Updated: Aug 15, 2020
By- Asst.Prof. Sugandha Sinha, Faculty Coordinator & Mrs. Sneha, Centre Coordinator CRC-CNLU
With deaths of children in Muzaffarpur owing to AES (Acute Encephalopathy Syndrome) finding unrelenting media attention, the time is ripe for Bihar to introspect the situation of children in the state and challenges in the way to assuring their well-being. The ensued responsibility is not of the government alone, but of all institutions involved in the caring and nurturing of children right from their birth to adulthood, working in close collaboration and communication with each other. To be honest, the situation in entire country is grim and it would be unjust to point fingers at Bihar alone, which has made huge strides at both social and economic fronts, and is continuing its struggle for greater economic development.
SITUATION OF CHILDREN IN BIHAR
For instance, Bihar has made substantial progress in some of the key indicators on child well-being in the last decade including infant mortality rate, neo natal mortality rate and maternal mortality rate. There has also been a substantial decline in the percentage of child marriages in the state. The infant mortality rate and neo natal mortality rate has declined from 60 (in 2003) to 35 (in 2017) and 32 (in 2002) to 27 (in 2016) respectively. The maternal mortality rate has also declined to 15.8 % as per the estimates of Health Management Information System, Ministry of Health and Family Welfare. In the last ten years, institutional delivery has increased from 20% to 63.8% (NFHS 4– 2015-16). At the same time, immunization of children has also increased substantially from 32.8% (NFHS -3) to 61.7% (NFHS-4).
Despite these impressive figures on well-being of children, mammoth challenges still remain. According to NFHS-4, 48.3 % children are stunted, 20.8% children are wasted and 43.9% children are under-weight in Bihar. 60% of women in Bihar are anemic leading to long term adverse impact on the survival and health of their off springs. Bihar accounts for highest number of stunted children in India. All districts of Bihar show high rate of stunting, above 35%. Almost half of the 20 districts worst affected by stunting in India, are in Bihar. Studies show that at a microeconomic level, 1 percent loss in adult height due to childhood stunting equals to a 1.4 percent loss in productivity of the individual. Bihar has one of the highest prevalence of child marriage in the country, standing at 43 %. With respect to child labour, of the 6.5 million children in the age group of 5 to 14 years working in unorganized sector in India, 11% of them are child workers from Bihar. Bihar is second in terms of number of child labourers. Data on elementary education shows high dropout rates and also reveals low learning outputs among the SC/ST community.
These figures become daunting if we compare them with population composition of the state. Of the total population of Bihar, approximately 46% are children (persons below the age of 18 years). This is much higher than the percentage share of children’s populations in the total world population (31%) as well as in total Indian population (37%). In fact, Bihar stands in league with countries like Afghanistan and Nigeria, where too, more than 40% of the total population are children.
Given the huge population pressure of the young, and especially those who are on the wrong side of many parameters of child well-being, an appalling landscape evolves. Poor human resources, low economic output, delinquency, illness, loan, continuous deprivation of essentials of life including healthy food, consequent inter-generational mal-nourishment leading further to the cycle of poverty, all these factors keep the entire population in a state of continuous strife, unhappiness and economic scarcity.
AES AND THE PLAN OF ACTION FOR CHILDREN (2019-2024)
The Government of Bihar is not unaware of this precarious situation and has been working persistently to bring ground level changes. As per the mandate of National Policy for Children, 2013, the Department of Social Welfare, Government of Bihar has come out with the Bihar State Plan of Action for Children 2019-2024 to ‘accelerate the pace of intervention’ to achieve the rights of children. In addition, it has also released the Bihar State Nutrition Action Plan 2019-2024. The Action Plan for children speaks the language of child rights. It discusses the situation of children in Bihar, identifies gap areas and priority areas of action, sets goals to be achieved, actions and strategies to be undertaken to achieve these goals.
The Action Plan identifies corresponding schemes, central as well of state, to which the actions/strategies suggested to be undertaken, relate to. In sum, the Action Plan does not express, however implicitly seeks to evolve an ecosystem in the state to guarantee over all well-being of children. It is interesting to note that the actions and strategies recognized in the plan are well known and easily discernable. The Action Plan does not go beyond the discernable, and possibly due to lack of mandate, will not be able to go beyond these and prepare a road map to illustrate the exact steps in implementing these actions.
The question before us is therefore that can this and such other action plans evolve an ecosystem to guarantee well-being of children or something more is required. To understand this further, let us evaluate challenges set before the government by AES and whether such challenges have been addressed by the Action Plan.
One of the most authentic sources to evaluate the outbreak would be Dr. T Jacob John who headed the team studying AES in Muzaffarpur in the years 2012, 2013 and 2014 (the Government of Bihar’s stand remains that none of the studies are conclusive). In his articulate write up in Hindu on June 19, 2019, Dr. Jacob John has elaborated the causes of outbreak. Thereafter, he also mentions necessary strategies for preventing the disease which were laid down in the year 2014 itself, viz. educating families to not let their children sleep empty stomach, parental supervision on consumption of litchis and administration of 10% glucose to the ill children. Dr. Jacob laments lack of maintenance of Glucometer, non-sustenance of health education and most importantly, administration of 5% glucose rather than the prescribed 10% as key reasons for the death of so many children. Another reason recognized by him is that children are taken to private nursing homes and by the time they reach the SKMCH in Muzaffarpur, it is too late. Further, shortage of adequate numbers of beds have been emphasized.
The Government of Bihar has been coming out with detailed Standard Operating Procedures (SOPs) for AES since the year 2015. The Standard Operating Procedures which includes awareness campaigns as well as local level interventions through Asha workers, PHC preparedness etc. are well articulated and exhaustive. It recognizes five levels of interventions before the child reaches the medical college hospital including at the primary health centres and at community level. However, none of these could work this time. A well-articulated and well entrenched system, laid down in the year 2015 and revised annually, collapsed in the year 2019. Some blame it upon the elections or political uncertainty. But again, the question remains that can well-articulated and well entrenched systems to deliver well-being to most vulnerable citizens of the country collapse by something as regular as elections in a democracy.
The Plan of Action recognizes three priority areas in the category of “Right to Survival” of the child, in which the primary focus is on health, which of course is the centre of attention due to AES as well. Three imperatives have been identified under this category, viz., reducing mortality rates among children, reducing malnutrition among children and improving accessibility of children to safe drinking water and sanitation. We are aware of numerous statements by experts that under nourishment is one of the major reasons of AES. To achieve these imperatives, a list of strategies and corresponding actions have been identified (awareness programmes, orientation programmes for example of VHSNCs (Village Health Sanitation and Nutrition Committee), availability of full time pediatricians, availability of pediatric medicines, adequate staffing in hospital, availability of ambulance facility etc.). These actions have been correlated to schemes which are already operational. For lack of space, we shall focus only on the National Health Mission because it is the most important and highly funded health programme of the country and in the plan of action, it has been linked to most of the actions prescribed to achieve the three imperatives mentioned above.
PROBLEM 1: RELEASE OF FUNDS
In a study conducted by National Institute of Public Finance and Policy, New Delhi, ‘Utilization, fund flows and public financial management under the National Health Mission’, the authors show that the institutional architecture for NHM’s resource delivery is so complex, it adversely affects the utilization of resources. It looks at the inordinate delay in the release of funds and consequent non utilization adversely affecting the achievement of targets and adverse impact on health situation. Specifically, mentioning the state of Bihar, it observes that significant delay was made in release of funds in the financial years (FY) 2015-16 and 2016-17 from the state treasury to the implementing agencies due to complex administrative procedures associated with release of NHM fund. ‘The file with the request for release of funds has to pass through a minimum of 32 and 25 desks up and down the administrative hierarchy in Bihar and Maharashtra.’ It observes that in the FY 2015-16 and 2016-17, Bihar and Maharashtra were able to utilize less than 50% of their NHM funds.
Another study shows that in the FY 2017-18, Bihar had received only 29% of its approved NHM budget by the third quarter. When we look at human resources in health sector, only 12 % of NHM budget was dedicated to human resources in the financial year 2016- 2017. Out of this, Bihar could spend only 14% of the approved budget. At the same time, Bihar had 96% shortfall of specialists at the CHC (Community Health Centre) level, as on March 2017. Quite interestingly, a Planning Commission Report of 2011 estimates that 0.6% of the GDP would be required to appoint adequate human resources in health sector, in 16 states alone. The plan of action has nothing to do with fund release nor does not it have the mandate to touch upon areas which are not directly related to child rights. However, ignoring these structural issues assure that all actions remain only on paper. Interestingly, in a study conducted by PRS, 93.3% of household in Bihar said they do not use the government health facilities, 83.7% of them because they think the quality of care is poor. No wonder, most ill children in Muzaffarpur were initially taken to private doctors.
PROBLEM 2: DISSATISFIED AND POORLY TRAINED WORKERS
The strategy to control AES in Muzaffarpur includes awareness campaigns. In fact, many actions proposed in the plan of action relating to health of women and children, are highly dependent on efficient working of Accredited Social Health Activists or ASHAs. ASHAs are frontline health workers who are incentivized for providing basic health facilities at the community level and spread awareness. In the SOP of the Bihar Government, they have, along with the Anganwadi Sevikas and the Self-help Groups, been tasked with the job of spreading awareness and identifying and providing first line of treatment for AES and such diseases.
ASHA had an instrumentalist origin, with the aim of utilizing women as first line health workers. The idea was that being accepted in a patriarchal set up as care givers, women accredited as ASHAs would have easy accessibility to women and children at community level, who are the primary focus of National Health Mission. ASHAs work on the basis of incentives. Voluntary and incentivized nature of ASHA was justified on many grounds including the government’s already overburdened health structure, under performance if fixed salaries were given (example Anganwadi workers), burden of life long pension and employment, idea was to utilize this cadre temporarily, need of flexibility in selection criteria, federal nature of the governance (health is state subject) etc.
Underlying ASHA however are numerous problematic presumptions like ‘poor women can set aside time for volunteer work’, the assumption that ‘women ought to act selfless, altruistic and apolitical, ’ late payment and consequent belittling by families and demoralization due to late payment, sexual harassment, caste based discrimination, inaccessibility (like an old ASHA not trusted by an adolescent beneficiary). Further, ASHAs donot earn a fixed salary and are eligible for performance based incentive based on activities under taken. In a study of ASHA workers, it was found that ASHAs depended on Janani Suraksha Yojana (JSY) as it was through this scheme that they received a more amount of compensation ‘as other tasks are either poorly incentivised or not incentivized at all.’ Incentive based model naturally attracts the ASHA workers to focus on those schemes which assure greater incentive. They may infact coerce people to access government services which may not be adequate and properly managed, because the incentive amount may be bigger. For instance, ASHAs may coerce people to access government facilities like institutional delivery despite absence of proper facilities and doctors.
According to National Health Mission’s update on ASHA programme (published in 2017), ASHAs who facilitate in institutionalized delivery in rural areas are proposed to receive Rs. 300 for one such delivery, while they receive Rs. 50 per case for ensuring quarterly follow up of low birth weight babies and newborns discharged after treatment from Specialized New born Care Units. Similarly, for undertaking six (in case of institutional deliveries) and seven (for home deliveries) home visit for the care of the new born and post partum mother, she is proposed to be paid Rs 250/- and for ‘mobilising’ and ensuring every eligible child (1-19 years out-of-school and non-enrolled) is administered Albendazole, she is proposed to receive Rs. 100/-, for distribution of 100 ORS packets, she is proposed to receive Rs 100/- at the rate of Rs 1 per ORS packet. ASHA may prefer, quite in consonance with the logic of incentive based model, to engage in those schemes which pay more with less effort. Terms like ‘mobilising’ and ‘ensuring’ requires much more mental and physical labour. Similarly, distributing 100 sachets of ORS to 100 children at the rate of Rs. 1 may not be economically appealing. The nature of responsibility on ASHA entails commitment, consistency, leadership, patience and hard work. Can incentive based model assure these qualities?
In Bihar, the practical challenges that ASHAs face is delay in payment (Bihar paid incentives of the year 2017, in the year 2018), and other challenges mentioned above. In December 2018, the ASHA workers launched an indefinite strike, demanding their 12-point charter to be addressed. They pointed out that the government had not yet implemented its own agreement with the ASHA unions, made in June, 2015. They demanded a minimum wage and government employee status along with other provisions.
Given their primacy in delivery of the basic, essential and the most important health care facilities to women and children including delivery of babies, neo natal care, nutrition and immunisation, spreading awareness, can a system so entrenched on market model and uncertainty and insecurity of tenure assure quality service? Can top down approach of policy making and training and bottom up approach of implementation work effectively? Is ‘fixed’ salary the monster which causes poor performance or is it the poor selection criteria, poor training and poor hand holding? Can this neo-liberal model of delivering health benefits work effectively to deliver results of universal health?
PROBLEM 3: TRAINING & CONTENT
The plan of action talks of proper training of health workers including ASHAs. However, training does not take into account the context in which the ASHA has to work. It also does not take care of the unique requirements of different regions of the country. For instance, till recently no guidance was provided to ASHA to tackle challenges at ground level, for instance patriarchal norms.
Further, According to the Government of India update on ASHA programme, 2017, the data available upto December 2016 with respect of training of ASHA workers shows ‘a plateau in training roll out’. ‘For instance, Bihar has reported no training progress for over a year as the percentage of Round 3 and 4 training completion has been stagnant at 79% and 8% respectively.’
With respect to dissemination, an interesting example is of the Mother Child Protection Card (MCPC). A study shares the following regarding discussion of a group of women on MCPC which contains numerous messages, ‘Yet they also mocked its messages. Particularly, the ‘save money’ message received laughter and jokes. With no work, no money and no job, what was there to save? Household reserves were not available to them. They felt that several of the messages were ill fitted to the realities of how they lived. ‘Arrange for transport’ was similarly subjected to jokes and shared experiences. ‘Transport, what transport? When I was sent to the hospital to give birth I was pulled in a wooden wagon and it took us hours to get there’. ‘I walked’ another young woman explained, ‘accompanied by my mother in law who kept yelling at me to stop complaining’. ‘Ah’ yet another woman complained, ‘my mother in law only took me there for the money – so I had to walk too as she did not want to waste the money offered her to take me there. She did not even allow the sister ASHA to take me as that was wasting money too’. Have these realities been taken into consideration when designing the card or training content of ASHAs?
The purpose of highlighting these issues which seem disconnected to child well-being, is to bring to fore the fact that problems do not lie in the plan of action per se. The plan merely reiterates what is commonly known, interlinks strategies, actions, and programmes - making a roadmap to child well-being. But it does not take care of the built-in fault-lines in the system at various levels. We hit upon the AES on our road of action for child well because the trenches of structural faults which have been dug deep on the road to child well-being have remained unaddressed, ignored or dismissed. Centre-state relationship, fund release, programme design and its implementing agencies and their choices, recruitment and training are the more obvious trenches. There is many lurking in the landscape.
THE FUNDAMENTAL QUESTION
However, the Frankenstein lurking in the darkness needs to be addressed without delay. In the very beginning of the plan of action for children, the author highlights and emphasizes upon ‘rights of children.’ The plan of action has been formulated ‘to determine priorities of action at the state level to protect the rights of children in Bihar.’ The plan of action draws upon the legal framework created at the international and national level to protect the child rights including the United Nations Convention on Rights of the Child (UNCRC), the Sustainable Development Goals (SDGs), the Constitution of India (Fundamental Rights and Directive Principles), Special laws and schemes ICPS, ICDS, state government schemes etc.
In short, we are essentially seeking to look at children from rights perspective and not from welfare perspective. It is not rocket science to realize that children lack agency. Children are neither voters nor do they have the legal capacity to move the court. They are dependent on adults for articulating and expressing their issues and moving courts in case of any violation against them. Adding to this, the hierarchical, patriarchal caste and class divided society with structural inequalities and acute poverty has built an ecosystem where moral, political, economic and sociological excuses are easily available to ignore children and dismiss their concerns. In such situation, there is no compulsion on any one to heed to children’s concern.
The benefits of rights perspective are that it guarantees equality of all children irrespective of their caste, class, gender etc., it assures to all children certain universal rights which children have the right to demand and the state and other agencies have an obligation to fulfill. It can assure that the Fundamental rights and the constitutional values engrained in our constitution, apply to children as well. The welfare approach does not guarantee equality and universality of rights and does not impose corresponding obligation on government and its agencies. Therefore, child rights approach is a more effective means of protecting children and assuring their well-being. The plan of action focuses on this fundamental change of premise underlying the regime of child well-being.
But has the rights approach made its way into the psyche of Indian society, political leadership, bureaucracy and implementing agencies or we are only paying lip service to this approach? AES is prevalent in the poorest and the most deprived sections of the society and children affected by them are mostly from poorest families and are malnourished. AES is therefore not only a disease of the body; it is disease of a society in which there is a huge gap between the rights guaranteed and actually enjoyed by children as citizens of India and as one of the most vulnerable groups globally. This disease puts a big question mark on the rights approach to children and their constitutional rights as citizens of India. Are we ready to heed?
Government of India, Report: SRS Bulletin (Registrar General, 2005), available at http://censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS_Bulletins_links/SRS_Bulletin_April_2005.pdf accessed on 29 June 2019 Institutional Deliveries, available at: (Last Updated On: June 30, 2019).  Supra footnote 10 Supra footnote 10; also see Vani Sethi & ors., “Bihar’s Burden of Child Stunting A District-wise Analysis”, Economic & Political Weekly, March 11, 2017. Purnamia Menon and ors., “Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from 2015-16.”, Maternal and Child Nutrition, (2018) 14. e12620. 10.1111/mcn.12620.  The World Bank, Repositioning Nutrition as Central to Development – A Strategy for Large Scale Action (October, 2010). Supra footnote 1 Government of India, Census of India (Office of the Registrar General & Census Commissioner, 2012).
(Disclaimer 1: The post was written in June, 2019 considering the then circumstances prevailing.)
(Disclaimer 2: The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of Child Rights Centre.)