Better funding, community training & cultural context can improve outcomes further, say experts
Children upto age six are now being provided hot cooked meals at spot
feeding centres in selected PVTG villages. Source: Aishwarya Mohanty Amita Sikaka (21), was anemic and underweight when she was pregnant with her first child. Weighing 35 kilograms, she felt frequent bouts of nausea and weakness.
But in the months that followed, Amita’s weight and nutrition parameters were constantly monitored. She was provided hot, sumptuous meals every day and her health parameters improved consistently. In February she delivered a healthy child.
Amita belongs to the Dongria Kondh tribe, a particularly vulnerable tribal group (PVTG). The PVTGs in Odisha are known for their particularly poor outcomes such as very low levels of literacy, high maternal and infant mortality from endemic malaria as well as poor nutritional indicators.
India has 75 listed PVTGs with the highest number found in Odisha. Odisha has 13 PVTGs, with a population of 240,000 spread across 11 districts.
These outcomes stem from underemployment of these groups on the one hand and poor access to service delivery outposts (such as primary health centers and sub-centres) on the other.
As poor nutritional status continues to remain an area of concern for the PVTGs, the state’s Jiban Sampark nutrition programme is trying to bring in improvements. Like Amita, today many expecting and lactating mothers across the PVTG villages are being monitored and provided with one-time meals to keep their nutritional parameters buoyant.
The state government has also initiated a focussed initiative, the Odisha PVTG Nutritional Improvement Programme (OPNIP) under the Odisha PVTG Empowerment and Livelihoods Improvement Programme (OPELIP).
OPNIP was initially started in three districts in phases in Malkanagiri, Rayagada and Kalahandi, and subsequently to nine others.
The major three interventions taken up under OPNIP were community-based creches for children of age 6 months to 3 years, spot feeding centres for children aged 3-6 yrs and maternal spot feeding centres for pregnant & lactating mothers.
There is no national health data specific to PVTGs but a study by Asian Institute of Public Health and the Scheduled Castes and Scheduled Tribes Research and Training Institute (SCSTRTI), conducted in 2015, shed some light.
Among those below the age of five years, 32 per cent of the respondents were severely stunted, 35 per cent were severely underweight and 18 per cent severely wasted. Around 34.9 per cent of the under-five age group were severely malnourished and 21.2 per cent were moderately malnourished.
Every third child who was weighed at birth had a low birth-weight.
Among women of reproductive age, 38 per cent were underweight and 54 per cent were found to be anaemic. Anaemia poses a significant risk for maternal and child survival.
SN Padhy, a social activist working with the PVTG groups for over 40 years, said:
The community lags behind the national average on several health indicators, with women and children being the most vulnerable. But we will also have to understand that this vulnerability towards poor health comes from multiple factors like lack of education, employability and financial security.
So when we speak of health, the approach needs to be holistic rather than unitary, the expert added.
These interventions, in convergence with related state departments, are designed to prioritise the first 1,000 days of life when rapid growth and development take place.
Local PVTG self-help groups are entrusted with managing the OPNIP interventions, noted OPELIP. This strengthens the community ownership and empowers local PVTG women’s collectives in managing such nutrition interventions in their community.
The extent of dietary energy and protein inadequacy was more pronounced among PVTGs, studies have shown, reiterating the fact that there remains a food gap. The intakes of various micronutrients, specifically that of iron, vitamin A, riboflavin and folic acid was found to be grossly inadequate, which is in consonance with inadequate intake of protective foods.
Considering that poor nutritional status of mothers puts the children at a higher risk of diseases and mortality, the OPNIP provides pregnant and lactating mothers with one hot cooked meal, through the supplementary nutrition programme for the period from registration of pregnancy till completion of exclusive breastfeeding.
Currently, around 900 pregnant women and nursing mothers are receiving the meals at 119 maternal spot feeding centres under OPNIP in the PVTG villages. And the initiative has shown results.
Drubi Kirsani (24) (name changed) had suffered two miscarriages and postnatal complications after the birth of her other three children. Drubi, who belongs to the Bonda tribe in Padeiguda village, Malkangiri district, had anemia and was underweight. “I have never been to the hospital for institutional deliveries. All my deliveries happened at home. There was no institutional care after delivery either. I always feared for my kids because they were thin and underweight,” Drubi said.
In August last year, she was enrolled at the spot feeding centre and provided daily meals and iron tablets.
“I generally eat just ragi or boiled rice for meals at home. My children eat that too,” she said. The centre offers further dietary supplements with dal, vegetables and whole grains.
The 105 spot-feeding centres for PVTG children aged 3-6 years similarly provide hot cooked meals to around 1,100 children six days a week.
“Since small children from these hilly, tribal areas are not able to regularly commute to the Anganwadi Centres due to geographic inaccessibility, they are provided with the supplementary nutrition entitlement of morning snacks and hot cooked meal, as prescribed under Integrated Child Development Services, in the village of their habitation itself,” an official from OPELIP said.
This is a deviation from the initial practice of providing take-home ration, said Namita Sahu, a nutrition coordinator. “We had observed that with take-home ration, there was no monitoring of what the mother would consume and what the child would consume. The spot feeding centres address this gap.”
Their health parameters are also observed every month to chart the difference,” she added.
Experts working with the tribal groups feel that the initiative can not exclusively address the issue of bridging the gap, but can complement in the process, bridging the nutritional gap. “A majority of the PVTG habitations are located in unreachable areas. These habitations are also scattered and there are villages / hamlets with just 10-15 households. In such a place, anganwadi centres are not feasible to be established,” said AB Ota, former director of SCSTRTI.
Also, ration / food distributed for children normally ends up in the family food basket as the entire family is food insecure, Ota added. Thus, setting up creches and spot feeding centres is essential to bridge the nutritional gap of PVTG children.
The initial years after birth, especially the first five years, are considered to be extremely vital for any child under five years of age, wherein optimal nutrition fosters healthy growth and improves cognitive development.
In Devgada village of Kandhamahal district’s Belghar block, Sanjuli Majhi drops off three children at the creche before venturing out into the forest to collect minor forest produce.
Belghar is home to the Kutia Kondh PVTG tribe. The creche facility not only addresses nutritional improvement for the children but also helps mothers leave their young children under proper care. The children would otherwise accompany their parents into the forests and get exposed to insects, snakes and vector-borne diseases.
“There was a constant fear that my children would be bitten by snakes or any other insects. I would also develop back aches because the trek into the forest is usually through an uneven rocky path and would fall ill often,” Sanjuli said.
Her children aged three years, two years and eight months had registered low birth weight. “When I enrolled them at the centre I was told that they were in the red zone. Now they are in the green zone and have shown significant improvement,” Sanjuli said.
At the centres for younger children aged 6 months-3 years, children receive three meals, supervised care and attention of trained crèche workers, who are members selected from the PVTG self-help group.
Creches function for 7-8 hours for six days a week and provide two snacks and one hot cooked meal, with a focus on calorie and protein-dense food items, said Jashoda Badanayale, nutritional manager in Belghar. “Around 60-70 per cent of calories and 75-100 per cent of their protein requirement is taken care of.”
A spot feeding centre and creche at Tanda, an inaccessible Dongria Kondh village in Odisha’s Rayagada district. Photo: Aishwarya Mohanty
Children from selected villages are scanned for malnutrition through various technical methods and those found to be suffering from severe acute malnutrition are identified and treated with curative food and technical support, according to the programme.
A monthly log and growth chart is maintained to evaluate and assess the nutritional status of children. As a procedure to assess changes, the mid-upper arm circumference and weight is measured for all the children every month while the height is measured every four months. A community growth chart is maintained for all the children marking all improvements in green, minor improvements which still need care in yellow and children who need focussed attention in red.
An analysis report of the intervention showed that for the 25 old creches, 49.5 per cent children fall under normal weight category and reported an improvement of 6 per cent from the baseline data.
From April 2022, 61 creches for children under three years of age have been made operational, catering to around 1,000 children under three years of age. Additionally, 46 new maternal spot feeding centres cum crèches are on the anvil and will be set up soon.
In the case of severe stunting, there is marked improvement with reduction from 34.8 per cent at baseline to 24.8 per cent in February 2023.
While the initiatives have shown positive growth, challenges over training ground cadre and finances remain.
In Odisha, the share of the nutrition budget was 20.05 per cent of the state’s total budget, while it was 5.03 per cent of the gross state domestic product in 2022-23.
There has been an increment of 5.61 per cent in nutrition-specific components and of 28.46 per cent in nutrition-sensitive components for 2022-23, compared to 2021-22.
For OPNIP, in 2020-21 the nutrition budget was Rs 6.37 crore, which went down to Rs 3.3 crore in 2021-22. But it was revised to Rs 7 crore again for 2022-23.
Among the initial challenges were that women from self-help groups had to be trained to take up the initiatives, said P Arthanari, Project Director, OPELIP. “For finances, we are converging with different departments, so this remains an area of challenge as well.”
Experts also feel that interventions like these can yield better results when they are contextualised culturally. “For nutrition, we have a common approach across the country, which is developed and tested by the Government of India. But food has more cultural than nutritional value,” said Biswajt Modak, a public health expert from Odisha.
“So whatever the cultural food they have available within their immediate ecosystem, we should have a discussion with the tribal population and based on their food patterns, ecological systems and traditions, we should have our plan for nutritional initiatives,” he added.
This the first of a three-part series on Odisha's PVTGs. The second part of the series talks about how distance and remoteness has impacted the healthcare accessibility and health care seeking behaviour of the population.
This article was supported by Health Systems Transformation Platform as a part of the Health Journalism Fellowship 2022.
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