the division were weighed every six months. Children with grade III and IV malnutrition were weighed every month. In addition to this, regular medical examination, supplementary nutrition, health and nutrition counselling for the mothers were also provided. The underlying approach of the campaign was to streamline the activities of the ICDS and health department, without additional budgetary allocations, and ensure effective service delivery. There was significant reduction in malnutrition following the campaign and the number of children with grade III and IV malnutrition plummeted to 3000 by March 2004 and further to below 500 by April 2005 in the Aurangabad division.
Rajmata Jijau Mother Child Health and Nutrition Mission22:
30
Based on the encouraging experience of reduction in malnutrition in the Aurangabad division, Rajmata Jijau Mother and Child Health and Nutrition Mission was set up. The Steering Committee of the Mission is headed by the Chief Minister of the state giving it the political sanction of the highest order. The government has not allocated any additional budget for the functioning of the mission, and the activities of the mission are implemented with the funds available under the NRHM and services of the ICDS. UNICEF is supporting the mission office financially for all its administrative and infrastructure expenses. In the first phase, the work was initiated in the five most critical districts of Thane, Nasik, Nandurbar, Amravati and Gadchiroli. In the second phase, spread over the next two years, ten other
21 This section is based on Ramani (2007)
22 The following sections are based on the available reports and presentations on the Mission website at www.hetv.org, and discussion with officers working in the Mission
districts with a high percentage of tribal population were covered. Over the last two years the Mission’s work has been initiated across all the 33 districts of the state.
Since 1975, malnutrition has been dealt with mainly with supplementary nutrition and health checkups under the ICDS in Maharashtra. To work in a mission mode an integrated approach has been adopted with emphasis on achievement of quantifiable goals in a time bound manner. The Mission has adopted the following as its key objectives23:
- Reduction of grade-III and grade-IV malnutrition in children in the 0-6 age group in the State of Maharashtra.
- Ensuring provision of ante-natal care to pregnant women, new-born care and special focus on health
- Nutrition and complete immunisation of children in the 0-3 age group (in effect, focus on the entire period from the stage of conception to the time the child is three years old)
- Reduction of grade-I & grade-II malnutrition in the state
- Assisting the Public Health Department in provision of training for implementation of the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and home-based new-born care programmes on a pilot basis in selected primary health centres (PHCs)
- Focus on the education of adolescent girls to reduce the incidence of child marriages and promote spacing between children
- Making efforts to bring about social transformation through participation of the community so that the responsibility for nutrition management is transferred from the government to civil society
The mandate of the mission, in line with its objectives, is training and motivation of the staff at all levels, coordination of activities of different departments, monitoring and evaluation, community involvement and participation and putting into operation the child development centres.
Training and Motivation
31
Training and motivation are central to the work carried out by the mission. Congruent to the malnutrition removal campaign, the mission follows “fact finding and not fault finding” as the cornerstone of all its initiatives. The emphasis is to motivate and train the staff to acknowledge, own and overcome the problem. The three objectives of the training exercise are:
23 http://hetv.org/nutritionmission/index.html
- To instil a sense of purpose among the field workers of the ICDS and health departments
- To upgrade the skills and capabilities of the staff at all levels
- To sensitise the entire machinery to the human aspects of the issue so that they look for solutions rather than treating their job as a routine exercise
Trainings of the various functionaries from the child development department as well as health department are organised. Motivation, communication skills and local leadership are the key aspects of the training programmes conducted. Although skill development also takes place maximum emphasis is laid on motivation of the personnel.
Trainings are held at the state, district, block/PHC and village levels. The state training module focuses on policy and coordination issues. The district training module includes all staff at the district level, officers like Project Officers, Tribal Development, Child Development Project Officers and Medical Officers and select anganwadi supervisors, anganwadi workers and ANMs who could then function as Master Trainers for other staff at PHC and village level. The district training focuses on operational issues, including survey and weighing of children and inputs on monitoring the health and nutrition status of children. The block/PHC training enables dissemination of information and sharing of experience amongst all anganwadi workers and ANMs and aims at promoting maximum cooperation and coordination between the ANM and the anganwadi worker in ensuring systematic coverage of the entire mother/child population in the village. Doctors and experts from organisations such as Breastfeeding Promotion Network of India (BPNI) are also invited for capacity building and motivation.
The anganwadi worker is trained to correctly weigh the child and plot, read and interpret the growth chart so as to identify children whose growth shows signs of faltering. She is trained on how to do nutrition counselling and also on when to refer children to a medical facility. The supervisor is trained to understand and further train people with regard to nutrition for the child and mother. The medical officers’ capacity to deal with severe malnutrition is enhanced and they work as local paediatrics at the PHC level. Review workshops are held after the first initial training. Most senior level officials of the mission conduct these training programmes so as to stir up the enthusiasm of the field workers and endorse the worth of their work.
Coordination
32
The soul of the mission is to provide holistic care to children suffering with malnutrition and this requires coordination between the ICDS and health departments. The key functions of the ICDS include provision of supplementary nutrition, growth monitoring of the children and nutrition and health counselling. The health department plays a substantive role in immunisation, health check-ups, medical care and treatment of infections and severe malnutrition among children. The services of the ICDS and health departments are both necessary to make a significant dent in order to combat malnutrition. The Mission, therefore,
cannot succeed in its objectives until there is a high degree of cooperation and coordination among the two departments at various levels, right from the village to the State Government level. As a first step, the training for the functionaries from these two departments is organised together. At the village level, the anganwadi worker and ANM work in coordination, at the block level the CDPO and the Medical Officer are encouraged to work in close liaison. At the district level, the focus is on the Deputy CEO (ICDS) and the District Health Officer working in co-ordination. The Collector and the Chief Executive Officer of the Zilla Parishad are key officers in ensuring the highest possible degree of coordination amongst the departments, since departments like Tribal Development, Water Supply and Public Works are also entrusted with crucial service delivery responsibilities.
Monitoring and Evaluation
At the time the mission was started, it was felt that a lot of data was being collected at the field level but very little analysis of this data aimed at corrective action was being undertaken. As one of its preliminary activities, the mission started to analyze data on ICDS released by the Government of Maharashtra every month and monitor progress of children’s weights in the various districts.
Percentage of Normal Children District Wise
APRIL 2005 DECEMBER 2008
Greater than 61% Between 50% and 61% Less than 50%
The mission has also concluded a 30 cluster sample survey in 14 districts of Maharashtra as a mechanism to check the reporting of the malnourished children in the state. A minimum of 4 to 15 times variation in reporting was found in these districts vis-à-vis the number of malnourished children as reported by the anganwadi workers. Such anomalies in the data are then shared with the respective divisional commissioner and remedial steps are taken.
33
The mission also conducts fact finding surprise visits to anganwadis and primary health centres. The visits are carried out to check the weighing efficiency, gradation of children and supplementary nutrition in the anganwadi centre. In the PHC, checks are made to ensure
Jalgaon Buldan
a 56 8%
Akola
Washim
Amravati
52 0% Wardha
55 8%
Nagpur
63 1%Bhandar
a 56 3%
Gondiya
50 6%
Gadchiroli
Chandrapur
49 6%
Yavatmal
53 4%
Nanded
60 2%
Hingoli
69 3%Parbha
ni 68 6%
Jalna
Aurangabad
63 2%
Raigarh
55 7%
Pune
Ahmadnagar
64 3% Bid63.3%
Latur
60 8
Osmanabad
71 8%
Solapur
75 1%Satar
a 82 9%
Ratnagiri
54.4%
Sindhudrg
u
Kolhapur
73 7%
Sangli
Nandurbar
43 8%
Dhule
Nashik
Thane
55 9
Jalgaon Buldan
a
Akola
Washim
Amravati
40 0% Wardha
43 8%
Nagpur Bhandar
a Gondiy
a
Gadchiroli
Chandrapur
Yavatmal
Nanded
47 8%
Hingoli
%Parbha
ni 56 8%
Jalna 51.0%
Aurangabad
53 8%
Raigarh
Pune 57.6%
Ahmadnagar
Beed 55.4
Latur
58 6
Osmanabad
Solapur
48 9%Satar
a 57 6%
Ratnagiri
47.2%
Sindhudurg
Kolhapur
62 9%
Sangli
Nandurbar
31 %
Dhule
Nashik
Thane
3 8
regular check up of children, maintenance of their medical records, referred and prescription follow ups. The gaps, if found, are communicated to the concerned department and reviewed.
The Mission also aims at developing an online reporting system that minimizes paperwork and enables two-way communication between the field machinery and the policy levels. The mission has recently even started a website (www.cdcmission.com) for recording the weight of the children online.
Community Involvement and Participation
Community participation is important to sustain the efforts of the mission. The mission works closely with the community and emphasises on capacity building and attitude change of the members of the community as well. It has also devised strategies to facilitate effective learning about the importance of nutrition of the mother and child and regular growth monitoring. Interactive sessions with the community are organised in order to discuss the quality and frequency of the diet given to a child, implications of an underweight child, how to increase weight of the child, ante natal and post natal care for mothers. The mission uses a 10 feet by 12 feet large community growth chart to organise these interactive sessions in the village. With the use of these large growth charts, growth monitoring is undertaken as a community exercise where all children are weighed in the presence of all the parents. After being weighed, the children are placed on the chart on the spot that reflects their age and weight. The anganwadi worker then uses this as a tool to educate the community on nutrition status of children and what needs to be done to improve it.
Simple innovations such as celebrating six-month birthday, at the ICDS, to correspond with introduction of complementary foods to the child have been successful in involving the community in the functions of the anganwadi.
Child Development Centres
Child Development Centres (CDC) have been started in the state of Maharashtra under the National Rural Health Mission, as one of the key strategies of the Rajmata Jijau Mother Child Health and Nutrition Mission. The first CDC was started in Gondiya in October 2007, a semi tribal district of Maharashtra. Since then, a total of 1076 CDCs have been established in 30 districts of the state. A total of 8222 children with grade III and IV have been admitted and 3182 have been moved to upper grades of nutrition.
34
CDCs are residential camps which provide complete care to children with severe malnutrition to improve their health. A CDC is set up in a Primary Health Centre (covering around 20 – 30 villages) in the event that 10-15 children are identified with grade III or grade IV malnutrition. The CDC is run for 21 days in accordance with the WHO guidelines for severe malnutrition, and a strict and scientific approach with health, nutrition, training and monitoring protocols is followed24.
24 A manual by the Mission for the child development centres called “Bal Vikas Kendra Margdarshika” (in Marathi) gives details of the protocol
- Health Protocol – This protocol defines a ten step management of a child with severe malnutrition, and prescribes treatment and prevention for any deficiency and infections. It also emphasises on feeding, emotional stimulation and sensational development of the child.
- Nutrition Protocol – The children admitted in the CDC are given food in eight different schedules in the first week and in six different schedules in the second and third week as per the guidelines. A separate diet schedule is followed for children between 7 months to 3 years of age, and children between 3 to 6 years of age. In case the child is suffering with diarrhoea, modifications are also made in the diet. The diet contains three schedules of amylase mix (made of wheat/ rice and pulses) recipes, three different recipes of seasonal food, eggs/ curd and sugar, potato and two schedules of regular food one at lunch and one at dinner.
- Training Protocol – It is mandatory for the mother of the child to stay in the CDC for the duration that the child is admitted there. She is trained for personal and community hygiene, trained in preparation of nutritious food and proper and frequent feeding practices.
- Monitoring Protocol – The children are weighed every morning at 8:30. The temperature, respiration and pulse rate of the child is also recorded. The food intake of the child is measured. In case the child does not show progress in the above indicators, the paediatrician is immediately consulted for any infection, deficiency etc. and the problem is corrected. The net weight gain of the child and malnutrition grade is calculated at the time of discharge from the CDC. The follow up is done by monitoring the weight of the child for the next six months. The Medical Officer and ICDS Supervisor go to the child’s house every month to weigh the child. In case the child does not show perceptible improvement in the CDC or does not continue to gain weight at home, she/he is admitted into the CDC again. With the launch of its new website the weights of children with grades III and IV malnutrition is recorded online. The website is equipped with the software to calculate the gradation and the information is accessible to all the officials of the concerned departments.
In the CDC, an ICDS Supervisor, an anganwadi worker, ANM/ Medical Officer are present to monitor the nutrition and health of the child. The CDCs do not follow a targeted approach and admit all children with severe malnutrition. Within this period of 21 days, some of the children are upgraded in upper grades and in the remaining children weight gain is found significantly. The weighing scales used in CDCs record weight of the child with high degree of precision in grams. The CDCs are located in a place/ building away from the PHC ward and toys and other playing material are also provided so as to provide a homely atmosphere.
35
The CDCs are run with the funds available under the National Rural Health Mission with the Department of Health, Government of Maharashtra. There’s a provision of Rs. 160 per day per child in the CDCs – Rs. 60 is paid to the mother as lost wages, Rs. 10 are earmarked for examination charges of the paediatrician and the remaining money is available for mother’s and child’s nutrition, diet, investigation, blood testing, supplementary medicines. Over a span
of 21 days, about 3400 rupees are spent per child in CDCs. An initial one time expenditure is also made on procurement of different materials, beds, utensils, repairs to building etc.
Accountability of the different departments is defined where the health department is made accountable for Grade III and grade IV children, while for the grade I and grade II children, the ICDS department is held responsible.
Conclusion
The mission has played a vital role in the last four years in the state of Maharashtra in improving the functioning of the anganwadi centres. The activities of the mission are spread across the state and continue to bring about a change in the remote areas as well.
It is still probably too early to measure the impact of the Mission on malnutrition levels in the state. Although the data generated by the Mission shows large improvements in the malnutrition status of children in the state, they themselves accept that these figures might not be completely reflecting the reality as their own independent surveys show that under-reporting of malnutrition continues to be a problem. What is positive however is that the state is now willing to see the truth and is working towards establishing a culture where the real picture is reported by the anganwadi workers. The Mission has been successful in bringing much needed focus on aspects such as training and capacity building of all ICDS functionaries and co-ordination between the ICDS and health departments.
The Government of Maharashtra has also shown its commitment to reforming the ICDS by removing corrupt (but politically powerful) private contractors from the supply of supplementary nutrition to anganwadis and setting up a system where local self-help groups of women are trained to prepare food for children of different ages in the anganwadi. For this process too innovative recipes and systems of training in partnership with the private sector have been worked out.
The focus of the Mission is on malnutrition among children under two, and addressing this problem primarily by changing behaviours at the community level. While it is true that there is a need for behaviour change communication, the Mission must be careful not to lose sight of the larger context in which many of its population live – which is of acute hunger and food deprivation. The line between changing attitudes and creating awareness and blaming the poor for their problems is thin, and the balance needs to be maintained.
36
While the Mission has been able to make many innovations in addressing the problem of malnutrition by activating the anganwadis without having to use much additional funds, it is not clear what is happening to pre-school education for older children in this process. At some point the Mission must also graduate to a comprehensive approach and try to make the anganwadis in the state effective in provision of all the services for children under six including health, nutrition and pre-school education. This might not be possible without investing additional resources in the programme.
The mission has been established for five years which end in 2010. The true challenge lies in the activities and ideology of the mission being internalized at all levels of the functioning of the various departments so as to continue the work with the spirit of the mission.
37
3. Nongovernment models of ECCD provision There are many NGOs engaged in child care related issues in the country. Like NGOs working on any issue, there are vast differences in the approaches of these different organisations, with some primarily doing service-delivery where they are providing day-care, crèche or balwadi services to the poorer sections of society. There are others that work in a rights-based approach and are working with the community to demand for ECCD services from the government and to make these services more accountable. Groups are involved in advocacy with local, district, state and national governments for policies for children under six. This is done as individual organisations and also as part of larger networks. It is difficult to classify organisations as belonging to any one category as most are engaged in working with a mix of all these strategies.
Even in terms of the specific issues related to children under six not all organisations take up all or the same issues. While some work specifically on health and/or nutrition of children under six, as part of a larger agenda of improving health of populations, there are others that work towards providing pre-school education as part of the larger agenda of improving education of populations. Based on their approaches, the focus age groups of organisations also vary – some work only with children under 2 or 3 while others work only with the preschool age group of 3 to 6 years. Further, there are also organisations which work specifically on the issue of early child care and these usually cover all the issues related to health, nutrition and development for all age groups of children under six. There is no survey or estimate of the actual number of NGOs working on these issues, or on the kinds of services that they provide.
For the purposes of this paper, four non-government practices were chosen from a list of well-known models of early child care provision in the non-government sector in the country. The four organisations were chosen to try and get a mix of strategies, approaches and contexts of work – therefore while Pratham is basically an organisation working on universal education with its work on ECCD having a focus on children in the age group of 3 to 6 and pre-school education; CINI is an organisation that works on a wide range of issues related to reproductive and child health, and among young children is primarily working with children under 2 and their access to health and nutrition. Mobile Crèches and SEWA on the other hand started from the perspective of providing child care services for working mothers and are working on the care, health, nutrition and pre-school aspects for all children under six. Pratham and Mobile Crèches are primarily urban-based while CINI works mostly in rural areas and SEWA’s crèches run in both urban and rural areas.
38
While each of these organisations are engaged in many other issues what is presented here is not a case study of the entire organisation’s work but only their work related to children under six. However, the other activities of the organisation are briefly described to understand the broader strategies and the context in which each of them work.
Towards Better Health and Nutrition – CINI (Child in Need Institute, West Bengal)
Background
Child in Need Institute (CINI) is a pioneer organisation in India working on child malnutrition and child health issues in a community based preventive health care approach. The bottom line of all its interventions is the child, the child whose basic rights have not been fulfilled and who is without rights. CINI is registered as a non profit body under the Society’s Act in India, with its head office in Kolkata. Founded by Dr. Samir Chaudhuri in 1974, CINI recognises “Sustainable development in health, nutrition, education and protection of child, adolescent and women in need” as the vision and mission of the organisation. CINI started with a target group of around 3000, and today reaches out to over half a million people directly and indirectly across the rural and urban areas in the states of West Bengal, Jharkhand, Chhattisgarh and Madhya Pradesh. Among its different units, CINI today has about 400 employees and an annual budget of over $3,500,000 (CINI, 2004).
39
Dr. Chaudhuri, a medical doctor from the prestigious All India Institute of Medical Sciences, offered to help Sister Pauline in the make shift clinics that she organised after school hours on Saturday afternoons at the Loreto Convent at Thakurpukur, Kolkata. The clinics were organised in order to treat malnourished children, advice mothers to feed their children cheap and nutritious food and adopt hygienic practices. The Saturday Clinic became very popular and mothers started coming in large numbers with their sick children. The clinic was then shifted to Pailan, and the clinic day was changed to Thursday in order to coincide with the weekly haat (market) at Pailan. The clinic was seen as an opportunity to cure, counsel and bring about a behaviour change among people. This was the beginning of the organisation and the name Child in Need Institute was formally adopted in 1975.
CINI, from its very inception, believed that most child health issues can be resolved by working with the community. “We spent a lot of time with the community, often meeting them late into the night explaining why we were not going to build a specialist hospital and buy ambulances”, says Dr. Chaudhuri of the initial years of CINI in ‘CINI at 30’(ibid.). While CINI’s work began with the Thursday Clinics, it soon expanded to working with the community with an emphasis on preventing malnutrition. Trained health workers visited homes of people to promote locally available nutritious foods, and counsel them to adopt hygienic practices to prevent diarrhoea, chest infections and worm infestations. In the last 35 years, the work of the organisation has grown multi-fold but the fundamental approach for all its interventions remains community based.
Nutrition Rehabilitation Centre and Emergency Ward
Some of the children who were brought to the Thursday clinics were severely malnourished and sometimes suffering from acute and chronic infections. They required more immediate and sustained attention than a one-time consultation in a Thursday clinic. This led to the creation of the nutrition rehabilitation centre (NRC).
CINI is the first institution in India to set up a Nutrition Rehabilitation Centre (NRC). The NRC was set up in the CINI campus at Pailan in 1976 with three important elements: curative services, capacity building of the mother and community monitoring. In Daulatpur, Pailan where the CINI campus is located, 600 to 700 children are cured for severe malnutrition every year. The child is admitted in the NRC, along with the mother or a care giver who may be related to the child. When the child is admitted in the NRC, special care is taken with regard to the frequency, quantity and quality of the diet of the child. In words of Dr. De, a senior paediatrician who has been working with CINI for nearly two decades now, “With proper feeding, within ten days the change in the child’s health is visible”. The basic approach of CINI therefore is that once infections are cured, the problem of malnutrition is basically food-related. By providing the child a high quality balanced diet based on locally available material, CINI believes that a child can bounce back on to a healthy growth path.
Simultaneously, there is a lot of emphasis in changing the feeding practices of the family and trying to ensure that the children continue to receive similar food even after they go back home. Hence, care is also taken to involve the mother in the preparation of the food. In this manner during the duration of treatment when the mother and the child are staying at the NRC, the mother is also trained in preparing cheap, nutritious and hygienic food. The kitchen provided at the NRC is well equipped and there is a cook and helper to guide and train the mothers.
40
Within a year of setting up the NRC, a specialised emergency ward was established in the CINI campus in Pailan to tackle severe illness related to malnutrition. The emergency ward and the NRC provide immediate hospitalisation, services of trained doctors and complete care in nutrition and health for the mother and child. Equipped with modern machinery, the emergency ward has ten beds and a child specialist doctor available at all times. There are 16 beds in the NRC and 10 beds in the emergency ward of CINI.
Under Five Clinics
The CINI campus in Pailan runs an Outpatient Department (OPD) every week from Monday to Friday. While children from the neighbouring areas are brought here regularly for treatment, the Thursday clinic, also known as Under Five Clinic, focuses specifically on young children and on that day offers a mix of services to those who come. This is very popular, and draws people in large numbers, even from far off places. This is subsidised vis-à-vis the regular OPD and offers integrated services comprising of weighing, growth monitoring, nutrition and health counselling, immunisation and consultation with a doctor under the same roof at the same time. The clinic starts at 8:30 in the morning, and goes on till 1:00 in the afternoon. As many as 500 children are seen in these under five clinics on a single Thursday. The main emphasis at these clinics is on preventive services.
While the children are waiting to be seen by the doctor CINI’s staff spend time with them counselling them on nutrition, health, immunisation and so on. Easy to make nutritious recipes, posters and pictures with nutrition and health related messages are on display. A popular tool that is used to explain the basics of a balanced diet is the Indian flag. People are told that every meal must consist something of all the colours that make the tri-colour (saffron, white and green). Examples of foods in each of these groups are given. Further the importance of water and oil is emphasised as being symbolised by the blue wheel, “chakra”, in the middle of the flag. This tool is also used during home visits in the community.
To follow up with children, a growth chart is maintained for each child. A health card is also maintained to record the history of the mother and child. Fathers are also encouraged to visit the clinic and are talked to by the doctors, health workers, counsellors to convey the importance of health and nutrition care for the child and the mother. While people come to these under 5 clinics with sick children, this opportunity is used to work with them to counsel them on health and nutrition behaviour in order to prevent future illnesses.
Nutrimix
One of the most important innovations at CINI to tackle the problem of malnutrition is Nutrimix, a cheap, nutritious and locally available infant food which can be initiated as the complementary food for infants from the age of 6 months onwards. This mix is made from locally available wheat/ rice and pulses. Nutrimix flour is prepared and packed by CINI and available for purchase at highly subsidised rates. Mothers are also taught how to make this mix. Over the years of CINI’s experience it has been seen that infants like the taste of nutrimix, it is convenient to use and can be made into delicious shira or laddoo with a little oil and jaggery which is very nutritious and easily accepted by the parents and the children.
41
Each of the interventions at CINI has emerged as learning from the field. As documented in the report ‘CINI at 30’,“CINI has a reputation of being a ‘learning organisation’ with (our) ears close to the ground, listening to the voices of women, children and community”. The expanding work and mandate of CINI over the decades also led to intense debate within the organisation and sanction of the ideological stance of the organisation in terms of the Life Cycle Approach and the Child Women Friendly Community.
Life Cycle Approach
CINI recognises the time period from pregnancy till the child is 2 years old as the most critical period of human lifecycle and has adopted the life cycle approach as the key approach
for all its interventions. The approach recognises the continuum between the three stages in life: child, adolescence and woman, as the cornerstone of its interventions to tackle malnutrition. Lack of care at any of these stages perpetuates a vicious circle of low birth weight and malnutrition across generations. Also, at all these stages the body undergoes rapid growth and the individual is highly dependent on others for care and support. Therefore CINI’s programmes have been now designed to address each of these critical stages of the life cycle – pregnancy, child up to
2 years and adolescence.
For instance, health workers trained by CINI visit and counsel the entire families, including the husbands and mothers in law, about the importance of regular ante natal care for the pregnant mother, proper nutrition and frequency of meals, safe delivery with trained birth attendants, thereby ensuring a new born birth weight of over 2.5 kilograms. They regularly visit the family after the child birth to further ensure exclusive breast feeding, immunisation, supplementation with home available foods from the sixth month onwards, and monitoring and promoting growth up to two years of age. The health workers interact extensively with adolescent girls and boys to provide them health and nutrition education through trained peer educators. The life cycle approach improves the health of women and children, helps break the vicious cycle of illness and poverty, draws on the synergy of intergenerational links, more effectively delivers essential services and engages partners, communities, NGOs, governments and agencies for better use of resources.
Child Women Friendly Community
42
Child Women Friendly Community is a key approach that is now adopted in all of CINI interventions. This approach is an outcome of the work carried out by CINI over three decades on issues related to education, health, protection and nutrition. While the targeted interventions of CINI focus on the families of those who are in the critical stages of the life-cycle (pregnancy, under-2 years child and adolescence) as identified by CINI, it is now recognised that there needs to be work done at the broader community level in order to bring about more sustainable change. Further, while in the initial years CINI was working only as a service delivery organisation it now sees itself having a role in activating government services and making them more effective. The cornerstone of this approach is that CINI functions as a facilitator and works towards establishing accountability of public functionaries such as ANMs, medical officers and anganwadi workers to the community. The
three key stakeholders in this approach are the local legislative bodies, the service providers and the community members. The strategies adopted under this programme aim at improved dialogue between these three stakeholders. For instance, CINI works towards generating demand for a service by making people aware and then work with the community to ensure that this service is provided.
The action strategies of the approach are:
- Convergence, linkage, partnership and leverage: These involve bringing the key stakeholders together for participatory planning, action and monitoring.
- Capacity building: It involves empowering the stakeholders to undertake informed dialogue and proactive rights based action.
- Advocacy at all levels: It focuses on advocating at all levels from Panchayats to the Parliament for creating an enabling environment for children and women based on programme learning and challenges.
There are different steps to the implementation process. First, a sensitisation programme is undertaken to generate awareness in the community on both the needs of the target groups and also the services available. An increase in the awareness in the community results in a process of collectivisation with the formation of different stakeholder groups such as women’s groups. Then the capacities of these groups are built engaging with them in collective analysis, planning and participatory situational analysis. A result of this process is one where the groups based on their analysis identify and prioritise key issues. Once the issues have been identified time based action plans with specific targets and responsibilities are made and the process of implementation of the action plan begins. A community based monitoring mechanism is also designed for continuous monitoring. This process is done with all the stakeholders together.
Therefore the following are the seven basic steps that have been identified by CINI for the implementation process25: Sensitisation – Collectivisation – Collective analysis – Prioritisation – Planning – Implementation – Monitoring. This is not a linear model but just a guide to the steps involved with the actual implementation being responsive to the community’s needs and response.
Other Activities of CINI
43
In addition to its extensive work on child malnutrition and health issues, in its pursuit to ensure health, education, protection and nutrition for all children, CINI has diversified work extensively resulting in many different units to deal with various issues. CINI Bandhan was formed in 2003 in response to the increasing numbers of rural women suffering from recurrent sexually transmitted infections (STIs). CINI Yuva, formerly known as the Adolescent Resource Centre, envisages fostering an environment where Young People's (10-24 years) Reproductive and Sexual Health (YRSH) is realized through youth participation
25 CINI (2008) Annual Report 2008
and community mobilisation. Women’s Health Division (WHD) was formed as a technical body that helps to enhance institutional learning regarding reproductive and sexual health related issues and interventions among women. CINI Asha, the urban unit of CINI, was initiated in 1989, in response to the needs of the deprived urban children. It aims at improving the quality of life of the urban, disadvantaged population and protects the rights of the child through education, health and social mobilisation.
CINI Chetna Resource Centre (CCRC), the training unit of CINI was set up in 1975 with the aim of providing appropriate and effective support services to the work of CINI through a range of training activities. It was registered as an independent body in 1989. CINI Chetana today specialises in different aspects of training such as training needs assessment, curriculum development, training package development, organising and facilitating training and evaluation of training programmes. CCRC is the central training unit and provides training for the anganwadi worker, helpers and supervisors of the ICDS programme in the state. It also provides training to various government functionaries on a range of issues including reproductive child health and behaviour change communication. Similar trainings are held for its partner NGOs in West Bengal. Trainings are also held for students from various academic institutions like Indira Gandhi National Open University (IGNOU), Calcutta University and Nursing Institutes (Government and Private). In more than two decades of its operation, CCRC has trained 18,000 front level functionaries from government organisations and NGOs.
CINI was identified as the Regional Resource Centre by the Ministry of Health and Family Welfare with the aim to collect, organise and disseminate information related to Reproductive and Child Health. Conceived in July 2003 as an information hub of institutional learning and experiences, the CINI Resource Centre today has evolved to serve information and communication needs not just internally but externally as well. It has a vast pool of resource materials catering to different target groups. It is responsible for developing standardized institutional publications and also provides strategic communication support to programmes through a range of inputs including needs assessment, strategic planning as well participatory resource development. In addition it has the responsibility of strengthening media advocacy.
Given the vast experience and work spread over 35 years, CINI has established a relationship with the government at central and local levels, as well as with non government agencies. CINI has significantly contributed in joint policy and programme development efforts with the government in areas of health care and child nutrition. Some of CINI’s core staff have also been involved as members of many policy making bodies such as the Planning Commission, the Ministry of Health and Family Welfare and the Indian Council of Medical Research.
Conclusion
44
Over the years, CINI has worked closely with the community with prevention of malnutrition and disease through behaviour change as the underlying objective of all its activities. In this sense, the ultimate objective of CINI would be achieved when there are no new children being brought to the clinic or the nutrition rehabilitation centre. However, in the context of
poor socio-economic conditions and existing social inequalities in the society, especially those related to gender, behaviour is not always only an outcome of choice but is often a result of circumstance. At the same time it is indeed true, that even within the given constraints the choices made by families are not always in the best interests of the child – due to lack of awareness and poor access to services. This is what CINI is trying to change and there has been slow progress.
The clinic in CINI often sees children from the same family coming back with the same problems. In the emergency ward of CINI, on the day of our visit, there were mothers who had been admitted earlier with their first child and were again admitted with their second or third child again. Therefore, providing treatment and saving lives of children once they are identified is proving to be easier than bringing about sustained change in the community where women and empowered and services are accountable. This is something that senior members in CINI acknowledge and are working towards. For instance in a candid conversation later with Dr. Pal and Dr. De who work at the Centre, they both acknowledged bringing about structural changes in the community is very tough, and that the work of CINI would be most meaningful when it brings about a sustained behaviour change in the community, unlike the work in hospitals where only the disease is treated and not prevented. The challenges therefore remain to be met.
CINI has carried out a significant amount of work in the last three decades becoming one of the leading organisations in the country working on child malnutrition. The Nutrition Rehabilitation Centre set up by CINI was the first in the country and is still the only NRC in the state of West Bengal, in spite of this being one of the low performers on child health and nutrition in India. NRC as a model for treatment of severely malnourished is now beginning to make an entry into public policy in India. The CINI model has many lessons to offer on not just the running of an NRC but also how it has to be made part of a comprehensive approach to child health and nutrition to have sustainable change. While CINI has learnt this lesson over time by being responsive to the community and listening to its target groups, others can learn from the CINI experience.
45
Every Child in School and Learning Well Pratham (Pratham Mumbai Education Initiative)
Introduction
Pratham is one of the leading organisations working on primary education in India. It was started in 1994 by Dr. Madhav Chavan and Ms. Farida Lambay in the slums of Mumbai to work towards universalising primary education. Given this formidable task, Pratham recognised from the very beginning its mission as “Every Child in School and Learning Well”. Pratham started its activities in Mumbai and by 2002-03 had expanded its work in 43 cities across the country. Since 2003, Pratham also began work in the rural areas and by 2006 had active participation in 160 districts of the country. Pratham has from time to time undertaken new challenges. Among its many initiatives, Pratham runs balwadis in slums, organises bridge schools, has developed an accelerated learning method, and provides scholarships to children from weaker sections of the society.
The inception of the Pratham Mumbai Education Initiative can be traced to a study “Rapid Appraisal of the Status of Basic Education in Mumbai”, commissioned by the UNICEF in 1993. The results of the study contradicted the general perception of the teachers and officials that parents in the slums do not value education. In interviews with over 4000 slum dwelling families, it was found that though parents were keen to admit their children in school; in general they felt that the teaching in municipal schools was ineffective. Lack of pre-school education was considered, by this report, to be one of the primary reasons that led to poor status of primary education in Mumbai.
To further test the waters, a survey was conducted in early 1994 to evaluate the status of schools in the city in terms of infrastructure and sanitation. Over 350 physicians from the Indian Medical Council, the Indian Association of Paediatrics and the National Integrated Medical Association visited nearly 900 municipal schools to inspect the premises. 75 percent of the schools were rated “good” by the surveyors, which helped in winning the trust of the
46
municipal corporations and helped forge a mutual relationship with the government (Chavan M, 2000). This laid the foundation for Pratham to enter into the arena of pre-school education and marked the beginning of the organisation. UNICEF committed the seed money of Rs. 6,00,000 for the next three years for Pratham to establish its work. Starting from there, Pratham today has traversed a long path. During the year 2006-2007 Pratham received donations amounting to Rs. 426.7 million (Rs. 42.67 crores); conducted urban and rural programmes in 18 states; directly served over 500,000 children in urban areas, and impacted learning levels of close to 4 million children in the rural areas (Pratham, 2007).
The work of the organisation has grown by leaps and it has made effective interventions to deal with the various gaps in the universalisation of primary education in India.
Emergence of Pratham Balwadis in Mumbai26
Pratham’s pre-school work began soon after the survey on the status of schools was completed. The activity was initiated by reviving a programme called Vasantik Varga, which was run in the late seventies as a joint programme of the Nirmala Niketan College of Social Work and the Municipal Corporation of Mumbai. In the Vasantik Varga programme of Pratham, classes were conducted during summer vacations in April and May in order to prepare children for the formal school starting in June. In 1994, out of 1,00,000 children who joined grade I in school, 5,000 were from the Vasantik Varga programme of Pratham. It was at this time that Pratham became aware of the Balwadi Programme run by the Municipal Corporation under the supervision of Community Development Officers. The inadequacy of the outreach of this programme compelled Pratham to initiate Pratham Balwadis across the slums in Mumbai.
Pratham Balwadis
With the underlying principle that universalisation of pre-school education is a stepping stone to universalisation of primary education, Pratham set up balwadis in the slums of Mumbai which focussed exclusively on pre-school education. Pratham believes that pre-school education is instrumental in ensuring higher enrolment, lower dropout rates, better attendance and improved academic performance of the child. In the balwadi, children learn the alphabet and numbers through rhymes and games, and also learn personal and social skills. The balwadi programme sharpens their motor, cognitive and language skills and cultivates creativity in them.
47
The Pratham balwadis are run by balwadi teachers who are generally women from within the community who have studied at least till the 8th standard. The balwadi teachers usually come from similar circumstances as the children themselves. When Pratham began the balwadis one of the fundamental issues that had to be resolved was that of finding the space for running the balwadis. This was also a constraint to upscale the programme across the city. It was, therefore, decided to conduct the balwadis in spaces available within the community
26 This section is based on field visits, interviews with Pratham staff and material available on the Pratham website www.pratham.org
such as places of worship, social centres, and offices of various social organisations, political parties, and residential premises.
Space is therefore provided within the community and the rent for the space is paid by the balwadi teacher. A nominal fee of Rs. 30 per child is charged by the teacher, but in case a parent is not able to pay the fees, the child is not to be turned away by the balwadi teacher and is admitted into the balwadi. The teacher also gets Rs.500 as an honorarium from Pratham. The balwadi teacher can conduct two separate balwadis everyday in different time slots if the number of children exceeds 30. Pratham trains teachers and also provides teaching
48
Visits to Pratham Balwadis in Mumbai
The balwadis visited in different locations of Mumbai told a similar story. All the visits were unannounced, but the attendance in each balwadi was good. The number of boys and girls enrolled in the register maintained in the balwadi and present at the time of the visit was almost equal. In each of the areas visited, there was one Pratham balwadi and 2 - 4 ICDS anganwadis. The balwadi teachers invariably said that parents preferred sending their children to her balwadi as compared to the anganwadis primarily because of higher emphasis on pre-school learning at her centre. The teachers underwent regular training and each of them showed competence in pre-school teaching and managing the children.
The children carry their own lunch boxes and water bottles in Pratham balwadis. The teachers have made it compulsory for the children to bring chapatti-bhaji for lunch, instead of biscuits or other snacks. The children are given iron supplements after they finish lunch.
All the children present in different centres were dressed well and looked smart. They were very active, mingled easily with visitors, were friendly with each other and were playful. They recited poems in Marathi and Hindi. The children are from within the basti only and their parents are mostly daily wagers, factory workers and housemaids.
Parents Teacher meetings are held every month in all the balwadis that we visited. The parents who we met felt that education was the most important aspect and valued the Pratham balwadis for this. One of the balwadi teachers in a cluster in Kandivali, North West Mumbai felt that literacy among the slum children was very vital and therefore balwadis played a very important role. She has been running the balwadi for the last 12 years and cited examples of children from her balwadi. One of the boys from her balwadi has finished his B. Com and is currently working with the ICICI Bank. Many girls from the basti are working as teachers in Satara, a district in Maharashtra. A deaf and mute child in the basti was given special attention by the balwadi teacher and is now studying in class X.
At the time of the interview for admission in the school, the parents are asked specifically if their child went to the balwadi. Children from these balwadis go to government or private schools. Balwadi teacher calls for a meeting in March and keeps a record of the children going to school in June. Private teachers and parents have come and said that the balwadi children who go to the school perform much better.
In Tanaji Nagar basti in Malad, the Pratham balwadi has been running for the last 12 years. It is run in the Mandal room and the balwadi teacher pays a rent of Rs. 300 a month. The balwadi is conducted in two shifts, one in the morning from 11 to 1:30 p.m. and second in the afternoon from 1:30 to 4:30 p.m. There are a total of 40 children and each one pays Rs. 30 a month. The children are divided on the basis of their age. In the morning, smaller kids of 3 – 4 years of age come and in the afternoon, older children come. The children played, sang and danced with their teacher. They were very enthusiastic and were reciting poems one after the other without being prodded. Three ICDS anganwadis have recently been set up in the basti, but parents prefer to send their children to the Pratham balwadi.
and learning material to the balwadi teachers. The teachers are also empowered as respected members of the community.
The pre-school education model of Pratham is a low cost model, offering even the poorest communities an opportunity to educate their children. It is a community based pre-school provision model and the low cost is achieved by tapping into unutilised resources in terms of infrastructure, staff and community involvement. The Pratham model was kept low cost so that it could be replicated and upscaled across the city of Mumbai. As stated by Madhav Chavan, one of the co-founders of Pratham Mumbai Education Initiative, in an interview of a national magazine, “We were accused of talking only numbers, not quality. But in a city where in 1993, 2 lakh children were not in school, scale was important. It is not enough to make a model and leave it to the government to scale it up. You have to go beyond that to make a difference.” (Khatri D, 2008)
In 1995, there were 200 Pratham balwadis catering to 4000 pre-school age children. By 1996, the number had risen to 350, reaching 7000 children between the ages of three and five. By 1998, the pre-school network had expanded extensively across the city; through approximately 3000 balwadis, close to 55,000 children had access to affordable early childhood education (Banerjee R, 2005). Such rapid increase in the number of Pratham balwadis contributed to establishing the need for pre-school. With the government now setting up 4500 anganwadis under the Integrated Child Development Scheme in Mumbai, Pratham Balwadis across the four zones in Mumbai have reduced in number to 300. This shrinking of the number of balwadis run by Pratham indicates a shift in the mandate of the organisation from that of being a service provider to being a facilitator. Since the ICDS services are expanding and are being universalised in both urban and rural areas, Pratham has decided not to run its own balwadis, a need that was stronger when the programme began. Now, what is required is to ensure that the anganwadis set up under the ICDS function and provide the services that Pratham balwadis used to.
Training Balwadi teachers
In the mid 1990s, support in training community workers in pre-school programme came from established institutions in Mumbai such as Mobile Crèches, SNDT University, Sadhana Training College and others. As the network of Pratham balwadis grew, external training support became insufficient. Also, these training programmes did not cater to the specific needs of Pratham balwadis which, given the low cost model, ran in smaller spaces, there were constraints on availability of teaching learning materials and children were not regular and often discontinued coming to the balwadis in the middle of the year. This established the need for an in-house training. A curriculum team was constituted in 1997 with experts from within and outside Pratham. The team developed different modules for the balwadi training programme. The content was more relevant to Pratham balwadi needs – issues such as maximum use of cramped space was discussed, use of low budget recycled teaching-learning materials such as straws, beads, clay were developed.
49
A one-time training was not sufficient and a need was felt to build in adequate and continuous support to the network of balwadi teachers. The work of supervisors diversified
into trainer-monitors, and now they were required to follow through the content of the training, and visit balwadis thereafter to support and show how activities were to be done, how materials were to be used and how time was to be effectively organised. The capacity building of trainer-monitors therefore became very important.
Training is one of the core competencies of Pratham, based on its work and experience in training balwadi instructors for over a decade now. In 2006-07, a survey was conducted in Pratham and non-Pratham areas in Mumbai to gauge people’s evaluation of pre-school education and if they felt that training in preschool education is important. A majority of the people interviewed felt that training was important and were willing to pay fees for such a training course. Based on these findings, the curriculum was redesigned and a Praman Patra (certificate) course was launched for women. The course is imparted over a period of six months and a nominal fee of Rs. 2000 is charged. The courses are conducted in Hindi, Marathi and Urdu. Some of the trained balwadi instructors have found jobs in ICDS anganwadis; some teach in private pre-school centres as well.
Pratham Health
Pratham initiated work in the area of health care in August 1999 in Mumbai for the children of the balwadis. A pilot study of 250 children was conducted to assess the health standards of children. The study results indicated that over 90 percent children were anaemic, over 70 percent were malnourished and over 50 percent suffered from vitamin deficiency27. Based on these findings, Pratham started a programme of micronutrient intervention for children in the Pratham balwadis. In June 2001, a separate organisation called Niramaya Health Foundation was established to expand and manage the health activities of the Pratham Mumbai Education Initiative. Niramaya is a non profit, non government organisation providing community based health services in the slums of Mumbai. It has over the years expanded its focus from primarily preschool children to one that covers different aspects of community health.
Anaemia Prevention and Control Programme
An anaemia prevention and control programme is implemented in the Pratham balwadis. This covers the children studying in other NGO balwadis as well. The programme aims to significantly reduce the serious problem of nutritional anaemia in young children in the slums of Mumbai. The Programme offers the following health related services:
- Provides iron supplementation and regular de-worming to the balwadi children and their mothers
- Growth charts are maintained for all the children in the balwadis - Annual medical check up of the children - Cooking demonstrations of nutritious recipes
50
- Health education about Anaemia, Worm Infestation and Nutritional Powder supplementation
- Covers younger siblings of the children as well as adolescent girls in the neighbourhood under the programme.
27 For details see Pratham website www.pratham.org/ourwork/health.php
Other programmes of Pratham28
Community Libraries
Books are provided to children from low-income families in their regional language as well as in English. A conscious effort is made to provide interesting, colourful and stimulating books to the children. The libraries are conducted in schools and other community spaces and usually young men and women from within the community are encouraged to take care of the books and carry out the functions of the library. In 2007-08 more than 600,000 children borrowed books from over 4,600 libraries in 13 states.
Remedial Learning Programme
Pratham conducts remedial learning programmes to develop and improve reading, writing and arithmetic skills among children of age 6 and above. These classes cover children who are enrolled in school but are not keeping up with their grade level and children who are not enrolled in schools in urban settlements.
Computer assisted learning centres
Pratham has set up centres in schools and communities where children and youth from low income families are provided access to computers. Computers are also used to improve the students’ learning in subjects like math, science, history and geography. It is observed that attendance is better in schools with computer centres. In the year 2007-08, 68,684 children learnt computers in 187 labs across 7 states.
Pratham’s Council for Vulnerable Children
It reaches out to child labourers, street children and children rescued from bonded labour. Pratham shelters provide residential care and education for children at risk who do not have homes to go to.
Pratham Books
Pratham Books, a non-profit trust, was established in 2004 with the mission to make books available and affordable for every child in India. Pratham Books publishes books in 11 Indian languages. The stories are written by Indian authors and are embedded in Indian culture and people. All the books are designed to look colourful and attractive and are priced between Rs. 10 and Rs. 25. Pratham Books has developed and published over 125 titles in the 3 years of its existence. In 2006-07 alone, it printed and sold over 1 million books and 2 million story cards.
51
28 This section mainly draws from the information available at www.pratham.org
Read India
Pratham's flagship programme Read India works with governments, communities and parents to improve the reading, writing and arithmetic skills of children aged 6-14 years. Read India was launched nationally in May 2007 in response to the insight that although over 94 percent of children in this age group were enrolled in school, less than half could read fluently or do arithmetic even by grade 5. Read India has reached over 21 million children in the last year.
Annual Status of Education Report
Since 2005, Pratham has facilitated the Annual Status of Education Report (ASER), a nationwide survey of children’s basic learning levels in India. All rural districts are covered by the survey. Local groups conduct the ASER survey, disseminate the findings and look for ways to improve the education situation in the district. Over 700,000 children across more than 16,000 villages were surveyed in 2008. ASER has emerged as a powerful advocacy tool and is impacting education policy in India by highlighting the quality of education imparted in schools.
Conclusion
Pratham is one of the pioneering organisations working in the country towards universalising primary education. Preschool education is seen by them as a crucial component towards achieving this goal. When Pratham began its activities it also found that this was an area where there was the least work done, especially in Mumbai city. At the time Pratham began the outreach of the ICDS and anganwadi centres was also very low. There were balwadis run by Muncipal Corporation but these were also few and far between. Pratham therefore decided to run its own balwadi centres in the communities to provide preschool education for children in the age group of 3 to 6. This was done through balwadi teachers selected from the community who were given intensive training and further support through monitoring and supervision.
Through this experience Pratham has established the importance of preschool education, shown that if good quality services are provided then the community will utilise it. Pratham now has an expertise in training of preschool teachers and development of methods and materials that can be used to run low cost balwadis. This forms an important resource for government and non-government initiatives involved in provision of preschool education, across the country. The key mandate of the organisation is now training and advocacy. With significant experience in training balwadi teachers, designing teaching aids and course modules, Pratham is now collaborating with the government to train anganwadi workers for the pre-school education component in the anganwadis.
52
The last few years have marked a change in the role of the organisation. Started as an initiative to reach out to all the children in the slums of Mumbai to secure pre-school education for all, the organisation today has made a shift from being a service provider to that of a facilitator. Ms. Lambay, one of the co-founders of the Pratham Mumbai Education Initiative, says that the balwadi programme of Pratham was seen as a means to an end in its
mission of “Every child in school and learning well”29. As the number of anganwadis is rising, the number of Pratham balwadis in Mumbai has reduced to 300.
Early Childhood Education (ECE) is not yet a fundamental right for the children in India; and the provision of ECE in the public sector is very limited. This, Pratham experience shows is a tremendous gap in universalising primary education in India. Pratham, foresees its own role in working towards strengthening pre-school education in India as a right of every child.
53
29 Interview with Ms. Lambay
Child Care for ALL – Mobile Crèches
Mobile Crèches was started in the year 1969 in Delhi at a construction site in Raj Ghat, where there was construction going on for the Centenary celebrations of Mahatma Gandhi. Meena Mahadevan, a Gandhian and the founder of Mobile Crèches, noticed young children around the construction sites sitting in the hot sun, exposed to the heat and dust of the construction site while their parents worked. She set up a tent and organised for a child care worker to take care of these children and this was the beginning of the organisation Mobile Crèches (Khalakdina M, 1998). Over the last 40 years Mobile Crèches has grown into an organisation that not only provides pioneering early child care and development services in construction sites but is one of the leading advocates for the rights of young children in the country.
In this journey from being a service provider to being a champion of the rights of young children, the programmes and activities of the Mobile Crèches have grown both in scale and content. For each of the goals that the organisation has set itself, different strategies are used without losing sight of the mission, which is to achieve the well-being of the young child, irrespective of their economic and social background.
54
Mobile Crèches’ Vision
A just and caring world which enables young children of marginalised and mobile populations to develop into competent and confident individuals. Mobile Crèches’ Work
Crèches and Daycare Centres to care for children at construction sites and slums in Delhi and adjoining states.
Training and Advocacy to involve communities, train childcare workers and make governments accountable. Mobile Crèches’ Mission
To ensure holistic development of young children with a special focus on birth to 3 years To work with partners and communities to enable them to develop crèche and childcare arrangements To champion the cause of children's rights at all levels of civil society Source: www.mobilecreches.org
While continuing to provide day care services in construction sites in and around Delhi, Mobile Crèches is also working intensively with slum settlements in mobilising communities in support of the rights of the young child, working with other organisations in building their capacities to provide early child care services, building alliances for the advocacy of the rights of the young child, and also participating in state and national level forums as a voice with a strong grassroots experience to inform and influence policy on early child care and development.
The work of Mobile Crèches can broadly be divided into two categories – one is the child care services provided in construction sites (and also some slums) and the other the advocacy programme where the work is with the entire community, where Mobile Crèches is not a service provider but a facilitator and mobiliser. These roles of service provider, facilitator and mobiliser also overlap sometimes.
Migrant Construction Labour and Child Care
Delhi being a growing city has been witnessing a construction boom for the last many years. Most of the construction is carried out by workers who are migrant labour who have come to Delhi on the lookout for better opportunities. Many of these workers have come out of their villages due to “push” factors such as agrarian distress, lack of employment opportunities, poverty and hunger. Once they come to the city, these people are vulnerable because they lack community support and are also seen by the middle classes and the governments as ‘illegitimate’ populations. They are denied of any public services and programmes such as rations, schools or anganwadi centres. Usually construction workers live at the construction sites in temporary structures that have been built by the builders. These structures have tin or asbestos sheets for roofs and are so low that an adult cannot even stand up straight inside the house. They are not serviced by any utilities such as water supply, drainage or sanitation facilities. Once the construction is completed the ‘camp’ is wound up and the workers move to another construction site or sometimes back to their villages. This is a very mobile population which requires services that are specially designed for their special needs.
Most government programmes however are designed for stable populations who have homes and live in the same address for a considerable amount of time. Therefore the ration card becomes also a proof of address, the school demands an address or identity proof and the anganwadi is open only to legitimate “residents” of the area. On the other hand people migrate as construction workers with their entire families and are able to make ends meet only when both the husband and the wife work. As a result children drop out of school, do not get admission anywhere because of the temporary nature of their existence. Young children are deprived of health, immunisation and nutrition services.
55
It is not rare to see many young children playing around in the dust and grime of a construction site exposed to the sun and the dangers of being around a structure that is yet to be completely made. Since mothers are also busy at work, these children lack adult supervision, are exposed to harmful conditions all day and in cases where they are left at home it is usually at the cost of the older sibling missing out on her schooling and childhood. These young children also lack access to immunisation and health care services, adequate
breastfeeding, proper nutrition and pre-school education. It is precisely for these children that the Mobile Crèches started running crèches in 1969. Crèches are seen not just as a day care arrangement that allows the mother to work but also an important intervention in protecting and promoting the health, nutrition and development of the young child.
Although the Government of India has no specific programme for setting up crèches at worksites, the Construction Workers Act stipulates that crèches must be run by the builders at all construction sites as one of the requirements of steps to be undertaken for workers’ welfare. But it is seen that this is not done in most places. Mobile Crèches intervenes in construction sites and in partnership with the builders and the workers sets up crèches that take care of all the children living in the camps of the construction site. The crèches take care of children who are few months old to those who are 12 years old and are school drop outs because of their parents’ migration.
Crèches at Construction Sites30
A typical crèche in a construction site run by the Mobile Crèches has three sections to it – one for children less than three years of age, a balwadi for the 3 to 6 years old and a non-formal education centre for the 6 – 12 year olds. The space for these crèches is normally provided by the builders/contractors. It is usually a brick building with three rooms and some space in the front with a compound wall and tin roof. The builders/contractors are also made to provide water and electricity for this space. Further, Mobile Crèches urges them to contribute at least in part to the running of the crèche (by contributing towards food and material costs and even towards the salaries of some of the crèche workers). This they do by reminding them that this is not an act of charity but something that must be doing as part of their obligation to the workers and also in compliance with the laws. Provision of child care facilities is one of the least priorities of the builders/contractors and something that very few do on their own without any pressure. It takes a lot of persuasion, cajoling and pressure to get a builder to agree to set up crèches and provide the required infrastructure for this.
Once the crèche is set up, the Mobile Crèches ensures that these are of good quality without compromising on any of the needs of the child. Health care is provided for all the children with regular health check-ups and immunisation organised in the crèches. The growth of children is regularly monitored and malnourished children are given extra food and care. The crèche workers negotiate with the builders and supervisors to ensure that lactating mothers are allowed to take breaks once in a few hours to come and breastfeed their child. Nutrition is an important component in the crèche. The young children are provided with cereal and milk and the older children are given a mix of rice, lentils and vegetables. Malnourished children are also given eggs. The children are also trained to wash their hands before and after the meal.
56
Right from the beginning, learning and stimulation also forms an important component of the crèche programme. Age appropriate toys and books are provided for the children. In the balwadi the teacher has more structured activities like singing, story-telling and so on to
30 Based on visits to crèches and interviews with Mobile Crèches staff
prepare the children for school. This aspect of the programme is also constantly reviewed with improvements being made regularly. For instance, when Mobile Crèches found out that while children from their crèches were good at verbal communication skills, confidence and so on, they were weak in writing activities; ‘paper-pencil’ activities were introduced in all the crèches, at the same time taking care to ensure that the learning remains joyful, non-formal and through play as is appropriate for this age group.
Mobile Crèches also takes care to ensure that the worker-pupil ratio is kept at the optimum and is not something that is compromised upon to cut costs. It is recognised that child care is a specialised activity which requires people who are adequately trained for the job. It has also started identifying women from among the construction workers’ families and training them to be assistants in the crèches. The builders are often made to agree to pay for these workers. After a short training these workers are mainly trained on-site by the trained Mobile Crèches crèche workers and the supervisory staff that regularly visits the centres.
A major handicap that this programme faces is the very nature of construction work. Being transitory in nature the families live in the construction site on an average for six months or so. This period is sometimes not long enough to bring about changes in children’s nutrition status or their learning levels. Further, it is not possible for Mobile Crèches to move wherever the labourers move because not all of them move together, and if they move to the site of another contractor then the entire process of sensitising the builders and getting them to agree to their contribution has to be started all over again. The result of this process is not always predictable or positive.
However, in order to maintain some continuity, Mobile Crèches has introduced a system of giving the children health cards with details of immunisation, history of illness and malnutrition etc. recorded in them. These cards are regularly updated and given to the family when they are moving away from the construction sites. It is hoped that whoever is providing services in the place they move to will be able to use the information provided in these cards for continuing care for these children. It is not rare to find some children in the crèches run by Mobile Crèches itself who have cards that have been issued in an earlier construction site. However, it does remain a problem that children do not remain in the care of Mobile Crèches for sufficiently long periods of time.
57
In construction sites as well, Mobile Crèches begins with mass media and sensitisation activities to convince the parents to send their children to the crèche. Although the need is great parents are not immediately trusting of a crèche and are vary of its utility. Therefore community meetings are held, street theatre is performed and door to door visits are made to motivate parents to send their children to the crèche. Contact with the parents is maintained to also educate them on child care practices such as breastfeeding, ante natal care, immunisation, complementary feeding, and so on.
The response of the builders/contractors varies quite a bit. But whatever maybe their response, Mobile Crèches is clear that it is their obligation towards the workers to proved child care services at the construction sites. Therefore Mobile Crèches will not open crèches unless the builders agree to make some minimum contributions to the crèche in the form of
space, infrastructure and/or some of the running costs of the crèche. The ideal situation is one where the builders contribute to the entire costs of the crèche with Mobile Crèches providing technical assistance in the form of training and supervision. Even this they would like to slowly handover to the builders/contractors.
Community Mobilisation31
The programme of Mobile Crèches in slums and more settled populations has a different strategy and is primarily based on community mobilisation. In the beginning, Mobile Crèches ran child care centres (balwadis) in some slums as well. But as the ICDS programme expanded (Mobile Crèches has been a prominent member of the national campaign for universalisation for ICDS) it was felt that its own role should be modified into one that activates the anganwadis and ensures that they function. In order to not set up parallel structures to the government but rather strengthen existing government structures, the advocacy and community mobilisation programme of the Mobile Crèches was started. Also a basic understanding of the advocacy programme is that a programme for early child care and development such as the ICDS is doomed to fail unless the community actively participates and feels the need for such a programme. It is seen that in different parts of the country in spite of expanding number of anganwadis these are not functioning and one of the main reasons for this is the lack of community participation.
As Mobile Crèches puts it, “Services for the all round care and development of the young child are still not an articulated demand in most communities, both in urban and rural areas. However, anyone working in the field knows how important this age group is for the health and well being of the entire future population and how critical it is for working mothers to have some sort of institutionalised child care support. Communities have to be sensitised to the needs of the young child and the mother.” (Mobile Crèches 2008)
Work in any new area therefore starts with efforts towards preparing the community to understand the learning and development needs of the young child. Towards this various mobilisation and sensitisation strategies such as street plays, puppets, folk art, bal melas, community meetings etc. are used. Although sensitising communities on the issue of early child care is a slow and time-taking process it is felt that it is a process worth investing in as it is more sustainable and can result in lasting change.
58
The programme is also flexible and changes according to local need (and also the history of Mobile Crèches intervention in that community). For instance, the strategies may be different in slums/resettlement colonies where Mobile Crèches has in the past run balwadis and in places where it is making a new entry. Whatever be the strategy, the objective is to “mobilise the community to put the young child on their agenda, change child-rearing practices and access/demand services from the government.”(Mobile Crèches 2008)
Self-help groups (SHGs) of women have been formed in some places to help women have some savings and access to micro-finance. This has been seen as an activity that gives Mobile
31 Based on field visits, interviews with staff and annual reports
Crèches an entry point to talk to women about issues related to early child care. Over time the focus of support from the organisation shifts to early child development, while the other components of the SHG are taken over by the women themselves. Similarly, in one slum where most residents are construction workers they have been linked to a union of construction workers thereby giving them access to many benefits such as registration, insurance and so on. Therefore, even while the focus is on early child care and development, some other pressing issues of the community have to be taken up from time to time, both because the context in which the young child lives cannot be ignored and also these activities contribute towards the acceptance and trust the community has in the organisation.
59
Basti Vikas Samiti – CBO in Kirby Place*
Basti Vikas Samiti (BVS) is one such CBO that has been formed in Kirby Place in Delhi. In the initial years of work in Kirby Place, Mobile Crèches undertook many community mobilisation activities including formation of SHGs, registration of workers with unions, setting up of balwadis and so on. Once the community was sensitised, Mobile Crèches suggested to them that they should start thinking for themselves how they wanted to take the work forward and that Mobile Crèches was not going to be there forever. The people said that this programme should be continued and decided to form their own CBO (Community Based Organisation) called Basti Vikas Samiti in the year 2006.
The Basti Vikas Samiti has 31 members. These include youth, men and women. The regular activities of the Basti Vikas Samiti are conducted by a co-ordination team. Mobile Crèches gives training support to the BVS. The Mobile Crèches has also helped the Basti Vikas Samiti form networks with other NGOs working in Delhi. The members of BVS now directly negotiate with the Cantonment Board, the nearby government hospital, government school etc. to get services for residents of its area. The BVS is now well established and also is recognised by government institutions as a credible organisation of the community. During the Cantonment Board elections the candidates visited the slum. The counsellor who has been elected gives Rs.1000 a month towards contribution to the salary of the balwadi teacher to BVS. He has been regularly contributing since the last nine months.
The BVS organised a campaign to demand for an anganwadi under the provisions of the Supreme Court order. An application with 250 signatures from the community was submitted at the Department of Social Welfare of the Delhi Government asking for an anganwadi to be set up at Kirby Place. When they did not get the anganwadi in three months as directed in the Supreme Court order they applied under the Right to Information Act for details on the status of their application. There was no response in 6-7 months, so the BVS met the MLA and the MLA also wrote to the department. Then another application under the RTI when they got a response that an anganwadi will be opened soon as the Government of Delhi has been recently sanctioned about 500 new anganwadis by the Government of India.
The BVS is part of the Neenv – FORCES network for children under six in Delhi. They say that what motivates them is the recognition they get from people. The BVS currently mainly runs on the basis of a membership fee which is Rs. 100 upon registration and then Rs. 60 every year for renewal.
– Based on field visit and interview with members of BVS in December 2008
In areas where there are no anganwadi centres of the ICDS programme, the community is mobilised to demand for one using the provision of “anganwadi-on-demand”32 provided under a judgement of the Supreme Court. When these demands are not met in time, they are followed up with groups from the community meeting the local authorities, elected representatives and so on. As a result of these efforts 53 anganwadis in Madanpur Khaddar, 2 in Shadipur and 4 in Noida have been sanctioned and operationalised33. Further, in places where there is an active anganwadi the community is prepared to monitor the functioning of the same. At the same time support is provided to the anganwadi worker in terms of training and suggesting ways in which she can improve the running of the centre.
To consolidate all these efforts and also to ensure sustainability, Mobile Crèches actively encourages the formation of Community Based Organisations (CBOs) by residents in the slums they are working in. Initially they are given a lot of guidance and support by Mobile Crèches, and they slowly grow into groups that are independently able to advocate for health, nutrition and education services for the children of their locality.
Focussed Intervention
A few years back Mobile Crèches started a focussed intervention programme in the slums where it is working. In this programme a baseline survey was first conducted by the MC staff and the facilitators. The local CBOs/SHGs were also involved in this. After this trained counsellors visited the families of the pregnant women and young children regularly to motivate them to get their immunisations, routine checkups done and also to counsel them on proper nutrition for the mother and the child. The number of visits to each family depends on the response and the need of the family. On an average each family was visited twice a month.
Growth monitoring was done for children under 3 years of age on a monthly basis while the 3 to 6 year olds were weighed once in three months. The weighing was done in a common place on a fixed day and the children who had been left out were then weighed at home. Then the mothers were accordingly counselled on feeding their children. They were even told about simple recipes that they could make at home with locally available foods and were motivated to do this.
After 18 months of this intervention an assessment survey was conducted and it was found that there was a good improvement in many indicators. For instance in Madanpur Khadar it was seen that birth registration increased from 26% to 100%; colostrum feeding from 46% to 70% and complete immunisation from 47% to 87%. In Shadipur institutional deliveries increased from 2% to 20% and in Kirby Place from 44% to 50%. Encouraged by these
60
32 The Supreme Court in the case PUCL vs. Union of India, issued an order in December 2006 directing all governments to provide for an anganwadi (‘anganwadi on demand’) in rural habitations and urban slums if there is such a demand from the community and there are at least 40 children under six in the area. The anganwadi is to be set up within three months of receipt of such a demand.
33 From Mobile Crèches’Report submitted to Bernard van Leer Foundation, 2008
positive results Mobile Crèches has decided to expand its focussed intervention programme to more families (Mobile Crèches 2008)34.
Conclusion
Mobile Crèches has been successful in not only highlighting the needs of children under six but also establishing a model of provision of ECCD which is comprehensive and meets the health, nutrition and development needs of the child. Mobile Crèches has been constantly modifying its programme and strategies based on what it learns from the field. Over the years, there has been a shift in Mobile Crèches’ approach towards its work from a charity mode to that of being a facilitator. Mobile Crèches now sees itself as having to sensitise all stakeholders, including the contractors and the community, towards making rights of young children people’s agenda. For this, builders, builder foundations and construction workers welfare board are being proactively targeted. Further, more and more of the resources of the organisation are being invested in community mobilisation in the slums.
This experience can inform the vision of public policy for children under six in the country. Some basic aspects of the programme such as the importance of community participation, basic infrastructure and facilities for children, and training and capacity building of the crèche/child care workers can be seen as being non-negotiable components of any programme for children under six. In the words of Mridula Bajaj, the Director of Mobile Crèches, “What the work is trying to do is to change perspectives – bring about a change in people’s perception about young children. Though the whole world knows it’s critical and everything is dependent on these kids, they are treated like “sub human beings”. As citizens in their own right, young children should get ECCD services. This is the mechanism to provide equity and give them a good start.”35
61
34 Also see Mobile Crèches (2005, 2008a and 2008b)
35 Interview with Mridula Bajaj
Child Care for Working Mothers – SEWA (Self Employed Women’s Association, Gujarat)
Background
Most women in India work – they work on the farms, in factories, in the fields and in homes, both for others earning a wage or for their own families doing unpaid labour. Of all the working women in India about 94% are working in the informal sector. They are outside most laws that guarantee workers’ rights and social security benefits. The few maternity benefits available to women workers in India are available for those working in the organised sector, which is a very small minority of all working women.
In order to organise women working in the unorganised sector to collectively fight for their rights, SEWA (Self-Employed Women’s Association) was set up. SEWA is India’s first trade union of women workers working in the informal economy. Established in Gujarat in 1972 by Ela Bhatt, SEWA has now expanded to other states in the country and has also supported the setting up of women’s trade unions in eight other countries. Currently SEWA has a membership of about 1 million women, including about 500,000 from different districts of Gujarat making it the biggest union of women workers in the country (SEWA website).
62
SEWA defines its objectives, broadly, as full employment and self reliance for all its members. Self Reliance is seen to be achieved through full employment which includes work and income security, food security and social security. The latter includes at least child care, health care, insurance, pension and shelter. Therefore, child care is seen as one of the components required to achieve the goal of full employment that SEWA has set itself for its members36.
36 This and the following section is based on information from SEWA’s brochures and website, www.sewa.org
SEWA’s Services
SEWA follows simultaneously the strategies of ‘struggle and ‘development’. Therefore while it pursues unionising activities to address constraints and demand change, it also makes development interventions to promote alternative economic opportunities. In order to pursue these different strategies SEWA organises its membership into “trade organisations and cooperatives; provides services of various kinds; advocates for change in the wider policy environment; and builds institutions to manage and sustain its activities”. The SEWA family therefore comprises of various institutions which fall either into the category of unions or cooperatives.
The membership based organisations of the SEWA family are SEWA Union (Swashree Mahila SEWA Sangh), SEWA Bank, SEWA Cooperative Federation (Gujarat Mahila SEWA Cooperative Federation), SEWA District Associations. And the service units are SEWA Social Security which provides health care, child care and insurance services, SEWA Academy is a centre for education, communication, SEWA Marketing (Gram Haat and Trade Facilitation Centre) and SEWA Housing. Another institution which is a part of the SEWA family is the SEWA Bharat which focuses on the development of SEWA organisations in other states based on the experience of SEWA in Gujarat.
All these organisations are managed and led by women. Since SEWA seeks to ensure that essential services are provided through membership-based organisations, the service units also have a democratic membership base. Most notably, SEWA Social Security provides childcare through its childcare cooperatives and health care through its health workers’ and midwives’ cooperatives. Also the insurance scheme developed by SEWA Social Security has been structured to become an insurance cooperative. Similarly SEWA Academy provides communication services through a video cooperative.
Profile of SEWA members
As mentioned earlier SEWA’s members are women working in the unorganised sector, both in rural and urban areas. Among SEWA’s members women are involved in various kinds of work – home-based, in factories and farms; working for daily wages or at piece rate basis. SEWA groups its members into four broad occupational categories as follows:
1. Hawkers and vendors, who sell a range of products including vegetables, fruits and used clothing from baskets, push carts, or small shops;
2. Homebased producers, who stitch garments, make patchwork quilts, roll handmade bidis or incense sticks, prepare snack foods, recycle scrap metal, process agricultural products, produce pottery or make craft items,
63
3. Manual labourers and service providers, who sell their labour (as cartpullers, headloaders, construction workers, or agricultural labourers), or who sell services such as wastepaper picking, laundry services or domestic services and
4. Rural producers including small farmers, milk producers, animal rearers, tree nursery growers, salt farmers and gum collectors.
The members of SEWA are generally very poor. A study conducted on the socio-economic status of SEWA members showed that half of SEWA’s urban members live in households where income per capita is below the US dollar a day poverty line. More than one third lives in households that are above that line, but where the per capita income is below two dollars a day. The rest are only slightly better off (Chen and Snodgrass, 2001). They are mostly from working class castes and tribes.
SEWA and Child Care
In an interview with Mirai Chatterjee, (Co-ordinator of the Social Security programme at SEWA) she mentioned that when they talked to their women members on the services that they require invariably one of the first things they demanded, along with financial services, was child care. However it was seen that there was no existing institutional mechanism providing child care for children of unorganised sector workers. There were a few crèches run by the private sector but these were usually in urban areas and charge high fees and are inaccessible to poor women workers. The ICDS programme of the Government had very little coverage in the beginning and was not designed to provide child care services as it functioned only part time, did not correspond to the work timings of mothers and was not equipped to take care of children less than three years of age. Child care therefore has been an integral part of SEWA’s services to its members right from the beginning.
SEWA’s approach to child care has been one that recognises women’s need to work and for income security. At the same there is a need for critical social security services which allows them the freedom to work and also assures them income security. Child care is one of these services and it has to be provided keeping in mind the needs of the mother.
Women from the community were identified and provided training to run the crèches. Further continued support is given to the crèche workers by the aagewans (leaders) and other supervisory staff who regularly visit the centres and hold meetings with the crèche workers giving them training on-the-job and also monitoring their work. The aagewans also help the crèche workers in their interactions with the community.
SEWA crèches
64
As with most of the services provided by SEWA the crèche services are also managed by co-operatives – two child care co-operatives Sangini and Shaishav have been formed to run the crèches. The SEWA crèche programme is operational in four districts of Gujarat – Ahmedabad, Anand – Kheda, Patan and Surendranagar. Currently there are about 80 crèches being run by SEWA in these four districts.
The crèches run all day, depending on the working hours of the mothers. So while in Ahmedabad the crèche opens at 9am, in Kheda some of the crèches open as early as 6 in the morning because that is when mothers leave to work in the fields. There are about two to
three crèche workers in each crèche, depending on the number of children. There are on an average about 30 – 45 children attending each crèche. There is a schedule of various activities
that are to be conducted in the crèche, including story-telling, painting and drawing, games and so on. Children are fed three times a day. There is a weekly menu that has been prepared after consulting with parents to understand local food habits. At the same time care has been taken to ensure that the food given to the children in the crèches is nutritive in content and meets all the needs of the child. Very young children are also given milk.
The crèches are located close to the homes of the children – either in a building donated by the community or one taken on rent. The crèches usually have a single room – with some having two. There are some cradles for younger children and the rest of the children sit/sleep on the floor. Children from all communities attend the crèches. Documentation by SEWA and also interviews with senior members of SEWA shows that setting up these crèches was not an easy task. Although it was clear that child care is one of the central needs of the women workers who were members of SEWA, it took time for the community to accept the crèches. Mothers did not have the faith that their children will be well taken care of and the whole idea of a crèche was something alien and therefore something that they did not trust.
However, the crèche workers, who were also local women from the same area and same class background, visited the mothers and convinced them that their children will be well taken care of. Slowly as a few children started coming, more and more followed, so much so that people from the neighbouring villages and districts also started arriving at SEWA offices demanding that crèches be started in their area as well.
Parents also contribute a small fee to the crèches. If the parents are too poor and unable to pay, then the crèche worker decides to give them a waiver. However, it was soon realised that running a crèche was an expensive proposition and would always require external support be it from the government, employees, private donors or international organisations. Currently, about 25% of the funds required for running the crèches come from the fees paid by parents and donations from the local community, whereas the rest is covered by grant money. Therefore, although there is a demand for child care services, the lack of funds is a great constraint. Even in the villages/slums where there are existing crèches there are more children outside who want to come in. But the crèche workers have to stop taking children after a point because they are already over-burdened in most places. They therefore try and ensure that they reach out to the poorest and most vulnerable who have no other options for their children.
65
Crèches for Peace
One of the centres visited was in a riot-affected area. Both Hindu and Muslim children used to come to the crèche. This slum witnessed violence and many Muslim families left the slum and went away. The crèche also had to be closed for about six months. Then slowly people started to come back. The SEWA crèche workers and supervisors held joint meetings with both Hindu and Muslim parents, and re-opened the crèche. Children of both communities continue to come here and of the two teachers, one is Hindu and the other is Muslim. It was very touching to visit this crèche and hear their story – it almost felt like these little babies had the potential to unite all communities.
Over the years through experience and learning, the crèches have expanded greatly from just providing custodial care to children so that mothers are free to work to now include services for improvement of health and development of children. SEWA recognises that along with child development, the crèches have a role in increasing subsequent school enrolment of children, especially for girls and reducing the time spent taking care of children or the stress associated with leaving children without proper care or supervision.
Children’s growth is monitored every month and those who are identified as being malnourished are given extra care. They are given extra food, milk and also some vitamin supplements. The SEWA health workers visit the crèches regularly and monitor the health of the children. First aid boxes are available in every crèche and the workers are trained to take care of common illnesses. During the monthly meetings with parents and home visits, the crèche workers also counsel the family on health and nutrition issues.
Similarly a lot of thought goes into the pre-school activities for the children. Crèche workers are regularly trained on using local songs and stories to teach children motor and cognitive skills. SEWA has a technical team that works on all these aspects. The walls in all the crèches are full of teaching learning material – charts, posters, cards etc. which the teachers make and use to teach the children. The walls also displayed the work of the children. In all the crèches visited, children were very active, mostly not very shy and would spontaneously perform in every centre.
The crèche workers have been given special training to identify disabled children. They make special efforts to enrol children with disabilities and are also quite confident of dealing with them. In almost all the crèches we visited the teachers had a story to tell about how by giving good care, food and massage they were able to bring a lot of improvement in children with physical disabilities or developmental delays.
Impact of crèches
SEWA has conducted many studies to understand the impact of the crèches on the women and the children themselves. In the SEWA studies and during field visits mothers reported that the crèche allows them to work more and work with a peace of mind. Even home-based workers leave their children in the crèches because they are able to work better, are more productive and therefore earn more. At the same time the children are not exposed to harmful conditions of the work place and are taken good care of.
66
“In mothers meetings, most of the mothers agreed that the double benefit of more monthly income as a result of being able to work regularly, and of having their young children properly looked after eased much of the burden of their older children. These children could now go to school, and the additional income of the mothers meant that they could afford to purchase school supplies like books and uniforms”, says one of SEWA’s study reports (Chhatterjee M and Macwan J, 1992).
Partnership with ICDS
For a period of about ten years SEWA worked in partnership with the ICDS. They joined
during a phase where the Government of Gujarat decided to hand over the running of anganwadi centres to NGOs in order to improve quality. Soon SEWA found that it was impossible to run the anganwadi within the existing norms of the government. The centres were supposed to run only for four hours a day and did not match the working hours of the mother, and so the mothers preferred to take the children along with them to work instead. Another major drawback of the ICDS was that it had no services for children under three and it was these children who actually required the services. Also the government was very stringent with its rules about the qualifications required for anganwadi teacher insisting that she must be at least a high school graduate. SEWA on the other hand had workers who had only completed primary school or even illiterate but with training did good work. Further they had the advantage of being from the same community and greater acceptance among the parents – it was also seen that they were able to be naturally affectionate towards the children. These things were negotiated with the government, and the government finally agreed to relax these norms. SEWA raised further resources for the anganwadis and were able to provide better food and pre-school education in the anganwadi centres. Unfortunately, due to some issues with the government this partnership had to be closed in 2007.
67
Impact of SEWA Child Care Services
SEWA has conducted studies to measure the impact of its crèche services. In three studies conducted by SEWA, significant shares of SEWA members who enrol their children in SEWA-run day care centres reported improvements in their children's development: in terms of general appearance and cleanliness, socialisation, and child development skills. Children enrolled in SEWA day care centres had a far higher rate of immunisation but also a slightly higher mortality rate - than children who were not enrolled in a day care centre. All three child care studies noted that many mothers reported another benefit of putting their children in day care: namely, reduction of the stress and anxiety of having to leave their children without adequate care and supervision while they work.
Two-thirds (66%) of SEWA's urban members who left their children in a SEWA child care centre reported that their child was better able now, compared to the past, to get along with others (Jhabvala and Bali 1993). Over two-thirds (66%) of the mothers who left their children in a rural SEWA child care centre reported that their children were cleverer and more healthy than in the past; and over 40 per cent (42%) reported that their children were eating better and more regularly than in the past (Chatterjee and Macwan 1992). A far higher percentage of mothers who left their children in a rural SEWA child care centre, compared to mothers who did not, reported that the general appearance of their children was good: clean hair (98% compared to 56%); combed hair (96% compared to 41%); clean clothes (95% compared to 41%); and cut nails (98% compared to 15%) (ibid.). A vast majority of the salt workers who left their children at a SEWA child care centre reported improvements in their children's development, including improvement in children's education (92%) and decrease in children's shyness (80%) (Parikh 1996). Two-thirds of the urban SEWA members who left their children in SEWA child care centres reported increases in their child's cleanliness (Jhabvala and Bali 1993). The children who went to the ICDS-SEWA child care centre had a slight edge over the control children in terms of several development indicators (Jhabvala et al 1996)
– From Chen MA, Khurana R and Mirani N (2005): ‘Towards Economic Freedom: The Impact of SEWA’
Conclusion
SEWA entered the field of child care from the perspective of ensuring full employment to the union member who was a working mother. The crèches also became an entry point for SEWA to introduce its members to the other services provided by the union and to the union itself. Therefore it’s not always the case that a SEWA member’s child is enrolled in the crèche, there are also instances where the mother of a child in the crèche eventually becomes a member of SEWA.
While it was seen that the availability of child care services did indeed increase the income and employment opportunities for women, through running the crèches SEWA also learnt and showed that crèches are an important intervention in securing the health, nutrition and development of young children. SEWA moulded itself to also think from the child’s perspectives thereby making innovations in the teaching learning methods, nutrition provided, linking with the health services and so on. The crèche programme is now a comprehensive programme for the well being of children under six; which is tailored to the needs of the mothers and the children.
The SEWA experience also shows that child care services require investments and that these investments cannot come from within the community alone. The ICDS programme has failed to reach out to children of working mothers, especially those who are under three years of age. With some innovations and more resources put into the ICDS, it has the potential of playing the role that the SEWA crèches play.
68
4. Lessons Learnt and Moving Forward It is seen that not only is it important that health, nutrition and development related services are provided to young children as a matter of their right, but that these investments also have very large returns. Providing child care services can contribute to increases in income and are therefore is also a measure for poverty alleviation and provision of social security. Good
nutrition and stimulation at this age can contribute to healthier bodies and minds resulting in a more productive workforce and thereby contributing to future national incomes. Well nourished people are less prone to disease and this can also decrease to a significant extent the burden of health expenditure on both families and governments.
A study of existing models can be useful in understanding how to reform large public programmes, like the ICDS, which have the potential to reach everyone and have the maximum impact. This report reviewed different models of provision of ECCD-related services in the country, both by the government and by non-government organisations. All these models had some aspects in common, while there were other unique innovations that were made by each of these.
This section looks at the shortcomings in the ICDS as it is today followed by an analysis of how these can be addressed based on the lessons learnt from the successful interventions that have been documented in these reports.
Gaps in ICDS and Government Experiences The following are some of the critical gaps in the ICDS programme:
Low coverage
69
While almost half the children in the country are malnourished, the coverage of children under the ICDS is very low. Recent Supreme Court orders direct that every habitation must be covered by an anganwadi centre and that every child under six, every pregnant and lactating mother and every adolescent girl must be provided all services of the ICDS.
Essential Components of Early Child Care
Strategies for children under six require three essential components:
• A system of food entitlements, ensuring that every child receives adequate food, not only in terms of quantity but also in terms of quality, diversity and acceptability.
• A system of child care that supplements care by the family and empowers women. Such care needs to be provided by informed, interested adult carers, with appropriate infrastructure
• A system of health care that provides prompt locally available care for common but life threatening illnesses. Such a system needs to address both prevention and management of malnutrition and disease.
Source: Working Group for Children under Six (2007)
Following this, there has been an increase in the number of anganwadi centres in the country from around 6 lakh to about 10 lakh centres. The Supreme Court has ordered that to achieve universalisation at least 14 lakh anganwadi centres must be set up across the country37. The number of beneficiaries has also been steadily rising but the coverage still continues to be very low. According to NFHS-3, while 81.1% children under age six living in enumeration areas are covered by an AWC, only 28.4% of them received any service from the AWC in the past one year. Only 32.9% of children living in areas covered by an anganwadi received any service from the AWC in the past one year. Only 26.3% of children under six received any food supplements in the 12 months preceding the survey. The coverage of other services such as pre-school education, growth monitoring was also very low.
Low on Human Resources
According to official statistics there are on an average about 94 beneficiaries (women and children) of the supplementary nutrition programme per AWC (Critical Statistics of ICDS Scheme as on March 31st, 2007 available at wcd.nic.in). This is too high a number to be handled by one anganwadi worker especially because the number of tasks to be performed by an anganwadi worker are also many. She is responsible for managing the supplementary nutrition programme and also has to provide health and nutrition counselling for families of children under three years of age and pregnant and lactating mothers, which is mainly a community based activity. On the other hand the anganwadi worker is also responsible for providing preschool education for the 3 to 6 year olds, which is mainly a centre based activity (the average number of children availing preschool education, per AWC, is about 37). For the anganwadi worker to be able to provide enough attention to all the different groups of beneficiaries (children under three, children in the 3 to 6 age group, pregnant and lactating mothers and adolescent girls) it is essential to have at least two anganwadi workers (other than the helper) per centre, as has been recommended by many38. Moreover the conditions of work of the anganwadi worker in terms of salary, training, support and monitoring also needs to be improved.
Further, for the anganwadi worker to function effectively, she needs proper support and guidance from the supervisors and the CDPOs. While the roles of the supervisors and CDPOs need to be properly defined, it is also important that there are a sufficient number of them. As of 2007, 43.3% of sanctioned supervisor posts and 34.3% of sanctioned CDPO posts were vacant.
Poor infrastructure
70
The physical infrastructure of AWCs such as the buildings they are located in, availability of toilet and drinking water facilites, weighing scales, medicine kits, pre-school education material etc. the anganwadi centres in the country are very poorly equipped. For instance, according to a recent evaluation by NIPCCD (2005-06), about 25% anganwadi centres were
37 For a report on the status of compliance of Supreme Court orders on ICDS see Saxena.N.C. and Mander.H (2007).
38 See FOCUS (2006), Working Group for Children under Six (2008)
running in kutcha buildings, huts or open spaces. Overall about 49% of the anganwadis had inadequate space for outdoor and indoor activities and 50% had no separate space for storage. In 44% of the AWCs, pre-school kits were not available. However, more than 90% of them had weighing scales. Further, the survey data of a rapid survey conducted by NCAER in 2004 reveals that more than 45 per cent anganwadis have no toilet facility and only 39 per cent anganwadis reported availability of water facilities.
Low budgets
While the anganwadi workers are paid very less, the amount allocated for rent or supplementary nutrition is also quite low. The current norm for supplementary nutrition which is Rs. 2 per beneficiary per day, (this amount was even lower and was increased by double in 2006)39, is even lower than the allocation for mid day meal in schools (which is Rs. 2 + 100gms of foodgrain). This has resulted in poor quality of SNP, while what is needed is nutritious, locally procured and culturally appropriate food that children will appreciate and eat. In this there is much to be learnt from the experience of mid day meals of the benefits of providing a freshly cooked hot meal.
The amount being spent on the ICDS, while it has been increasing in the last couple of years, has been very low. The allocation of the Government of India in 2006-07 for ICDS was around Rs. 5000 crores, while during the same year almost Rs.10,000 crores was allocated for the National Highway Development Project and the defence budget was about Rs. 90,000 crores (indiabudget.nic.in) The share of child development (which includes ICDS and the crèche scheme) budget and child health budget in total union budget is as low as 1.3% while children under six form about 15% of the population (Haq, 2007).
Low priority
71
Children’s issues, especially the issue of early childhood care and development, receive very little attention in the newspapers, political debates or the parliament. It is not the priority of any political party or government. For instance, according to a recent analysis of parliamentary proceedings by HAQ: Centre for Child Rights, only three per cent of the questions raised in Parliament during the last four years related to children. Further, among the child-related questions, less than 5 per cent were concerned with child care and development in the age group of 0-6 years. However, with the repeated orders from the Supreme Court on the issue, increased civil society action, availability of updated information on the lack of progress on improving nutrition etc. has brought some focus onto children under six. The National Common Minimum programme of the previous UPA government made a commitment for universalisation with quality of the ICDS and the 11th plan approach paper states, “Development of children is at the centre of the 11th Plan. We are committed to ensure that our children do not lose their childhood because of work, disease or despair. We
39 With effect from April 2009, this amount has been further increased to Rs. 4 per beneficiary per day. While this is a welcome move, the state governments are expected to contribute 50% of the funds and it needs to be seen whether this amount is actually spent.
aim to give the right start to children from 0-6 years with effective implementation of the ICDS programme.” (Planning Commission, 2007)
There is therefore a lot of innovation and investment required to make the ICDS effective in providing early child care and development services to children in the country. While the story of the ICDS has been one largely of failure (with some notable exceptions), the experiences documented in this report reflect the importance of young children as given in the literature. The government programmes in Tamil Nadu and Maharashtra show that with political will and bureaucratic commitment, the ICDS programme can be made to deliver. At the same time it is seen that while in Tamil Nadu a well functioning ICDS is deeply rooted in a system of good governance and priority in the state for social sector programmes, in Maharashtra the Mission is more in response to an almost crisis-like situation whose current successes are based on the commitment of the officers running the programme. Therefore Tamil Nadu has seen greater investments in the ICDS, with all the services being given equal priority while Maharashtra is still in a stage where malnutrition is being tackled by making innovations but within the existing resources.
Learning from NGO Programmes Each of the NGOs documented in this report approached the issue of services for children under six from a different perspective, there are a lot of commonalities in approach and some aspects come out as being non-negotiable for any programme for children under six. While SEWA set up crèches for children to support their members who were working women so that they could work for longer hours and in peace thereby increasing incomes, for Mobile Crèches, the motivation behind setting up the crèches was that children of working mothers, in construction sites, are exposed to the dirt and grime of construction and therefore need to be protected and given a more caring environment while their mothers are at work. Further, Pratham an organisation whose primary area of interest was in the field of education saw that although there was a large primary school network what was missing was the provision of early child care and pre-school education, whereas an intervention at this stage could ensure school readiness, and also better outcomes from school education. CINI on the other hand started off as a clinic for poor children and learnt that malnutrition is the root cause of the morbidity with which children came for treatment and to address malnutrition one should focus on children under two, pregnant women and adolescent girls.
Some broad principles that are essential for any strategy for children under six emerge from these experiences:
Community participation is critical
72
Whether by design or by accident all the interventions have had to work with the community for making the services they provide more effective. For mothers to send children to the SEWA crèches, they had to hold community meetings and convince parents on the need for crèches and that it was for their benefit. When employers opposed the crèches in reaction to SEWA’s other union activities it was the community that came forward in support of the
crèches. When the Government of Gujarat withdrew its funding to SEWA, many of the crèches were continued with support from the community. Similarly Mobile Crèches also found that a lot of time has to be invested to prepare a community before a crèche or a balwadi can be opened in any area. Further, it’s only when the community is prepared that the monitoring of the anganwadi becomes possible or there is support for breastfeeding mothers or working mothers to leave their children in crèches. In the CINI experience, it was found that unless there was behaviour change in the community and unless they were involved in understanding nutrition, running Nutrition Rehabilitation Centres would be futile because children would get cured and then again come back with the same complaints because habits at home had not changed. This is seen even now in the case of children who are treated in CINI but come from areas where CINI does not have an outreach programme. Pratham’s balwadis are run by women from the local community and are in regular contact with the parents.
Mothers’ rights is central
While services are needed for the health, nutrition and development of young children these programmes showed that for these programmes to be successful, the context and needs of the mothers has to be understood. In India, women are primarily responsible for all reproductive functions and the care of children. In the absence of institutionalised care available for children, it is mothers whose lives have to be adjusted to ensure that children are taken care of. At the same time the context of poverty and lack of food, that they live in, makes it necessary that they work for a living. This double burden of work and home makes it difficult for them to take care of the children exposing the children to harmful conditions without proper nutrition and care. Any programme that aims at addressing this must understand the situation of the mother and design the services accordingly. Therefore, crèches run by Mobile Crèches or SEWA have to be according to the working time of the mothers starting at 6 in the morning if need be and closing at 7 in the evening if that’s the timing of the mother. The programmes also have an impact on women, by helping them concentrate on their work and also sparing them some of the work of taking care of children.
Frontline worker is the backbone
73
While there is a lot of thought that goes into the food given or the teaching methods used in each of these programmes, what makes the programme a success or a failure are the people who are working with the community. It is the balwadi worker in Pratham, the nutrition counsellor in CINI, the crèche workers of SEWA and the community organisers of Mobile Crèches who make the programme what it is. Each of the organisations recognises this and invests in the capacity building of the workers. The systems of supervision and monitoring are such that they support these workers to do their job well. Their needs are listened to and programmes are designed keeping them in mind. While it is indeed the motivation and commitment that makes these people work so hard and with the community, the organisations also understand that they too have rights to decent wages and working conditions. Even though this is probably the most expensive component of the programme, it is the one aspect which can make or break it.
74
Government services must be strengthened
All the organisations are conscious that their role as a service delivery organisation should only be restricted to those services that are not available through the public systems. It is understood that non-government organisations cannot be an alternative to public provision of services, and instead their role is to demonstrate models of effective service delivery and also to facilitate the community’s access to services. Therefore, once there was an expansion in the ICDS, gradually moving towards universalisation Mobile Crèches and Pratham have decided to scale down on their balwadis and work towards strengthening the ICDS instead. SEWA worked out a model of working with the government to improve on the ICDS to provide crèche services as well. While CINI continues to run its Nutrition Rehabilitation Centre as a model, it has expanded its operations to mobilise communities and help them access government services.
One Size Does Not Fit All
The programmes that were reviewed in this report were all flexible and responsive to local needs, with decentralised decision making processes. While there is a broad framework within which rights of the young child is understood, the services provided are moulded to fit the context in which they are working.
Good quality care costs money
Although not expensive when compared to the long term benefits of early child care and development, these models of care require high costs and resources need to be mobilised both from within the community and outside. The table below, reproduced from NCERT (2006) shows what the potential differences could be between and high cost and a low cost programme. However, while high quality is related to high cost, high cost did not ensure high quality.
S. No. High Cost/High Quality Low Cost/Low Quality 1. High worker-child ratio Low worker-child ratio 2. High worker salary and good working
conditions, leading to satisfaction/motivation
Low salaries and poor working conditions, leading to absenteeism, apathy, poor motivation, and low job satisfaction
3. High supervisor–worker ratio Low supervisor-worker ratio, or no supervisor
4. Flexible programming Fixed programming 5. Continuous training No/minimal training, or one-time initial
training only 6. Community involvement and structures for
local initiative and Centralised decision making with little/no scope for community involvement
For high quality, along with the right investments a programme that is providing early child care and development services must include community involvement, have a strong component of workers’ training, sufficient number of workers, a strong and supportive system of monitoring and supervision, understand mothers’ needs and be sufficiently decentralised and flexible to take into account different contexts.
75
Summarising the “Models” Tamil Nadu ICDS Maharashtra Mission Mobile Crèches SEWA Pratham CINITarget age group 0 - 6 The ICDS is for 0 -6
children, but the focus of the mission is on children under three
0 – 6 0 - 6 3 - 6 0 - 2
Focus issues Most innovations are in nutrition, but also some on pre- school education
Nutrition Nutrition, Health and Development
Nutrition, Health and Development
Mainly development/ preschool
Mainly nutrition and health
Interventions for Health and Nutrition
Growth monitoring, supplementary nutrition and nutrition counselling; Immunisation.
Growth monitoring, supplementary nutrition and nutrition counselling. Child Development Centres for the severely malnourished. Immunisation.
Growth monitoring, feeding in the crèches, nutrition counselling in crèches and slums. Immunisation, first-aid and referral.
Nutritious food in the crèches, nutrition counselling in the community, growth monitoring. Immunisation, first-aid and referral
Micronutrient interventions for children in balwadis, health services in the community through Niramaya Health Foundation
Nutrition counselling in the community, treatment of severe malnutrition in rehabilitation centres.
Interventions for Preschool
Active anganwadis which are open longer hours
Preschool services provided in crèches, opening of balwadis facilitated in slums and mobilisation to make ICDS function
Preschool provided in crèches
Balwadis provide preschool
Role of community
Village nutrition committees monitor the anganwadi
Training anganwadis for community outreach, community growth monitoring
Mobilises community for demanding services, formation of SHGs and CBOs, community monitoring of anganwadis
Monthly meetings with parents; union related activities with mothers and other women in the community
Behaviour change communication through work in the community, mobilising community to demand monitor services
Fees None None In the balwadis in slums run by CBOs a monthly fee is collected
Children in the crèches pay a monthly fee
Children in the balwadis pay a monthly fee
None; they sell a locally made weaning food called nutrimix which is sold at very
76
subsidised prices In house training, CINI Chetna Resource Centre provides training for CINI staff and also is a resource for government and non-government organisations across the country.
Training Innovations in training with block level training teams
Focus on training anganwadi workers on growth monitoring, community participation and training as a tool to motivate workers
In-house training with courses for crèche workers and for community workers. A resource organisation for many others across the country.
In house technical team to meet training needs
In house training for own teachers and also runs a certificate course for balwadi teachers at a nominal cost
Outreach The entire state of Tamil Nadu. Currently, 22.9 lakh children are beneficiaries of the ICDS programme in the state.
The entire state of Maharashtra. Currently, 58.1 lakh children are beneficiaries of the ICDS programme in the state. 8,222 severely malnourished children have received treatment at the child development centres
Mobile crèches reached over 12000 children in the last one year through its day care programme, community partnerships and training partnerships. 650,000 in the last 40 years have benefitted from the services of Mobile Crèches.
Currently there are about 80 crèches being run by SEWA in Gujarat covering more than 2000 children. Earlier it was running more than 200 crèches in partnership with ICDS. SEWA union has a membership of about 1 million women.
Pratham runs more than 2500 balwadis across the country reaching approximately 60,000 children. Overall, Pratham is reaching out to half a million children in 43 cities and 33 million children in 305,000 villages through a range of programs.
In its NRC in Daulatpur 600 to 700 children are cured for malnutrition every year and as many as as many as 500 children are seen in these under five clinics on a single Thursday. CINI works not only in West Bengal but also Jharkhand, Chattisgarh and Madhya Pradesh.
Recommendations for Funding Support There is obviously not enough being done for children under six in India. Although India has the largest early child care programme in the world in the form of the ICDS, it is seen that this programme requires greater investments and better implementation. While there are some very good models of provision of ECCD available within the country, as seen in this report, the number of civil society organisations working on this issue is still small. The ultimate aim would be to achieve good quality early childhood care and development services being provided by the government for all those who need it, in the interim however, there is a need to have many more models of what needs to be done and also efforts towards improving the ICDS. The following are some interventions/activities that a funding organisation can support towards this larger goal:
Support the ICDS
As seen in this report the ICDS is under-resourced and can do with additional support from other sources. Anganwadi centres can be adopted by providing them infrastructure, additional workers, better food and so on. Further, support can also be provided in improving the training and capacity building of the anganwadi workers, the supervisors and also the CDPOs, Project Directors etc.
Strengthen Community Participation
One of the critical gap areas in early child care is the absence of community participation. Communities need to be mobilised to actively take an interest in the rights of child under six and monitor anganwadi and other public services that affect young children. At the same time, practices in the home, especially those related to health and nutrition need to change and this again requires counselling at the individual, family and community level. This is a role that civil society organisations can play, which can not only bring about changes in the community but also improve the functioning of the anganwadis.
Local Monitoring
Capacities of local bodies, such as gram panchayats and women’s groups, need to be built so that they can play a monitoring role in ensuring that anganwadis function and that the community is supportive of rights of young children. Local groups can be trained and supported to conduct social audits of the ICDS.
Build ‘models’ of Child Care
77
While there are existing models of child care (set up by NGOs) in the country, as seen in this report, there is a need for more, especially in the ‘backward’ states of North India such as Uttar Pradesh, Bihar and Jharkhand. There is a need for more and more interventions to understand what works in these areas. Further, services which are currently not available by the government need to be supported, both to establish the need for these and also provide
models. Therefore, crèches for working mothers, services for young children of migrant families and homeless children, etc. need to be provided.
Anganwadi cum crèches
Civil society groups and even the 11th Plan has recommended setting up of ‘anganwadi-cum-crèches’ on a pilot basis. Non government organisations can be initially involved in a process of working with the ICDS in setting up anganwadi-cum-crèches by providing the additional resources required and also the technical expertise.
Crèches at NREGA worksites
Similarly there is a provision for crèches at the worksites, under the National Rural Employment Guarantee Act (NREGA). Although it is almost four years since the passing of the Act, this is one aspect that has not really taken off. There is a need for pilots and models which work out the various steps involved in making this happen.
Research and Documentation
Since there are so many gaps in the provision of ECCD in the country, there is a need to resolve many policy questions through proper field research and documentation into what works and what does not. Some areas for further areas of research include:
• Efficacy of using local foods for treating severe malnutrition, • Role of universal feeding programmes vis-a-vis targeted programmes • Strategies to change behaviours and practices • Pedagogies and teaching material for preschool education in local languages • Role of conditional cash transfers for improving nutrition • Impact of maternity benefits on child health outcomes and so on.
Further, other than the National Family Health Survey (NFHS) there are no independent sources of data that give us the nutrition and health status of children in different parts of the country on a regular basis. A study looking at some simple indicators, based on an ASER-kind of model, can be thought of for measuring nutrition outcomes of young children.
78
References Banerjee Rukmini (2005) “Pratham Experiences”, Seminar, Issue No. 546 also available at http://www.india-seminar.com/2005/546/546%20rukmini%20banerji.htm (Accessed by author in June 2009)
Chen Martha Alter, R Khurana and N Mirani (2005) Towards Economic Freedom, The Impact of SEWA, SEWA Academy, SEWA, Ahmedabad
Chen, Martha Alter and Don Snodgrass (2001) Managing Resources, Activities, and Risks in Urban India: An Impact Assessment of the SEWA Bank. AIMS Project. Washington,
Chhatterjee Mirai and Jyoti Macwan (1992) Taking Care of Our Children: The Experience of SEWA Union, SEWA Academy, SEWA, Ahmedabad
CINI (2004) CINI at 30: Celebrating 30 Years of the Founding of Child in Need Institute, Kolkata, India.
Doherty, G. (1997), [Cited in NCERT (2006)] Zero to Six: The Basis for School Readiness. Applied Research Branch R-97-8E, Human Resources Development, Ottawa, Canada.
Dreze, Jean (2006) “Universalisation with Quality: ICDS in a Rights Perspective”, Economic and Political Weekly, 26 August.
FOCUS (2006), Focus on Children Under Six: Abridged Report, Citizens Initiative for the Rights of Children Under Six
FORCES Delhi (2002) Bachon ko Sambhalte Bache: Sibling Care: A Status Report From the Slums of Delhi, Neenv, FORCES, New Delhi
Garg, Samir (2006), “Chhattisgarh: Grassroot Mobilisation for Children’s Nutrition Rights”, Economic and Political Weekly, 26 August.
Government of Tamil Nadu (GoTN) (2003) Making Tamil Nadu Malnutrition Free: A Policy Document, Department of Social Welfare and Nutritious Meal Programme, Chennai
Gupta A, Biraj Patnaik et. al. Strategies for Children Under Six in the 11th Plan, Right to Food Campaign, New Delhi
HAQ, Centre for Child Rights (2007) Budget 2007-08 and Children: A First Glance, mimeo, HAQ, New Delhi.
HAQ, Centre for Child Rights (2007), Budget 2007-08 and Children: A First Glance, mimeo, HAQ, New Delhi.
International Institute for Population Sciences (2000), National Family Health Survey 1998-99 (NFHS-2), Mumbai:IIPS
79
____________ (2006), “NFHS-3 Factsheets”, National Family Health Survey 2005-06 (NFHS-3), Mumbai: IIPS
Jhabvala Renana, Mirai Chatterjee, and Meeta Parikh (1996) Implementation of ICDS through the Sangini Child Care Workers Co-operative: An Alternative Model, SEWA Academy, Ahmedabad
Jhabvala, Renana and Namrata Bali (1993) “My Life, My Work: A Sociological Study of SEWA's Urban Members” SEWA Academy, Ahmedabad
Khalakdina Margaret (1998) “In Sight – On Site: Day Care for Construction Workers’ Children”, in Swaminathan (1998)
Khatri Deepika (2008) “Learning Curve” India Today, 26th June 2008
Madhav Chavan (2000) “Building Societal Missions for Universal Preschool and Primary Education: The Pratham Experience”, Working Paper in the series Strategies of Education and Training for Disadvantaged Groups, International Institute for Educational Planning, UNESCO, Paris
Mascarenhas Anuradha (2009) “Child Development Centres Bring Cheer to the Malnourished”, Indian Express, 4th March 2009, Pune Edition
Menon Purnima, Anil Deolikar and Anjor Bhaskar (2009) India State Hunger Index: Comparisons of Hunger Across States, IFPRI, Welt Hunger Hilfe and UC Riverside available at http://www.ifpri.org/pubs/cp/ishi08.pdf (Accessed in June 2009).
Mobile Crèches (2005) "Health and Childcare Practices" Action Research on 256 Families Madanpur Khadar and Subhash Camp, Delhi, 2004-05
Mobile Crèches (2008) Annual Report 2007-08, Mobile Crèches, New Delhi
Mobile Crèches (2008a) "Action for Young children"- Study of interventions in Early Childhood Care for Development and Behaviourial Changes in an Urban resettlement Colony, 2004-07
Mobile Crèches (2008b) "Distress Migration Identity and Entitlements" - A Study on Migrant Construction Workers and the Health Status of their Children in the National Capital Region, 2007-2008
MoWCD (Ministry of Women and Child Development) (2008) Annual Report 2007-08, Government of India
National Advisory Council (2004) ‘Recommendations on ICDS’, available at www.righttofoodindia.org (Accessed in June 2009).
– (2005) ‘Follow-up Recommendations on ICDS’, available at www.righttofoodindia.org (Accessed in June 2009).
NCERT (2006) Position Paper, National Focus Group on Early Childhood Education, NCERT, New Delhi
80
NNMB (2007), NNMB (National Nutrition Monitoring Bureau) Reports (2006-07), National Institute of Nutrition, Hyderabad
Pandit Harshida (1998) “Children of the Union: Crèches for Women Tobacco Workers”, in Swaminathan (1998)
Parikh, Meeta (1996) Children Among the Mirage: A Study of the Balwadis under the Overall Development Scheme for Salt Workers of Surendranagar District SEWA Academy Ahmedabad
Planning Commission (2007) Towards Faster and More Inclusive Growth: An Approach to the 11th Five Year Plan, Government of India
Pratham (2007) Pratham Mumbai Education Initiative Annual Report 2006-07
Rajivan, Anuradha K (2006), “Tamil Nadu: ICDS with a difference”, Economic and Political Weekly, 26 August.
Ramani (2007) Combating Child Malnutrition in Maharashtra – The Marathwada Initiative and the Road Ahead, ramani2007.blogspot.com, available at http://ramani2007.blogspot.com/2007/02/mission-mode-for-tackling-malnutrition.html (Accessed by author in June 2009)
Sainath P (2009) “HDI Oscars: slumdogs versus millionaires”, The Hindu, newspaper published on March 18, 2009
Save the Children (2009) Freedom from Hunger for Children Under Six: An Outline for Save the Children and Civil Society Involvement in Child Undernutrition in India, Save the Children, New Delhi
Saxena, N C and Harsh Mander (2007): ‘Seventh Report of the Commissioners’, report to the Supreme Court; available at www.righttofoodindia.org
SEWA (2003) Utsah: The Effectiveness Initiative (EI) at SEWA Child Care, SEWA, Ahmedabad
SEWA (2007) Taking Care of our Children: Ensuring Long Term Impact (Balwadi Study), SEWA Academy Research Unit, Ahmedabad
Sinha, Dipa (2006), “Rethinking ICDS: A Rights Based Perspective”, Economic and Political Weekly, 26 August.
Sridhar Devi (2008) The Battle against Hunger, Oxford University Press
Sundararaman, T (2006), “Universalisation of ICDS and Community Health Worker Programmes: Lessons from Chhattisgarh”, Economic and Political Weekly, 26 August.
Supreme Court Commissioners Report (2009) Draft Report on food and livelihood schemes
Swaminathan Mina (1998) The First Five Years: A Critical Perspective on Early Childhood Care and Education in India, Sage Publications, New Delhi
81
Tamil Nadu FORCES (2008) Best Practices in ECCD in Tamil Nadu, Background Note for ‘Bal Adhikar Sammelan’, September 2, 2008
82
The Hindu (2005) Implement report to arrest malnutrition deaths: High Court, August 27 2005, Mumbai, www.hindu.com/2005/08/27/stories/2005082703451300.htm (Accessed by author in June 2009)
Viswanathan Brinda (2003) Household Food Security and Integrated Child Development Services in India, (A report prepared as part of collaborative study by Centre for Economic and Social Studies (CESS), Hyderabad and International Food Policy Research Institute (IFPRI), Washington on Food Security At Household Level in India) available at www.righttofoodindia.org (Accessed by author in June 2009)
World Bank (2004) Reaching Out to the Child: An Integrated Approach to Child Development, Oxford University Press, New Delhi
World Bank (2006) Repositioning Nutrition as Central to Development, World Bank, Washington
Web Resources: Tamil Nadu Government: www.tn.gov.in
Maharashtra Malnutrition Mission: www.hetv.org (Rajmata Jijau MCHNM Presentations and Reports are available) The Constitution of India, Ministry of Law and Justice, Government of India available at http://lawmin.nic.in/coi/coiason29july08.pdf (Accessed by author in June 2009). CINI: www.cini.org
Pratham: www.pratham.org
Mobile Crèches: www.mobilecreches.org
SEWA: www.sewa.org
Right to Food Campaign: www.righttofoodindia.org