Improving child nutrition: the way ahead for Maharashtra

The recently released National Family Health Survey (NFHS-4) data on maternal and child health and nutrition outcomes in Maharashtra provides sobering food for thought. This data does not provide the cheer that the 2012 UNICEF Comprehensive Survey on Nutrition in Maharashtra (CNSM 2012) brought to Maharashtra, with the showing of a stunning reduction in under-2 child stunting rates (between 2006 and 2012) from 39% to 23% and a corresponding reduction in under-2 child underweight rates from 30% to 22%. The NFHS-4 figures, which cover under-5 children, show a reduction in stunting from 46% to 34% and in underweight from 37% to just 36% over a ten-year period between 2005 and 2015. More tellingly, the NFHS-4 data reveals that high malnutrition rates are not a feature only in predominantly tribal districts; districts like Parbhani and Yavatmal (with tribal population percentages of 2.2% and 18.5% respectively) show stunting rates over 45%. As many as 13 districts in the state show underweight percentages in excess of 40%. What is disquieting is the fact that districts in Vidarbha, like Buldhana and Washim (apart from Yavatmal), and in Marathwada, like Jalna and Osmanabad (apart from Parbhani), show a high percentage of underweight children. Considering that the campaign to reduce child malnutrition in Maharashtra had its beginnings in Marathwada in 2002, the regression in performance of districts in this region indicates that the gains in child nutrition in the first ten years of this century seem to have been lost in the past few years.

Another noticeable feature of the NFHS-4 data for Maharashtra is the variance of its figures from the ICDS monthly progress reports (MPRs) of the corresponding period. Since the NFHS-4 survey was carried out in mid-2015, a comparison of district-wise under-5 children underweight percentages as shown in the June 2015 ICDS MPR was made with the district-wise figures of the NFHS-4 data. The analysis shows that as many as 20 districts showed ICDS MPR underweight percentages which were more than 25 percentage points below the corresponding NFHS-4 percentages (Table 1). Unless one wishes to contest the accuracy of the results of the NFHS-4 sample survey, the only conclusion that can be drawn is that the ICDS MPR figures are understated. My personal experience, as a former Director General of Maharashtra’s Rajmata Jijau Mother Child Health and Nutrition Mission (“the Mission”), is that there is generally a tendency, on the part of the ICDS machinery (not just in Maharashtra, but in most states) to underreport underweight numbers, both because of lack of emphasis on accurate growth monitoring, as also to avoid criticism.

Sources: NFHS-4 (2015-16) and Maharashtra ICDS MPR (June 2015)

The above analysis becomes even more relevant in the context of the recent furore over child deaths in Palghar district (newly carved in 2014 out of the existing Thane district and comprising the predominantly tribal-populated talukas), attributed to the high child malnutrition rates in this tribal region. Why has this state of affairs come about in a state which, barely a few years ago, was in the forefront of efforts to reduce child malnutrition and whose achievements gained national and international recognition?

Over the last five years, during the second phase of the Mission, there was a move away from data monitoring at a disaggregated level ranging from the district down to the Anganwadi. The Mission focused on behavioural change processes at community and family levels and on pilot initiatives to promote nutrition-sensitive projects in association with corporates/nonprofits. While these yielded results at the micro-level, there was no specific focus on scaling up these initiatives or ensuring their sustainability. More importantly, the emphasis on strengthening health and nutrition systems at the cutting edge levels, a significant feature of the operations of the first phase of the Mission, was not stressed in the second phase. Neither was there systematic follow up of the under-5 child nutrition status at the ICDS project level, a measure which is crucial to monitor the high malnutrition burden areas. With little pressure on them to monitor or ensure achievement of key nutrition outcomes, the ICDS machinery at the Zilla Parishad level and below paid little attention to outcomes.

There was also a diminution in the role of the Mission in terms of coordinating the nutrition-specific and nutrition-sensitive activities of different government departments. Departments continued to function in their respective silos; even fundamental activities like the medical facility based treatment of severe acute malnutrition and the community management of acute malnutrition suffered setbacks on account of budgetary cuts and what can only be termed as the absence of a clear policy focus. The lack of coordination in the nutrition-sensitive/specific programmes of different departments is manifest even to date in the manner of implementation of the Abdul Kalam Amrut Aahar Yojana, a maternal nutrition scheme aimed at pregnant and nursing mothers. The ICDS machinery is yet to wholeheartedly take responsibility for making this programme a success; delayed fund transfers to the village level and failure to put in place effective monitoring systems continue to bedevil the programme even a full year after its commencement. Few systematic reviews of the child malnutrition position have been undertaken at the apex levels of the political and administrative hierarchies in recent years.

The need for a mission approach to tackling child malnutrition in Maharashtra arose in the early 2000s out of the perceived inability of the ICDS machinery to make a significant impact on reducing child malnutrition despite almost three decades of its existence: its overwhelming focus on supplementary nutrition, the lack of attention to under-3 children and the failure to adopt a data-based implementation strategy. Frequent transfers of officers at the helm of affairs of the ICDS and the Department of Women & Child Development (DWCD) and absence of accountability for outcomes have bred a “business as usual” approach. The situation on the ground has deteriorated to the extent that over 70% of posts of Child Development Project Officers, the lynchpin of the ICDS programme, lie vacant today, with the DWCD apparently unable to draw up a recruitment policy for this crucial post. The creation of the Mission was expected to engender a sense of purpose in the ICDS, improve its coordination of activities with other departments and enforce accountability for measurable outcomes. This approach, largely successful in the first phase of the Mission till 2010, has been diluted greatly in the second phase.

As matters stand, the government of the day, despite having in hand a clear proposal on the modalities for launching the third phase of the Mission, has not been able to take a decision for over eighteen months. Current thinking seems to be in favour of subsuming the operations of the
Mission within the ICDS Commissionerate, a move that will make the Mission a toothless entity and, in effect, ensure a regression to the status quo prevailing prior to 2005.

Ultimately, any structure to tackle child malnutrition can only be effective if it is staffed with personnel with the passion and commitment to make a difference. The indifferent experience of a number of other states that launched Nutrition Missions based on the Maharashtra model is a clear indication that standard bureaucratic interventions will not work. Maharashtra is free to experiment with any governance structure for addressing the issue of child malnutrition. There are, however, certain fundamental steps that are a sine qua non for making a significant dent on the problem:

  1. Accurate, real-time data has to be the basis for a strategic approach. Both the health department and the ICDS need to use technology to gather real-time data on maternal and child health and nutrition to strengthen systems to tackle underlying causes. Maharashtra made a beginning in 2011-2012 using the Janani and Jatak software systems for individual mother and child tracking to monitor maternal and child health and nutrition outcomes with a view to build service delivery capabilities of the health and ICDS systems. Unfortunately, both departments have not made use of these softwares, specifically customized for Maharashtra, to aid them in efficient service delivery.
  2. A far greater sense of accountability needs to be enforced in the ICDS and public health systems, as well as in other departments with a role to play in reduction of child malnutrition and mortality, from the Secretariat to the village level. A clear political message needs to go out that the death of even one child or the continued prevalence of stunting, underweight and wasting in under-5 children will not be tolerated.
  3. Whether as a Mission or as a high-level council under the Chief Minister, there needs to be an organisational structure that coordinates the activities of government departments/agencies, nonprofits and civil society organisations. This body would plan strategies for high incidence areas, garner financial and other resources for tackling malnutrition, help develop innovative, sustainable programmes and set time-bound, measurable goals.

The Brexit fallout – a return to atavism?

No man is an island, Entire of itself, Every man is a piece of the continent, A part of the main. (John Donne: No Man Is An Island)

…it is clear that what divides this world is first and foremost what species, what race one belongs to. (Frantz Fanon: The Wretched of the Earth)

If 2015 was the year of Greece’s struggle to resolve its relationship with the European Union (EU), 2016 saw a far more dramatic battle as the United Kingdom agonised over its tempestuous relationship with the EU. The die has finally been cast with Old Blighty deciding to sever her over four decade old association with the European Union. In the words of Jean-Claude Juncker, President of the European Commission, “It is not an amicable divorce, but it was also not an intimate love affair.” It is time now to dispassionately analyse the political and social forces at work behind the Great Drama of 2016 and what these imply for the directions that societies around the world seem to be taking.

Cynical politics underlay the UK referendum move from 2013 onwards, when the British PM announced it as a poll promise. Once he returned to power, his (and the Conservative Party’s) trousers were firmly nailed to the mast. The opposition Labour Party was in a win-win situation: if Britain voted to quit the EU, early elections were a possibility, given the internal dissensions over the issue in the Conservative Party, and, if the vote favoured remaining in the EU, the Labour Party was still on the winning side. The far-right, xenophobic UK Independence Party saw this as an opportunity to whip up domestic passions on immigration and increase its support base ahead of the next elections.

Meaningless debates took place on the implications of Brexit for the British economy in terms of the impact on trade, employment and growth. Any undergraduate student of economics would be aware of the hazards of an assessment of its probable effects, given that ceteris paribus (other things being equal) is a textbook concept that has almost no relevance to the real world. How human actions will play out over time and what effect they will have on economic parameters can be predicted neither by astrologers nor by economists.

As support veered from one side to the other, it became increasingly clear that the impact of factors like migration on employment opportunities and the composition of social classes were the major issues exercising the minds of the lay public. There was also the question of national sovereignty, of the extent to which the UK was comfortable with an agenda ostensibly set in Brussels. The UK was always a reluctant European partner, as evidenced by her non-participation in the Monetary Union and the Schengen Agreement. Even so, questions were raised in the UK over the abridgement of national sovereignty by the diktats of the European Parliament. There were increasing fears in the UK over what were perceived as European attempts to impose greater integration, with moves towards fuller economic, political and social union.

In the final analysis, the Brexit vote is more a reflection of the hardening attitudes of the traditionally white populations of the UK and Western Europe towards the adverse effects of globalisation, notably loss of jobs and fears of loss of social benefits. The “unwashed millions” from Asia and Africa could be denied entry by stringent immigration controls, which are of no use in an EU dispensation that allows the free movement of EU nationals seeking employment anywhere in the EU. As EU membership spread in an easterly direction, the UK has seen the influx of migrants from more recent EU entrants like Poland, Albania and Romania. Technology has promoted the offshoring of jobs, leading to growing fears in the UK and elsewhere in Europe (as also in the USA) of being “Bangalored”. Imposition of austerity measures also stokes fears of a loss of social security benefits.

What is a cause for more immediate concern is the likely domino effect of Brexit. Far right, Eurosceptic, nationalist movements in France, Germany, Austria and the Netherlands already pose serious challenges to the established political order. An exit from the EU of more members could place the future of European unity in serious jeopardy, raising fears of a reversion to a pre-1914 scenario, at the very juncture when the social fabric of Europe is coming under increasing strain. In a rapidly changing international scenario with the rise of huge Asian markets and new centres of production of goods and services, smaller European nations, operating in isolation with a limited resource base and technological skills, could find economic survival an increasingly difficult task.

“Third World” countries have adequate reason to smile wryly at the predicament of the UK and her European neighbours. Pax Britannica, followed by the Cold War era and then Pax Americana, has seen the interests of large segments of the world’s poorer population being at the mercy of the economic and political interests of the world’s powerful nations, essentially from the Western Hemisphere. Apart from overt military intervention (Afghanistan, Iraq, Libya and Syria being only the prominent recent examples), Western powers have sought to use regional and international platforms (NATO, the UN, IMF, WTO) to promote their narrow economic and political interests, be it the suppression of inconvenient regimes or the negotiation of one-sided treaties on trade, intellectual property rights or the environment. Free movement of goods, services and capital from the West has been promoted, while movement of labour to the West and use of intellectual knowledge in critical areas like generic drug manufacture (which can save innumerable lives) have been sought to be restricted.

Unfortunately, the statements that are emanating from the victorious British politicians on the “Leave” side of the Brexit debate only serve as ominous warnings of their narrow, parochial approach to economic, political and social issues. Trump-etings from the USA in this crucial election year are no better: a campaign against an entire religion, xenophobia against the Hispanic population in the USA and promises to tinker with immigration and trade policies to secure jobs for the local populace. It would seem that influential opinion makers of the Western world are reverting to a tribal, insular worldview, in negation of the plural values that are supposed to have been the basis of Western civilization over the past century and more.

It does not need Samuel Huntington’s “The Clash of Civilizations” to remind us of the ferment in many cultures around the globe and their efforts to resist the domination of Western influence and the Western way of life. China is well placed to supplant the USA as the world’s leading economy in the decades to come. India and a host of nations from Asia, Africa and Latin America are looking to find their place in the sun. Brexit will have had a salutary impact if it pushes political leaders in the UK, USA and other European nations to work towards promoting a more equitable and just world economic and political order in consultation with their counterparts from other nations around the globe, as well as striving to achieve greater integration of diverse ethnic and religious groups in their respective countries. The West’s failure to see the writing on the wall will only hasten its eventual decline. The lights may be going out all over Europe once again, with consequences one cannot even begin to imagine!

Reaping the wages of state oligopoly/monopoly

I recently read a lament by India’s Surface Transport Minister, Nitin Gadkari, on how vested interests were thwarting the passage of the Road Transport and Safety Bill in Parliament. One would have thought that legislation aimed at reducing India’s horrendous record of road fatalities/injuries (1,50,000 fatalities and over 5,00,000 injured in the calendar year 2015 alone) would have received widespread support and would have passed through both Houses of Parliament in a jiffy . Alas, this bill languishes, like many others, while the God of Death continues to add to his numbers. And the sneaking suspicion lingers that powerful lobbies are at work to forestall the coming of this law. The commercial road transport lobby is against any measures that would require them to invest in new, safer transport vehicles. The bare-headed idiot wants to ride his scooter/motorcycle without the impediment of protective headgear, blissfully oblivious to the implications for his life and the future of his family. Above all, the state road transport authorities are totally averse to what they see as this encroachment on their divine right to extract economic rent from the licensing and operation of motor vehicles, which is why the transport portfolio is one of the most sought after by politicians. This huge state oligopoly (actually a monopoly in any one state) has been responsible for a large part of the mess in India’s road transport sector. Visit any state road transport office and you can hardly miss the ubiquitous tout peddling his wares in full public view. Every service has a price, whether it is the registration of a new vehicle, the transfer of vehicle registration from one state to another or the issue/renewal of driving licenses. No wonder even the Minister admits that at least 30% of driving licenses (almost certainly an underestimate) are wrongly issued. The road transport imbroglio goes even further. A mobile, globalised economy requires frequent labour movements. But move to another state with your vehicle and the authorities are after you to pay your lifetime road tax afresh in the new state. Take a private taxi from one state to another state and you end up paying for the privilege of entering that other state: an amount that varies from ₹ 1000 for Andhra Pradesh to ₹7000 for Maharashtra. Road transport checkpoints (along with other state monopoly agencies extracting their pound of flesh) are responsible for interminable delays in shipments to other countries and adversely affect India’s export competitiveness. But who cares: certainly not state governments, which are interested only in short-term revenue collection.

Things are only marginally better in the sector that fuels the transport sector. In spite of valiant efforts by reform-minded administrators to introduce free markets in this sector, supply of petroleum products has remained the preserve mostly of the three public sector marketing giants. Political patronage played a significant role in the allotment of dealerships in petrol pumps and cooking gas, a fact which attracted adverse attention of the higher courts about two decades ago. Politically powerful owners of these distribution agencies consider themselves immune to punitive action even when they supply adulterated fuel or indulge in black marketing of cooking gas cylinders. Booking of gas cylinders on phone has certainly been a welcome step and has reduced retail consumer uncertainty on when their supply will be replenished. But there are still areas where service falls woefully short, including the crucial one of safety. If your gas cylinder or stove develops a leakage after 6 PM, rest assured that you will receive no response till 9 AM the next morning from your gas agency, presuming that the next day is not the weekly off day for your agency. The three distribution companies have provided contact numbers. The problem is that, when you call those numbers, all you get is a polite message informing you that your complaint will be attended to. Even the agency responds in a leisurely manner, three to four hours after they are informed.

The two sectors that meet basic requirements of the citizen, health and education, are prime examples of how state monopoly has impeded the process of economic development and, more importantly, meeting customer needs. The public health system is the only avenue for a large section of the population which cannot afford private health care. Apart from a few islands of excellence, the public healthcare system falls miserably short of the expected standards of effective, good quality service provision. Especially in remote tribal areas (but also elsewhere), doctors just do not turn up for duty; when they do, attention to patients is often perfunctory, if not dismissive. Diagnostic equipment, like x-ray and scan machines, are, when provided, often out of order, generally because of outmoded bureaucratic procedures that prevent timely supply of spares. I speak from personal experience: antenatal care in primary health centres is generally routinely and superficially carried out, with no clear focus on mothers who face high risks at delivery time. Post-delivery, neonatal follow up is extremely poor, with the result that a large proportion of child deaths occur in the first year of birth (of that, a large proportion occurs in the first four weeks after birth). The public health machinery also takes no responsibility for severely malnourished children, disregarding the dictum that prevention is better than cure.

Education is an even more unfortunate example of the malevolent effects of state monopoly. Oligarchies have taken root in this system – the state education bureaucracy and the teachers’ unions. State schools are tightly controlled by the bureaucracy, which decides every aspect from school location and curricula to teacher remuneration and career progression. Unions have resisted efforts to enforce accountability, leading to the phenomena of absent teachers, poor quality instruction, high dropout rates and unemployable students with limited language and arithmetic skills. Growth of private schools is stifled by the system of recognition by the education department, with its inbuilt tendencies towards patronage and corruption. Higher education also suffers from the stultifying effects of bureaucratisation. Low quality, private education empires, run by those with political muscle, have become the norm, rather than the exception. Even more unfortunate has been the tendency of the state, more so in recent years, to encroach on the autonomy of once reputed public institutions of higher learning by stacking their managements with pliable, political appointees and, increasingly, seeking to dictate the content and pedagogy to be followed by these institutions.

Public service can be efficient and effective only if it adheres to the three basic principles of integrity, professionalism and empathy. Integrity implies both financial probity and a commitment to the outcomes that are sought from the provision of the service. Professionalism requires a clear understanding by those in the system of their tasks and a willingness to discharge their duties honestly and to the best of their abilities. Above all, public service requires the very human quality of empathy, of placing oneself in the shoes of one’s’ less privileged brothers and sisters and understanding what difference the access to high quality public service can make to their lives: as a government functionary, one needs to look behind the file/statistic and visualise the face of the person you are dealing with. Since these attributes are becoming increasingly difficult to inculcate in a bureaucracy that is influenced by the prevailing social values of consumerism and self-centredness, what is required is the introduction of competition (to the extent that it is possible) in every sector of economic and social activity.

Competition has certainly helped in the telecommunications and automobile sectors. The public sector behemoths, BSNL and MTNL, have lost a lot of ground to private telecom operators but their loss has been the consumers’ gain, leading to an explosive growth in mobile communications. Gone are the days when one waited for days for a telephone connection. Nor does one wait patiently month after month for the supply of an Ambassador or Fiat (Premier Padmini) car, or, later on, a Maruti 800 car. Hyundai, Honda, Ford and Toyota cars are available today virtually off the shelf. Of course, there are sectors like utilities (energy and transport) and public goods (education and health), where, because of heavy, long gestation investments, the nature of technology or the impact on human capabilities, some regulations on entry and on quality/price will have to be implemented.

Competition in sectors like health and education can be introduced by providing options, in addition to state-provided ones, to the consumer. These could take the forms of private health care and education provision, as in the case of charter schools in the USA. Unviable or poorly functioning state institutions could also be entrusted to private management, with accountability for performance and sound management. The fundamental aim should be to ensure that public sector providers compete with private parties for funding for providing services of a specified quality (with designated outcomes) at reasonable prices. Provision of cash vouchers for spending on health and education would provide the consumer with the choice of that provider who best meets her expectations. Of course, this will require a high quality of regulation, with the regulators ensuring a level playing field for both parties and monitoring performance and cost of services to the consumer. In the infrastructure and utility sectors, the same principle of competition will have to be applied, with existing public sector providers having to compete for customers with private participants. An auction route is the best method of attracting the best offers, whether from the public or private sectors.

The state has two major responsibilities in such a competitive set up. Firstly, it has to set up autonomous regulatory systems in different sectors that discharge their duties in a fair, impartial manner and ensure the provision of reliable, reasonably priced goods and services to consumers. Secondly, the state also has to work towards providing an environment to public sector providers which gives them the freedom and flexibility to compete in the marketplace, with the clear understanding that there is no guarantee of their survival if they do not perform. It would be in the best interests of all for the state to abide by the maxim “The business of government is not business”.

The politics of infant mortality…and the tragedy

“There are three kinds of lies – lies, damned lies and statistics”
(Mark Twain: Chapters from My Autobiography)

A recent comment by India’s Prime Minister (PM) during an election speech comparing the infant mortality rate (IMR) in the tribal areas of Kerala state with those in Somalia kicked up a furore. A wounded Chief Minister of Kerala (from the opposing political party) has threatened to sue the PM, though the exact nature of the offence is not clear. Now that the electoral battle in Kerala has been lost and won, it is time we dispassionately analysed the contention of the PM and the implications for health policy in India. Let us first get to the numbers; at 60 deaths per 1000 live births in the tribal areas of Northern and Eastern Kerala, he felt that the area was not lagging far behind the African country of Somalia, which, as per the number he had, registered 85 deaths per 1000 live births in 2015. This is where statistics can be dangerous, and it does not need a Mark Twain to convey this message. Firstly, there seems to be no basis for concluding that the tribal areas of Kerala have an IMR of 60: whether this covers just the tribal population or the districts with a larger proportion of tribal population is not clear. Secondly, the PM’s information feeders seem to have culled the magic number of 85 from the latest country wise estimates of infant mortality released by the UN Inter-agency Group for Child Mortality Estimation ( The problem, as with all statistics, lies in the level of confidence reposed by the estimators in their own estimates. In the present case, three sets of numbers are given for each country: low, median and high. While the variation in these three numbers in countries like the United Kingdom with excellent reporting systems is minimal (3.0 to 3.5 to 4.1) and reasonable for a country like India (34.1 to 37.9 to 41.8), the range from the low to high figure is from 53.3 to 143.3, with a median figure of 85, for a country like Somalia with underdeveloped reporting systems. The UNICEF State of the World’s Children Report 2015 gives an IMR of 108 for Somalia and the CIA Fact Book places it at 98, showing that there is no unanimity on the number. With such a vast range of uncertainty regarding the numbers, it would be hazardous to plump for a number like 85 with any degree of confidence. The matter is further complicated when we compare the tribal population of Kerala with that of Somalia – 0.49 million versus 34 million. A small population, especially when it is largely comprised of poor tribals, will display higher figures of mortality in infants, given the prevalence of poverty and the poor reach of essential health services. The law of averages operates as the sizes of populations increase. To give one graphic example: just two infant deaths in a village with a population of 1000 (with an annual population growth rate of 2%) imply an IMR of about 100 per 1000 live births: which is why mortality statistics are never calculated below the district level. As statistics combine disadvantaged with more prosperous
areas, these numbers come down, in the case of Kerala state to 12 per 1000 live births, which compares very favourably with many developed country figures.

The tragedy lies in the lessons that are not learnt from areas in Kerala like Wayanad, Idukki and Attappady, Palakkad (in the news a couple of years ago for infant deaths in significant numbers) and the mistakes committed through apathy and misgovernance across much larger swathes of India. Politicians would do well to remember the adage “Those who live in glass houses shouldn’t throw stones”. Of the nine states that are at the top of the high child malnutrition pecking order, seven are presently ruled by the party whose PM has spoken disparagingly about IMR levels in the tribal areas of Kerala, and all nine, including his own state of Gujarat, have or have had BJP governments (either on their own or in alliance with other parties). Barring two states where the BJP has recently come to power, its governments have had ample time to tackle the menace of child malnutrition, which is attributed by experts to contribute at least 45% of child deaths in India (and probably an even greater percentage of infant deaths, given that an overwhelming majority of under-5 children die before they cross the age of one). And yet, it is precisely these states which are the greatest contributors to infant mortality and child malnutrition. Don’t get me wrong: I am not in any way absolving other political parties which have ruled these states for many years without making a significant difference to the problem. The fault, dear Brutus, lies not in our stars, but in ourselves: in our dysfunctional systems, our cavalier disregard of data, our failure to focus on key geographical areas with a high child malnutrition burden and our failure to evolve a coherent, time bound public policy to effectively tackle the problem.

Let us start with our dismal grasp of the magnitude of the problem. Growth monitoring has always been one of the main components of the ICDS strategy right from its inception. Unfortunately, the monthly exercise of weighing of all under-5 children by the Anganwadi Worker (AWW) has been treated mostly as a routine task, with little or no importance being given to the use of this massive body of raw data. In the absence of weighing scales, weighing is sometimes not carried out; where weighing is done, there is no analysis of the data to chart out a meaningful course of remedial action in case of underweight children at any level, whether the anganwadi, ICDS project, district or state. Almost no state posts aggregated data, ICDS project wise, on the nutritional status of children online and it is doubtful if any administrator, at the project, district or state level, pays any attention to this data.

This blissful neglect of valuable data leads to governmental failure to identify and focus attention on the geographical regions requiring urgent, sustained intervention, be they remote tribal areas or congested urban slums. Aggregated data of monthly weights of children helps identify the specific localities (villages, hamlets, slums, etc.) that need to be focused on to reduce the burden of child malnutrition. The common budgetary approach of allocating funds to areas on a child population basis, without weightage for high burden malnutrition areas, discriminates against the latter. Poor infrastructure and inadequate staff in tribal areas lead to underutilisation of even allocated budgets.
Resources of different departments are generally not combined in an innovative manner to deliver the crucial health and nutrition (both nutrition-specific and nutrition-sensitive) services to children and women that can reduce undernutrition and mortality. The new methodology of untying central fund releases to states is likely to see even further diminution in fund allocations to politically weak tribal regions of states and to urban slums. Public nutrition and health services for mothers and children are in short supply in urban slums. There are no systematic efforts to reach out to urban communities to develop their capacities to self-manage their nutrition and health issues. This limited attention given to identified high burden geographical areas is likely to see a continuation of high child malnutrition and mortality rates in these areas.

Resource misallocation to this critical area is aggravated by the absence of a clear cut vision on how to most effectively tackle the problem in the short run. India’s policy makers refuse to use height/length of under-5 children as a measure of nutrition status, in addition to weight (which has been used for nearly four decades). This would enable an immediate estimation of wasting (weight/height) status for taking action to improve the health and nutrition status of children suffering from severe acute malnutrition. Software exists to record both anthropometric measures digitally so that the wasting status of any child can be immediately established (a pilot project in Attappady, Kerala has proven the feasibility of such a digital approach to recording data using IVRS technology). Tackling moderate and severe wasting in India’s children (which goes upto 25% in many states) through inpatient and outpatient methods would significantly reduce malnutrition. But India’s ICDS and public health departments are unconvinced that they need to make this programme a key step to reduce child malnutrition and mortality. Adequate international evidence linking child malnutrition (especially wasting) to a higher incidence of mortality has had little to no impact on the thinking processes of the bulk of India’s medical professionals. Governments (at central and state levels) have failed to make such a programme the cornerstone of efforts to reduce malnutrition/mortality. The ICDS Commissionerates/Directorates are obsessed with centralised, contractor-dominated food supplies (rather than child feeding practices and micronutrient interventions), a policy which has drawn much critical comment from the Supreme Court and High Courts (the reasons are not difficult to fathom!). The resultant haphazard, ill-directed programmes to manage malnutrition, with no systematic measurement of nutrition outcomes and no focus on geographical areas most in need of such programmes, are the reason for India’s dismal world ranking in child nutrition indicators.

Finally, there is gross underutilisation of one of the most extensive systems set up anywhere in the world to deal with the issue of maternal and child nutrition — the ICDS. With anywhere from 50,000 to over 100,000 AWWs in each state of India, spread over almost every habitation in the country, this valuable human resource could well be the underpinning for a revolutionary transformation of the child malnutrition scenario in India. Unfortunately, with the ICDS largely functioning as a khichdi kitchen, these workers have never been empowered with the knowledge, skills and resources necessary to fulfil their innate potential. My experience in the nutrition sector in Maharashtra opened my eyes to the fantastic work they can do given the right working environment — upgraded knowledge/skills, access to resources, appreciation for their good work and the development of self-esteem for the important tasks they are undertaking. Even the huge public health system has no specific focus on the preventive aspects of health and good nutrition that could develop a generation of healthy girls and mothers, leading ipso facto to the birth of healthy, normal weight children.

For a country on the cusp of economic power and a growing global presence, it reflects poorly on India that she takes her place among the league of failed and failing nations in indices of child/infant mortality and undernutrition, whenever the exercise of evaluating each country’s performance in these areas is taken up. Latin America and East Asia have left us behind, as they made significant strides over the past few decades. Our immediate southern neighbour, Sri Lanka, is an object lesson to us that improvement in human development indicators can be achieved. Even within India, states like Goa, Kerala, Maharashtra and Tamil Nadu have performed far better than their counterparts in Northern and Eastern India in reducing IMR, though they still need to reduce wasting rates in under-5 children. If “Make in India” is to have any real meaning, children born in India need to have the guarantee of a healthy, disease-free, long and productive life.

What’s in a name?

“What’s in a name? that which we call a rose
By any other name would smell as sweet.”
(William Shakespeare: Romeo and Juliet)

William Shakespeare would never have had the hapless Juliet fret about the irrelevance of a name in the face of true love if he had been a twentieth or twenty first century inhabitant of India that is Bharat. My first tryst with our name-changing proclivities came when, as a newly posted probationer in the civil service, I landed at Bombay (Mumbai?) Central railway station one hot May morning in 1981. Getting into a taxicab, I directed the cabbie to take me to the Maharashtra State Administrative Training Institute located on Hazarimal Somani Marg, where I had been ordered to report for being inducted into the state bureaucratic culture. For good measure, the letter from the Institute informed me that the Institute was close to the Victoria Terminus (VT) (Chhatrapati Shivaji Terminus?) railway station. At VT, the cabbie asked me which road he should take. Clueless about Bombay’s (Mumbai’s?) roads, I directed him down the road to Flora Fountain (Hutatma Chowk?). Not finding the Institute, we took a one-way road back to VT and explored other alleys in our vain search for the elusive Institute. On our tenth or so sortie (as the taxi meter merrily shot up), we finally located the Institute located in a modest, single-storey premise, it’s innocuous signboard hidden from public view by large creepers. My eureka moment was spoilt by the contemptuous glance I received from the wizened cabbie who growled “Why didn’t you tell me it was Waudby Road?” before driving off with the inflated amount he received from me.

My engagement with Mumbai’s road names continued when I joined the Greater Mumbai Municipal Corporation (better known to the locals as BMC) in 1996. I was allotted a house within the premises of the Mumbai Zoo in midtown Byculla. Its northern boundary abutted E. S. Patanwala Road. Intrigued by the name, I made inquiries and discovered that Mr. Patanwala was the founder of a large cosmetics empire, responsible, among other products, for Afghan Snow, a vanishing cream that was applied on my face before I left for school every day. As fate would have it, my boss allotted me the subject of maintenance of Mumbai’s roads. My padayatras across many kilometres of Mumbai’s roads and pavements threw up many names hitherto unknown to me: Barfiwala Road, Veera Desai Road and Lokhandwala Road, not to mention Bhulabhai Desai Road and Gopalrao Deshmukh Road, better known by their earlier names of Warden Road and Pedder Road respectively. But it was at my weekly attendance at the General Body meeting of BMC corporators that I was privy to the extreme interest that the subject of road naming (and renaming) generated in the city fathers (and mothers), something that dreary budget items failed to excite. The meeting agenda was never complete without the inclusion of at least one item pertaining to a stretch of road that was to be renamed, often after some local benefactor or even some deceased relative of a corporator, whose memory was thus preserved for prosperity.

If the BMC was so active in the game of the name, how could the Maharashtra state government show tardiness? Shortly after it assumed state power in 1995, the ruling Shiv Sena-Bharatiya Janata Party combine put all its might behind renaming Bombay as Mumbai. Not content with this, the government of the day strove valiantly to rename Aurangabad as Sambhajinagar and Osmanabad as Dharashiv, hoping probably to erase the Mughal-Nizam legacy. While Bombay became Mumbai, the then state government was not successful in renaming other cities, though politicians of parties like the Shiv Sena still use Sambhajinagar to refer to Aurangabad.

If you think Haryana’s politicos showed great drive in renaming the urban jungle of Gurgaon as Gurugram, please shower your appreciation on Karnataka’s present government which has, with great gusto, gone about renaming the state capital and just about every district, albeit sometimes only to reflect the Kannada inflection of tone — Bengaluru for Bangalore, Mysuru for Mysore, Mangaluru for Mangalore, Belagavi for Belgaum, Vijayapura for Bijapur and Kalaburagi for Gulbarga. The epidemic is now spreading further; the Vishwa Hindu Parishad is demanding that Shimla be renamed Shyamala!

It is almost as though the rechristening of places indicates a deep rooted desire to erase certain not so pleasant historical memories, especially of the colonial era. Delhi went through the phase of historical cleansing when Cornwallis, Canning, Curzon, Hardinge, Irwin and Willingdon, all representatives of East India Company/British rule in India, made way for their Indian counterparts after independence. Mercifully, smaller places in India named after Britishers who made a local impact — Forbesganj, Daltonganj and McCluskieganj — have withstood the renaming mania. More recently, the present central government decided to remove Aurangzeb’s name from a Delhi road, renaming it after a respected former Indian president to forestall any criticism of religious or historical bias. Each government obviously favours its admired icons in the naming/renaming exercise. While the Congress pantheon dominated the landscape in the first few decades after 1947, governments of other political persuasions have been no less diligent in introducing their favourites into road names. Sometimes, the repetition of the same name can cause confusion in giving directions; my area in Bengaluru has many roads named after the great engineer, M. Visvesvarayya. Mahatma Gandhi, Jawaharlal Nehru, Chhatrapati Shivaji Maharaj and Netaji Subhas Bose are perennial favourites across towns and cities of India and are often repeated in the same city. Ideological, literary and anti-colonial affinities also influence road names: Kolkata has its Ho Chi Minh, Lenin and Shakespeare Saranis, while Delhi has roads named after Nelson Mandela, Josip Broz Tito and Archbishop Makarios; where Olof Palme fits in this group is still a matter of conjecture.

Actually, names are meant to be markers of one’s origin, ethnicity and religion in the masala dabba that represents India’s diverse, heterogeneous population, although the forces of national integration and globalisation are ironing out these distinctions. Still, in a country that is more a continent (like India), there are delicious vignettes that highlight the complexities of names that are commonplace in some parts of the country but are foreign to the ears of those from other parts. Take my own example. I stuck to a six letter name like Ramani since, based as I was in Delhi, I was not sure how my northern confreres would mutilate Subramaniam. Now, Ramani is generally a name more associated with the female sex in its linguistic origins, including in states like Kerala, although there are hordes of male Ramanis emanating from Tamil Nadu. But when I was to join the civil service training academy at Mussoorie, the Assistant Course Director (from a northern state) used his extant knowledge to assign me accommodation in the Ladies Block. My good fortune (??) at this turn of events did not, however, last long. The other Assistant Course Director (a Tamilian) promptly rectified the gender error. He gleefully related to me how he inadvertently paid back his colleague in the same coin. The Tamilian allotted Maheshwari to the Ladies Block, till his northern colleague pointed out that Maheshwari was a male surname in the northern reaches of India. Imagine also the plight of the Punjabi receptionist at the entry desk of Shastri Bhavan, in the heart of the Indian government, who asked this strapping Tamilian visitor his name. When the visitor blithely replied “Thirunavukkarasu”, the receptionist, visibly blanching, hastily handed over his pen to the Tamilian to enter his name in the entry register, a name as Greek to the receptionist as Varoufakis (for more on the latter, refer to the Greek economic crisis).

I wonder if Nandan Nilekani devised the unique identification Aadhaar number for every Indian to get over the problem of mutilation and misspelling of names. A number (accompanied by fingerprint and iris scanning) that enables individual identification from Kashmir to Kanyakumari and Dwarka to Dimapur would do away with the need to get the spelling right. Pronunciation is another matter altogether. Maybe we should all adopt the Beagle Boys formula — the three brothers were distinguished solely by the numbers boldly emblazoned on the front and back of their sweatshirts: 176-167, 176-671 and 176-761. After all, there’s always safety in numbers!