Mapping India’s Children: UNICEF in Action
Mapping India’s Children: UNICEF in Action
All rights reserved First published 2004 1 3 5 7 9 10 8 6 4 2 ISBN: 92 806 3796 7 Produced for UNICEF by Myriad Editions Limited 6–7 Old Steine, Brighton BN1 1EJ, UK www.MyriadEditions.com Copyright © The United Nations Children’s Fund (UNICEF) 2004 For permission to reproduce any part of this publication, please contact the Communication Section at UNICEF. Permission will be freely granted to educational or non-profit organisations. Others will be requested to pay a small fee. UNICEF, 73 Lodi Estate New Delhi 110 003, India Tel: +91 11 2469-0401, Fax: +91 11 2462-7521 and +91 11 2469-1410 Email: newdelhi@unicef.org Website: www.unicef.org/india Cover photo: © UNICEF India / Ami Vitale 2003; India Today: UNICEF India / Ami Vitale 2003; Health: Child kissing at mother’s nose, Mother breast feeding, Pregnant women © UNICEF India/ Amar Talwar 1986; Mother in blue sari with child in lap, Girl child © UNICEF India / Ami Vitale 2003; Polio drop being administered © UNICEF India / Sandeep Biswas; Child Development and Nutrition: Mother breast feeding, Mother breast feeding with toddler © UNICEF India/ Amar Talwar 1986; Mother in magenta sari with child © UNICEF India/ Gurinder Osan 1999; Girl eating bread © UNICEF India/ Sondeep Shankar 1998; Group of children eating, Two children with serving plates © UNICEF India / Ami Vitale 2003; Child’s Environment: Boy carrying water © UNICEF India / Sanjay Barnela 1997; Girl holding soap case © UNICEF India / Ami Vitale 2003; Boy washing face © UNICEF India/ Gurinder Osan 1999; all others © UNICEF India; Education: Girl riding bicycle, Girls practising karate, Boy reading, Laughing girls © UNICEF India / Ami Vitale 2003; Girls in school uniform © Heather Gratton 2003; Girl with pencil © UNICEF India/ Gurinder Osan 1999; HIV/AIDS: Parents with child, Women waiting, Mother and child in green © UNICEF India / Ami Vitale 2004; Child Protection: Smiling girl © UNICEF India/ Gurinder Osan 1999; all others © UNICEF India / Ami Vitale 2003 Printed and bound in Hong Kong, China through Phoenix Offset Limited
Introduction India is home to the largest number of children in the world. Millions more are born every year, far more than in any other country. But what distinguishes India is not merely the sheer numbers, but rather the intricate and complex pattern of differences that emerges through gender, caste and geography. Out of a hundred children born in India today: 35 of those births will be registered 93 will make it to their first birthday 51 will be fully immunised 5 will die of malnutrition 42 will remain underweight which will affect their performance throughout their lives 25 will complete primary school Furthermore, these numbers vary greatly when gender is taken into account. For example, in Uttar Pradesh, 70 per cent of boys aged 6–10 years attend school but only 43 per cent of girls. Add to this the place where a child is born and his or her caste, and further inequalities emerge: malnutrition in India currently stands at 47 per cent, but the figure for scheduled castes is 54 per cent and for scheduled tribes it is even higher, at 56 per cent. Only by examining these differences, can we really begin to understand the chances of a child’s survival, good health, equitable access to education and protection from exploitation and harm. It is this complex and, at times, paradoxical setting that makes planning and implementing development work in India so challenging. The marked disparities between regions and social groups, between rich and poor, and between the sexes mean that there is no straightforward way to overcome the obstacles preventing so many children from reaching their full potential. The maps in this atlas illustrate some of these disparities and the very particular challenges posed by this vast and complex country. With almost half of the total population living in just eight of India’s most under-developed states, the country’s development as a whole, as the Government of India acknowledges, largely depends on the human and economic development here. Working closely with the Government, UNICEF is uniquely positioned to help meet these development challenges. It is the largest UN organisation in India and has been operating in the country since 1949, building up sound research and an extensive field presence over the decades. Its network of ten state offices enables the organisation to focus attention on the poorest and most disadvantaged communities in addition to its work at the national level. As this atlas shows, UNICEF’s policies and practices support the Government transform its commitment into the action that is needed in order to save, protect and improve the lives of children throughout India. Cecilio Adorna Representative UNICEF India
India Today India and its Children • Contrasts and Challenges • Commitments and Responsibilities • UNICEF in India •
6 8 10 12
Reproductive and Child Health • Child Development and Nutrition • Child’s Environment • Elementary Education • HIV / AIDS • Child Protection •
14 22 30 38 46 54
Table and sources • 62 Index • 64 4
5
India and its Children
I
ndia is home to 414 million children and 26 million more are born every year – more than in any other country. The multitude of religions, languages, dialects, ethnic groups and cultural backgrounds in this vast and diverse country, combined with a wide range of socio-economic groups, can humble those who try to summarise the rapid changes that are taking place in India today.
India Today
India has made considerable economic and social progress since independence. Hundred of thousands of people now enjoy healthier and longer lives and greater access to basic education. India’s economy is racing ahead; the stock market is buoyant and foreign exchange reserves are at unprecedented levels. The information and communication technology revolution has positioned India as one of the world leaders in this important and growing sector. The vibrant civil society and robust democratic tradition has enabled the population to participate actively in decisions affecting their lives. However, the benefits of the economic transformation taking place in India have not been equally shared and disparities are growing. There are 260 million people currently living below the poverty line; one
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out of every two children under three years of age is malnourished; nearly 1.8 million infants die each year, most from preventable causes; every four minutes a woman dies in childbirth or from pregnancy-related causes; discrimination against the girl child continues, and is perhaps most visible in the declining child sex ratio. The challenge is to bridge these widening disparities so that all of India’s children can benefit from the country's transformation. The Government’s commitment is reflected in the Constitution and 10th Five Year Plan, as well as its ratification of the Convention on the Rights of the Child. Transforming this commitment into action will ensure that each and every child reaches its full potential.
Population Population of India’s states compared to populations of countries Sources: Census of India 2001, SOWC 2004 Uttar Pradesh 166 million 97 Maharashtra 83 Bihar 80 West Bengal 76 Andhra Pradesh 62 Tamil Nadu 60 Madhya Pradesh 56 Rajasthan 53 Karnataka Gujarat 51 37 Orissa Kerala 32 Jharhand 27 Assam 27 Punjab 24 21 Haryana Chhattisgarh 21 Delhi 14 Jammu & Kashmir 10 Uttaranchal 8
176 million 102 Mexico 82 Germany 80 Vietnam 79 Philippines 62 Thailand 60 France 57 Italy 51 Congo, Dem. rep. 49 Ukraine 38 Argentina 31 Canada 27 Peru 26 Uzbekistan 25 Uganda 22 Romania 20 Ghana 14 Cambodia 10 Belgium 8 Austria
Brazil
India’s share of world responsibilities Progress since 1951
Sources: SOWC 2004, UNAIDS
• Life expectancy at birth
maternal deaths
25%
people living on less than $1 a day
More than doubled: 32 years in 1951 64 years in 2001
underweight children
• Literacy
34%
28%
people living with HIV/AIDS
under-5 children deaths
13.5%
23%
India is home to 19% of the world’s children
Six-fold increase in female literacy: 9% in 1951 54% in 2001
Progress in India In the 57 years since attaining independence, India has made remarkable progress, but the high economic growth rates of the recent past have not been matched in the social sector. Important policies and programmes, aimed at improving people’s lives, have led to significant progress in certain key social indicators, including life expectancy and literacy rates, but translating these polices into measures that improve social services and empower communities, children and women throughout the country is the key challenge for the years to come. This is made more urgent because investment in the social sector brings the additional benefit of accelerating and sustaining economic growth.
Income growth vs. infant survival
Income Per capita income in Rs
10,067
10,254
9,647 9,007
9,242
8,489
7,212
920
920
1990
1991
7,433
Decrease in proportion of the population living below the poverty line: 55% in 1973–74 26% in 2000
129 per 1,000 in 1971 63 per 1,000 in 2002
• Smallpox eradicated
8,070 7,321
• Poverty
• Infant mortality
Source: Selected Socio-economic Statistics, India 2001 and Sample Registration System
Infant survival Number reaching the age of one per 1,000 live births
Male literacy rates almost tripled: 27% in 1951 76% in 2001
7,690
921
926
926
926
928
929
928
930
932
1992
1993
1994
1995
1996
1997
1998
1999
2000
• Guinea-worm disease eradicated
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Contrasts and Challenges
I
ndia is a country of contrasts and great complexity. The picture is not simply one of rich versus poor. Rather, the enormous challenges for development are the marked disparities among different geographical regions, between social groups, among different income levels and between the sexes. Even within states there are marked differences. Female literacy rates in Maharashtra, for example, range from 83 per cent in the district of Mumbai to 46 per cent in Nandurbar. Similarly, while the average child sex ratio for Maharashtra is 917 females per 1,000 males, it ranges widely between districts: from 974 in the district of Gadchiroli to 850 in Sangli. Malnutrition afflicts more than half of all rural children even as problems related to obesity threaten their more affluent peers. While India boasts of state-of-the-art hospitals offering some of the best medical
care in the world, there are communities where a health worker has not been seen for years. The growth of modern infrastructure in cities contrasts with the most basic needs: only two out of every three urban households have water taps and three out of every four have toilets. The Indian Institutes of Technology provide world-class education to thousands, while over 190 million Indian women remain illiterate. Gender disparity is evident as almost twice as many girls as boys are pulled out of school, or never sent to school.
Birth registration Percentage of children aged under 5 years who are not registered at birth Source: MICS 2000
India Today
India average: 65%
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more than 75% 50% –75% 25% – 50% fewer than 25% no data
Birth registration is an area where there are significant differences between states, ranging from only 2 per cent of births being registered in Bihar to 95 per cent in Goa. With such diversity throughout the country, it is important for reliable disaggregated information to be available and used at all levels. While monitoring progress towards the national targets as outlined in the 10th Five Year Plan is important, data should also be generated and analysed at local levels to ensure that services reach the most disadvantaged. Through evidence-based programming and targeting, resources can be directed to the most disadvantaged populations, resulting in a narrowing of the disparities.
Health and education expenditure in context Percentage of central government expenditure allocated to health and education Source: SOWC 2004
30% 24% 18% 16%
12% 5% India
Brazil
Sri Lanka
Viet Nam
Philippines
Thailand
Child sex ratio – gender disparity The number of girls per 1,000 boys, in the 0–6 age-group, fell sharply from 945 in 1991 to 927 in 2001 – a reflection of the continuing discrimination against the girl child. Some of the worst declines were in more prosperous states, such as Gujarat, Haryana, Himachal Pradesh and Punjab. Easy access to PreNatal Diagnostic Tests that help in sex-determination, and selective abortion of the female foetus, combined with rising purchasing power in these states, appear to have cost the girl child dearly.
Number of females aged 0–6 years per 1,000 males Source: Census of India 2001 India average: 927 fewer than 850 851 – 899 900 – 949 950 and above
Education – rural-urban disparity The rural–urban geography of gender disadvantage is more acutely reflected in school education data. Further, school attendance is better in urban areas: 86 per cent of girls aged 6–14 attend school in urban areas as opposed to 70 per cent in rural areas.
79.3%
90.4% 84.1%
68.4%
63.5%
Rural
Percentage of children aged 6–10 years attending school Source: NFHS-2 81.9%
1992–93
Urban
1998–99
Total
Malnutrition – intrastate disparities Malnutrition is common across the whole of India. The highest levels are found in Bihar, Orissa, Madhya Pradesh, Rajashthan and Uttar Pradesh. In these states, more than half of the children aged under three are malnourished. In Kerala, malnutrition levels are contrastingly low. Several factors contribute to these differences between states: the parents’ level of knowledge about infant feeding, hygiene and care of a sick child; health service delivery; genderrelated socio-economic issues.
Percentage of children aged under 3 years who are underweight Source: NFHS-2 India average: 47% 50.0% and above 40.0% – 49.9% 30.0% – 39.9% below 30.0% no data
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Commitments and Responsibilities
T
he 10th Five Year Plan of the Government of India acknowledges the huge challenges before the social sector as well as the existing disparities throughout the country. Its targets and benchmarks to achieve development are more ambitious than the Millennium Development Goals. Within its national targets, the government aims to improve the demographic indices of the least developed states. It acknowledges that the human and economic development of the country will depend on eight states, all with a poor human development record, because they constitute almost half of India’s population. Constitutionally, states can frame their own policy on certain issues, such as
education and health, which is why state and district levels are key focuses for UNICEF action. India’s ratification of the Convention on the Rights of the Child and the Convention on the Elimination of all Forms of Discrimination Against Women, and its signing of the World Fit for Children, all set a powerful framework for committed action by the government and civil society at large.
Commitments made by the Government of India • Poverty
by 2007: Poverty ratio reduced by 5 percentage points by 2012: Poverty ratio reduced by 15 percentage points
• Education
by 2003: All children in school by 2007: All children to complete 5 years of schooling
India Today
• Literacy
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by 2007: At least 50% reduction in gender gap in literacy 75% increase in literacy rates
• Birth
by 2010: 80% institutional deliveries and 100% deliveries by trained birth attendents 100% registration of births
• Infant mortality
by 2007: Reduction of infant mortality (IMR) to 45 per 1,000 live births by 2012: Reduction of infant mortality (IMR) to 28 per 1,000 live births
• Maternal mortality
by 2007: Reduction of maternal mortality (MMR) to 200 per 100,000 live births by 2012: Reduction of maternal mortality (MMR) to 100 per 100,000 live births
• Water
by 2007: All villages to have sustained access to potable drinking water All major polluted rivers cleaned
• HIV / AIDS
by 2007: 80% coverage of high-risk groups through targeted interventions 90% coverage of schools and collages through education programmes 80% awareness among general population in rural areas
• Child labour
No child below 14 years of age shall be employed to work in any factory or in any hazardous employment (Constitution of India, Article 24)
Education for All programme The Government of India’s Education for All programme aims to ensure that, by 2007 all children complete at least five years of schooling. The government is taking measures to get all children into school and also to retain them there, with a special focus on girls and other disadvantaged groups. The measures include a primary school within one kilometre of every habitation, adequate and wellmaintained school buildings, and an emphasis on provision of quality education. The programme is committed to bridging the existing gender gap in education as a critical step towards achieving Education for All goals.
100%
Percentage of children aged 6–10 years currently in school Source: MICS 2000
85.9% 78.6%
Male
Female
2007 target
Reproductive and Child Health programme
Total Sanitation Campaign
The Reproductive and Child Health (RCH) programme is seeking ways to perfect, accelerate and scale up successful interventions presently being implemented to reduce maternal, neonatal and child mortality. Strategies are designed to increase access to, availability of and the utilisation of quality services. These include skilled attendance at birth, fixed-day immunisation sessions, mobility and supervisory support for outreach sessions, safe injection practices and behaviour change communication (BCC).
Launched in 1999, the Government’s Total Sanitation Campaign (TSC) aims to transform attitudes and behaviours related to rural sanitation and hygiene, with the participation of panchayats (village governing bodies), NGOs and the private sector. TSC generates, and responds to, demand for sanitation and hygiene in homes and communities, moving from high to low subsidies for toilet construction and introducing rewards for communities that eliminate open defecation and achieve cleanliness in homes, schools and anganwadi (childcare) centres.
Maternal Mortality Ratio (MMR)
present: 540
Integrated Child Development Services (ICDS) is the world's largest early child development programme. It reaches more than 34 million children aged 0–6, and more than 7 million pregnant and nursing mothers from disadvantaged community groups through 612,000 anganwadi (childcare) centres across the country. It converges basic services for integrated early child development.
Annual number of deaths of women from pregnancy-related causes per 100,000 live births target: fewer than 100 by 2012
present: 63
Infant Mortality Rate (IMR) Number of babies per 1,000 born alive who die before target: the age of one
HIV / AIDS The objective of the National AIDS Control policy is to prevent the epidemic from spreading further. It envisages effective containment of the infection levels of HIV/AIDS in the general population in order to achieve zero-level of new infections by 2007.
fewer than 30 by 2010
Immunisation Percentage of children aged 12–23 months fully immunised
target: 100% by 2010
Integrated Child Development Services
present: 57%
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UNICEF in India
U
India Today
NICEF has been working in India since 1949. The largest UN organisation in the country, it is currently implementing a $400 million programme from 2003 to 2007.
12
UNICEF is fully committed to working with the Government of India to ensure that each child born in this vast and complex country gets the best start in life, thrives and develops to his or her full potential. The challenge is enormous but UNICEF is well placed to meet it. The organisation uses quality research and data to understand issues, implements new and innovative interventions that address the situation of children, and works with partners to bring those innovations to fruitition. What makes UNICEF unique in India is its network of ten state offices. These enable the organisation to focus attention on the poorest and most disadvantaged communities, alongside its work at the national level. UNICEF uses its community-level knowledge to develop innovative interventions to ensure that women and children are able to access basic services such as clean water, health visitors and educational facilities, and that these services are of high quality. At the
same time, UNICEF reaches out directly to families to help them to understand what they must do to ensure their children thrive. UNICEF also wants them to feel a sense of ownership of these services. That same knowledge and interface with communities enables the organisation to tackle issues that would otherwise be difficult to address: the complex factors that result in children working, or the growing threat that HIV/AIDS poses to children. UNICEF knows that key to addressing these challenges are its partnerships with sister UN agencies, voluntary organisations active at the community level, women’s groups and donors. The organisation also works with an array of celebrities, including members of the Indian cricket team and leading actors from the Indian film industry, as well as hundreds of thousands of unnamed volunteers who tirelessly give their time and influence to ensure that, together, they are able to help every child realise his or her full potential.
Monitoring and Evaluation: UNICEF‘s objectives Key components of the monitoring and evaluation system include:
• Supporting evaluations at key times in the project cycle
• Synchronising information collection and dissemination for optimal use in decision-making
The programme also actively propagates the use of data related to children and women, especially those from marginalised communities. It also encourages the use of data related to current trends vis-à-vis established targets to enable decision-makers to take proactive steps to meet established targets.Key
• Streamlining major data-gathering activities in support of key results • Helping improve accountability by allowing a transparent overview of how performance is appraised
UNICEF projects by district 2003–2007 districts in which UNICEF has projects
JAMMU AND KASHMIR
UNICEF State Offices UNICEF Country Office
HIMACHAL PRADESH PUNJAB UTTARANCHAL
CHANDIGARH HARYANA
DELHI
ARUNACHAL PRADESH
SIKKIM
UTTAR PRADESH
ASSAM
RAJASTHAN BIHAR
NAGALAND
MEGHALAYA MANIPUR
JHARKHAND
GUJARAT
WEST BENGAL
TRIPURA MIZORAM
MADHYA PRADESH CHHATTISGARH
ORISSA
MAHARASHTRA
DAMAN AND DIU DADRA AND NAGAR HAVELI
ANDHRA PRADESH GOA
KARNATAKA PONDICHERRY LAKSHADWEEP
ANDAMAN AND NICOBAR ISLANDS
TAMIL NADU KERALA
UNICEF programme structure 2003–2007 Children aged under 3
Reproductive and Child Health
Child Development and Nutrition
Children of school age
Child's Environment: sanitation, hygiene and water supply
Advocacy and Partnership
Elementary Education
Adolescents
Child Protection
HIV / AIDS
Planning, Monitoring and Evaluation
13
Reproductive and Child Health
14
15
Reproductive and Child Health The Picture in India
D
espite health improvements over the last 30 years, lives continue to be lost to early childhood diseases, inadequate newborn care and childbirth-related causes. More than 2 million children die every year from preventable infections.
16
33
24
62
29
31
35
33
57 26
31
31
52
51
51
51
34
25
26
30
26
25
21
18
48 25
14 8
Kerala
Andhra Pradesh
31
62
Maharashtra
30
Karnataka
65
43
Bihar
67
Gujarat
44
West Bengal
41
75
Tamil Nadu
44
46
Himachal Pradesh
45
79
per 1,000 live births Source: Sample Registration System 2000
Punjab
Health
Infant deaths within 7 days of birth (early neonatal mortality)
42
Haryana
43
Infant deaths 83
Assam
87
Rajasthan
50
Uttar Pradesh
Infant deaths between 7 days and 1 year of birth
95
Madhya Pradesh
Total number of infant deaths
Orissa
14% of deaths amongst women of childbearing age is due to pregnancy or childbirth
to vaccine-preventable diseases such as measles, which remains the biggest killer. Tetanus in newborns remains a problem in at least five states: Uttar Pradesh, Madhya Pradesh, Rajasthan, West Bengal, and Assam. The number of polio cases in India declined from 1,934 in 1998 to 268 in 2001. There was a setback in 2002 as 1,600 cases were confirmed at the end of the year. But with only 225 cases of polio reported in 2003, India is well on its way to interrupting transmission and eradicating the disease. However, the proportion of children who receive vaccination against measles has dropped considerably, from 72% in 1995 to a low of 50% in 1999. It now stands at 61%.
Infant mortality in India is as high as 63 deaths per 1,000 live births. Most infant deaths occur in the first month of life; up to 47 per cent in the first week itself. While the Infant Mortality Rate showed a rapid decline during the 1980s, the decrease has slowed during the past decade. Maternal deaths are similarly high. The reasons for this high mortality are that few women have access to skilled birth attendants and fewer still to quality emergency obstetric care. In addition, only 15 per cent of mothers receive complete antenatal care and only 58 per cent receive iron or folate tablets or syrup. Children in India continue to lose their life
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6
106
India in context Infant Mortality Rate Number of babies per 1,000 born alive who die before the age of one Source: SOWC 2004, Sample Registration 5 System 2002 High-income countries
56
World
62
63
Developing countries
India
70
South Asia
Sub-Saharan Africa
Infant Mortality Rate Number of babies per 1,000 born alive who die before the age of one India average: 63 42% JAMMU AND KASHMIR
80 and over
Birth attendance
60 – 79
Percentage of births attended by a health professional India average: 42%
40 – 59
30% of the world’s neonatal deaths occur in India
HIMACHAL PRADESH
40%
PUNJAB CHANDIGARH
fewer than 50%
fewer than 40
Sources: Sample Registration System 2002; NFHS-2
no data
UTTARANCHAL
HARYANA
35% 42%
DELHI
UTTAR PRADESH
35%
ARUNACHAL PRADESH
SIKKIM
32%
36% 22%
BIHAR
23%
JHARKHAND GUJARAT
MADHYA PRADESH
30%
18% CHHATTISGARH
DAMAN AND DIU DADRA AND NAGAR HAVELI
NAGALAND
ASSAM
RAJASTHAN
MAHARASHTRA
32%
ORISSA
MEGHALAYA
WEST 21% BENGAL
21% 33% MANIPUR
TRIPURA
48%
MIZORAM
44%
33%
ANDHRA PRADESH
69 die per 1,000 live births
ANDAMAN AND NICOBAR ISLANDS
GOA LAKSHADWEEP
KARNATAKA
40 die per 1,000 live births
PONDICHERRY
TAMIL NADU KERALA
Rural
Government of India Action on Health • Strengthen existing health systems by increasing the number of health workers • Prevent newborn deaths through home-based medical visits • Increase children’s access to immunisation
Urban
Rural and urban differential in IMR Source: Sample Registration System 2002
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Reproductive and Child Health UNICEF in Action
U
NICEF supports the national Reproductive and Child Health (RCH) programme in its aim to reduce maternal, neonatal and child mortality by improving healthcare services for communities.
in a community’s overall health. Hepatitis B vaccine is being integrated into the existing routine immunisation programme, and in its initial phase has been introduced in 15 cities and 32 districts across the country. A second area of focus is maternal and newborn care: UNICEF trains birth attendants in areas that have reported fewer than 30 per cent of deliveries as safe. It also focuses on obstetric care and early complications, and on reducing the delays in seeking medical care, reaching a medical facility and receiving adequate care. As health and nutrition are inseparable, in BDCS districts, nurses (ANMs) and nutritional workers (AWWs) work as a team to ensure increased quality and functional synergy at subdistrict and village level. A crucial component within UNICEF’s assistance to the RCH programme is the Integrated Management of Neonatal and Progress in Immunisation Childhood Illnesses (IMNCI), an innovative Percentage of children aged 12–23 months approach to tackle early newborn and child who received measles vaccination deaths through home-based visits. UNICEF Source: WHO/UNICEF 2001; CES 2002 helped adapt the global strategy in 72% collaboration with experts from the World 67% 66% 61% Health Organization. A pilot project of the 59% 56% 55% 51% 51% 50% IMNCI is currently underway in five states. 43%
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2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
Health
UNICEF’s primary support is through the Border District Cluster Strategy (BDCS), an initiative spearheaded by the Government and designed to reduce maternal and infant deaths in 49 under-developed districts. Within BDCS, the Immunisation Plus project aims to increase multiple antigen immunisation coverage and Vitamin A supplementation. It supports the Government’s efforts to eradicate polio and tetanus in newborns and to ensure more effective measles control. It focuses on reaching under-reached and un-reached children with meticulously planned outreach sessions. UNICEF also promotes awareness among decision-makers, donors, partners and Government functionaries about how routine immunisation is a crucial investment
UNICEF Action on Health • Promote acceleration of routine immunisation • Provide quality care for women and newborns and safe deliveries • Monitor district-level availability, access, utilisation, quality and effective coverage of services
Children fully immunised Source: DLHS-RCH 2002
fewer than 50% 50% – 75% more than 75%
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) Close to 50 per cent of newborn deaths in India occur during the first seven days of birth. Many young lives are lost due to parents failing to recognise warning signs and sick children not being taken to health facilities on time, and because many mothers do not have sufficient knowledge on the protective value of breastfeeding. The IMNCI addresses such issues. It focuses on strengthening homebased care and provides HIMACHAL special care for under-nourished newborns. During home visits by health PRADESH workers the mother is taught how to recognise diseases early and when to PUNJAB seek medical help. She is also educated on the benefits of exclusive CHANDIGARH UTTARANCHAL breastfeeding. UNICEF has initiated the programme in one district in each of the following five states – Maharashtra, Rajasthan, Gujarat, HARYANA Tamil Nadu and Madhya Pradesh – with plans to ARUNACHAL expand it into 20 other districts across the country. JAMMU AND KASHMIR
UNICEF in Action
PRADESH
DELHI
SIKKIM
UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
JHARKHAND MADHYA PRADESH
GUJARAT
NAGALAND
MEGHALAYA TRIPURA
WEST BENGAL
MANIPUR
MIZORAM
CHHATTISGARH DAMAN AND DIU
MAHARASHTRA
DADRA AND NAGAR HAVELI
ANDHRA PRADESH GOA
KARNATAKA
KERALA
PONDICHERRY
TAMIL NADU LAKSHADWEEP
Immunisation Plus
ORISSA
ANDAMAN AND NICOBAR ISLANDS
In addition to collaborating with the Government’s Pulse Polio Immunisation programme, UNICEF promotes an integrated routine immunisation strategy for polio eradication, measles control, newborn tetanus elimination and Vitamin A supplementation at the state, district and subdistrict levels. Some weeks before the national and state immunisation days, UNICEF provides support at the district and sub-district levels in identifying areas where services need to be urgently provided and in ensuring their delivery. UNICEF encourages social mobilisation as a means of reaching the maximum number of people by engaging community-based groups and self-help groups. The power supply needed to store the vaccine is unreliable in some states, so UNICEF supports monitoring and supervision of storage and transport equipment. The use of auto-disposable syringes remains crucial to injection safety; UNICEF works to help raise awareness about this.
Community action for safe motherhood Dhar, Madhya Pradesh Dhar is a predominantly tribal district in southwestern Madhya Pradesh. Most deliveries take place at home. Long distances, the shortages of trained nurses, equipment and supplies and, of course, the lack of proper maternity wards in health centres, are the key deterrants to institutional deliveries in this area. Through local community structures, such as the Village Health Committees, Panchayati Raj Institutions and self-help groups, and in co-ordination with the District Administration, UNICEF has helped to raise awareness and concern among families in the villages. More than 90 Auxiliary Nurse and Midwives (ANMs), from four blocks, were trained in standard midwifery practices and the equipment needed for standard deliveries has been provided. The referral health centre in Kukshi block of Dhar is now just one of several with an efficient maternity ward. As a result, in Kukshi alone, there has been a 10 per cent increase in institutional deliveries between 2001 and 2003.
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Inspired Champions On the face of it, Noorjehan, a mother in her mid-fifties, is like any other woman of her community in India’s northern state of Uttar Pradesh. She has four children, two of whom work in Saudi Arabia, sending back enough money to ensure their mother, who lives in the state’s eastern district of Basti, has a comfortable life in what is largely an under-developed area. But what distinguishes her is her mission: to help eradicate polio from her community.
Health
I have freed 14 immunisationresistant villages in this district. Everyone in the area knows me. I love my work
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Wealthy enough to buy additional property or other assets, Noorjehan spends her resources rather unusually – on raising money to help increase awareness about polio. She travels between villages in a hired jeep, educating people about the immunisation programme and, not being literate herself, pays a young man to help her complete paperwork related to polio. Her lined face breaks into a proud smile when she says, “I have freed 14 immunisation-resistant villages in this district. Everyone in the area knows me. I love my work.” Noorjehan is one of UNICEF’s 3,000 community mobilisers working to free the state of Uttar Pradesh from polio. She is also one of the many thousands who are making a crucial contribution to improving the state’s public-health profile. In 2003, Uttar Pradesh accounted for more than 88 per cent of the world’s current polio cases. UNICEF, along with government authorities and partners such as Rotary and CORE, is leading a large-scale strategic intervention mobilising communities and
families to increase immunisation coverage. The result of one such elaborate intervention is that clusters resistant to immunisation have been identified and progressively addressed with specific messages. Around 452 blocks (sub-district administrative areas) of UP have a social mobilisation coordinator (SMC), and each block has a block mobilisation co-ordinator (BMC) with several community mobilisers (CMC) under him or her. Together, they are bringing about a quiet revolution to help turn around the fate of one of India’s poorest and most densely populated areas. The three-tiered set-up of the SMC, BMC and the CMC do receive financial compensation for their work. But for most, the work is more like a calling. The mobilisers educate communities on nearly everything, ranging from reproductive health, child immunisation and demonstrations on Oral Re-hydration Salts to the critical importance of polio immunisation. Although awareness activities carry on around the year, they reach a crescendo just before the stipulated national immunisation days, when polio booths are set up across the state and house-to-house immunisation takes place. The mobilisers concentrate on techniques proven to work most effectively. Intensive one-to-one sessions are combined with saas-bahu sammelans (mother-in-law, daughter-in-law meetings), rallies, slogans and health melas (or fairs). The mobilisers are chosen with care so that each is familiar with virtually every family in his or her area.
At first, there were a lot of resistant homes in the village. Now there is not a single one
Mohammed Tyeb is an imam (or cleric) in Jogapur village in the state’s Basti district. This community mobiliser is a respected man in the area, with five children of his own. “At first, there were a lot of resistant homes in the village. Now there is not a single one,” he says proudly.
We remind people about the smallpox virus and the kind of suspiciousness it had been met with initially – but also how effective immunisation against it has been
So how does he motivate people of his community, which is particularly resistant to immunisation, who fear it would lead to impotency and infertility? “We remind people about the smallpox virus and the kind of suspiciousness it had been met with initially – but also how effective immunisation against it has been,” says Tyeb. Others like him repeat this argument and it helps strike a chord, particularly amongst members of the older generation who remember the time when smallpox was rampant. “We have to approach people with what they understand. Just telling them about immunisation in the abstract does not help,” says Onkar Nath Upadhyaya, a social mobiliser responsible for supervising seven other mobilisers who work under him. All day he roams the rutted, pot-holed roads of villages, talking, convincing and cajoling. As we walk with him, Mr Upadhyaya points to the work going on in his area. There are wall writings everywhere, rallies with several hundred children were held one day before booth day. A fellow community member is appreciative of the work UNICEF does,
despite the fact that his one-year-old niece has been diagnosed with polio. The untiring mobiliser is proud of his record. His area is virtually free of resistance. Other community mobilisers have virtually moved in with resistant families to help break their reluctance. Faced with hostility from the khatiks, or gypsies, in his area, Ram Naresh Singh actually lived with them for 15 days at a time, talking to them and convincing them to bring their children to the booth on pulse polio day. “I ate with them and drank with them. It helped. There is no resistance left in this area,” he says.
We know exactly which house in the area has refused the drops, and we will redouble our efforts to break this resistance
But others have a tougher time. Kamaluddin is the block mobilisation coordinator of Semariyan, an area known locally to be a hotspot for polio. He has to deal with daily rejection by people who throw him out of their house or bang their doors shut on him. But the young man carries on almost unaffected. “I do think I have been successful in the face of such resistance. We know exactly which house in the area has refused the drops, and we will redouble our efforts to break this resistance.” This relentless dedication is producing results. There are thousands of community mobilisers working to inspire awareness and sustain demand for immunisation to help lead to the eradication of polio in villages throughout India. They know that if Uttar Pradesh does not increase routine immunisation coverage and eradicate polio, India cannot eradicate polio. For as long as polio exists in India, it continues to pose a threat to the world at large.
21
Child Development and Nutrition
22
23
Child Development and Nutrition The Picture in India
M
Nutrition
1 in 3 of the world’s malnourished children lives in India
24
alnutrition is more common in India than in Sub-Saharan Africa. One in every three malnourished children in the world lives in India.
Malnutrition limits development and the capacity to learn. It also costs lives: about 50 per cent of all childhood deaths are attributed to malnutrition. In India, around 46 per cent of all children below the age of three are too small for their age, 47 per cent are underweight and at least 16 per cent are wasted. Many of these children are severely malnourished. The prevalence of malnutrition varies across states, with Madhya Pradesh recording the highest rate (55 per cent) and Kerala among the lowest (27 per cent). Malnutrition in children is not affected by food intake alone; it is also influenced by access to health services, quality of care for the child and pregnant mother as well as good hygiene practices. Girls are more at risk of malnutrition than boys because of their lower social status. Malnutrition in early childhood has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults, at greater risk of disease and early death. Around one-third of all adult women are underweight. Inadequate care of women and girls, especially during pregnancy, results in lowbirthweight babies. Nearly 30 per cent of all
newborns have a low birthweight, making them vulnerable to further malnutrition and disease. Vitamin and mineral deficiencies also affect children’s survival and development. Anaemia affects 74 per cent of children under the age of three, more than 90 per cent of adolescent girls and 50 per cent of women. Iodine deficiency, which reduces learning capacity by up to 13 per cent, is widespread because fewer than half of all households use iodised salt. Vitamin A deficiency, which causes blindness and increases morbidity and mortality among pre-schoolers, also remains a public-health problem.
Anaemia in India Anaemia has a serious impact on learning capacity, productivity and survival Sources: NFHS-2, DLHS-RCH-2 95.0% 74.3% 52.0%
children under three years
adolescent girls
married women
India in context Underweight under-fives Percentage of young children who are underweight Source: SOWC 2004
46%
27%
27%
World
Developing countries
47%
29%
Sub-Saharan Africa
South Asia
India* * Under 3s
Underweight under-threes Percentage of children aged under three who are underweight India average: 47%
Use of iodised salt
50% and over JAMMU AND KASHMIR
over 30% of households use salt without iodine
40% – 49%
Source: NFHS-2 30% – 39%
HIMACHAL PRADESH
20% – 29%
PUNJAB CHANDIGARH
UTTARANCHAL
no data
HARYANA
DELHI UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
MANIPUR
TRIPURA
WEST BENGAL
MADHYA PRADESH
NAGALAND
MEGHALAYA
JHARKHAND GUJARAT
ARUNACHAL PRADESH
SIKKIM
MIZORAM
CHHATTISGARH DAMAN AND DIU DADRA AND NAGAR HAVELI
ORISSA MAHARASHTRA
ANDHRA PRADESH
GOA
KARNATAKA
47% of children aged under three are underweight
ANDAMAN AND NICOBAR ISLANDS
PONDICHERRY LAKSHADWEEP
TAMIL NADU KERALA
Government of India Action on Nutrition • Commitment to reduce malnutrition and low birthweight through national and state-level policies • Use of community-based approach to address malnutrition and child development • Provision of Vitamin A and iron supplementation to address damage caused by vitamin and mineral deficiencies
25
Child Development and Nutrition UNICEF in Action
U
Nutrition
NICEF supports the Government in its objectives to reduce and prevent malnutrition, and to improve the development of children under three years old, especially those in marginalised groups.
26
The Government’s Integrated Child Development Services (ICDS) programme, reaches 34 million children aged 0–6 years and 7 million pregnant and nursing mothers. The world’s largest early childcare and development programme, it is designed to play a significant role in the improvement of early childcare. UNICEF is assisting the Government to further expand and enhance the quality of ICDS in various ways: by improving the training of anganwadi (childcare) workers; by developing innovative communication approaches with mothers; helping to improve monitoring and reporting systems; providing essential supplies; by developing community-based early childcare interventions. Vitamin A and anaemia programmes are strengthened through the provision of supplies, the training of field workers and the support of programme management. UNICEF supports iron supplementation for adolescent girls in 12 states and Vitamin A supplementation in 14 states. It encourages the universal use of adequately iodised salt by educating the general population and collaborating with the salt industry. The nutritional and development status of children under three years old is also improved through community-based early childcare interventions currently being
UNICEF Action on Nutrition • Special focus on the nutritional status of under-three year olds • Improvement in quality and efficiency of existing government programmes • Strengthening of nutrition intervention policies supportive of families and communities
implemented in seven states. These interventions aim at bettering the care children get by educating their parents and communities. For example, in Madhya Pradesh a big effort was made through a state-wide programme to identify all children who were malnourished. After weighing the children, those who were severely malnourished were identified for treatment, and all parents were given information on adequate feeding and child care. As a result the number of severely malnourished children reduced by half. UNICEF continues to support the government in linking vitamin A supplementation and immunization services to these weighing and information provision sessions.
Women with anaemia Percentage of women aged 15–49 years who are anaemic Source: NFHS-2 India average: 52% 60% and above 50% – 59% 40% – 49% below 40% no data
Community-based interventions Bihar, Jharkhand
JAMMU AND KASHMIR
UNICEF in Action
HIMACHAL PRADESH PUNJAB CHANDIGARH
UTTARANCHAL
HARYANA
The Dular strategy promotes home-based changes in parents’ day-to-day care practices. As part of the strategy, the anganwadi worker in every targeted village teams up with a small group of local people who are then given a basic training in nutrition, childcare and hygiene. Once trained, the team visits pregnant women and mothers of newborns in their homes to educate them about safe delivery, breastfeeding, immunisation, and other essential care practices during pregnancy and early childhood. Since the team is made up of local people from the community, parents respond positively. The strategy, currently being implemented in four districts each in Bihar and Jharkhand, has successfully improved infant feeding behaviour and reduced malnutrition. ARUNACHAL PRADESH
DELHI SIKKIM
UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
MEGHALAYA TRIPURA
JHARKHAND WEST BENGAL
MADHYA PRADESH
GUJARAT
NAGALAND
MANIPUR
MIZORAM
CHHATTISGARH
ORISSA
DAMAN AND DIU DADRA AND NAGAR HAVELI
MAHARASHTRA
Working with salt producers Tamil Nadu ANDHRA PRADESH
LAKSHADWEEP
GOA
Adolescent anaemia Gujarat
KARNATAKA
In 2000, a baseline survey conducted among more than 2,800 adolescent TAMIL NADU girls in Gujarat’s Vadodara district, showed that up to 75 per cent were anaemic. The KERALA survey also showed that nearly all these girls were willing to take iron and folic acid tablets in school. As a result, the state government stepped in with UNICEF to provide iron supplements to 64,544 adolescent girls across 410 schools. An assessment completed after 18 months of weekly supplementation showed that anaemia prevalence had been reduced to 53 per cent. The government plans to implement this programme throughout the state.
PONDICHERRY
ANDAMAN AND NICOBAR ISLANDS
Although Tamil Nadu is one of the three major salt producing and exporting states in India, only about 20 per cent of its households were using adequately iodised salt in 1999. As a result, in collaboration with the government, UNICEF intensified its advocacy among salt producers to produce iodised salt. Collaboration was initiated with FEDCOT, a federation of 350 registered consumer organisations in Tamil Nadu and Pondicherry, whose members work at the grassroots. Together with FEDCOT, an awareness-raising campaign was started among shopkeepers and the general population. After several meetings with local salt producers, and a campaign to raise awareness amongst the local people, preliminary indications showed an increase in the production of iodised salt: the sale of potassium iodate, the fortificant added to the salt, increased from about 300 kilograms per month to 500 kilograms per month in the second half of 2003.
27
Mapping Nutrition At first sight, it is a bit incongruous. What is a chart of cartoon figures doing at a nutrition counselling and childcare session for malnourished children in a village in South 24 Parganas in West Bengal? And why are some of the caricatures ‘incomplete’, with a hand or a leg missing? There is a method behind the seeming madness. Each stroke of the cartoon depicts how many times the mother has brought her child to the feeding centre, with the ideal being 12 times a month. “Nobody wants to see their child being depicted as incomplete in the cartoon chart, with a limb or a nose missing. This is one of the ways in which our centre provides these non-literate women an incentive to ensure they don’t miss a feeding session,” says an officer of a local voluntary group.
Nutrition
Nobody wants to see their child being depicted as incomplete in the cartoon chart, with a limb or a nose missing
28
This unique strategy is part of what is known as the Positive Deviance (PD) project, which covers 500 villages in state districts of Murshidabad, South 24 Parganas, Purulia and Dakhin Dinajpur. The statistics are alarming. There is high prevalence of malnutrition, particularly amongst children under three years old: every second child in the state is underweight, three out of four are anaemic and four out of 10 newborns are at risk of being iodine deficient. The project is aimed at the state’s malnourished children and identifies local solutions and available resources to rectify the situation. It is called Positive Deviance because it looks at the positive side of an otherwise very grim picture. Even in the
most backward, poor communities, some children will be healthy and well nourished. The project looks at what makes that young child healthy, nourished and well developed, and it focuses on those aspects.
Our idea is to teach them how to cook a nourishing meal with available food stuff. They can then continue the same feeding practice in their homes
With the help of key partners – the Department of Social Welfare and WCD, Health, Panchayati Raj Institute and NGOs – Rupali Haldar, the anganwadi (childcare) worker in the village of Mala in South 24 Parganas, has detailed the nutrition status of all the children in a series of maps. By using colour coding, wherein the colour red indicates severe malnutrition, yellow the moderately malnourished and green normal, the maps show exactly how many children are in each household, and details their nutrition status. Plotted with the help of panchayat (village local governing body) members, the maps also show the location of the feeding centres in the village.
Whenever we see that there are 10 to 12 children in the area, we open a PD centre for women to come and feed their children 12 times a month
“Whenever we see that there are 10 to 12 children in the area, we open a PD centre for women to come and feed their children 12 times a month,” says Rupali. Under the project, the most malnourished children up to three years old are chosen for a PD centre. The basic food, consisting of rice and pulses, is provided by ICDS. However, mothers contribute all the vegetables and eggs that are then cooked collectively. “Our idea is to teach them how to cook a nourishing meal with available food stuff. They can then continue the same feeding practice in their homes,” says a field level facilitator. The centre, a small house in the village, is buzzing with activity at lunchtime. Groups of mothers are feeding khichdi (a nourishing gruel made with rice, lentils and vegetables) to their babies. The khichdi made with contributions from all the mothers is nourishing, hot and the children are clearly enjoying their meal.
I give him khichdi twice and rice once a day and I can see the difference. He used to be very irritable and cranky. Now he is happy and healthy
Kashmira Bibi, whose 14-month-old son was in the third grade of malnutrition is now in the first grade. She is quite sure that the PD programme has made a definite difference to the way that she takes care of her son. She used to feed him three meals a day but, she admits, it was not nourishing enough. The meals would comprise vegetables or dal (lentils) or suji kheer (a
sweet dish, made from semolina and milk), but all given separately. Now, she makes sure that she feeds her son khichdi at least twice a day, and adds fresh green vegetables, eggs, potatoes and dal. “I give him khichdi twice and rice once a day and I can see the difference. He used to be very irritable and cranky. Now he is happy and healthy,” she says.
I like coming here so that my child continues to remain normal. She also eats better when she is with all the other children
Other mothers can also see the difference between the time the centre started and a few months later. Ameera Bibi’s two-yearold daughter was not able to walk; three months at the centre has helped her to walk and also has improved her overall health, moving her from the second stage of malnutrition to the first. In fact, there are some mothers who cook food at home but make it a point to attend the feeding session. Lalbano Bibi’s daughter Shenaz is not malnourished but she likes to bring her to the centre because of the useful advice that she gets from the others. “I like coming here so that my child continues to remain normal. She also eats better when she is with all the other children,” she says.
29
Child’s Environment: Sanitation, Hygiene and Water Supply
30
31
Child’s Environment: Sanitation, Hygiene and Water Supply The Picture in India
A
Child’s Environment
n estimated 400,000 children under five years of age die each year due to diarrhoea. Several million more suffer from multiple episodes of diarrhoea and still others fall ill on account of Hepatitis A, enteric fever, intestinal worms and eye and skin infections caused by poor hygiene and unsafe drinking water.
32
Despite the Government and UNICEF’s best efforts, diarrhoea remains the major cause of death amongst children, after respiratorytract infections. Unhygienic practices and unsafe drinking water are some of its main causes. More than 122 million households in the country are without toilets. Even though toilets are built in about 3 million households every year, the annual rate of increase has been a low 1 per cent in the past decade. Lack of awareness, exacerbated by poverty, low literacy and a lack of easy availability of water are reasons for poor hygiene practices in homes and communities. The absence of toilets affects women and children in particular. The lack of toilets also affects girls’ school attendance. Of India’s 700,000 rural primary and upper primary schools, only one in six have toilets, deterring children – especially girls – from going to school. Access to protected sources of drinking water has improved dramatically over the years. Most rural water supply systems, especially the hand-pumps generally used by the poor, are using groundwater. But inadequate maintenance and neglect of the environment around water sources has led to increasing levels of groundwater pollution. In many areas, the problem is
exacerbated by falling levels of groundwater, mainly caused by increasing extraction for irrigation. In some parts of the country, excessive arsenic and fluoride in drinking water also pose a major health threat.
Drinking water Percentage of rural households using protected water Source: Census of India 2001 India average: 73%
fewer than 30.0% 30.0% – 59.9% 60.0% – 79.9% 80.0% – 89.9% 90.0% and over
India in context Sanitation Percentage of the population using adequate sanitation facilities Source: SOWC 2004
52% 34%
36%
South Asia
India
53%
Developing Sub-Saharan countries Africa
Rural sanitation Percentage of rural households using toilets Source: Census of India 2001 India average: 21.9%
JAMMU AND KASHMIR
fewer than 15.0%
Under-fives with diarrhoea
15.0% – 24.9%
20% or more under-fives with diarrhoea in rural areas Source: NFHS-2
25.0% – 49.9%
Two out of three HIMACHAL households PRADESH do not have PUNJAB a toilet CHANDIGARH
percentage given
50.0% – 74.9% 75.0% and over
UTTARANCHAL
HARYANA
DELHI
32% UTTAR PRADESH
20%
33%
SIKKIM
NAGALAND
MEGHALAYA
BIHAR
22%
22% JHARKHAND
22%
21%
22%
WEST BENGAL
MADHYA PRADESH
GUJARAT
ARUNACHAL PRADESH
ASSAM
24%
RAJASTHAN
24%
MANIPUR
TRIPURA
MIZORAM
30%
CHHATTISGARH
ORISSA DAMAN AND DIU DADRA AND NAGAR HAVELI
28%
MAHARASHTRA
23%
74%
ANDHRA PRADESH
GOA
Diarrhoea kills 400,000 under fives each year
KARNATAKA
ANDAMAN AND NICOBAR ISLANDS
PONDICHERRY
TAMIL NADU KERALA
22%
Rural
Urban
LAKSHADWEEP
More urban households use toilets
Government of India action on the Child’s Environment • Achieve full coverage in rural water supply • Strengthen the sector reform initiative in rural water supply and sanitation • Increase use of toilets and improve hygiene practices in homes and schools
Rural and urban differentials Source: Census of India
33
Child’s Environment: Sanitation, Hygiene and Water Supply UNICEF in Action
U
Child’s Environment
NICEF supports the national and state governments in developing and implementing a range of replicable models for sanitation, hygiene and water supply: elements from these have influenced Government policy and programmes.
34
The availability of protected drinking water sources has improved significantly over the past few years. The current priority is to maintain water systems, monitor and regulate water quality and ensure sustainability of sources. One particular concern is to ensure that marginalised groups, especially women and the poor, participate in decisions about, and benefit from, improved water supplies and sanitation services. Protecting drinking water from faecal contamination remains a major challenge because of a widespread lack of sanitation. One strategy is to protect vulnerable water sources by maintaining platforms and
drainage around hand-pumps. But the most effective solution is to focus on home hygiene practices, including propagating the sanitary use of toilets and washing hands with soap or ash. UNICEF also supports low-cost solutions to protect drinking water from excessive arsenic and fluoride. Groundwater resources are over-exploited in many regions, and an equitable management of demand, coupled with interventions to improve recharge, are needed. UNICEF supports local initiatives in four water-scarce states (Gujarat, Madhya Pradesh, Maharashtra and Rajasthan) to sustain drinking water sources.
Improving sanitation
Improving water supply
Percentage of households with a toilet Sources: Census of India 1991, 2001
Percentage of households taking drinking water from protected sources Sources: Census of India 1991, 2001
74%
90% 81%
64%
73% 56%
10%
1991 urban 2001
22%
1991 rural 2001
1991 urban 2001
1991 rural 2001
UNICEF Action on the Child’s Environment • Improve the child’s household hygiene and sanitation environment • Improve the child’s school environment • Improve community management and sustainability of water and sanitation interventions
Women in the forefront Jharkhand
JAMMU AND KASHMIR
UNICEF in Action
HIMACHAL PRADESH PUNJAB CHANDIGARH
UTTARANCHAL
HARYANA
Chakulia, in the East Singhbhum district of Jharkhand, has high infant mortality and poor sanitation. Women working in the Government's Integrated Child Development Services as anganwadi workers spearheaded an initiative to persuade over 2,500 families to build low-cost toilets. Families below the poverty line contributed by helping to dig the toilet pit. Slipping into roles traditionally assigned to men, the childcare workers functioned as masons, production centre managers, and accounts managers. They became deft at mixing cement, creating moulds, making rings for the low-cost toilets and even transporting them. UNICEF supported this example of quiet change by focusing on rural women and their ability to lead and inspire action.
ARUNACHAL PRADESH
DELHI SIKKIM
UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
TRIPURA
JHARKHAND WEST BENGAL
MADHYA PRADESH
GUJARAT
NAGALAND
MEGHALAYA MANIPUR
MIZORAM
CHHATTISGARH
ORISSA
MAHARASHTRA
DAMAN AND DIU
DADRA AND NAGAR HAVELI
Combating Fluorosis Andhra Pradesh ANDHRA PRADESH
GOA
KARNATAKA PONDICHERRY
TAMIL NADU
LAKSHADWEEP KERALA
Excessive fluoride in drinking water sources in Anantapur district of Andhra Pradesh has made the area’s marginalised, rural population vulnerable to fluorosis. UNICEF has introduced domestic de-fluoridation filter units, which can be used in homes to remove excess fluoride from drinking water. Developed in collaboration with the Indian Institute of Technology, Kanpur, this easy-to-use device, where water poured into the upper chamber is collected and filtered into the lower one, reduces the fluoride content to acceptable levels. ANDAMAN AND NICOBAR ISLANDS
State-wide planning for rural schools Tamil Nadu If the click of a mouse could open up an entire range of data on a school in a remote area of India, planning would become better and funds would reach the right place. UNICEF has been able to accomplish this in Tamil Nadu through the use of a Geographic Information System supported by Sarva Shiksha Abhiyan (SSA). It has ensured an efficient distribution of funds to schools that need toilets and drinking water facilities under the government’s Total Sanitation Campaign, based on data
collected systematically from the state’s over 31,000 primary schools. This has helped map details of water, sanitation and hygiene education in all of the state’s schools. Started in Erode, the project was initially expanded to cover three more districts. Soon the results prompted the state Government to expand the initiative to all of its 30 districts. The plan has been shared at the national level as a model for all districts targeted by the Total Sanitation Campaign.
35
Child’s Environment
Catching Them Young
36
The bell has been sounded for lunch at a primary school in a remote part of Gujarat and within seconds there is pandemonium all around. Children by the dozens are pouring out of their classrooms, laughing and shouting, clearly enjoying the break from lessons. But amidst all the rush they seem to be heading somewhere with an apparently focused zeal. When asked, a group of them shout in chorus that they are going to wash their hands before eating. Under ordinary circumstances, this would not attract much attention. But here in the Mandvi block of the state’s Kutch district, the children’s enthusiasm is a sign of recent improvements in hygiene practices, the result of a programme by the State Education Department, supported by UNICEF. The area where the school is situated is one amongst many in the state that was badly hit by the massive earthquake of 2001. The quake razed the old school building to the ground. UNICEF not only constructed a new pre-fabricated primary school, with 11 classrooms, but also made provisions for drinking water, separate toilets for boys and girls and a fenced playground. As part of its objective to improve the quality of the learning environment, UNICEF, in partnership with the Education Department, also initiated a health and hygiene programme. Its primary focus has been to acquaint all students with better hygiene practices both in terms of sanitation and drinking water safety. The programme has shown positive results. Rani, a girl student of class five at the primary school explains with a sigh of relief
that she and her friends no longer need to run home to use the toilet now that there is one at school. This, she says, is a great change from earlier days, when she used to find it hard to concentrate on studies or even play freely because of needing to use a toilet but not being able to do so until she got home. Other students have benefited similarly. The programme has been implemented primarily through the setting up of health and hygiene committees consisting of students supervised by the school’s eight teachers. Committee members have been trained in elementary aspects of sanitation, including the clean use of toilets, the need to wash hands before eating, and handling drinking water safely. The committee members are in turn responsible for training the rest of the school – numbering over 300 students – in health and hygiene. For members of the committees, the day begins early with duties to sweep the school’s open ground and classrooms clean. Tushar, an active member of what students call the H&H (or health and hygiene) committee, says the reason the programme has been so effective is because all the school’s children are involved in every part of implementation. The entire student population is roped in to help keep the school clean. During school time, each class is allotted five minutes every hour to use the drinking water facility and toilets to help prevent crowding. The head teacher, Jagdish Bhai is a happy man. He says the programme has been successful because teachers and students have been equally committed and equally involved in making it work.
He also says that the programme has shown how effective children are in helping bring about behavioural change. The fifth standard student, Rani, has not only been practising better hygiene herself but has also been an instrument of change – she now ensures that her mother always washes her hands before cooking meals and has also been teaching other children in the neighbourhood what she has learnt at school.
I do not let anyone touch this water. My teacher has told me that water can become dirty easily and we can fall sick if care is not taken
Ramesh, another student of class V proudly displays how he dispenses drinking water safely from water containers to fellow students and juniors at school. "I do not let anyone touch this water. My teacher has told me that water can become dirty easily and we can fall sick if care is not taken," he says. The teacher in charge of hygiene committees, Mr Parikh, says that to ensure clean drinking water, two children from the senior classes have been given the responsibility of ladling water from steel containers in which water is stored.
In a water-scarce region, this ensures not only that the water is stored safely but also that it is not wasted. Children have also been provided steel tumblers for drinking. Older children direct younger children on how the glass has to be held to prevent contamination of water. Child Environment Corners have been set up in the school to help reinforce messages on personal hygiene. This includes plastic models of various options for low-cost home toilets, flip charts on seven principles of hygiene education, and a chloroscope; these are used as tools for training the students and Village Education Committee (VEC) members. Soap, nail-cutters and mirror are kept here, and children are encouraged to frequent the corner during the lunch break or at the end of the day. The health and hygiene programme is seen to have not only helped improve the overall hygiene and sanitation standards of children inside and outside school but also helped indirectly retain, through the provision of toilets on the premises, girl students, in school. A successful rural sanitation programme, supported by UNICEF, in West Bengal has become a global model for developing countries. Starting in 1991, the project has demonstrated that remarkable improvements can be made in household toilet coverage through a decentralised system that is dedicated to serve the poor and managed by the local government with NGO support. Over one million toilets were built in 2003 alone, and household toilet use has increased from 12 per cent in 1991 to an estimated 50 per cent in 2003.
37
Elementary Education
38
39
Elementary Education The Picture in India
D
espite a major improvement in literacy rates during the 1990s, the number of children who are not in school remains high. Gender disparities in education persist: far more girls than boys fail to complete primary school.
190 million females in India are non-literate
The literacy rate jumped from 52 per cent in 1991 to 65 per cent in 2001. The absolute number of non-literates dropped for the first time and gross enrolment in Government-run primary schools increased from over 19 million in the 1950s to 114 million by 2001. But 20 per cent of children aged 6 to14 are still not in school and millions of women remain non-literate despite the spurt in female literacy in the 1990s. Several problems persist: issues of ‘social’ distance – arising out of caste, class and gender differences – deny children equal opportunities. Child labour in some parts of the country and resistance to sending girls to school remain real concerns. School attendance is improving: more children than ever between the ages of 6 and 14 are attending school across the
country. However, the education system faces a shortage of resources, schools, classrooms and teachers. There are also concerns relating to teacher training, the quality of the curriculum, assessment of learning achievements and the efficacy of school management. Given the scarcity of quality schools, many children drop out before completing five years of primary education; many of those who stay on learn little. Girls belonging to marginalised social and economic groups are more likely to drop out of school at an early age. With one upper primary school for every three primary schools, there are simply not enough upper primary centres even for those children who complete primary school. For girls, especially, access to upper primary centres becomes doubly hard.
Education
Women are less educated than men
40
Literate men and women as percentage of male and female populations aged 7 and over Source: Census of India 2001 India average: Male 75%, Female 65% below 40% 40% – 49% 50% – 59% Male
60% – 69%
Female
70% – 79% 80% – 89% 90% and over
74%
India in context Adult female literacy Percentage of females aged 15 years and above who are literate Source: SOWC 2004
53% 42%
South Asia
45%
India
Sub-Saharan Africa
Developing countries
Primary school attendance Percentage of children aged 6–10 years currently attending school Source: MICS 2000
JAMMU AND KASHMIR
India average: 82% HIMACHAL PRADESH
below 75%
PUNJAB
75% – 84%
CHANDIGARH
UTTARANCHAL
85% – 94%
HARYANA
95% and above
DELHI UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
MANIPUR
TRIPURA
WEST BENGAL
MADHYA PRADESH
NAGALAND
MEGHALAYA
JHARKHAND GUJARAT
ARUNACHAL PRADESH
SIKKIM
MIZORAM
CHHATTISGARH DAMAN AND DIU
ORISSA
MAHARASHTRA
DADRA AND NAGAR HAVELI
Upper primary school attendance Percentage of children aged 11–14 years currently attending school Source: MICS 2000 India average: 74%
ANDHRA PRADESH GOA
KARNATAKA
below 70.0% 70.0% – 79.9%
PONDICHERRY LAKSHADWEEP
TAMIL NADU KERALA
ANDAMAN AND NICOBAR ISLANDS
80.0% – 89.9% 90.0% and above
Government of India Action on Education • Make elementary education a fundamental right • Strengthen coverage of the Education for All programme • Intensify efforts in accelerating girls’ education
41
Elementary Education UNICEF in Action
U
NICEF is an active partner in Sarva Shiksha Abhiyan, the National Programme for Universal Elementary Education, which aims to provide quality education for children between the ages of 6 and 14 years by 2010. UNICEF supports the national programme in its objective to ensure that all children complete five years of school and have access to good quality education. UNICEF strategy is built around three inter-linked themes: access, quality and equity in basic education. This includes the implementation of a ‘quality package’ in 14,000 schools across 14 states. The package aims to improve the quality of teacher education, curricula, learning assessments and the classroom environment; it advocates gender-sensitive and child-centred processes along with interactive learning to make teaching and learning a motivating experience. UNICEF is also committed to strengthening
More children enrolled
Education
Number of children enrolled at government elementary schools 97.4 in millions
42
113.8
Source: MHRD 2003
effectiveness of school-based interventions focusing on HIV/AIDS prevention. In order to help eliminate gender and social disparities in primary education, UNICEF supports the provision of equal opportunities for disadvantaged children, especially girls, the urban poor, Scheduled Castes and Scheduled Tribes, and working children. UNICEF is working closely with the Government’s recently launched National Programme on Girls’ Education at the Elementary Level (NPEGEL) to further accelerate progress in girls’ education. UNICEF also supports alternative learning strategies, such as bridging courses and residential camps for adolescent girls who are out of school. The effort is to ensure that these girls emerge motivated to continue their education. In addition, as part of efforts to strengthen education planning and monitoring, UNICEF supports the District Information System for Education (DISE) to promote better collection, collation, and analysis of data, thereby improving educational statistics.
19.2 UTTAR PRADESH
RAJASTHAN
1950–51
1990–91
2000–01 MADHYA PRADESH
UNICEF Action on Education • Improve quality of education • Increase access to education for disadvantaged children, especially girls • Improve monitoring systems and data analysis
BIHAR WEST BENGAL
MAHARASHTRA
ANDHRA PRADESH
65% of non-literate people live in just 7 states
School sanitation and hygiene education Rajasthan The absence of safe drinking water and toilets in many schools in Rajasthan’s Alwar district used to make children fall frequently ill and seriously affect the enrolment and retention of students, especially girls. In 2000, UNICEF, with the state government, launched a project to address sanitation and hygiene education in schools. Toilets were HIMACHAL built and drinking water was provided. Students were also educated PRADESH about how to handle drinking water safely, dispose of wastewater, PUNJAB human excreta and garbage and act as ‘sanitation scouts’ for the CHANDIGARH UTTARANCHAL community. Involving children as agents of change helped transform the mind-set of communities and facilitated the widespread adoption of hygienic practices. HARYANA JAMMU AND KASHMIR
UNICEF in Action
ARUNACHAL PRADESH
DELHI SIKKIM
UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
TRIPURA
JHARKHAND WEST BENGAL
MADHYA PRADESH
GUJARAT
NAGALAND
MEGHALAYA MANIPUR
MIZORAM
CHHATTISGARH DAMAN AND DIU
ORISSA
MAHARASHTRA
DADRA AND NAGAR HAVELI
ANDHRA PRADESH GOA
LAKSHADWEEP
KARNATAKA
KERALA
TAMIL NADU
Nali Kali initiative Karnataka Developed in 1995 by teachers in Karnataka’s Mysore district, the Nali Kali strategy adopted creative learning practices to help retain children in school and bring in those not attending school. Child competencies were pegged to a learning ladder, and the learning process was organised into milestones, providing every child with the opportunity to assess his or her own progress. The initiative has helped improve enrolment, particularly of girls, and has been expanded to cover more areas within Mysore and 10 more districts in the state. Plans are underway to extend the initiative across the state.
ANDAMAN AND NICOBAR ISLANDS
Girls’ education initiative Uttar Pradesh In 1999, in partnership with the government and other voluntary organisations, UNICEF initiated a project for girls’ education in four blocks of Uttar Pradesh’s Barabanki district, where female literacy was about 15 per cent. Alternative learning centres (ALCs) were established in villages that did not have a primary school within a one-kilometre radius, with the active participation of communities. Instructors were selected in co-operation with panchayats, and preference was given to local candidates. The number of alternative learning centres increased from 50 in 1999 to 140 in 2001, when more than 4000 children were enrolled – a significant majority of whom were out-of-school girls. A one-year residential camp programme for girls was also introduced to provide learning opportunities for older out-of-school girls. This is now being replicated under SSA across the state.
43
Education
Kicking to Freedom
44
Imagine living in a hut that even a five-yearold child would have to bend to enter. Imagine beginning each day with dim prospects of finding work and ending it by going to sleep hungry. Imagine fishing out snails from floodwaters as the only source of food during the monsoon months. For 16-year-old Lalita and her community, living in a remote village in the northern state of Bihar, all this is for real. But despite such odds and furious attempts by the family to stifle her desire to study, Lalita today is the only educated girl in her community, due to support from the UNICEF. She is not only a role model for her own family, but also for other girls and their parents in her community. “I have suffered deprivation all my life, I want to help other girls,” she says. “I want all girls in the world to be literate, parents not discriminate between the male and female child and encourage girls to attend school.” Until two years ago, Lalita used to spend her day doing household chores, cutting grass and fetching firewood. But this all changed when she got the opportunity to attend a Jag Jagi Kendra or ‘wake up’ centre. In about eight months, she reached Class Five. She then continued her education at the Mahila Shiksan Kendra, a boarding school for semi-literate students. The school provides, in the span of eight months, a basic education in maths, painting, language skills and vocational training. Lalita attended karate lessons there and won her brown belt. She now teaches karate to other girls attending these special schools. Bihar is one of the poorest states in India, with a population of over 80 million, more than half of whom are not literate. Literacy amongst women is especially low, at 34 per cent. Sitamarhi, Lalita’s home district, accounts for one of the state’s lowest female
literacy rates, with only 1 in 4 women being literate. UNICEF played a crucial role in the initiation of the Bihar education programme, which now covers over 2,000 villages. It began in 1989 as a partnership between the central government, the state government and UNICEF. Mahila Samakhya, involved until then only in developmental work, also became a partner in the education programme. The challenging situation in Bihar prompted UNICEF to begin one of its key initiatives in the education sector. Even though the programme has now been expanded with the help of World Bank funds, UNICEF continues to play a significant role in decision making as well as in training programmes. The Mahila Shikshan Kendra started by Mahila Samakhya are now benefiting many more girls like Lalita across the state.
Before I started studying and going to school, I never had the confidence to speak to any adult, or go out and meet anybody
The Mahila Shikhsan Kendras, while imparting education, also provide girls with empowering skills. Lalita, unlike most other girls in her community, is not shy any more. “Before I started studying and going to school, I never had the confidence to speak to any adult, or go out and meet anybody. I hadn‘t even seen another village or district or town,” she says. Lalita’s newfound confidence and ability to earn a living has sparked off a process of change. Her younger sister, Punita, now attends an education centre, without having to fight with her family. Others in the community too are keen to follow Lalita’s
example. Roopa Kumari, an adolescent girl says, “After seeing Lalita, all the girls here have started going to the centre.” This is quite a change from the time Lalita struggled to gain access to education. One of the first people to oppose Lalita was her mother. She was furious and unable to understand why a girl would want to be educated. But Lalita was determined. She endured stern punishments, including beatings, from her family members who did all they could to stop her from attending classes. The process of making girls’ education available was initiated by a field worker of the Mahila Samakhya, who helped set up a women’s group in Lalita’s village. But the first time Lalita learnt that education was within reach was when a saheli’, a woman worker from the Mahila Samakhya , came knocking at their door and asked all girls to enrol at the Jag Jagi Kendra. Even though her parents refused, Lalita found a way of sneaking off to attend classes, with help from the village saheli. Once Lalita learnt to write her name, she did not wait for approval from her parents to enrol for the next session. “When I wrote my name, everyone was surprised, and so many more wanted to be able to write,” says Lalita. Her mother too was taken aback but for the first time showed signs of relenting. “The saheli explained to my mother that if I attended school I would be able to work even more efficiently for the household.” The Jag Jagi Kendra also taught Lalita the importance of hygiene and cleanliness. She started boiling water in the house and insisted that all food be properly covered. The next obstacle Lalita faced was to obtain her parents’ permission to attend the residential centre for girls in Muzaffarpur, a good ten-hour drive away. This time her father relented and let her go. The eight months she spent at this centre changed Lalita’s life. She showed great promise as a karate student and soon emerged at the top of her class. This
prompted the supervisors at the centre to send her for higher levels of training to another district, Hazaribagh. Lalita’s first salary brought tears to her father’s eyes. “Even my sons have not done this,” he says. Her father has never earned more than 300 to 400 Rupees a month. Nor, as Lalita says, has he travelled to the places that she has seen in her young life. “Earlier I couldn’t talk before anybody,” says Lalita. “I had never stepped out alone. Now I can even fight.” Karate has given Lalita a newfound sense of confidence. She is no longer scared of the village boys, who are used to teasing the village girls. In fact, one day, when she was returning alone from her centre in Sitamarhi, she was accosted by some of these boys, who wanted to teach her a lesson for being so daring. Her first impulse was to run. But she realised she had to fight. She dealt them a couple of heavy blows – leaving them both stunned and asking for forgiveness. Karate has transformed this simple village girl. Apart from serving as self-defence, it is a skill she is now passing on with a sense of inspiration to several other adolescent girls. Her mother is now reluctant to admit that she had at any time opposed her daughter’s education. On being reminded by Lalita, she hides her face in embarrassment and explains that her earlier reluctance had to do with being unaware of the value of education in one’s life. Now, she is so proud of Lalita that she resents the idea of marrying her to a less educated boy.
I have suffered deprivation all my life, I want to help other girls
45
HIV / AIDS
46
47
HIV / AIDS The Picture in India
W
ith an estimated 4.58 million HIV positive cases, India has the second largest number of people in the world living with HIV. This accounts for 11.4 per cent of global HIV infections.
HIV / AIDS
1 out of every 3 births to HIV infected mothers will be HIV positive
48
very few people correctly understood how to prevent transmission. Fewer than half of all people interviewed were aware of the two important methods of prevention of transmission: consistent condom use and sexual relationships with faithful and uninfected partners. Awareness is especially low amongst women. The survey found that while 70 per cent of men were aware of the protective value of a condom, only 48 per cent of women knew about this. The epidemic is shifting towards women and young people, with women accounting for 25 per cent of all HIV infections. Low levels of awareness, spiralling violence within the home and limited access to health-care are also responsible for the growing incidence of HIV/AIDS amongst women. Stigma and discrimination continue to be among the biggest barriers to prevention, care and treatment.
The epidemic is unevenly distributed across India, with just six states accounting for 80 per cent of the estimated cases: Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. In these states, the HIV prevalence rate among women attending antenatal clinics exceeds 1 per cent – an indication that the epidemic has spread from high-risk groups, such as sex workers and injecting drug users, to the general population. The main mode of HIV transmission is through sexual contact. The exception is in the north-eastern states of Manipur and Nagaland, where injecting drug use accounts for the majority of the transmission. Awareness and knowledge of prevention are crucial to checking the spread of HIV. In 2001 a behaviour surveillance survey (BSS) conducted by the National AIDS Control Organisation (NACO) indicated increased levels of awareness but also revealed that
5.0
People living with HIV Countries with highest number of people infected with HIV (in millions) Sources: SOWC 2004, NACO 2.3
2.5
Zimbabwe
Kenya
4.6 3.5
Nigeria
India
South Africa
9.0%
India in context HIV/AIDS prevalence Percentage of people aged 15–49 living with HIV/AIDS Source: SOWC 2004 0.3% High-income countries
0.6% South Asia
0.8%
India
1.2%
1.4%
World
Developing countries
Sub-Saharan Africa
Prevalence of HIV / AIDS 4.58 million people in India are living with HIV Source: NACO high-prevalence HIV prevalence in antenatal women is 1% or more JAMMU AND KASHMIR
moderate-prevalence HIV prevalence in antenatal women is less than 1% and prevalence in STD and other high-risk groups is 5% or more
HIMACHAL PRADESH
low-prevalence HIV prevalence in antenatal women is less than 1% and prevalence in STD and other high-risk groups is less than 5%
PUNJAB CHANDIGARH
UTTARANCHAL
HARYANA
DELHI
ARUNACHAL PRADESH
UTTAR PRADESH
SIKKIM
RAJASTHAN
ASSAM
BIHAR
TRIPURA
JHARKHAND WEST BENGAL
MADHYA PRADESH
GUJARAT
NAGALAND
MEGHALAYA MANIPUR
MIZORAM
CHHATTISGARH DAMAN AND DIU
MAHARASHTRA
ORISSA
DADRA AND NAGAR HAVELI
ANDHRA PRADESH
Port Blair ANDAMAN AND NICOBAR ISLANDS
GOA
KARNATAKA PONDICHERRY
LAKSHADWEEP
KERALA
TAMIL NADU
Government of India Action on HIV/AIDS • Ensure safe blood transfusion • Scale up programmes for individuals and communities at high risk • Scale up prevention of parent-to-child transmission, care, support and treatment
49
HIV / AIDS UNICEF in Action
U
NICEF is an active partner in the Government’s programme for the prevention of HIV/AIDS transmission from parents to children and among young people. UNICEF supports scaling up of programmes and demonstrates their effectiveness at district level. It assists in developing policy based on best practices.
4 out of every 5 young women don't know how to prevent HIV infection
At one level, UNICEF is raising awareness about HIV/AIDS, mobilising voluntary groups and advocating with the media in support of Government efforts. At another, it is empowering individuals, especially young people, through appropriate information on HIV prevention. UNICEF is one of the co-sponsors of the joint UN programme on HIV/AIDS (UNAIDS). All the UN agencies and the World Bank work together through a UN Theme Group on HIV/AIDS. UNICEF plays a catalytic role in India’s National AIDS Control programme. UNICEF began its work in India by conducting a feasibility exercise for the Government
How AIDS is transmitted
HIV / AIDS
Known modes of HIV transmission by percentage of total Source: NACO
50
needle-sharing drug users 2% blood and blood products 3%
sexual 85%
parent-to-child 3%
programme for Prevention of Parent to Child Transmission of HIV (PPTCT). Subsequently, it extended support for the full programme. The PPTCT goal is to set up 780 centres by 2005–06 across India so that pregnant women with HIV have access to appropriate interventions, especially at the time of labour. Around 235 centres are currently functional. UNICEF assistance includes supporting the delivery of a package of services that offers counselling, testing and anti-retroviral treatment to pregnant HIV-positive women. Feasibility studies are planned to help expand treatment to mothers and positive spouses as well as extend care and support to the families. UNICEF works with young people to provide them with life skills, services and a supportive environment. A school AIDS education project focuses on life-skills based education and training of peer educators. The programme is being implemented in Andhra Pradesh, Karnataka, Maharashtra, Nagaland and Tamil Nadu. Programmes for young people in vulnerable communities are being formulated in high-prevalence states.
AIDS awareness unknown 7%
UNICEF Action on HIV/AIDS • Primary prevention in adolescents, young people and women of childbearing age • Quality assurance and monitoring • Advocacy
Percentage of all women aged 15–49 who have heard of HIV/AIDS Source: MICS 2000
fewer than 30% 30% – 49% 50% – 69% 70% and above
PPTCT Programme Andhra Pradesh, Tamil Nadu
UNICEF in Action
UNICEF actively supports the Government’s programme for Prevention of Parent to Child Transmission of HIV (PPTCT). Giving anti-retroviral drugs to HIV-positive pregnant mothers has helped bring down transmission rates from 30 per cent to less than 10 per cent. Around 65 PPTCT centres in Tamil JAMMU Nadu and 37 in Andhra Pradesh help provide counselling to women AND KASHMIR attending antenatal clinics. Those who test positive are encouraged to get started on anti-retroviral drugs and have regular follow-ups. Instead of simply addressing prevention of transmission from an HIV positive mother HIMACHAL to her infant, the strategy includes care and support for the mother, PRADESH prevention of HIV in young people and prevention of unintended PUNJAB pregnancies in HIV-positive women. In Tamil Nadu, the programme has CHANDIGARH UTTARANCHAL led to the creation of a Positive Mothers network, which is a tremendous source of support. It has also helped reduce stigma HARYANA among medical and paramedical workers and improved the ARUNACHAL supply of nutritive supplements for positive PRADESH mothers. DELHI UTTAR PRADESH
RAJASTHAN
ASSAM MEGHALAYA
BIHAR
WEST BENGAL
MADHYA PRADESH
MANIPUR
TRIPURA
JHARKHAND GUJARAT
NAGALAND
MIZORAM
CHHATTISGARH
ORISSA
DAMAN AND DIU DADRA AND NAGAR HAVELI
MAHARASHTRA
ANDHRA PRADESH GOA
KARNATAKA
PONDICHERRY LAKSHADWEEP
TAMIL NADU
ANDAMAN AND NICOBAR ISLANDS
KERALA
Schools’ AIDS Education Programme Karnataka Over 1 million children studying in Classes VIII, IX and X in Karnataka have been targeted under a School AIDS Education Programme. The programme aims to provide correct information on HIV/AIDS so that students can protect themselves from infection. Preventive aspects of HIV/AIDS awareness, including the importance of being faithful to one’s partner and knowing how to use a condom correctly, are discussed with these students as they
prepare to leave school. Close to 50 per cent of all schools in the state have already been covered. Work on the programme was initially difficult as teachers were hesitant about attending the programme. But once this was overcome the programme has helped bring about a change in attitude, with parents welcoming the initiative. It has also helped increase the number of people going to voluntary counselling and testing centres.
51
HIV / AIDS
Treatment of Hope
52
Jyoti knew little about AIDS when she came for her first check-up to a government-run maternity hospital in Hyderabad, the capital city of Andhra Pradesh, in southern India. But today, as she learns to live with the HIV virus that causes this syndrome, her only prayers are that her newborn daughter remain HIV negative. Jyoti’s daughter had a 33 per cent chance of acquiring the infection. If infected, the baby would not be expected to survive beyond a few months, a couple of years at best. But Jyoti has been lucky. She was given nevirapine, an anti-retroviral drug that reduces the chances of a woman transmitting the virus to her baby. It is a simple treatment: a 200 mg pill is given to the mother during labour and a spoonful of syrup to the baby within 72 hours of birth. This new treatment for the prevention of parent to child transmission (PPTCT) is an important component of the Indian government’s AIDS control programme. The National AIDS Control Organisation (NACO) has already extended this programme to 235 centres located in medical colleges and district hospitals across the country. UNICEF support begins right at the start of the programme, helping train a fivemember team at each of the designated PPTCT centres. The team consists of a gynaecologist, a paediatrician, a microbiologist, a counsellor and a staff nurse. At the end of training, the teams hold workshops in their respective hospitals to help initiate the programme. In Andhra Pradesh, 37 PPTCT centres are helping reduce the transmission of infection, and providing support to women who test HIV-positive. Of these 37 centres, 14 are in medical colleges and 23 in district hospitals. Andhra Pradesh has the second highest reported prevalence of AIDS in the country after Tamil Nadu and Maharashtra. In such high-prevalence states, the government has expanded the reach of its programme to include the provision of anti-
retroviral drugs to positive mothers before and after delivery and not just, as usually done, at the time of delivery. The PPTCT project has helped reach out to thousands of women. Most of the hospitals covered under the project benefit poor, illiterate women, who cannot access expensive private health care. Between January and December 2003, at 235 centres across the country, more than 980,000 women were counselled. About 519,000 of these women agreed to be tested, of whom around 2 per cent turned out HIV positive. In Andhra Pradesh, the project was piloted in Hyderabad’s Osmania Medical College hospital. Much has been achieved since the project was initiated in July 1999. When women visit the antenatal clinic at the hospital, they are at first given general counselling on pregnancy care. Women who agree to go in for HIV tests are then taken for individual counselling. Once the test reports are received, women who test positive go through a post-test counselling. They are encouraged to come back for their delivery to the hospital so that they can be given anti-retroviral drugs.
We can only provide antenatal care. There has to be a continuity of care after these women return home
Progress is not all straightforward, however: many couples who test positive do not come back to pick up their test reports; women who test positive do not necessarily come back for delivery to the same hospital and fewer still come back after the birth of the child for follow up.
Often, positive mothers do not get the required support from their families. As gynaecologist Dr Savita Desai remarks: “We can only provide antenatal care. There has to be a continuity of care after these women return home.” Typically, the programme is initiated in the following way. When around 15 pregnant women are gathered in the room, counselling begins.
It takes a long time for a person to look sick. You will not be able to say that a person is living with HIV simply by looking at the physical appearance
“Please listen to me carefully. If you don’t understand anything, you can stop me any time and ask me questions,” says Mary, one of the counsellors and begins a detailed session on various issues related to pregnancy, including HIV/AIDS. She describes the nature of HIV/AIDS and how it spreads, and she explains its consequences. “It takes a long time for a person to look sick. You will not be able to say that a person is living with HIV simply by looking at the physical appearance,” she explains, to emphasise that taking steps to prevent infection is the only way. She advises her audience on the use of condoms, on why they must buy a syringe each time they have an injection and on the dangers of having multiple partners. “If you agree, fill in the form. The test will take a week.” There is little resistance. Most women agree to the test. If any of them test positive, they are encouraged to bring in their partners for testing. Once an HIV positive mother delivers her baby though, the programme shifts its focus to the child. The risk of transmission through break-milk is about 15 per cent. But given
India’s high infant mortality rate, the benefits of being fortified against diarrhoea and other life threatening infections far outweighs the risk of HIV transmission through breastfeeding. Parents are nevertheless encouraged to make an informed choice. After delivery, HIV-positive women are kept in the general ward of the postnatal unit to avoid segregation. Several other issues need attention. Adequate support systems need to be built within the community for affected or infected children. Care and support for HIVpositive mothers and their families need to be improved. But for now, a beginning has been made.
I am a photographer by profession, living with HIV/AIDS for the last 17 years. I was diagnosed with the virus almost by accident in 1988. I withdrew into a shell: shocked that I had it, frightened of what those close to me would think. A doctor I met at the time made it worse: he said I’d die in four years. But hope surfaced when I joined an NGO that gave me correct information on HIV. I met others like me, living with HIV, including Asha, my wife. We married in 2000 and decided to have a baby after consulting our doctors. To my relief and delight, our son who turned two in 2003, tested negative. I spend much of my time now planning for a safe, stable future for him. I want to tell all those who read this that living with HIV is not as bleak or hard as most people fear. I have had some of the best times in my life in the last 10 years and believe that others like me, can, as well.” Elango Ramachandar, Karnataka, India
53
Child Protection
54
55
Child Protection The Picture in India
Child Protection
A
56
large number of India’s disadvantaged children, especially girls, are vulnerable to violence, abuse and exploitation.
While many families live in remote areas with very few livelihood options, others are caught up in unrelenting cycles of migration in search of work. Still other families consist of single-parent households where survival itself is at times a formidable struggle. Violence and abuse in some of these settings fails to provide children with an environment where their rights are protected. Such children are often pushed either into commercial sex work or low-paid labour. Often families with little or no income are compelled to sell their children to others who offer the child work. There are estimated to be more than 12 million child labourers in India. Most have never been to school or have dropped out before completing primary school. In Bihar, Nagaland, Mizoram, Rajasthan and Uttar Pradesh, 60 per cent or more girls dropped out before completing their first five years of education. The significance and impact of violence on children’s lives is also enormous. It can force children out of school and into work and drive them from home onto the streets. The presence of a large number of street children, who do not have any identity and receive no protection either from the family
or the state, makes the situation more complex. Roughly 20 per cent of the Indian population is considered migrant, 77 per cent of whom are women and children. They are often at greater risk of exploitation and tend to accept jobs on unfair terms. Mobility usually means surviving without family and community support networks, and children tend to suffer disruption to their education and access to basic services. Forced relocation in conditions of distress, natural disasters or conflict also affects whole families, psychologically and economically. Trafficking of girls for commercial sexual exploitation, domestic labour and forced early marriages continues to be a serious problem. For a vast number of trafficked women and children, who are subsequently rescued, rehabilitation and repatriation mechanisms are scarce and reintegration is arduous.
Over 12 million 5 to 14 year olds are working
India in context Birth registration
90%
Percentage of children under 5 years who are not registered at birth Source: SOWC 2004
61%
65%
66%
Myanmar
India
Nepal
38% 27%
28%
Maldives
Viet Nam
17%
Philippines
Indonesia
Afghanistan
Child Labour Percentage of children aged 5–14 working for others Source: MICS 2000
Children involved in any activity
India average: 5.2% JAMMU AND KASHMIR
More than 15% of children aged 5–14 are working for others or doing household chores for more than four hours a day or doing other family work Source: MICS 2000
15% and more 5.0% – 14.9%
HIMACHAL PRADESH
3.0% – 4.9%
PUNJAB
fewer than 3.0%
CHANDIGARH
UTTARANCHAL HARYANA
20.3%
DELHI
16.4%
UTTAR PRADESH
RAJASTHAN
19.2% CHHATTISGARH
DAMAN AND DIU
19.8%
NAGALAND
MEGHALAYA TRIPURA
JHARKHAND MADHYA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
GUJARAT
23.3%
SIKKIM
WEST BENGAL
MANIPUR
MIZORAM
15.4% ORISSA
MAHARASHTRA
DADRA AND NAGAR HAVELI
41 per 1,000 children aged below 15 only have one parent alive
ANDHRA PRADESH
25.2%
GOA
ANDAMAN AND NICOBAR ISLANDS
KARNATAKA PONDICHERRY LAKSHADWEEP
TAMIL NADU KERALA
21.6%
Government of India Action on Child Protection • Strengthen National Child Labour Project (NCLP) active across 13 states • Expand coverage of services for sexually exploited children • Expand coverage of services for children of adult sex workers
57
Child Protection UNICEF in Action
Child Protection
U
58
NICEF has played a key role in promoting an approach that focuses more on prevention than just relief and rehabilitation.
Education is seen as one of the primary strategies to tackle issues around child labour. But often accessing schools is hard, the quality of education is poor, and there are problems of overcrowding, inadequate sanitation and sexual abuse. As a result, parents often encourage their children to go to work instead of going to school, to help supplement the family income. In areas where child labour is intensive, alternative learning centres have been set up for children who have never been to school. UNICEF recognises the need for communities to push for quality services to help secure their children’s futures. The community is encouraged to generate solutions and provide livelihood opportunities for its members. Self help groups have been set up where women learn to address their issues and, in many places, they have successfully broken the debt–poverty cycle by starting their own saving schemes. Simultaneously, UNICEF has been working in close partnership with the Indian government and state governments on the issue of child labour. Improving the quality of life for women and children has received emphasis from the Government of India.
A National Child Labour Project (NCLP) is being implemented in 13 states where child labour is endemic, and UNICEF is working closely alongside. State policies on, and approaches to, the elimination of child labour were influenced by the ‘learning in action’ interventions supported by UNICEF in Andhra Pradesh, Uttar Pradesh and Karnataka. Issues of trafficking have not yet received sufficient policy and institutional attention. For children who have been commercially sexually exploited, or whose parents are engaged in commercial sex work, facilities and alternative options for protection and development are scarce. But a critical breakthrough has been made in shifting the trafficking discourse from rescue to prevention strategies and mechanisms. UNICEF has also focused on developing a knowledge and resource base on issues of child trafficking. The Government of India is also working at expanding its services by providing rehabilitation and reintegration programmes through the Swadhar scheme. But progress on these issues has to be sustained to meet the remaining challenges.
UNICEF Action on Child Protection • Promote Alternative Learning Centres in intensive areas of child labour • Strengthen knowledge base on Comercial Sexual Exploitation of Children and trafficking • Support advocacy and public awareness campaigns to change mindsets and promote community action against child labour and trafficking
Trafficking Andhra Pradesh
UNICEF in Action
UNICEF, in collaboration with the district administration and a local NGO, has set up a data base of trafficking routes, traffickers, and trafficked minors and women in JAMMU order to help make effective interventions. UNICEF's AND KASHMIR focus on community mobilisation and prevention has facilitated the establishment of village based anti- trafficking committees comprising of local youth, self- help group members and elected representatives. HIMACHAL PRADESH These committees monitor, follow up and counsel girls PUNJAB and women who are approached by relatives or friends CHANDIGARH UTTARANCHAL in the guise of offering employment. The committees have also initiated action against traffickers by HARYANA registering police cases against them. And, motivated by the local administration, they have linked DELHI ARUNACHAL PRADESH
SIKKIM
UTTAR PRADESH
RAJASTHAN
ASSAM
BIHAR
TRIPURA
JHARKHAND WEST BENGAL
MADHYA PRADESH
GUJARAT
NAGALAND
MEGHALAYA MANIPUR
MIZORAM
CHHATTISGARH DAMAN AND DIU DADRA AND NAGAR HAVELI
vulnerable women and girls to development schemes. Minors and women are trained in livelihood skills and facilitated to find alternative options. A variety of conditions compel women and children to take up sex work. These range from acute poverty, the family's inability to pay dowry, desertion or widowhood, or being lured into the profession by promise of a job, to an overall lack of skills as a result of little or no education.UNICEF, in ORISSA
MAHARASHTRA
ANDHRA PRADESH GOA
KARNATAKA PONDICHERRY
TAMIL NADU LAKSHADWEEP
KERALA
Child Labour Elimation Karnataka In 1994, about 10,000 children were estimated to be working in Magadi's silk twisting units; by 2003, this figure was reduced to 1,000. This was a result of the collaboration between the community groups and the Department of Labour-GOKN, UNICEF and the four community based NGO's under the Magadi Makkala Dhawani project (Voices of Children in Magadi). The project focused on raising awareness, strengthening families against
indebtedness, forming community-based groups and educating families and employers on the pitfalls of child labour. Four bridge education centers were set up to facilitate the transition of children from work to education. After six months, the children were admitted into mainstream schools or, if over 14 years old, given vocational training. In 2000, the Government declared work in the silk industry as hazardous, giving an additional fillip to this initiative.In 1994, about 10,000 children
ANDAMAN AND NICOBAR ISLANDS
59
Child Protection
Breaking Free
60
Until a year ago, eight-year-old Laxmina was too busy working to even think of going to school. She earned about 30 Rupees (less than a dollar) a day in return for delivering milk to nearby villages more prosperous than her own. But all that has changed now. Laxmina has been attending an alternative learning centre (ALC), along with 40 other children in her home district of Mirzapur, which is located in India’s most populous state of Uttar Pradesh. It is one amongst many such centres set up four years ago with UNICEF support to help educate children who have never been to school. Over 20 per cent of India’s working children are from Uttar Pradesh, most of whom work at odd jobs, in factories and in the carpet industry for meagre wages. But their labour plays a key role in supplementing their families’ meagre income. One of the main reasons for the high prevalence of child labour in these areas is the burden of debt, which forces families to send their children to work. Low literacy rates further compound the problem. UNICEF addresses the issue of child labour through a combination of approaches including a focus on changing prevalent mindsets, forming self-help groups, improving the quality of mainstream education, providing transitional schools to return children to learning levels appropriate to their age. But education is seen to play a crucial role in eliminating child labour. UNICEF’s approach therefore focuses on motivating communities to send girls and boys (who have never been to school or who have dropped out) to alternative learning centres. The centres have been set up mostly in areas that do not have a school within a 1.5 kilometre radius and each caters for around 40 students. The aim is to help children complete primary education – which normally takes five years – within three years. At the end of this period, the children are integrated into formal school.
Assessments occur throughout this period. An examination is organised at the end of each class semester, which lasts for six months, while the final examination for class V is conducted by the district education officer. All those who pass the exams are awarded a certificate, which is key to getting admission to other schools recognised by the government.
When we would go to a village, they would all run away saying, these people have come to take away our children
The initiative, funded by IKEA (with about 500,000 dollars), through UNICEF’s German National Committee has covered around 650 villages in two districts of Uttar Pradesh. Around 200 Alternative Learning Centres (ALCs) are currently functional. These help in reaching out to more than seven thousand children, of whom 55 per cent are girls. Education has helped these children not only read and write but has also provided them with a sense confidence and empowerment. Eight-year-old Laxmina who had until recently thought that the only work her community would ever do was weave carpets, now talks of wanting to be a doctor for her village – a clear sign of change. Organising women into self-help groups has also set off its own process of social transformation. It has helped wrench them out of a debt–poverty cycle since they no longer need to take loans at high interest rates. Over 14,000 women from these 650 villages have saved more than 10 million Rupees. More than 50 per cent of this money is now circulating as loans in these villages. In one village, a woman succeeded in rescuing her son, who was taken away to work as bonded labour in exchange for her inability to pay back a small loan, with the help of these collective savings.
More children are now going to school instead of going to work, and women have learnt through their association with selfhelp groups crucial lessons that are helping them be far more self-reliant and informed than before. The districts of Bhadohi, Mirzapur, Jaunpur, Varanasi, Allahabad and Sonbhadra account for over 85% of the country’s total carpet exports. The growth of the industry in these areas is attributed to the availability of cheap labour here, since a large number of people live below the poverty line and are willing to work for very meagre wages. Carpet weaving is done through a traditional process of hand knotting on simple looms kept inside homes. This is one reason why it is difficult to enforce labour laws since large exporter-manufacturers don’t employ the labour force directly, and nor is a large proportion of work carried out on exporters’ premises. Children get involved in the work because families require as many hands as possible.
If I had been educated, I would not have faced the kind of problems that I do today
Understandably, there was strong resistance to the interventions when they were first introduced. “It was extremely difficult to convince people to send children to school. When we would go to a village, they would all run away saying, these people have come to take away our children,” says Sanjeev Srivastava, of the Bal Adhikar Pariyojana, a state government initiative for the prevention and elimination of child labour in the carpet belt, supported by UNICEF. It took several months before people began to see that setting up schools or starting their own savings, would only help
them improve their own lives. Nandlal, a father of four, whose two children have been mainstreamed into a formal school, did not get an opportunity to go to school himself. He used to work with his father on the loom and expected his sons to do the same. He too was reluctant at first to send his children to school. But now he says he understands the value of education and feels that this is the only way people like him can improve the quality of their lives. “If I had been educated, I would not have faced the kind of problems that I do today.” His wife, Susheela, who was married off by the time she was thirteen, could not even have dreamt that girls could ever have access to education. But both her daughters are now in school. She wants them to complete their education before marrying. While getting out-of-school children to ALCs, the project also works at addressing high dropout rates at formal schools. In areas where the ALCs have been phased out, support centres have been started to help children adjust to primary schools for a year. These support centres use innovative techniques to make learning a creative exercise. For instance, Panchdeep, a local instructor, teaching at a support centre in a village in Mirzapur district, is able to engage students of classes III, IV and V at the same time. The younger ones learn mathematical tables by counting bundles of sticks, while older ones write them on the blackboard. Panchdeep, who is a young graduate from this village, in this way plays a crucial role in reinforcing concepts that these children are learning in their formal schools. On the whole, the intervention has helped encourage communities send more and more children to school in the knowledge that education is truly empowering and that it has the potential over time to change their debt-ridden lives.
61
Population
Income
per capita (Rs)
Poverty
Percentage living below the poverty line
Infant Mortality Rate
Immunisation
Number of babies per 1,000 born alive who die before aged one
Percentage of children fully immunised
States Total
Andaman & Nicobar
Rural
Malnutrition Percentage of children aged under 3 who are underweight
Urban
356,265
19,777
21.0
15
17
10
–
–
75,727,541
14,878
15.8
62
71
35
62.7
38
1,091,117
13,352
33.5
37
38
12
–
24
Assam
26,638,407
9,720
36.1
70
73
38
–
36
Bihar
82,878,796
4,813
42.6
61
62
50
21.6
54
900,914
42,410
5.8
21
25
21
–
–
Andhra Pradesh Arunachal Pradesh
Chandigarh Chhattisgarh
20,795,956
10,405
–
73
80
59
56.8
–
Dadra and Nagar Haveli
220,451
N.A.
17.1
56
58
21
–
–
Daman and Diu
158,059
N.A.
4.4
42
42
43
–
–
Delhi
13,782,976
36,515
8.2
30
31
30
–
35
Goa
1,343,998
44,613
4.4
17
19
14
–
29
Gujarat
50,596,992
18,685
14.1
60
68
37
57.0
45
Haryana
21,082,989
21,551
8.7
62
64
51
59.4
35
Himachal Pradesh
6,077,248
17,786
7.6
52
53
28
88.0
44
Jammu and Kashmir
10,069,917
12,373
3.5
45
47
34
32.5
35
Jharkhand
26,909,428
9,223
–
51
55
33
23.5
–
Karnataka
52,733,958
16,654
20.0
55
65
25
71.4
44
Kerala
31,838,619
17,709
12.7
10
11
8
82.7
37
60,595
N.A.
15.6
25
31
18
–
–
Lakshadweep Madhya Pradesh
60,385,118
11,626
37.4
85
89
56
32.7
55
Maharashtra
96,752,247
22,604
25.0
45
52
34
72.3
50
Manipur
2,388,634
12,721
28.5
14
12
21
–
28
Meghalaya
2,306,069
12,083
33.9
61
62
49
–
38
891,058
14,909
19.5
14
14
14
–
28
1,988,636
12,594
32.7
–
–
15
–
24
Mizoram Nagaland Orissa
36,706,920
8,733
47.2
87
90
56
55.8
54
973,829
29,348
21.7
22
29
17
–
–
Punjab
24,289,296
23,254
6.2
51
55
35
78.5
29
Rajasthan
56,473,122
13,046
15.3
78
81
55
24.7
51
540,493
14,751
36.6
34
34
25
–
21
62,110,839
18,623
21.1
44
50
32
95.2
27
3,191,168
13,195
34.4
34
35
32
–
–
Pondicherry
Sikkim Tamil Nadu Tripura Uttar Pradesh
166,052,859
9,323
31.2
80
83
58
28.7
52
Uttaranchal
8,479,562
N.A.
–
41
62
21
46.6
–
West Bengal
80,221,171
14,894
27.0
49
52
36
55.9
49
1,027,015,247
15,626
26.1
63
69
40
44.0
47
India
62
Sources: Population: Census of India 2001; Income and Poverty: Government of India, Economic Survey 2002-03; Infant Mortality Rate: SRS 2004; Immunisation: DLHS-RCH 2002; Malnutrition: NFHS-2 1998-99.
Water
Sanitation
Percentage Percentage of of rural rural households households using using protected toilets water
HIV/AIDS
School Attendance
Prevalence in those attending:
Literacy
Percentage of children aged 6-10 attending school
Antenatal STD clinics clinics
Total
Girls
Birth Child Labour Registration Percentage
Percentage of population over 7 years who are literate
Boys
Total
Girls
Percentage of children aged under 5 who are not registered at birth
of children aged 5-14 working for others
Boys
66.8
42.3
0.0
2.6
96.9
97.9
96.0
81
75
86
7.5
0.2
76.9
18.1
1.3
30.4
87.7
84.3
91.0
61
50
70
67.6
18.1
73.7
47.3
0.0
0.0
71.7
69.9
73.5
54
44
64
67.0
3.9
56.8
59.6
0.0
0.8
82.0
77.7
86.0
63
55
71
70.2
3.9
86.1
13.9
0.3
1.6
64.9
58.3
71.6
47
33
60
98.4
3.1
99.9
68.5
0.3
0.8
96.0
95.8
96.1
82
77
86
28.6
1.6
66.2
5.2
0.3
0.8
83.9
81.4
86.6
65
52
77
53.7
5.4
70.5
17.3
1.0
–
81.4
75.4
86.9
58
40
71
28.6
5.2
94.9
32.0
0.2
–
96.7
94.7
98.5
78
66
87
5.8
1.4
90.1
62.9
0.3
3.2
91.0
90.1
91.8
82
75
87
29.2
1.5
58.3
48.2
1.4
11.3
97.3
97.3
97.4
82
75
88
4.7
4.4
76.9
21.7
0.4
6.2
82.6
79.1
85.7
69
58
80
12.5
4.0
81.1
28.7
0.4
1.1
90.0
87.4
92.2
68
56
79
25.3
5.0
87.5
27.7
0.0
0.4
97.6
97.3
97.8
77
67
85
6.4
1.0
54.9
41.8
0.1
1.0
87.4
83.4
91.3
56
43
67
52.1
1.5
35.5
6.6
0.0
0.1
67.7
62.0
73.1
54
39
67
93.7
4.1
80.5
17.4
1.8
13.6
88.3
86.3
90.2
67
57
76
49.0
5.9
16.9
81.3
0.4
2.5
99.0
99.0
99.0
91
88
94
11.0
2.2
4.6
93.1
0.0
0.0
97.5
97.1
97.8
87
81
93
7.6
0.9
61.5
8.9
0.0
2.4
79.9
76.9
82.7
64
50
76
70.1
1.8
68.4
18.2
1.3
7.6
94.0
93.9
94.1
77
67
86
19.6
5.5
29.3
77.5
1.1
9.6
94.9
93.9
95.9
71
61
80
72.5
8.1
29.5
40.1
0.0
0.9
82.0
82.3
81.6
63
60
65
67.4
1.9
23.8
79.7
1.5
2.6
88.5
89.0
88.0
89
87
91
15.8
1.0
47.5
64.6
1.3
2.4
90.6
89.6
91.5
67
62
71
51.2
1.1
62.9
7.7
0.3
0.8
79.1
74.0
83.9
63
51
75
90.3
4.5
96.6
21.4
0.3
2.0
97.4
98.9
96.0
81
74
89
6.3
5.8
96.9
40.9
0.5
1.6
90.1
88.8
91.2
70
63
75
11.1
2.0
60.4
14.6
0.5
6.0
82.0
73.6
89.3
60
44
76
87.6
7.6
67.0
59.4
0.1
0.0
95.4
95.5
95.4
69
60
76
31.3
4.9
85.3
14.4
0.9
14.7
95.8
95.3
96.3
74
64
82
30.9
15.5
45.0
77.9
0.0
1.4
91.9
90.5
93.2
73
65
81
52.1
1.7
85.5
19.2
0.3
0.8
80.1
75.4
84.5
56
42
69
93.5
2.2
83.0
31.6
0.2
0.3
93.3
92.7
93.7
72
60
83
78.1
0.9
87.0
26.9
0.0
0.5
81.9
79.8
83.8
69
60
77
48.8
3.6
73.2
21.9
–
–
82.3
78.6
85.9
65
54
75
65.3
5.2
Water and Sanitation: Census of India 2001; HIV/AIDS: NACO; School Attendance: MICS 2000; Literacy: Census of India 2001; Birth Registration and Child Labour: MICS 2000.
63
Index alternative learning centres 43 anaemia 24, 25, 26, 28 anganwadi workers 11, 26, 27, 28–29, 35 antenatal care 16, 18, 24 HIV/AIDS 49, 50, 51, 52–53, 63 arsenic in water 34 birth registration 8, 63 breastfeeding 19, 26, 27 Child Environment Corners 37 Child in Need Institute 28 child labour 10, 12, 40, 56–59, 57, 63 childcare workers 11, 26, 27, 28–29, 35 community mobilisers 20–21 Convention on the Elimination of all Forms of Discrimination Against Women (UN) 10 Convention on the Rights of the Child (UN) 6, 10
girls discrimination against 9 education of 8, 9, 11, 32, 40, 42, 44–45, 63 guinea-worm disease 7 health services 24 health workers 8, 12, 19 Hepatitis A 32 HIV/AIDS 7, 10, 12, 42, 48–53, 48, 49, 50, 52, 63 hygiene practice 24, 32, 34, 36–37, 43
illiteracy 8, 32; see also literacy immunisation 11, 16, 18, 19, 62 resistance to 20–21 Immunisation Plus 18, 19 income per capita 7, 62 infant mortality rate 6, 7, 10, 11, 16–17, 35, 62 infant survival 7, 8 Integrated Child Development deaths Services (GoI) 11, 26, 35 from diarrhoea 32 Integrated Management of from malnutrition 24 Neonatal and Childhood of under-fives 7, 33 Illnesses (UNICEF) 18, 19 see also infant mortality rate; iodine deficiency 24, 25, 28 maternal iodised salt 25, 26, 27 mortality rate; neonatal mortality iron supplementation 26, 27 rate diarrhoea 32, 33 life expectancy 7 District Information System for literacy 7, 10, 40, 63; see also Education 42 illiteracy economic development 6, 7, 10 education 6, 9, 10, 11, 12, 32, 40–45 alternative learning centres 43, 60–61 education camps 42, 43 HIV/AIDS awareness 50, 51 Jag Jagi Kendra 44 Mahila Shiksan Kendra 44–45 school attendance 41, 63 Education for All programme 11 Five Year Plan, 10th 6, 8, 10 fluoride in water 34, 35 gender discrimination 6 disparity 8, 63 gap in education 9, 11, 32, 40, 63
64
malnutrition 6, 8, 9, 24–29, 62 maternal mortality rate 6, 7, 10, 11, 16 measles 17, 18, 19 migration 56 Millennium Development Goals 10 National AIDS Control Organisation 48, 52 National AIDS Control policy (GoI) 11 National Child Labour Project 57 National Programme for Universal Elementary Education 42 National Programme on Girls’ Education at the Elementary Level 42 neonatal mortality 11, 16, 17, 18
nutrition 18, 24–29 obesity 8 obstetric care 18 panchayats 11, 28, 43 polio 16, 18, 19 population 6, 62 Positive Deviance project 28–29 poverty 6, 7, 7, 10, 32, 35, 62 Prevention of Parent to Child Transmission of HIV 50, 51, 52 Reproductive and Child Health (RCH) programme 11, 18 respiratory tract infections 32 rural–urban differential: education gender gap 9 infant mortality rate 8, 17, 62 sanitation 33, 34 water 34 sanitation 8, 32–37, 32, 33, 34, 43, 63 Sarva Shiksha Abhiyan 42 schools 32, 36–37, 40–45, 50, 51, 63 sex ratio 6, 9 skilled birth attendants 10, 11, 16, 18 smallpox eradication 7, 21 tetanus 17, 18, 19 Total Sanitation Campaign (GoI) 35 Total Sanitation Campaign (TSC) 11 UNAIDS 50 underweight children 7, 24, 24, 25 UNICEF programme and projects structure 13 Village Education Committees 37 Vitamin A deficiency 24, 25, 26 water protected source 8, 10, 12, 32, 34, 63 pollution of 10, 32, 34, 35 women death in childbirth 6, 7 HIV/AIDS awareness 48, 49 literacy 40 working in the community 35 World Fit for Children 10 World Health Organization 18
India is home to 19 per cent of the world’s children. This vast country of stark contrasts and striking disparities – between urban and rural, men and women, rich and poor – is brought to life in a rich palette of maps and graphics to highlight the areas of UNICEF in action: its achievements and the challenges ahead.
ISBN: 92 806 3796 7
79.3%
90.4% 84.1%
63.5%
Rural
Urban
57%
2001
50%
2000
1999
47% 47%
1998
1997
52% 53%
1996
Every year, some 26 million children are born in India – many more than in any other country. For some, globalisation has brought increased access to information, better health care and improved living conditions. For millions more, daily survival without safe drinking water or sanitation remains a struggle, and death from preventable diseases is common. This atlas endeavours to show how UNICEF assistance helps to improve the quality and reach of health care, nutrition and education. It also provides snapshots of particular issues confronting India – from HIV/AIDS to child labour – and shows how the success of small, communitybased programmes can be developed, replicated and sustained.