Keystone II

Issue – 02: Mar - Apr 2017 Strategy and Research Management, World Vision India For feedback and queries, contact: bestin_samuel@wvi.org

World Vision India

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TABLE OF CONTENTS

Editorial

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National Family Health Survey – 4: An Overview (Factsheet)

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World Vision’s impact in Daryapur, Maharashtra (Impact Report)

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Child Sexual Abuse in India (Opinion)

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Disability in India (Factsheet)

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EDITORIAL We are happy to bring to you the second issue of Keystone, a research publication from the Strategy and Research Management Team, World Vision India. Let me thank you for all the encouragement and the enriching feedback we received for the first issue. We hope to do better in every issue, as we work together towards building an evidence-based culture of learning within the organization.

This issue of Keystone carries discussions around health, child sexual abuse, and disability. The tribal population in Amaravathi District in Maharashtra is known for its malnutrition deaths. However, thanks to World Vision India’s work, there was a decrease in underweight from 34.90% to 23.80% while the state average remained at 40% in rural areas. The stunting rate reduced from 61% to 50% among children. The Impact Report of World Vision India’s work in Daryapur, featuring in this issue of Keystone narrates the story behind these numbers. Program Impact Reports showcase the impact of our work and serve as channels to engage, inform and inspire all our stakeholders. May it be Kottayam in the last issue or Daryapur in this issue, Keystone aims to promote evidence-based reports of impact. Instead of focusing on what we did, these reports focus on what happened because of what we did.

The haunting fact of increased Child Sexual Abuse (CSA) calls for an immediate action both from civil societies and government. An Opinion on CSA vividly captures the intensity of the issue with statistics which cannot be ignored. Addressing the issue of CSA is going to be the theme for World Vision’s global and national campaign for the coming years.

An analysis of recently released National Family Health Survey (NFHS – 4) adds an interesting comparison between some of these indictors and World Vision India’s baseline survey results which helps to understand the status in our target areas. A way forward is also suggested for programming, especially in the worst performing states. Also featuring in this issue of Keystone is the fact sheet on children with disabilities, highlighting key numbers and dimensions of the impact of disability on children.

Packed with information and analysis, we hope this issue of Keystone will make for interesting reading and also provide insights for better program decisions.

Happy reading!

Prasad Talluri, Head – Strategy and Research Management, World Vision India

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NFHS – 4: An Overview FACTSHEET This factsheet offers an overview of the key highlights of the National Family Health Survey – 4, one of the most comprehensive and insightful health surveys done by the Government of India. The factsheet reveals the performance of the country in comparison with NFHS-3 data as well as World Vision India’s baseline data, in terms of certain key indicators. It also looks at some of the worst performing states in the country when it comes to health, offering scope for discussions on programme priorities and investments.

Author: Sarojitha Arokiaraj (Policy Research), Bestin Samuel (Research)

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NFHS – 4: AN OVERVIEW What is NFHS 4?

The National Family Health Survey (NFHS-4) 2015-16 is the fourth in a series of national surveys; earlier National Family Health Surveys were carried out in 1992-93 (NFHS-1), 1998-99 (NFHS-2) and 2005-06 (NFHS-3). This has data from each of India’s 29 States and all 7 Union Territories.

Approximately 570,000 households across the country were covered for information.

All National Family Health Surveys have been conducted by the Ministry of Health and Family Welfare, Government of India, with the International Institute for Population Sciences, Mumbai, serving as the nodal agency.

The most recent health survey by the Government of India – NFHS – 4, has shown improvement in key health indicators. More children live beyond their 5th birthdays, children have become healthier, early marriages have reduced and there are lot more to celebrate.

What is the purpose of NFHS? NFHS has three specific goals: 

to provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare and other agencies for policy and programme purposes



to provide information on important emerging health and family welfare issues



to enable the Government of India to provide national and international agencies to monitor and evaluate policies and programmes related to population, health, nutrition, and HIV/AIDS.

With reducing malnutrition and childhood illnesses as one of our strategic priorities and our commitment to contribute to the achievement of SDGs, these indicators / results will guide our programming and advocacy directions.

Key Highlights of NFHS - 4 

Health status improved over the last 10 years, but not much for those in the lowest wealth quintiles.

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Though there is a reduction in U-5 mortality from 74 (2005-06) to 50 (2014-15), we still have not reached the MDG target of 42.

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IMR reduced by half in urban areas (29) from 57, but remains at 46 in rural areas.

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Sex ratio for children born in the last five years shows a marginal increase. Though it has improved to 919 from 914 (NFHS 3), the urban sex ratio is still very low at 899.

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Women married before the age of 18 years reduced by 26.8%.

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Average Out of Pocket expenditure for delivery in a public health facility is INR 3198, suggesting a need for awareness of entitlements.

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Number of children fully immunized increased to 62% from 43.5%; no significant difference between rural and urban areas.

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Institutional births increased dramatically (from 38% to 78.9%) in the last ten years possibly due to Janani Suraksha Yojana, a safe motherhood intervention from the government.



Though nutritional status of children improved, wasting among children has increased.



More than half of the children aged 15-49 months (58%) are anaemic.

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One in every two pregnant women is anaemic.

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One in every two children in the lowest wealth quintile is stunted – same for mothers with no education.

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Underweight is higher than national average (35.7) among the lowest wealth quintile, Scheduled Castes, Scheduled Tribes and mothers with no education.

What does World Vision India’s baseline data say?

Though these sets of data are not fully comparable, the following few slides show the status of our communities in few relevant indicators as against the NFHS – 4 data.

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States needing more focus on Maternal and Child Health The graphs below show the bottom 5 States in the country in select few indicators:

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What are the implications of NFHS-4 data for World Vision India?

In spite of our presence among the most vulnerable communities, our baseline indicators are better than national average. In areas where World Vision India is performing better, we need to: 

Document and share what worked well for us



Share these findings with district level authorities

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Explore means for scale and replication

There are states where the indicators are glaringly worse than the National average. In such states, we need to consider the following: 

Increase advocacy efforts on MNCH issues.

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More awareness on healthcare entitlements need to be given as people are spending more than INR1000 per delivery in a public health facility across all states.

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North Eastern states need to focus on improved access to Healthcare services. (While the average out of pocket spending in a public health facility for a delivery remained at INR 3198, Manipur, Nagaland, Tripura, Mizoram and Assam spent well above the average).

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Efforts need to be more in the area of improving access to full antenatal care as only 21% of the mothers had full care.

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Activate the CHN state level NGO networks to continue the momentum of advocacy.

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Explore possibilities for addressing needs within LEAP 3 for these states.

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Identify needy areas / issues for future opportunities

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Prioritising these areas for partnerships

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World Vision India’s Impact in Daryapur IMPACT REPORT This is an impact report which gives a summary of the impact of World Vision India’s work in Daryapur, Maharashtra, through the successful Early Childhood Care and Development (ECCD) Project. World Vision India was able to significantly improve the community’s access to healthcare and nutrition status, working closely with the government in a tribal-dominated area known for its high number of malnutrition deaths.

Authors: V A Praveen Kumar (Evaluations), Sarojitha Arokiaraj (Policy Research)

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WORLD VISION INDIA’S IMPACT IN DARYAPUR (Early Childhood Care and Development Project) Abstract India has shown improvement in the status of malnutrition among children in recent years. However, tribal children remained at a higher risk of malnutrition even though the greater population was making positive gains. This was especially true of communities from the Amravati region of Maharashtra, dominated by tribal population which was known for its malnutrition deaths. However, this has now started to change.

Through an Early Childhood Care and Development (ECCD) project implemented by World Vision India for three years (2012-2015) in 35 tribal dominated villages in Daryapur Taluk, Amravati District, communities were able to have better access to health care services and improved nutrition status for their children. By working closely with the Integrated Child Development Services (ICDS), the largest ECCD programme run by the Government, this project was able to make a significant change. The core partners were the volunteers of the village level units of ICDS, the Anganwadi Centres and the community health volunteers (ASHA). As per the latest NFHS – 4 data, Maharashtra has 40% of its rural children underweight.

But over the period of three years, in the communities we served, there was a reduction in the percentage of underweight children from 34.90% in 2011 to 23.80% in 2015 and an 11 percentage point reduction in stunting. Children below the age of 5 years who were moderately and severely stunted also decreased from 35% (2011) to 24% (2015). Additionally, there was an increase (21%) in House Holds (HH) having sufficient food diversity.

Working with the health system also resulted in a 32 precentage points increase in the coverage of essential vaccines. 84% of the caregivers reported that they have good access to health care services.

There was an increase of 48 percentage points of mothers who made health related decisions of their children. It is reported that early marriages are reduced and more children are enrolled in Anganwadi centres. Some anganwadi centres have an International Organisation of Standardisation (ISO) certification for good quality. By promoting healthy behavior and practices in the households, mobilizing communities and improving their involvement in monitoring Anganwadis and building partnerships with the Government the project was able to facilitate this change.

Background Over 5.9 million children under 5 die every year in India and malnutrition is the underlying cause of over 60% of these deaths. Amaravati district in the otherwise economically thriving state of Maharashtra witnesses malnutrition deaths every year among the most vulnerable population – the scheduled caste and scheduled tribes.

World Vision India implemented a three year Daryapur ECCD (Early Childhood Care and Development) Project from 2012-2015. The Project was executed in its operational area of 35 villages of Daryapur Taluk, benefitting children in the age group of 0-6 years with the purpose of improving the nutritional status of children and their access to essential health care services. The 10 | P a g e

communities are predominantly Scheduled Caste and Scheduled Tribes. This project worked on improving the knowledge and behavior of mothers and care givers, strengthening the functionality of Anganwadi centres and health care services, increasing the capacity of the frontline health care workers and involving communities in the monitoring of services.

Methodology This evaluation design used both quantitative and qualitative tools. Another source of data for the study was the monitoring/output data gathered by the Project as part of the ITT (Indicator Tracking Table).

The tools used include house hold survey questionnaire tool and data was collected through a 30 cluster survey technique with a sample of 600 households using a sampling frame consisting of 35 communities where the program was implemented. Other tools used include Development Tree, Focus Group Discussions, Key Informant/Semi Structured Interviews, Most Significant Change Stories, Stakeholders meetings and an Anganwadi Assessment Tool. The participants in qualitative data collection include 143 community members (men, women, children and service providers.

Key Findings Improved behavior and practices   



1

86% of the new born children received critical components of essential care1.

There was an increase (13 percentage points) among mothers who have reported feeding Colostrum during their last pregnancy.

There was an increase of 63 percentage points (from 30% in 2011 to 93% in 2015) in mothers who have reported using appropriate ORS when their children had an episode of diarrhoea.

There was an appreciable increase of mothers and caregivers who are practicing hand washing from 68% in 2011 to 97% in 2015.

Cord kept dry and clean; skin-to-skin contact and head covered; exclusive breast feeding

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Improved nutrition status   

There was a reduction in underweight among children under 5, from 34.90% to 23.80% while the state average remained at 40% for rural areas.

There was a decrease of 11 percentage points in stunting among children.

There was an increase of 21 percentage points in HHs having sufficient food diversity.

.

Increased access to improved health care services      

Coverage of essential vaccines increased from 60% (2011) to 92% (2015).

84% of the caregivers reported that they have good access to health care services.

An increase of 48 percentage points was observed in mothers taking decisions regarding their child’s health.

Increased enrollment was recorded in Anganwadi centres, as better infrastructure was available.

Increased participation of the community in Anganwadi centre’s functioning.

15 model Anganwadis are in place and have received ISO certification for quality

Good relationships have been established with the service providers (ICDS and Department of Health and Family Welfare) at different village and block level which has resulted in better care and facilities. Early Childhood Care and Education has been rolled out well in the Anganwadi Centres which has increased the ease of transition into primary school. Communities participate in monitoring as well as mobilizing resources for Anganwadi centres, which resulted in better care for children. Anganwadi workers were motivated to provide good care.

Recommendations The following recommendations have been gathered from the important lessons World Vision India learned through our extensive work with this project.

Community participation and motivated cadre of grassroots workers (AWW) Lack of motivation and training for Anganwadi workers had been affecting the care children received at the Anganwadi centres. By working closely with the Anganwadi workers and the health care 12 | P a g e

workers, the project was able to increase the nutritional status of children. A visit organized to interact with well-functioning Anganwadis motivated the volunteers and communities. The project observed that poor infrastructure led to children dropping out. Improving the environment in the centre has led to increased attendance in the Anganwadi centre and a smooth transitioning of children to Primary School.

At every stage, the project involved the communities and built their relationship with the service providers. Communities were also equipped to engage in monitoring the angawadi centres and got together in raising resources for better functioning of the centre. When communities start to participate with the service providers, it creates a very collaborative environment to facilitate effective service delivery, thereby setting right the institutions that neglect the needs and rights of children.

Targeted approach to reach children below 5 years of age The project’s focused approach to reach out to children below 5 years of age, adolescent girls and pregnant mothers, has produced positive results. Empowering mothers to make decisions related to children’s health enabled in them in making the right decision when their children needed health care.

The project also realized that the children need to be continually fed with nutritious food apart from the food and care they receive in Anganwadi centres. The project promoted kitchen gardens in the families with children less than 5 years so that they will continue provide nutritious food for children.

The evaluation also found out that while targeting the children below 5 years of age, more focus should also be given to strengthening the CBOs to sustain the changes this project had brought.

Conclusion What does the Government says about World Vision India’s work?

“Based on my visit I can say that in Daryapur block we are working in 204 ICDS centres, of which 40 are in 35 target villages of World Vision. These centres stand apart in terms of the infrastructure and physical and intellectual growth of children. I have experienced the drastic change in these ICDS centres. Also, our Anganwadi workers have inculcated the skills of joyful teaching and counselling the mothers and caregivers. I have also seen the replication of these activities in centres outside World Vision’s target areas. The ICDS workers in other Anganwadis are motivated to equip their own ICDS centres with the help of their community and the ICDS Department.” – Kailash Ghodke, Deputy CEO, ICDS Department.

What worked best for us?

Participation of the community was observed to be the biggest factor that contributed to bringing change. One of the key initiatives was the Udan Yatra, an activity aimed at awareness generation and 13 | P a g e

active community contribution towards the issue. Initially the project had organized Udan Yatra in 5 villages in collaboration with ICDS Department. During this event, the parents, ICDS Workers and Nutrition Volunteers organize rallies in all the villages. They go around the village raising slogans, and encouraged the villagers to send their children to the Anganwadi, and donate food grains that would be used in the supplementary food program. As a result in one incident the people donated 55 kg of Wheat, 42 kg Rice and 7 kg of dhal (lentils). Some other donations included LED TV, Wall clocks, Fans etc that can be used in the Anganwadi centre. This intervention promoted community engagement, contributing to sustainability.

The findings of this evaluation show that the goals of the Daryapur ECCD project were met.

Children’s nutrition status has improved and communities, especially women and children have better access to health care services. This evaluation has also shown that there are areas to improve, especially in providing sanitation facilities in the Anganwadi centres, strengthening the capacity of the CBOs to sustain this change and in addressing social determinants, especially superstitious beliefs that are detrimental to child health, to address malnutrition.

SOURCES 1.

http://siteresources.worldbank.org/EXTSOCIALDEVELOPMENT/Resources/2443621265299949041/6766328-1285599693282/WPS5231.pdf

2. http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/

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Child Sexual Abuse in India OPINION This opinion talks about the stark reality of child sexual abuse in India – its prevalence, impact and ways to address. The threat of child sexual abuse is real and relevant to every child regardless of their class, caste, gender or physical appearance. India has the world’s largest number of sexually abused children, and it needs urgent measures to put an end to this. Child Sexual Abuse is also the theme for World Vision India’s campaign towards ending violence against children. This piece has been accepted for publication by aarambhindia, one of the leading NGOs working to end child sexual abuse in India.

Author: Bestin Samuel (Research)

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CHILD SEXUAL ABUSE: INDIA’S CHILDREN WAGE A LOSING BATTLE On 12th February 2017, around 20 children from across Chennai’s schools came together for a candlelight vigil, in the wake of the shocking rape and murder of 7-year-old in the city. Talking to the media after the protest, Classs 6 student Kamakshi Athreya said, “When I am walking on the road with my mother, I feel nervous. Random men on the street pass comments.”

It is not every day that schoolchildren hold press conferences and demand justice. The incident only points to the nightmarish numbers thrown up when one looks into child sexual abuse. India has the world's largest number of sexually abused children. A child below 16 years is raped every 155th minute, a child below 10 every 13th hour and one in every 10 children sexually abused at any point of time. In India, 53% of sexually abused children are boys, and 47% were girls.

Who are these abusers? It is easy to imagine a dark alley and a random criminal pouncing upon innocent children, but reality couldn’t be more different. A 14-year old boy in Jaipur was sexually abused for 3 years by his private tutor at the perpetrator’s home. In Tamil Nadu’s Thiruvallur district, a 14-year-old girl was continuously abused by her father, resulting in the girl being pregnant.

In most cases of the reported cases, the perpetrator of sexual abuse is a relative, family member, friend, or someone known and trusted by the child. According to the National Crime Records Bureau (NCRB) data for 2015, 94.8% cases of rape registered under the Protection of Children from Sexual Offences (POCSO) Act 2012, the perpetrator was known to the victim. Other sources reveal that family members account for 34.2% of all perpetrators, and acquaintances account for 58.7%. Only 7% of perpetrators are strangers to their victim.

It is impossible to brand or stereotype the typical perpetrator. Their profiles cut across class, vocation, social status and age. Media reported in 2016 that a doctor in Bihar raped a teenage girl after her parents failed to pay for her treatment. An MLA from Meghalaya was arrested for trafficking and sexual abuse of a 14-year old girl in January 2017. It was in February 2017 that an Event Manager in Bengaluru was arrested for the rape and blackmail of a 17-year-old girl. A shopkeeper in Jaipur was arrested in January 2017 for the rape of a minor girl. In the same month, the Principal of a Kendriya Vidyalaya school in Bengaluru was arrested for sexually abusing girl students. What does this tell us? Men who sexually abuse children are often ordinary, respectable men holding positions of responsibility in the family, society, work place and fulfilling their duties as per the demand of their role.

The universality applies to the victims as well. All children, irrespective of their appearance, colour, family background, sexual knowledge are vulnerable to abuse. The most common reason behind abuse is the power imbalance between the perpetrator and the victim. This leaves the child at the mercy of the more powerful abuser, where beauty or sexual precociousness of the child, or its lack thereof, is not a deciding factor in the context of vulnerability. From international level Taekwondo players to mentally challenged girls, sexual abuse cuts across all strata. The range of crimes also varies – according to NCRB, the 14,913 cases reported under POCSO in 2015 include cases of rape, sexual assault, sexual harassment and child pornography.

While the reported numbers are indeed alarming, one should not be fooled to believe that these numbers tell the full story – these form only the tip of the iceberg. Most children do not report abuse to anyone – as per data from the Ministry of Women and Child Development. This could be 16 | P a g e

due to several reasons: they are afraid no one will believe them, they are afraid that the abuser may harm or kill them or their loved ones, they are afraid they will lose the love of their parents and near and dear ones, they do not have a language to disclose abuse. Also, children are unable to take informed, mature decisions when it comes to sex – which means that the perpetrators are manipulating the ignorance, helplessness and fear of these children. Nearly all victims will experience confusion, shame, guilt, anger, and suffer from possessing a poor self- image. Child sexual abuse can result in long-term relationship problems as well. According to research, the long-term emotional and psychological damage of sexual abuse can be devastating. Government data says that 50% of the abusers are persons known to the child or in a position of trust and responsibility – which means that the children suffer from severe trust issues following the trauma. There have been numerous instances of sexual abuse, where children have been blackmailed for years, either using threat of physical violence or sharing of images/information on abuse.

Many cases go unreported also because children are experts at hiding their pain. Unless the incident was forcefully violent, it is difficult to say from external appearance if the child was sexually abused.

A traumatic experience in a child's life is often expressed through indirect means. Also many children may not show any change in their behaviour or other patterns until much later. In many cases, pregnancy, bleeding and visible physical injuries to private parts have been the primary indicators to ascertain sexual abuse. It needs to be noted that in the absence of an adult witness to the crime and a distinct physical injury on the victim, it is very unlikely that the incidence of abuse will see the light of day.

It is beyond doubt that the issue needs to be tackled at a war footing. However, the question of accountability looms large in any discussion aimed at addressing child sexual abuse. India boasts of the landmark POCSO Act – an extremely powerful legislation which provides unprecedented legal protection for children from sexual abuse. However, little has been done apart from POCSO, in terms of prevention and redressal. Equally significant is the fact that to bring down the number of incidents, it takes the entire universe of the child to join hands – the family, school, neighbourhood, and the civil society at large. Such a synergetic effort would, as the POCSO Act says, ensure the best interest and wellbeing of the child, regarded as “being of paramount importance at every stage, to ensure the healthy physical, emotional, intellectual and social development of the child.” Though reliable mechanisms for reporting, like the POCSO e-box (online) and 1098 (telephone) exist, the onus is on the adults around each child to ensure safety from sexual crimes. Until India – with children comprising around 40% of its population – evolves as a child-friendly, child-trusting society, the truth that every child is a potential victim of sexual abuse will remain haunting.

SOURCES 1.

http://timesofindia.indiatimes.com/city/chennai/sexual-assaults-kids-hold-candlelightvigil/articleshow/57116417.cms

2.

Study on Child Abuse: INDIA 2007, Ministry of WCD, Govt of India

3.

http://timesofindia.indiatimes.com/city/jaipur/minor-abused-by-tutor-casefiled/articleshow/57028693.cms

4.

http://www.newindianexpress.com/states/tamil-nadu/2017/jan/20/monster-dad-in-tiruvallurimpregnates-minor-daughter-arrested-1561442.html

5.

Crime in India 2015: http://ncrb.gov.in/

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6.

Rape, Abuse, and Incest National Network: http://www.rainn.org

7.

http://www.ibtimes.sg/india-doctor-rapes-16-year-old-girl-after-parents-fail-pay-treatment-5691

8.

http://www.hindustantimes.com/india-news/meghalaya-mla-5-others-chargesheeted-for-rape-of-minorgirl/story-Tvtjp0g83ex5Nesrih7FZJ.html

9.

http://indiatoday.intoday.in/story/bengaluru-event-manager-arrested-for-raping-17-year-oldgirl/1/878276.html

10. http://indianexpress.com/article/india/bengaluru-kv-principal-held-for-sexually-abusing-girl-studentswomen-staff-4505775/ 11. American Academy of Child and Adolescent Psychiatry: http://www.aacap.org/cs/root/facts_for_families/child_sexual_abuse 12. http://wcd.nic.in/sites/default/files/childprotection31072012.pdf

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Disability in India FACTSHEET

This factsheet gives a picture of disability in India and the vulnerabilities that it brings along. It brings to light the status of children with disabilities in India and the barriers they face in terms of access to health, education and protection. The document looks at the prevalence, impact and ways of approaching disability, discussing a rights-based approach, as well as World Vision’s notion of inclusion.

Author: Sarojitha Arokiaraj (Policy Research)

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Introduction b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b 2 The current status b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b3 Status in India b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b4 Key statistics b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b5 World Vision's understanding of disability b b b b b b b b b b b b b6 How does disability affect children b b b b b b b b b b b b b b b b b b 7 Access to health b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b 8 Access to education b b b b b b b b b b b b b b b b b b b b b b b b b b b b b 10 Protection from violence and abuse b b b b b b b b b b b b b b b b b12 What are the barriers they face b b b b b b b b b b b b b b b b b b b b b14 Disability and inclusion b b b b b b b b b b b b b b b b b b b b b b b b b b b15 Disability and rights b b b b b b b b b b b b b b b b b b b b b b b b b b b b b 16 Commitments to enable b b b b b b b b b b b b b b b b b b b b b b b b b b 17 Looking ahead b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b b 18

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“Each girl and boy is born free and equal in dignity and rights; therefore, all forms of discrimination affecting children must end.... We will take all measures to ensure the full and equal enjoyment of all human rights and fundamental freedoms, including equal access to health, education and recreational services, by children with disabilities and children with special needs, to ensure the recognition of their dignity, to promote their self reliance, and to facilitate their active participation in the community -� UNGA Special Session on Children, May 2002.

However, in reality, children with disabilities don’t seem to enjoy their rights. They remain the most excluded and are denied their most fundamental rights and dignity. Most often, they are not counted, have poor access to healthcare services, face barriers in getting quality education and are extremely vulnerable to abuse and violence.

Most barriers faced by children with disabilities are due to the environment and not their medical condition. bThese barriers increase their vulnerability and poverty multiplies it. b Generally, the response to children with disabilities has been a charity based approach. UNCRC and UNCRPD gave the much needed shift of focussing on the removal of barriers that prevents them from enjoying their rights.b

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General Overviewb • World Bank’s World Report on disability estimates that more than a billion people live with some form of disability, or about 15% of the world’s population.b • Global data from the World Health Survey show that employment rates are lower for disabled men (53%) and disabled women (20%) • The World Bank estimates that 20 per cent of the world's poorest people have some kind of disability, and tend to be regarded in their own communities as the most disadvantaged. • People with disabilities thus experience higher rates of poverty than non-disabled people. • Women and girls with disabilities are particularly vulnerable to abuse.b • According to UNICEF, 30 per cent of street youths have some kind of disability. • The World Bank has estimated that persons with disabilities account for up to one in five of the world’s poorest people, that is, those who live on less than one dollar a day and who lack access to basic necessities such as food, clean water, clothing and shelter. • There is an estimated 4 million children with physical disabilities, and conflict is the leading cause of disability in childrenb

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Key highlights from Census 2011 • People with disability in India - 26,810,557 who form 2.21% of the population. • Children with disabilities 7,862,921 • Percentage of disabled persons in India has increased both in rural and urban areas during the last decade. • Proportion of disabled population is higher in rural areas (69%) • There is significant increase of PWD in urban areas. • Disability among SCs is higher than Others in all age-groups • 20% of the persons with disabilities are having disability in movement, 19% are with disability in seeing, and another 19 % are with disability in hearing. 8% has multiple disabilities. • The number of PWD is highest in the age group 10-19 years (46.2 lakhs) • One in every 100 children in the age group 0-6 years suffered from some type of disability. • 50% of the children with mental illness never attended educational institution. • Uttar Pradesh has the highest number of disabled persons (16%)b • Bihar (12.48%) has the highest share of disabled children (0-6 years) In India, the disability sector in general estimates th at 4-5% of the population is disabled. The Planning Commission recognizes this figure as 5%. A report by the World Bank states that while estimates vary, there is growing evidence that persons with disability are around 40-80 million, which constitute between 4-8% of India’s population.

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World Vision adopts the social model approach to include persons with disabilities in the development work it supports, and looks at disability from a human rights perspective: that the rights of people who have impairments are violated by stigma, assumption, discrimination and the lack of or insufficient access that exists in society. Impairments, disability and inclusion are defined as follows: b bImpairments refer specifically to a person’s physiological condition, structure or mechanism that is lacking or does not fully or effectively function. Impairments may be long-term or short-term, and may be physical, sensory, neurological, intellectual or another physiological condition. b bDisability is a result of the limitations imposed on people with impairments by attitudinal, institutional, and environmental barriers to their participation in society. b bInclusion is the desired state that all people, including people with disabilities, equally participate in and benefit from policies and programmes in political, economic, societal and spiritual spheres without barriers or discrimination.

The following are some of the key issues identified by a comprehensive review in a UNICEF Fact sheet on Children with Disabilities, 2013.

• Poverty and disability reinforce each other, contributing to increased vulnerability and exclusion.

• Children are not only born with impairments, but can acquire impairments later in their childhood, be it through disease, accidents or as a result of conflicts and natural disasters.

• A significant proportion of children with disabilities are denied access to basic services including education and health care.

• While all children have an equal right to live in a family environment, many children with disabilities continue to spend much or all of their lives in institutions, nursing homes, group homes or other residential institutions.

• Children with disabilities are disproportionately vulnerable to violence, exploitation and abuse.

• Cultural, legal and institutional barriers render girls and young women with disabilities the victims of two-fold discrimination: as a consequence of both their gender and their disability.

• Children with disabilities are often overlooked in humanitarian action and become even more marginalised as fewer resources are available in the midst of an emergency.

• Finally, the greatest barriers to inclusion of children with disabilities are stigma, prejudice, ignorance and lack of training and capacity building.

Under the Convention on the Rights of the Child (CRC) and the Convention on the Rights of Persons with Disabilities (CRPD) all children have the right to the highest attainable standard of health. Under article 24 of the CRC, every child has the right to enjoy the highest attainable standard of health and to have access to facilities for rehabilitation and the treatment of illness.b While talking about Inclusive Health, UNICEF’s State of World’s Children 2013 says that under the CRC and the CRPD, all children have the right to the highest attainable standard of health and they are entitled to the full spectrum of care – from immunization in infancy to proper nutrition and treatment for childhood ailments and injuries, to confidential sexual and reproductive health information and services during adolescence and into early adulthood. Equally critical are such basic services as water, sanitation and hygiene (WASH).b However the reality is not so. The Report highlights the following: • Many children with disabilities are still not benefiting from increased immunization coverage, though they are at the same risk of childhood diseases as all children.

• Mortality for children with disabilities under five can be as high as 80 per cent in some income poor countries.

• Children with severe disabilities may not survive childhood because of a lack of basic primary health care facilities. In addition, rehabilitation services are often concentrated in urban areas and can be very expensive.36 • Even the simplest aids and appliances to reduce the impact of a child’s impairment b bmay not be available.

• Children with disabilities face difficulties accessing basic sanitation A Lancet paper says that one of the biggest barriers to accessing appropriate health care is the attitude of health professionals, which might further isolate and stigmatise people with disabilities. b A Baseline report Health for Persons with Disabilities in India bsays that there is a huge gap in terms of health services available for disabled and non-disabled people in the country. Issues vary from inaccessible buildings and diagnostic equipments, negative/stereotypical attitude of health professionals or their ignorance, lack of training to communicate with people with hearing/speech impairment or intellectual disability, inaccessible transport to reach the health centre, or sheer expense of treatment/rehabilitation. The report also says that • Majority of disabled people have no access to Rehabilitation Services in the country.

• Only 15% of the people living in urban areas and 3% of the people living in rural areas can avail rehabilitation services • Many people with disabilities are being denied insurance on the grounds of disability When it comes to sexual and reproductive rights, the needs of people with disabilities are ignored and while accessing SRH services they face physical barriers, the lack of disability-related clinical services, and stigma and discrimination.b

"It pains me that there are children with disability who are not being properly cared and loved. No child with disability should be left to die without proper care. I want to urge every citizen and government to help realize the dream of every child" Prakash Nag,b17, Assam

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) states that persons with disabilities should be guaranteed the right to inclusive education at all levels, regardless of age, without discrimination and on the basis of equal opportunity.

The Convention, Article 24 states that persons with disabilities should be guaranteed the right to inclusive education at all levels, without discrimination and on the basis of equal opportunity, and children with disabilities shall not be excluded from free and compulsory primary education or from secondary education on the basis of disability.

However, children with disabilities are denied their right to education, which denies an opportunity for them to enjoy their rights, develop skills, find a gainful employment and gain dignity. Though Sarva Siksha Abhiyan increased the enrollment of children with disabilities in schools, they continue to remain the most excluded groups while accessing education.b Census numbers reveal that nearly • 45% of the total disabled population are illiterates. • 13% of the disabled population has matric/ secondary education but are not graduates • 5% are graduates and above

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• Only around 8.5% among the disabled literates are graduate.

• 39% of CWD aged 5-19 years are not attending an educational institution.

• 54% of the disabled children with multiple disabilities never attended educational institutions.

• Also, 50% of the children with mental illness never attended educational institution.

• One in every 25 disabled children in the age group 0-14 years is working; According to a World Bank analysis of India’s 2002 National Sample Survey, children with disabilities are five and a half times more likely to be out of school.

The constitution of India guarantees education as a fundamental right (Article 21 A) and the PWD Act 1995 for the first time ensured that every child with a disability has access to free education in an appropriate environment till he attains the age of eighteen years and many other provisions added to it. Under the Right to Education Act, all children have the right to go to school.

The Status of Implementation of RTE Act-2009 in Context of Disadvantaged Children at Elementary Stage Report’ by NCERT raises some key observations.

• Orientation of teachers for RTE (except for Orissa) did not include information about disadvantaged and children with disabilities • Suitable ramps for wheelchair users were not available in most of the schools.

• Disabled friendly toilets were available in very few schools of states/UTs. • Educational materials for children with disabilities were non-existent in most sample schools.

"Education changes life. Not many children with disabilities are able to go to school. I go to school, I love to write. I want to become a pilot".

Rohit, 14, Haryana

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The World Report on Violence against Children, commissioned by the UN Secretary- General observes, “Children with disabilities are at heightened risk of violence for a variety of reasons, ranging from deeply ingrained cultural prejudices to the higher emotional, physical, economic, and social demands that a child’s disability can place on his or her family.�

Children with disabilities are more likely to be physically, sexually and psychologically abused.

Their vulnerability, stigma makes them highly exposed to violence and exploitation.

Children with disabilities are especially vulnerable in emergency situations. They are usually the last receive emergency relief and support.

Persons with disabilities are up to three times more likely than non-disabled persons to be victims of physical and sexual abuse and rape Children with disabilities are three to four times more likely to be victims of violence.

Consistent evidence emerges from research that children with disabilities are 3–4 times more likely to experience physical and sexual violence and neglect than non-disabled children.

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A study on corporal punishments found that children with disabilities were significantly more likely to experience severe physical punishment .

In residential institutions, children with disabilities may be subject to violence in the guise of treatment. In many residential facilities for children with disabilities, there is no access to education, recreation, rehabilitation or other programmes.

Children with disabilities are often left in their beds or cribs for long periods without human contact or stimulation .

A study by HRW found that women and girls with psychosocial or intellectual experienced a range of abuses including forced institutionalization and neglect, physical or verbal abuse, and involuntary treatment while in institutional care .

"I wanted to go for higher education out of my village but several people discouraged and gave possible reasons to me and my family not to send me in the city for education.

But today I am studying in 10th grade and performing well in my education.".

Babaljeet Kaur, 16, Faridkot

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The human rights approach to disability has led to a shift in focus from a child’s limitations arising from impairments, to the barriers within society that prevent the child from having access to basic social services, developing to the fullest potential and from enjoying her or his rights. This is the essence of the social model of disability.

The emphasis given to equality and non-discrimination in international human rights instruments is reflected in the social model of disability. This model rejects the long-established idea that obstacles to the participation of disabled people arise primarily from their impairment and focuses instead on environmental barriers.

But children with disability face many barriers. These include: • Attitudes and misconceptions • Inaccessible buildings, transport and other infrastructures. • Impact of poverty and related deprivations • Lack of community awareness • Low priority for children with disabilities among decision-makers; • Absence of adapted curricula • Lack of appropriate capacity building for teachers. • Expensive health care services • Inadequate skills and knowledge of health workers • Lack of targeted funding. • Inadequate opportunities for CWD to participate in decision making • Lack of research, data and evidence.

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Every Government and community is required to take steps towards promoting inclusion of people with disabilities in the society. According to UNICEF Innocenti Digest No. 13, inclusion requires the recognition of all children as full members of society and the respect of all of their rights, regardless of age, gender, ethnicity, language, poverty or impairment.

Inclusion involves the removal of barriers that might prevent the enjoyment of these rights, and requires the creation of appropriate supportive and protective environments.

"Education will help us to be self dependent, selfbreliantband employed.

We are not a burden to our parents and society".

Jhumri Biswal, 18, Odishab

Disability is a human rights issue and over the past few decades, disability is viewed as a socially created construct, not an attribute of an individual. • Children with disabilities are entitled to all rights guaranteed to children under the Convention on the Rights of the Child (CRC)1. Article 2 asserts that children should never be discriminated against on grounds of disability. Article 23 emphasises the rights and freedoms of children with disabilities and the importance of promoting their full enjoyment of life experiences and of exercising their independence to the greatest extent possible. • Children with disabilities are also specifically cited in the Convention on the Rights of Persons with Disabilities (CRPD). Article 7 ensures their full enjoyment of all human rights and fundamental freedoms on an equal basis with all other children. The CRPD also demands measures to protect the equal rights of children with disabilities in respect of inclusive education, family life, freedom from violence, opportunities for play, access to justice, birth registration and protection from forced sterilisation.

India's Global Commitments

• India is a signatory to the ‘Declaration on the Full Participation and Equality of People with Disabilities in the Asia Pacific Region’ (2000). • India has ratified the ‘UN Convention on the rights of Persons with Disabilities’ (2008). • India is also a signatory to the ‘Biwako Millennium Framework ‘(2002) for action towards an inclusive, barrier free and rights based society. • The Incheon Strategy to “Make the Right Realâ€? for Persons with Disabilities in Asia and the Pacific (2012) provides the Asian and Pacific region and the world with the first set of regionally agreed disability inclusive development Goals. • The Sustainable Development Goals (2015) pledges for ‘leaving no one behind’.

Constitutional Provisions Article 41 of Constitution of India: It provides that the State shall, within the limits of its economic capacity and development, make effective provision for securing the right to work, to education and to public assistance in cases of unemployment, old age, sickness and disablement and in other cases of undeserved want.

Acts & Legislations • The Rights of PWD Act 2016 • The Rehabilitation Council of India Act, 1992 • The National Trust for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999 • Mental Health Actb1987 • Right to Education Act 2009

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Creating an inclusive environment by removing all barriers requires a concerted effort from all stakeholders, especially the government and the community. Inclusion of children with disabilities is a moral issue. For children with disabilities to grow up to their fullest potential we need inclusive budgets, programming, disability disaggregated data, building awareness and changing attitudes. The SDGs provide a great opportunity for the global community and our nation to rectify the imbalances and inequality that are caused by low priority for the issues faced by children and people with disability so that no one is left behind.b

SOURCES 1. Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)62043b b b b 2/fulltext) 2. DNIS (https://www.dnis.org/Health.pdf) 3.bUNFPA/WHO. (2009) Promoting sexual and reproductive health for persons with b bdisabilities: WHO/UNFPA guidance note. b(https://www.unfpa.org/sites/default/files/pub-pdf/srh_for_disabilities.pdf) 4. UNICEF. CAY with disabilities, UNICEF Factsheet.

5. UNICEF (https://www.unicef.org/violencestudy/reports/SG_violencestudy_en.pdf) 6. Human Rights Watch (https://www.hrw.org/sites/default/files/report_pdf/india1214.pdf) 7. Census India 2011. Office of the Registrar General & Census Commissioner, India.

Population Enumeration Data (Final Population). (http://www.censusindia.gov.in/2011census/population_enumeration.html) 8. Disabled Persons in India - A Statistical Profile 2016. MoSPI, Government of India.b 9. UNICEF. The State of World's Children 2013.b 10. UN ENABLE. Factsheet on Persons with Disabilities.

11. Strategic Guidance for Disability Inclusion, 2014, World Vision International.b b

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ABOUT US: World Vision is one of the world’s leading child-focused humanitarian organisations.

Through development, relief and advocacy, we pursue fullness of life for every child by serving the poor and oppressed regardless of religion, race, ethnicity or gender. With nearly 65 years of experience in India, World Vision works in 191 districts impacting 2.6 million children and their families in over 6200 communities spread across 26 states of India.

We work along with children, families and communities to address issues of Health, Nutrition, WASH, education, child protection, climate change, gender, disability and humanitarian emergencies in partnership with governments, civil society, donors and corporates.

CONTACT: Sarojitha Arokiaraj (sarojitha_arokiaraj@wvi.org) Evidence and Learning World Vision India National Office 16 VOC Main Road, Kodambakkam, Chennai 600024, Tamil Nadu, India Delhi Liaison Office 16 Pandit Pant Marg CNI Bhavan, 4th Floor New Delhi 110001 India

Prepared by Strategy and Research Management, World Vision India