EVERY monsoon, over 40,000 children slip into malnutrition in tribal-dominated Nandurbar. Last year in September, 118 infant deaths were reported in the district, with the overall number for 2015-16 at 484. A recent Health Ministry survey, conducted in December 2016, of Bhil and Pawara tribes in two blocks found 4,556 children (or 9 per cent) malnourished.
On paper, there are at least 15 schemes to augment the nutrition of children and mothers in Nandurbar. On the ground, as funds for these schemes see a cut for the second consecutive budget, the road out of hunger is paved with their failures.
Scheme 1: Trained ASHA workers to give ORS (oral rehydration solution) to children with diarrhoea living in inaccessible pockets
2: Rs 200 for parents who miss a day’s labour to bring their malnourished child to hospital
3: ‘Flying Doctors’ — homeopathic doctors on motorbikes — to treat cases of fever in inaccessible pockets
4: Navsanjivani Yojana for ante-natal care, immunisation, and monitoring of children below 6 in tribal areas
Nestled within the Western Ghats is Toranmal, one of the most inaccessible tribal hamlets in Nandurbar. The Health Ministry survey found 103 severe acute malnourished (SAM) and 142 moderately acute malnourished (MAM) children in these villages.
Jiten Harsingh (5) and Dhilu Harsingh (2) of Khadki village were among them. Their sibling, Viren (18), says no government health worker has ever visited them. The only time the boys were weighed was when they were a month old.
“There is an anganwadi, I don’t know who the worker is. She never comes,” claims Viren, who lives in a mud-splatter hut with Jiten, Dhilu, four other siblings, and two donkeys. Their parents work as labourers in Madhya Pradesh.
Anganwadis are centres where children below six are given free breakfast and lunch under the Women and Child Development (WCD) Ministry’s Integrated Child Development Services (ICDS) to control malnourishment. There are 2,364 anganwadis across Nandburbar. The system also ensures children of working parents are looked after by anganwadi workers.
Jiten and Dhilu have never visited an anganwadi. Viren says Jiten had fever last monsoon, along with severe vomiting that left him weak. He took him to the Toranmal Rural Hospital, 9 km away, where he was given antibiotics. For the past seven days, Dhilu has had high fever and has been vomiting. But Viren hasn’t been able to take the two-year-old to a doctor so far. “I have to carry him and climb up 9 km to reach the hospital. Who will look after the other children while I am gone?” says the 18-year-old, who does farming to support the family. Though there is no pediatrician, the rural hospital is the closest to their house and has medicines for occasional fever.
Toranmal also does not have a single toilet, with open defecation causing stunting and scabies. Government officials claim transporting construction material is difficult in the hilly terrain.
Of Toranmal’s eight villages with over 11,000 children, immunisation has reached only 17 per cent, with the scattered population making any monitoring difficult. Those requiring medical aid mostly cross the border to Madhya Pradesh, over 15 km away, where they find private doctors easy to reach.
Awareness about the scheme that pays tribals Rs 200 for loss of wages in bringing a child to hospital is low. Besides, tribals do not have bank accounts in which the money is to be transferred. At 20.57, the infant mortality rate in Nandurbar is higher than the state average.
In 2015-16, of Rs 2 crore sanctioned by the Tribal Department to the ICDS in Nandurbar, there has been zero expenditure.
Latika Rajput of the NGO Narmada Bachao Andolan says the reasons medical help remains out of reach are the same as several years ago. “There is no mobile range to call for an ambulance, no road network and very few health workers visit these tribals,” she says.
While 23 of the 25 posts of Flying Doctors have been filled, since road connectivity is poor, they sometimes spend hours reaching a tribal’s hut.
Scheme 5: Egg/banana four times a week for children in anganwadis
6: An MoU between Tata Trusts, UNICEF and state government for high-nutrient meal to malnourished children
7: Village Child Development Centres (VCDCs), Children Treatment Centres and Nutrition Rehabilitation Centres
At the end of a rocky climb in Toranmal lives 60-year-old Khadki Zebla Dola, who grows groundnut and jawar, earning Rs 3,000 a year from the groundnut he sells. That’s the only time he visits the Nandurbar town, 60 km away.
Dola’s five grandchildren fell ill last monsoon. No health worker visited them, neither was a health camp, organised once in two or three months in rural areas, held. He took one of the five to Chervi village in MP to a private doctor, after the 5-year-old had been ill three days.
Nandurbar district health officer Dr Radhakishan Pawar says high vacancies have crippled the system. There are 34 vacant posts of doctors in 58 PHCs of Nandurbar, as doctors are unwilling to work in tribal postings or leave within a few months. Of 581 doctors tagged as “absconding” in Maharashtra by the Health Ministry recently, several are posted in Nandurbar.
In Nandurbar’s Son village, near the Narmada river close to the Gujarat border, 56 children and 22 pregnant and lactating mothers are registered with the defunct anganwadi centre. A crate of eggs has been lying here, unused for a week. Helper Sevanti Zuzeria, who lives nearby and visits the centre daily, admits less than 10 per cent children and pregnant woman come. Delivering free meal to each is difficult.
The Sunday Express visited 10 anganwadis, seven were found shut during working hours (8 am-1 pm). In Dhadgaon region, 113 of 213 have not even been constructed.
Instead of two meals a day as per ICDS guidelines, more than 90 per cent anganwadis serve one, generally cold khichdi. A banana and an egg are mandatory four times a week, but children are never given bananas, while eggs are unevenly distributed. On December 22, an anganwadi served spoilt eggs to 60 children in Dhadgaon. Later, children complained of vomiting and diarrhoea and had to be rushed to a health centre.
“Bananas are not easily available in this region. But we do procure eggs for kids,” says Ashok Bagul, deputy ICDS officer in Nandurbar, adding, “Since eggs are procured locally by the zila parishad, we do not interfere in their working.”
Anganwadi workers say they can’t help but stock stale eggs. In Jhapi anganwadi, 90 children are registered. Worker Shakuntala Chawdhary collects money from the zila parishad and travels 90 km to Shahada to buy eggs. “I go once a month as it is not possible to go every day,” she says. Chawdhary walks at least 9 km with the crate, and sometimes the eggs fall and break. Of the 90 children at her anganwadi, only 30 come regularly.
While the MoU for high-nutrient meals has been functioning well since 2014, it ends in 2017. The state government does not have enough funds to continue it.
The government also provides for Village Child Development Centres for six meals a day to malnourished children. In 2014, these had shut down due to budget cuts by the Centre, but last monsoon, in a knee-jerk reaction to high infant deaths in Maharashtra’s tribal areas of Palghar, Gadchiroli and Nandurbar, the BJP-led state government announced it would re-open VCDCs in each anganwadi. While other tribal regions such as Melghat and Palghar in Maharashtra have started the VCDCs, providing meals at a cost of Rs 40 per child per day, Nandurbar is still to open any.
For a population of 1.8 lakh children, Nandurbar has only one nutrition rehabilitation centre. This centre, with 10 beds, is meant to treat a malnourished child for 21 days to improve their weight. “It is always full,” says district health officer Radhakishan Pawar.
Scheme 8: Maher Ghars at PHCs to ensure institutionalised deliveries in areas where hospitals are far away
9: Incentives to ASHA workers to identify pregnant women and to refer malnourished children for treatment
At a review meeting held in January, Nandurbar Collector Mallinath Kalshetty pulled up ICDS officers for not doing enough. “The local officers need motivation to work in tribal areas. The biggest difficulty is to reach out to those living in isolated pockets. Migration has made monitoring all the more difficult,” he says.
However, not all is in the hands of health and anganwadi workers. ASHA workers face delay in payments. There are 12 Maher Ghars in Nandurbar’s PHCs – set up to aid in deliveries. In several regions, they also identify pregnant women, but immediate access to ambulance and hospital is often difficult.
Besides the high infant mortality rate, Nandurbar’s maternal mortality rate (MMR), at 72, is much worse than the state average of 46.
In 2014, the ‘108 ambulance service’ was started to aid emergency cases to complement an existing 102 ambulance scheme. Pankaj Wankhede, the driver of one such ambulance, says when he gets calls for help from tribals, he often finds he can’t reach them due to kuchcha roads.
Two months ago, he got a call from Kuklat village about a 24-year-old woman in labour. “I took the ambulance as far as I could and asked them to bring the woman on bamboo sticks from some 2 km away. They could not and she delivered at home,” Wankhede says. The baby died due to complications.
The lack of roads and mobile network is a fact also acknowledged by the state Planning Department and NITI Aayog. Thirty-three villages and 79 hamlets have no road at all in Nandurbar. About 47 of 947 villages are not accessible for four months during the monsoon. Of the 65 projects sanctioned in Nandurbar under the Pradhan Mantri Gram Sadak Yojana, only 28 have been completed.
Mobile connectivity may take longer. BSNL network is currently available only on certain hills and a senior Health Ministry official says private mobile operators are unwilling to invest. Says Medical Officer Dr Malathy Thakre, “Tribals go to the hilltop and call us when they get network.” Another medical officer, Dr Revati Joshi, says she walks to remote huts to help in deliveries if she knows the due date in advance.
Scheme 10: Weekly Folic Acid Scheme to improve iron intake of girls and to reduce anaemia among women
11: Manav Vikas Mission for immunisation of pregnant women, including payment of Rs 4,000 to encourage delivery in hospitals
12: Janani Suraksha Yojana for safe motherhood under the National Health Mission, which overlaps with Manav Vikas. Women get Rs 700 for institutional delivery
13: Matrutva Anudan providing pregnant women Rs 400 for regular check-ups during pregnancy
14: A P J Abdul Kalam Amrut Aahar Yojana to provide free meals to pregnant and lactating mothers
15: Misoprostol tablets, to be distributed by ASHA workers, to check post-partum bleeding after delivery, especially births at home
Pishi Patle appears to be in her teens —she refuses to give her age — and is pregnant with her third child. Her younger son Vinesh has scabies while elder son Dinesh is malnourished. Patle is herself anaemic but has never received folic acid tablets under the government’s scheme, or ever availed of any of the other schemes. Her husband is a migrant sugarcane worker in Gujarat, and she spends six months a year there.
Local anganwadi worker Morga Durga claims Patle has not received the folic acid tablets as supplies have not come for a week. The Health Department survey shows that 69 per cent of women in the district are anaemic. Most of them are young and married, many also have children.
At PHCs, 10 of the 17 posts of gynaecologists are vacant, making regular check-ups or antenatal tests difficult. Payment of Rs 4,000 or Rs 700 to encourage women to get hospitalised, meanwhile, is not possible due to lack of bank accounts.
WCD data shows in 2016-17, Rs 13 crore was sanctioned and released to zila parishads in Nandurbar under the A P J Abdul Kalam scheme, but in the absence of monitoring, not all women are registered or get their free meals.
Misoprostol helps, especially as 65 per cent of total maternal deaths are caused by post-partum haemorrhage, but it does not ensure that bleeding entirely stops.
In five years, Barfi Pawara has given birth to four children. Her twins, Sajan and Sawan, passed away last November after battling malnutrition, and spending 14 days at the Nutrition Rehabilitation Centre. Their elder sister Modi is also malnourished. Says Dr Revati Joshi, “Barfi has undergone sterilisation now to avoid pregnancy. We are trying to improve her haemoglobin count.”
In Toranmal, 18-year-old Disha Pawara is among the tribals loading their children and belongings into a truck. As her four-month-old daughter clings to her, Disha says they are going to Tarapur in Gujarat for work. “We don’t know when we will return,” she adds.
According to the Maharashtra Planning Department, over a lakh tribals migrate from Nandurbar every year to Gujarat and Madhya Pradesh for work. They remain eight months of the year there, working in sugarcane fields or construction sites.
No, she can’t wait for the government to help them, Disha says, hauling her thin frame into the truck. “Humein koi umeed nahin unse (We have no expectation from them).”
Disha is anaemic, her daughter has low weight. They are moving out of the WCD’s radar.