SECTION X: APPLICATIONS
X-a. India
As a party to the International Covenant on Economic, Social and Cultural Rights and the Convention on the Rights of the Child, India has committed itself to honoring the right to adequate nutrition. In response to a question raised in Parliament regarding the status of children’s nutrition rights, the Department of Women and Child Development answered as follows, on December 7, 1993 in the Lok Sabha and December 10, 1993 in the Rajya Sabha:
The Government of India has ratified the UN Convention on the Rights of the Child. Appropriate legislative and administrative measures are being taken for implementing the Convention by the concerned Ministries/Departments.
A National Plan of Action on Children has been adopted under which goals have been fixed for the decade 1990-2000. The Plan seeks to cover the programmes in the areas of Child and Maternal Health, Nutrition, Water and Sanitation, Education, Children in difficult circumstances and adolescent girls. All sectors have reviewed their programmes for strengthening keeping in view the goals set in National Plan of Action on Children.
A number of child care programmes for improving the nutritional status of children are being implemented. Integrated Child Development Service (ICDS) Programme is a major intervention for providing a package of services including supplementary nutrition to 1.63 crores children under 6 years of age. Nutrition supplementation is also being provided to children under the scheme of creches (3 laks children) and Balwadi Nutrition (2.29 laks children). A new initiative to improve nutritional status of adolescent girls has been started, on a selected basis, in 507 ICDS Projects. Again, through nutrition education programmes the mothers are also being educated and empowered to look after the nutritional needs of their children better.
The Department has identified 180 focal districts in country based on criteria of poverty, concentration of Scheduled Castes and Scheduled Tribes and high crude birth rate. While expanding Child Care Programmes, preference is given to these focal districts.
There are other programs as well, such as the noon meals programs and the Public Distribution System which markets low-cost food. The Mobile Creches reach some of the migrant workers. Many health, development, and social welfare programs contribute directly or indirectly to the alleviation of malnutrition.
While the reply offered in the Parliament discussed the situation with regard to nutrition-related programs, more is needed to fully address the question of nutrition rights. What are those rights, and where are they stated in the law? To what extent are these rights implemented? And what are the mechanisms of accountability for assuring that the law is implemented?
One way in which nutrition rights can be strengthened is through the adaptation of established programs. The Tamil Nadu Integrated Nutrition Project (TINP) can be used to illustrate the possibilities.
In the 1970s it was recognized that malnutrition was particularly severe in India’s state of Tamil Nadu. At the time about 25 different nutrition programs were operating in the state. About three-quarters of the state’s funding for nutrition programs was devoted to the school meal program. All together, these programs reached only a small fraction of the groups identified as most vulnerable, and were of limited effectiveness. In response to these problems, TINP was launched in 1980.
The overall goal of the project was to improve the nutritional and health status of pre-school children, primarily those 6 to 36 months old, and pregnant and nursing women. Four targets were specified: (1) a 50 percent reduction in protein-energy malnutrition from a level at appraisal of about 60 percent; (2) a 25 percent reduction in the infant mortality, then about 125 per 1,000; (3) a reduction in vitamin A deficiency in children under 5 from about 27 to about 5 percent; and (4) a reduction in nutritional anemia of pregnant and nursing women from about 55 to 20 percent. Informal project targets for service delivery called for 80-90 percent coverage of target populations.
The package of services provided to accomplish these objectives included nutrition education, primary health care, growth monitoring, supplementary on-site feeding, education for diarrhea management, administration of vitamin A, and deworming. The program operated through a network of about 9,000 Community Nutrition Centers.
Growth monitoring was the key means for targeting interventions to problem cases, thereby controlling program costs. It provided a simple, objective way to decide when supplemental feeding and other services were called for. Growth monitoring also was viewed as an important educational tool, to explain to mothers why some children received services while others did not, and to provide mothers with feedback on how well they were doing in caring for their children.
TINP’s design set out clear objectives based on measurable outputs. It identified its intended target population and reached a large proportion of that population. Growth monitoring provided an effective means for assessing the effectiveness of the services. There were explicit rules (based primarily on weight gain patterns) for determining when supplementary feeding should begin and when it should end. Outreach was vigorous, with Community Nutrition Workers going to individual homes to persuade mothers if they did not bring in their children on their own. The costs per beneficiary were modest, and lower than that for other less sharply targeted nutrition programs.
Several deficiencies were found in TINP. Only about 77 percent of the eligible children were enrolled. While the program design called for the enrollment of children at 6 months of age, the mean enrollment age was higher than that. Although coverage was supposed to be provided until 36 months of age, many children exited much earlier. Enrolled children were supposed to be weighed once a month, but weighing was skipped quite often. Prenatal care was generally poor, and fell short of the target levels. Community involvement in TINP was judged to be deficient. Communications with participants were good, but the project’s reach beyond the participants was minimal. Boys participated and benefited more than girls. Scheduled caste children had low rates of participation. The community had little involvement in the monitoring of the project. Overall it was judged that health-related service delivery was below target and uneven.
The evaluation by the World Bank focused on improvements in nutritional status among children who were enrolled in the project. It gave little attention to the substantial numbers of children who were eligible but not enrolled. Apparently there has been no systematic analysis of why some did not enroll. There were some cases in which people refused to participate, but most non-participation probably would be explained in terms of obstacles, and perhaps biases, in the recruitment process.
The original TINP operated until March 1989. The follow-on project, TINP-II, extended the area of coverage. Many modifications were made to correct deficiencies in TINP-I. TINP-II came to a close on December 31, 1997, but some of its activities are continuing as part of the Integrated Child Development Services (ICDS) and the Woman and Child Development Project.
Even in its first version, TINP had many qualities of a nutrition rights program. In the view of Dr. Anuradha Khati Rajivan, formerly Collector in the Pudukkottai District:
In the State of Tamil Nadu, India, it is now possible to think of the feeding programs for children as entitlement programs. Here the term entitlement is being used in the sense of a right, something accepted by the society and political leadership and which is unlikely to be questioned for reasons of resource constraints. . . . Budgetary pressures have not led to cutbacks for the feeding program. . . . The noon meal program now has a first call on the state budget along with food subsidies of the public distribution system and electricity subsidies.
Adequate nutrition still is not a hard right in Tamil Nadu because there are no explicit laws assuring children of this entitlement, and there are no laws and institutional arrangements to make corrections when the right is not fulfilled. It would not be difficult to make those improvements.
Projects like TINP can be strengthened through the incorporation of nutrition rights principles. For example, the basic criteria for the delivery of some of the services would be transformed into entitlements. With minor modifications, TINP's criteria for supplementary feeding could have been formulated follows:
- Every child 0 to 12 months old who fails to gain at least 300 grams per month for two months is entitled to supplementary feeding, and the child’s parents are entitled to associated educational programs.
- Every child 12 to 36 months of age who fails to gain at least 300 grams per month for four months is entitled to supplementary feeding, and the child’s parents are entitled to associated educational programs.
- Every child assessed to be severely malnourished is entitled to a double ration.
- Once begun, feeding is to continue once a day for a minimum of three months.
- If a child gains 500 grams or more within three months, supplementary feeding is to cease. If not, the child is to be referred to the health subcenter, and feeding continued until adequate weight gain is recorded.
Further specifications would have to be made to define various terms, and to specify the quality and character of the basic ration in feeding, and where and how it is to be obtained. A technical definition of severe malnutrition would have to be supplied. "Adequate weight gain" would have to be defined. It could be described in numerical terms, or be left to the judgment of a health professional, or some combination of criteria might be used. The point here is not to propose a specific service protocol, but to suggest a form of language that could be used to provide assurances regarding the conditions under which specific services will be provided. People need to know what commitments have been made to them.
In a rights-oriented service program, a complaints procedure would have to be established, to be called upon when it appears that commitments have not been fulfilled A group could be assigned the ombudsman function, taking complaints and seeing that they are acted upon. Over time the groundrules for this complaint service would need to be articulated, and its performance should become a matter of public record.
With such modifications, nutrition projects such as TINP could remain much the same as they had been, except that parents would be informed that under the specified conditions these were services they had a right to claim for their children. If they were turned away, they would know where they could go to complain, and they would have reason to expect that the situation would then be corrected. There might be a requirement that those who do not get services to which they are entitled must be compensated in some way, perhaps with extra food rations. These rights should be stated in the law and implemented through mechanisms described in the law. These assurance and institutional arrangements should also be specified in the rules of operation of the project itself.
Continue to X-b. United States
Section X-a last updated on June 15, 1999