Hunger, Universal Health Care, and the Right to Food in India
TRANSCEND MEMBERS, 1 Apr 2019
Prof. George Kent – TRANSCEND Media Service
1 Apr 2019 – Like the United States, Brazil, Venezuela, Nigeria and other countries, India is rich and at the same time it has many poor people. The widespread hunger and poverty is due not to an overall lack of resources, but to the fact that the abundant resources in those places are used mainly for the benefit of those who already have a great deal. With Global Gross Domestic Product estimated at $143 trillion in 2019 (World Bank 2019), why is there any hunger at all? One has to pay attention to how the political economy of a place determines who gets what benefits and who gets what harms. This is important in understanding how countries work and also how the world as a whole works.
I appreciate Moin Qazi’s recent article on India’s losing the battle against hunger (Qazi 2019), but reducing waste in India’s food system is not likely to be an effective remedy. If large quantities of food are prevented from rotting, who is likely to get it? In the food chain, refrigeration and other technologies for preserving foods are more likely to be used to protect food for the rich than food for the poor. In market-dominated food systems, food migrates toward money, not toward needs. This is abundantly clear when one notices that India is a major food exporter, shipping great quantities of beef (actually buffalo), rice, and other food commodities to the highest bidders (USDA 2014).
For many employers in India, the persistence of widespread hunger is not a problem. It is an asset, ensuring the availability of abundant cheap labor. Like the world as a whole, India is in no hurry to end hunger. But we should continue the search for solutions. Gandhi offered ideas on how the problem could be addressed, based on his talisman:
“Hunger should be addressed not by feeding the poor, but by making sure that the poor have increasing control over their own destinies (Kent 2010).”
One good way to do that would be to help strengthen their local communities (Kent 2018). In some cases this can be done by disconnecting communities from the dominant market system and the control it exercises over people’s lives (Richards 2019).
If the will is there, it would not be difficult to end hunger in India, at least among young children.
Universal health care, sometimes called universal health coverage, refers to health systems in which basic health care is provided to all regardless of their ability to pay (Amadeo 2018). It has the advantage of lowering health care costs to the people served, but it can involve high total costs to government, depending on the benefits offered. It costs money, but it can be money well spent. Universal health care benefits society as well as individuals (WHO 2013).
By joining the concepts of universal health care with those of India’s Integrated Child Development Service (ICDS) and also the right to food, the combination could provide a sound approach to dealing with the high level of child hunger in India.
The World Health Organization explains:
Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.
This definition of UHC embodies three related objectives:
- Equity in access to health services – everyone who needs services should get them, not only those who can pay for them;
- The quality of health services should be good enough to improve the health of those receiving services; and
- People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm. (WHO 2018)
Universal health care is feasible even in low-income countries:
Rwanda has introduced ultrabasic health insurance for more than 90% of its people; infant mortality has fallen from 120 per 1,000 live births in 2000 to under 30 last year (The Economist 2018; also see Mason 2017).
Rwanda has reduced its child mortality rate faster than any other country (Roser 2018). Many elements help to explain its success, especially the fact that government “has improved access to services for the poor and other vulnerable groups through the community Mutuelle de Santé medical insurance system, which covers 90 per cent of the population (UNICEF Rwanda 2018; also see Ministry of Health, Rwanda 2018).
India does not have the highest rate of child deaths in the world, but as a large country, it has a larger number than any other country, more than a million child deaths a year (UNICEF 2017).
The ICDS program is dedicated to serving all children under six and pregnant and lactating mothers. The results have been disappointing (Malik et al. 2015; Shukla 2018; Venugopal 2012). Both child and maternal mortality remain high. The desired health outcomes are not achieved partly because the services that are promised are not delivered. A study in Uttar Pradesh found:
About 76% of intended beneficiaries–lactating mothers, children below six, pregnant mothers–in the state did not avail supplementary nutrition in anganwadis, according to the Rapid Survey on Children. (Yadavar 2018).
According to another report:
As on March 2017, 88 per cent of children registered in an AWC [Anganwadi] in Odisha and 83 per cent in Gujarat received supplementary nutrition. In contrast, only 39 per cent of children registered in AWCs in Haryana and 33 per cent in Rajasthan received supplementary nutrition. (Budget Briefs 2017, 7)
The proportion of total ICDS beneficiaries who are malnourished has been rising. As on March 2015, 15 per cent of total ICDS beneficiaries were malnourished. This increased to 22 per cent as on March 2016 and 25 per cent as on September 2017.
There are, however, significant state wise differences. As on March 2015, the proportion of ICDS beneficiaries that were malnourished was the highest in Bihar at 48 per cent. This decreased marginally to 46 per cent as on September 2017. Proportion of beneficiaries malnourished decreased in West Bengal and Punjab. (Budget Briefs 2017, 8)
The situation remained about the same a year later (Budget Briefs 2018).
Linking Universal Health Care and the Right to Food
A remedy might be found by linking India’s commitment to achieving universal health coverage (Deyl 2018; Dharmshaktu 2018) with its commitment to the right to food. This is not a new idea:
In April 2001, the People’s Union for Civil Liberties (PUCL, Rajasthan) submitted a writ petition to the Supreme Court of India seeking enforcement of the right to food. . . . the Supreme Court has issued a series of “interim orders” aimed at safeguarding various aspects of the right to food.
The first major order, dated 28 November 2001, directed the government to fully implement nine food-related schemes as per official guidelines. In effect, this order converted the benefits of these schemes into “legal entitlements”.
Integrated Child Development Services (ICDS) . . . is one of the schemes covered by this Supreme Court order. In the case of ICDS, the order actually went further than just converting existing benefits into legal entitlements: it also directed the government to “universalize” the programme. This means that every hamlet should have a functional Anganwadi, and that the coverage of ICDS should be extended to all children under six years of age and all eligible women. (Right to Food Campaign 2014, 3).
This report’s promising introduction was followed by detailed accounts of failures of implementation. The Indian press steadily reports on problems with the ICDS program, many of them about failures to deliver the required services. It provides similar reports of failures in the Mid Day Meals program and other programs as well.
Many of the problems could be addressed by giving more attention to what I call the “missing piece” in India’s right to food law. It relates not to the content of what is promised, but to the poor functioning of the rights system.
The Missing Piece: Recourse Mechanisms
There is a broad lack of accountability in India’s rights system because of the lack of effective recourse mechanisms through which rights holders themselves can act to have violations of their rights corrected.
Applying the concept that rights holders should be involved in ensuring that their rights are realized could help strengthen the ICDS (Kent 2006). Entitlements should be specific. Rights holders should have safe and effective recourse mechanisms available to them if they feel they have not gotten what they are supposed to get. This would apply to goods such as food rations and also services such as specific types of health care.
A list of current entitlements for the rights holders should be readily available (Right to Food Campaign 2018). If entitlements are not clearly articulated and communicated to the rights holders, that in itself undermines the concept of a right to food. Rights don’t mean much if people don’t know what they are supposed to get.
To start the process of holding the government accountable for fulfilling obligations it has explicitly accepted, parents together with their children could be asked, systematically, whether they know what they are supposed to get, and whether they did in fact get those things. They could also be asked about their quality.
This inquiry could be organized in a variety of ways. Interviews could be done by small committees of mothers that lead the process for each Anganwadi. There could be checklists to record who did or did not receive the specific things to which they are entitled in a sample time period. The committee could conduct interviews with individuals and small groups. It could discuss the findings with the parents before passing them on to designated officials.
Repeating this exercise regularly could help to refine the parents’ understanding of what they should expect from ICDS through the Anganwadi. The process could make it clear to them that they have the possibility, and even the responsibility, of making complaints and expecting corrections when the circumstances justify it. Over time, as the parents become more fully engaged with it, this procedure could be strengthened to become a well-functioning rights system. Without that sort of regular feedback in the delivery system, it would meander, like a ship without a rudder, never getting to its destination (Kent 2012).
The children could be engaged in various ways, depending on their level of maturity. They could learn to function as active rights-holders not only in ICDS, but also in the Mid Day Meals program, and in other situations in which rights matter. The parents could apply their understanding of how rights should work in dealing with other situations in which their rights might not be fully realized.
As the rights holders become more active, the entitlements themselves could be stated in forms that more readily enable children and their parents to judge whether they have gotten what they are supposed to get. This would help them in learning about nutrition as well as learning about how rights should work.
There are new possibilities for holding government agencies to account with the Aadhaar scheme, established to provide everyone in India with a unique and verifiable identification (Bhatia 2018; Gelb and Mukherjee 2018; The Economist 2017). Aadhaar authentication (are you who you say you are?) is already used to access a variety of services, and to ensure that people don’t claim services to which they are not entitled (Bhatnagar 2018). With adaptations, the system could also be used to ensure that people do get what they are supposed to get. People with entitlements could be asked to certify that they have actually received what they are supposed to get by providing Aadhaar-verified receipts. Aadhaar is commonly viewed as giving government more power over the people. It can also be used to provide people with more power in relation to their government.
The health services in Rwanda are similar to those in India. The difference in results may be due mainly to differences in the degree to which those who should get the service actually get it.
Coverage can be increased by linking payments to health care workers to specific services rendered, or to results. In Rwanda, in some contexts:
The workers are not given a regular salary, but are paid for what they achieve:
“If they have 100 children in the community who need to be vaccinated during the month, we pay them according to the number who are vaccinated. If 80% of children are vaccinated, we give them 80% of the money.” (BBC News 2015)
Something similar could be done for Anganwadi workers. Their low salaries could be augmented with bonuses based on actual improvements in the health of the mothers and children they serve. Apart from bonuses, arrangements could be made so that people who are responsible for delivering particular goods or services will not be paid or will be fired unless they can show receipts, perhaps Aadhaar-based receipts. Modern technologies for verifying the delivery of packages could be applied to ensure accountability in governments’ services. The technology could help reduce corruption. “Leakage” from the food supply chains could be detected when the complaints of people whose food has been diverted are heard.
Of course ICDS cannot be expected to function properly until the program is funded properly (Newsclick Report 2018; Pallapothu 2018). Until that happens, the idea that young children are entitled to specific services from ICDS based on their having specific rights cannot be taken seriously. The performance of the whole system should be steadily monitored. Systematic failures to deliver on entitlements should be challenged in court. Rights, including the right to food, are supposed to be enforceable claims.
These types of procedures could help to keep the programs on track toward the goal of ending hunger. However, it will not work if the government is not sufficiently motivated to make it work. The key to ending hunger is caring about it (Kent 2016).
Amadeo, Kimberly. 2018. “Universal Health Care in Different Countries, Pros and Cons of Each.” The Balance. https://www.thebalance.com/universal-health-care-4156211
BBC News. 2015. How Has Rwanda Saved the Lives of 590,000 Children? BBC News. https://www.bbc.com/news/world-africa-32438104
Bhatia, Rahul. 2018. “How India’s Welfare Revolution is Starving Citizens,” The New Yorker. May 16. https://www.newyorker.com/news/dispatch/how-indias-welfare-revolution-is-starving-citizens
Bhatnagar, Guarev Vivek. 2018. “In Jharkhand, Suspected Starvation Deaths Indicate Failure of Governance: Right to Food Campaign,” The Wire. June 21. https://thewire.in/government/jharkhand-starvation-deaths-right-to-food
Budget Briefs. (2017. “Integrated Child Development Services (ICDS): GoI [Government of India], 2017-2018.” Centre for Policy Research: Accountability Initiative, Vol. 10, No 7. http://accountabilityindia.in/sites/default/files/pdf_files/Integrated%20Child%20Development%20Scheme.pdf
—. 2018. “Integrated Child Development Services (ICDS): GoI [Government of India], 2018-2019.” Centre for Policy Research: Accountability Initiative, Vol. 10, No 7. http://accountabilityindia.in/sites/default/files/pdf_files/Integrated%20Child%20Development%20Services.pdf
Deyl, Sushmi. 2018. “India Committed to Achieving Universal Health Coverage: J P Nadda.” Times of India. May 22. https://timesofindia.indiatimes.com/india/india-committed-to-achieving-universal-health-coverage-j-p-nadda/articleshow/64276648.cms
Dharmshaktu, N. S. 2018. “Achieving Universal Health Coverage in India,” LiveMint. June 1. https://www.livemint.com/Opinion/NOeZLlSF16NIwnAzdDPIGP/Achieving-universal-health-coverage-in-India.html
Gelb, Alan and Anit Mukherjee. 2018. “The Aadhaar Debate: Where Do We Go From Here? Center for Global Development. April 13. https://www.cgdev.org/blog/aadhaar-debate-where-do-we-go-here
Kent, George. 2006. “ICDS and Right Food,” Economic and Political Weekly (Mumbai, India). November 11. Vol 41, No 45), pp 4702-4703. http://www2.hawaii.edu/~kent/ICDS%20and%20Right%20to%20Food.pdf
—.2012. “ICDS: Steering an Ungainly Ship,” Economic & Political Weekly (Mumbai, India). September 15. Vol. XLVII , No 37, pp 32-34. http://www2.hawaii.edu/~kent/ICDS_Steering_an_Ungainly_Ship.pdf
—. 2016. Caring About Hunger. Sparsnäs, Sweden: Irene Publishing.
—. 2018.“Nourishing Communities.” Transcend Media Service. December 17. https://www.transcend.org/tms/2018/12/nourishing-communities/
Knaul, Felicia Marie et al. 2012. “The Quest for Universal Health Coverage: Achieving ocial Protection for All in Mexico.” The Lancet, October 6, Vol 380, No 9849, pp 1259-1279. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61068-X/fulltext
Malik, Akash, Meenakshi Bhilwar, Neeti Rustagi, Davendra K. Taneja. 2015. “An Assessment of Facilities and Services at Anganwadi Centers Under the Integrated Child Development Service Scheme in Northeast District of Delhi, India,” International Journal for Quality in Health Care. 27(3): 201-206. https://academic.oup.com/intqhc/article/27/3/201/2357363
Mason, Emily.2017. “Universal Health Coverage: How Rwanda is Moving Forward with Healthcare for All.” Duke Fuqua. September 8. https://centers.fuqua.duke.edu/case/2017/09/08/health-builders-emily-mason/
Ministry of Health, Rwanda. 2018. Success Factors for Women’s and Children’s Health: Rwanda. Ministry of Health Rwanda, PMNCH, WHO, World Bank, AHPSR and participants in the Rwanda Multistakeholder Policy Review. http://www.who.int/pmnch/knowledge/publications/rwanda_country_report.pdf
Newsclick Report.2018. “Thousands of Scheme Workers Protest in Bihar and Punjab,” Newsclick. https://newsclick.in/thousands-scheme-workers-protest-bihar-and-punjab
Palla Pothu, Sravan. 2018. “Child Health in India: 14 Out of 20 States Cut Spending on Key Programmes.” Business Standard. May 30. https://www.business-standard.com/article/current-affairs/child-health-in-india-14-out-of-20-states-cut-spending-on-key-programmes-118053000122_1.html
Qazi, Moin. 2019. “Food for Thought: India Losing Battle Against Hunger.” Transcend Media Service. March 25. https://www.transcend.org/tms/2019/03/food-for-thought-india-losing-the-battle-against-hunger/
Richards, Howard. 2019. “Thomas Piketty vs. Yanis Varoufakis.” Transcend Media Service. March 25. https://www.transcend.org/tms/2019/03/thomas-piketty-vs-yanis-varoufakis/
Right to Food Campaign. 2014. Anganwadis for All: Action for Rights of Children Under Six: A Primer. Right to Food Campaign, Secretariat. New Delhi. Fourth Edition. March.
—. 2018. Children Under 6 (ICDS and More). http://www.righttofoodcampaign.in/pre-school-nutrition/official-documents
Roser. Max. 2018. “Child Mortality.” Our World in Data. https://ourworldindata.org/child-mortality
Shukla, Ritwik. 2018. “India’s Stunted Progress on Child Health.” Accountability Initiative. http://accountabilityindia.in/india%E2%80%99s-stunted-progress-child-health
The Economist. 2017. “India’s Biometric Identity Scheme Should Not be Compulsory,” The Economist, April 15. https://www.economist.com/news/leaders/21720599-bjp-government-should-listen-peoples-qualms-about-snooping-indias-biometric-identity?cid1=cust/ednew/n/bl/n/20170412n/owned/n/n/nwl/n/n/na/23215/n
The Economist. 2018. “Within Reach: The Case for Universal Health Care is a Powerful One—Including in Poor Countries,” The Economist, April 28. https://globalhealth.washington.edu/sites/default/files/The%20Economist_UHC_WithinReach.pdf
UNICEF. 2017. UNICEF Data: Monitoring the Situation of Children and Women. New York: United Nations Children’s Fund. https://data.unicef.org/resources/levels-trends-child-mortality/
UNICEF Rwanda. 2018. Child Survival and Development. UNICEF Rwanda. https://www.unicef.org/rwanda/child_rights.html
UNICEF/WHO/World Bank Group. 2017. Levels and Trends in Child Malnutrition. Joint Child Malnutrition Estimates. https://data.unicef.org/wp-content/uploads/2017/06/JME-2017_brochure_June-25.pdf
USDA. 2014. “India’s Agricultural Exports Climb to Record High.” United States Department of Agriculture. Foreign Agricultural Service. August 29. https://www.fas.usda.gov/data/india-s-agricultural-exports-climb-record-high
Venugopal, K. R. 2012. The Integrated Child Development Services: A Flagship Adrift. New Delhi: Konark Publishers.
WHO. 2013. Arguing for Universal Health Coverage. World Health Organization. http://www.who.int/health_financing/UHC_ENvs_BD.PDF?ua=1
—. 2018. Universal Health Coverage and Health Financing. World Health Organization. http://www.who.int/health_financing/universal_coverage_definition/en/
World Bank. 2019. “Gross World Product.” Statistics Times. February 24. http://statisticstimes.com/economy/gross-world-product.php
Yadavar, Swagata.2018. “Why Health Workers, Paid Rs 4,000 Per Month, Are Vital To India’s National Nutrition Mission” IndiaSpend.July 28. http://www.indiaspend.com/cover-story/why-health-workers-paid-rs-4000-per-month-are-vital-to-indias-national-nutrition-mission-22093
After more than forty years of teaching in the University of Hawaii’s Department of Political Science, TRANSCEND member George Kent retired in 2010 as Professor Emeritus. Currently he serves as an Adjunct Professor with the Department of Peace and Conflict Studies at the University of Sydney in Australia and also with the Department of Transformative Social Change Program at Saybrook University in California. He teaches an online course on the Human Right to Adequate Food for both these universities. Professor Kent has worked with the Food and Agriculture Organization of the United Nations, the United Nations Children’s Fund, the World Food Programme and several nongovernmental organizations. He is on the Board of Directors of the International Peace Research Association Foundation. His major books on food policy issues are Freedom from Want: The Human Right to Adequate Food, Global Obligations for the Right to Food, Ending Hunger Worldwide, Regulating Infant Formula, Caring about Hunger, and Governments Push Infant Formula. He serves as Deputy Editor of the World Public Health Association’s online journal, World Nutrition and as Associate Editor for Public Health Nutrition. He can be reached at email@example.com. Academia Website – Google Scholar.
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[…] In an insightful article explaining why hunger in India cannot be addressed simply by reducing waste in the national food system, Professor George Kent writes that ‘One has to pay attention to how the political economy of a place determines who gets what benefits and who gets what harms. This is important in understanding how countries work and also how the world as a whole work.’ You can read more in his fine article: ‘Hunger, Universal Health Care, and the Right to Food in India’. […]