On a November afternoon, Alimunissa prepared for winter by stitching a blanket from tattered clothes. As she sat inside her small mud hut with a thatched roof on the outskirts of Balrampur district, the youngest of her four children – eight-year-old Arbaaz – slept next to her. Outside, children his age were running around playing catch.

Arbaaz is a weak child. “Badta hi nahin hai,” complained Alimunissa. He does not grow.

No government worker has bothered to measure Arbaaz’s height and weight, even though the Indian government has been running the Integrated Child Development Scheme since 1975, which aims to track the nutritional and health status of all children through a network of centres for pre-school education and nutrition called anganwadis.

Low height for age is called stunting and low weight for age shows wasting in a child. One of the main causes of both stunting and wasting is poor nutrition. While wasting is more likely due to acute malnutrition, that is, a severe shortage of food in a short span of time, stunting occurs more due to longer and chronic undernutrition. In Uttar Pradesh, 46% of children upto the age of six are stunted, while the national average for stunting is much lower at 38%. The districts of Bahraich, Balrampur and Shravasti in the state’s Terai region report even worst rates of stunting: according to the most recent round of the National Family Health Survey, 60% of children living here are stunted.

In addition to the various systemic failures that have led to high maternal and infant mortality in the region, as reported previously in this series, a long standing failure of government policies to provide adequate nutrition is showing up as stunting in children and putting them at greater risk of dying.

Graphic: Anand Katakam, Manas Sharma

To tackle malnutrition, under the Integrated Child Development Scheme, anganwadi centres are supposed to provide hot cooked meals to children between three and six years of age and powdered mixes called take-home rations to those below three. In Uttar Pradesh, however, the scheme is barely functional.

Neither Balrampur or its neighbouring district Bahraich have received any funds from the central or state governments for ICDS interventions for the year 2017-’18, said ICDS programme officers in both districts. Therefore, since April this year, anganwadis in Balrampur have been able to serve hot cooked meals – usually khichdi or daliya – for only 11 days. In Bahraich, no anganwadi in the district has been able to serve hot cooked meals for even a single day.

Such shortages are not new. In Bahraich, freshly cooked meals were made available for about three months in the last three years. But this year, even the distribution of take-home rations was disrupted for a month. In October, the Uttar Pradesh government did not send Bahraich district any supplies of take-home rations, said Sunil Kumar Shrivastav, district programme officer for the ICDS scheme.

Government record showing that the Bahraich block was not supplied with take-home rations in October.

“Villagers think we are lying to them when we tell them that the government has not sent the take-home ration,” said Kumari Ramavati Bharti, an anganwadi worker in Bahraich. Even when families do collect their take home ration, the poor quality puts children off the supplements. “My daughter does not like the powder provided at the anganwadi,” said Salimunissa, whose two-year-old daughter Saheen is severely malnourished.

Tool for exclusion

Compounding these problems, the state government issued an order in May 2017 saying that district officials should distribute take-home rations only to children with Aadhaar cards. Aadhaar is a 12-digit biometrically-linked unique identity number for residents of India, which the government has tried to link to several welfare schemes but such linkages are being challenged at the courts. The order allows that if a child does not have Aadhaar card, the Aadhaar card number of his or her parent can be recorded instead. If neither parent has an Aadhaar card, one of their voter identifications can be used for documentation.

But, on the ground, officials continue to insist on Aadhaar. “We have been asked [by senior ICDS officials] to supply take home ration to only those children who have Aadhaar cards,” said Shrivastav. “In case a child does not have Aadhaar card, we will record the Aadhaar number of one of the parents and encourage them to apply for the card for their offspring.”

In Balrampur as well, health officials are trying to coax parents to enrol their newborns in the Aadhaar database. “We are trying to help these children and parents to get Aadhaar cards,” said Shrivastav.

The move to link take home rations with Aadhaar is ill-advised, say health experts, particularly in a state with such high levels of stunting.

“The anganwadi worker entrusted with the duty to distribute take home ration has a record of all children living in the village,” said Dr Vandana Prasad, a right to food activist. “She knows them by face. Why does she need an ID?”

Prasad said that the government’s insistence on Aadhaar or any form of identity proof shows the its disconnect from ground realities. “No one is thinking about how much exclusion and chaos it is causing,” she said.

Invisible to the healthcare system

Even before the government linked it to Aadhaar, Arbaaz had little chance of getting take-home rations because he has never been enrolled at an anganwadi centre.

Alimunissa delivered all her children at home, like three out of every ten women in Balrampur. When Arbaaz was born, he appeared to be too small and she took him to the hospital, where they weighed him. “He was two kg,” recalled Alimunissa. “They told me to breastfeed him. I did that.”

The hospital staff should have referred Arbaaz to the local anganwadi, which is supposed to provide children between the ages of six months and three years with take-home ration, which is essentially supplementary nutrition that consists of micronutrient fortified or energy dense food.

Alimunissa with her eight-year-old son Arbaaz who is very small for his age and might be stunted. (Photo: Priyanka Vora)

Alimunissa who lives in a slum like settlement called Banjaranpurwa in Balrampur town has never sent any of her children to any anganwadi, neither has she been approached by an anganwadi worker.

“I don’t know where the anganwadi is,” said Alimunissa. She has also not got any of her children vaccinated because she did not know when or where to take them. Despite the presence of grassroots health workers to bring people into the public healthcare system, Alimunissa and her family have fallen through the cracks and have been left to fend for themselves.

“I try feeding Arbaaz thrice a day,” said Alimunissa, who struggles to make ends meet. Both Aluminissa and her husband are daily wage labourers and rely on getting work though the National Rural Employment Guarantee Scheme. However, work under the scheme is uncertain, and in November, neither of them had paying jobs to feed their family of six. Though the family is eligible for subsidised rations from the public distribution system, Alimunissa has been unable to get a ration card.

“I have applied several times but my request keeps on getting rejected,” she said.

Balrampur district supply officer BK Mishra said that he did not know why Alimunissa’s family has been left out of the public distribution system. He said the oversight could be due to office’s records not being updated regularly or gaps in the survey of families below the poverty line who are eligible for rations.

No support for anganwadi workers

It is easy for families like Alimunissa’s to escape the attention of anganwadi workers, who are poorly paid and lack the motivation to perform the hard tasks of tracking poor families and ensuring their nutrition.

“They are rarely paid on time which demotivates them,” said Dr Nomita Kumar, assistant professor at Giri Institute of Development Studies In Lucknow, who had studied the ICDS scheme in Uttar Pradesh.

Moreover, most anganwadis operate out of homes of the anganwadi workers, which rarely have enough space for large numbers of children to sit comfortably. “If we don’t have attractive anganwadis, why will children come there?” asked Kumar.

The ICDS programme decided to construct 200 separate anganwadi centres in Bahraich district during the year 2017-’18. So far, it has finished building 80.

Kiran Devi, an anganwadi worker in Lokhava village of Balrampur, runs an anganwadi centre from the smallest room of her brick home. Devi has worked in the anganwadi system for the last two decades and maintains a register of children who are malnourished. “Earlier, I would go to their homes, but now I can’t walk much, so I distribute take home ration to mothers who come here,” she said.

Anganwadis often lack the tools to do their jobs. Anganwadi workers need to weigh children periodically. Balrampur needs at least 1,044 weighing machines, the district programme officer estimates. “We have only 400 machines,” said Rakesh Sharma, child development project officer in Balrampur.

Earlier in the year, Devi got the dysfunctional weighing machine at her anganwadi replaced. But the new electronic machine did not last long either. In November, the district observed Weight Day, where anganwadi workers were expected to weigh all children in their jurisdiction. “We weighed some children and the machine stopped working,” said Kiran Devi. “We had no option but to estimate the weight of the other children.”

In October, anganwadi workers and helpers in Bahraich and Balrampur joined their counterparts in different districts of Uttar Pradesh in going on strike, asking for an increase the honorarium they are paid. At present, an anganwadi worker in Uttar Pradesh is paid Rs 4,000 per month. The strike, which lasted about two months, disrupted an already precarious system. For instance, on Weight Day, only 22 children were weighed across 44 anganwadis in the urban blocks of Balrampur district. “If we don’t know the proportion of undernourished children, we can’t really focus our efforts,” said Sharma.

Failure of nutrition rehabilitation

Anganwadi workers are supposed to identify severely malnourished children and take them to nutritional rehabilitation centres. They also have to monitor their health, once they go home from these centres.

Uttar Pradesh has 25 nutritional rehabilitation centres, specialised facilities under the National Health Mission to rehabilitate children suffering from severe acute malnutrition. A child is diagnosed with severe acute malnutrition when he or she has very low weight for height. The child may also have symptoms like severe muscle wasting and nutritional oedema characterised by swollen feet, face and limbs as well as medical complications like infections.

However, in the districts of Bahraich and Balrampur, where the proportion of undernourished children is high, these specialised units lie vacant, again due to lack of motivation on the part of poorly-paid anganwadi workers. There have been even fewer children brought to the centre after the anganwadi strike began.

The few children who have been admitted at the nutrition rehabilitation centres have been referred there from district hospital’s where they were admitted for other illnesses like diarrhoea and pneumonia.

A malnourished child being weighed at a nutritional rehabilitation centre in Balrampur. (Photo: Priyanka Vora)

Between 2013-’14 and 2014-’15, the number of children admitted to the centres in Uttar Pradesh dropped by 30%. Shrivastav attributes the drop to a delay in payments to anganwadi workers.

Doctors working in the district say that these specialised nutrition wards do not help tackle malnutrition. “They should shut these wards or ensure that parents bring their malnourished children here,” said Dr KK Verma, a paediatrician at the district hospital in Bahraich. “We are spending Rs 2.5 lakh to Rs 3 lakh on the centres, with zero results.”

He said that at any given time, only three to four beds at the centres are occupied at any given time. “And often, mother run away from the hospitals with their children within a few days, once the symptoms subside,” he said.

Children have to remain at a nutritional rehabilitation centre until they gain specific target weights. This could take between seven and 21 days depending on the extent of the child’s undernourishment.

Dr Ajay Pandey who is in-charge of the nutritional rehabilitation centre at Balrampur said that it is impractical to expect women to give up their daily wages and leave their other children for weeks to look after one child at the nutrition rehabilitation centre. “We have to take the services closer to their homes,” he said.

The nutritional rehabilitation programme has made only a small difference to Rajiya Khatoon, a resident of Bhagwatpur village. Khatoon has ten children – the eldest is 18 and the youngest is two. Her daughters, two-year-old Rehnuma and three-year-old Khushnuma are severely malnourished. Rehnuma weighed only one kg at birth. Khatoon has taken both girls to the nutritional rehabilitation centre at Bahraich, but it is not for the first time.

“The problem is that once they gain weight and are discharged, they again become malnourished,” said Dr Rupam Aggrawal, who runs the nutrition rehabilitation centre in Bahraich.

Rajiya Khatoon feeding her severely malnourished daughter. Khatoon has 10 children. (Photo: Priyanka Vora)

Such relapses occur due to two main factors – how much attention the mother can give the child and the child’s exposure to infection.

Aggarwal said that while at home, women like Khatoon have to cook, maintain the house and look after all their children. “Here her focus is only one child which automatically improves the feeding and care that the child gets,” he said.

Malnourished children are likely to have low immunity and are more likely to contract infections like diarrhoea and pneumonia. The Balrampur and Bahraich districts also happen to have the lowest immunisation rates in Uttar Pradesh and are among the lowest across the country. Children who are not fully immunised become vulnerable to recurrent infections.

“Any infection leads to weight loss in these children making them undernourished,” said Verma. “So, it becomes a vicious cycle.”

And that is why Khatoon finds herself coming back to the nutrition rehabilitation centre again and again. “I go home and feed them properly but they keep falling sick and lose weight quickly,” she said.