Document search results
A total of 18 policy documents were identified and 48 peer reviewed articles were included for the narrative evaluation of drowning-related government programs. See Appendix 4 for PRIMSA flow diagram of search results and Appendix 5 for full list of policy documents included in analysis.
Drowning and drowning reduction in policy
The policy review found very limited acknowledgement of drowning in any policy aside from some mention of drowning in disaster-related policy. The National Disaster Management Plan 2016 acknowledged drowning as a cause of death during disasters. However, no specific mechanisms to avoid drowning were discussed. No other policy document specifically mentioned drowning (or physical water safety).
Health-related policy, including the National Health Policy 2017, showed greater focus on non-communicable diseases and included only minor reference to injuries. Policy related to the repair and management of water bodies, such as the National Water Policy 2012 and the Scheme on Repair, Renovation and Restoration (RRR) of Water Bodies under PMKSY (HKKP) 2017, did not consider physical safety around water bodies. Like national-level policy, state-level policies from West Bengal did not mention drowning or physical water safety.
Policy linkages to drowning interventions
The review identified which policies described general principles or specific programs that related to the four drowning interventions recommended by WHO. Figure 1 shows how many policies mapped against each of the four recommended interventions followed by Table 2 which highlighted which programs were applicable. Policies that included principles relating to drowning reduction interventions did not necessarily specify programs to address these.
Table 2 below summarises the government programs identified in relation to each WHO intervention. These programs were currently implemented by the National or West Bengal Government in the Sundarbans region as of July 2019.
Table 2
Programs that may contribute to drowning interventions
Relevant government program identified in policy | Potential contribution to recommended drowning interventions |
Barriers and fencing | Supervised safe spaces | Swim and rescue training | First responder training |
Integrated Child Development Scheme (ICDS) | No | Yes | No | No |
Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA) 2005 | No | Yes | No | No |
Rajiv Gandhi National Crèche Scheme for the Children of Working Mothers 1994 | No | Yes | No | No |
National Bank for Agriculture and Rural Development (NABARD) Self-Help Group Bank Linkage Program | Yes | Yes | Yes | Yes |
Accredited Social Health Activist (ASHA) program | Yes | Yes | Yes | Yes |
Village Health, Sanitation and Nutrition Committees (VHSNC) | Yes | Yes | Yes | Yes |
The discussion below reflects on both the policies and programs that were identified that may be of value in taking forward specific drowning interventions.
Barriers and fencing
A few policies stated principles that aligned with the provision of barriers (Fig. 1). For example, the National Policy for Children 2013 acknowledged that all children have the right to a safe, secure and protective environment, including at home. The National Disaster Management Plan 2016 stated that dams and reservoirs should be enhanced for safety. However, the mechanisms through which safe environments should be ensured were not clearly defined, and no government programs had been introduced that aimed to provide physical protection from water bodies.
Supervised safe spaces
The provision of supervised safe spaces for children was the most supported drowning-related intervention in policy. Education policy, such as the Early Childhood Care and Education Policy 2013 and National Policy on Education 1992 both stated that children have the right to free early childhood education up to the age of six years old, provided through supervised crèche-based programs.
Three programs that provide crèche-based supervision were identified. Firstly, the Indian Government introduced and implemented the Integrated Child Development Scheme (ICDS). The ICDS sets up local Anganwadi centres, where children are provided basic early childhood education and nutritionally-sufficient meals by locally trained women. West Bengal also launched Shishu Aloy in 2015, which aimed to transform some Anganwadi centres into enhanced early childhood learning centres with a structured pre-school curriculum.
A second program identified was the Mahatma Gandhi National Rural Employment Guarantee Act (MNREGA) 2005, which guaranteed 100 days of paid work to rural workers in the country. This program provisioned that a crèche service must be provided in any workplace where more than five children aged under 6 years old attend with their mothers.
Lastly, the Rajiv Gandhi National Crèche Scheme for the Children of Working Mothers 1994 aimed to provide day-care facilities for children aged 6 months to 6 years in both urban and rural community-based settings.
Swim and rescue training
There was no policy requirement found for children to learn swimming skills. Education policy, such as the National Policy on Education 1992, necessitated the provision of physical activity classes in schools with the appropriate infrastructure (Fig. 1). However, policy did not identify swimming as a requirement within this. No specific swim and rescue training programs have been introduced by government.
First responder training
Policy focussed on building the capacity of communities to manage their own health and disaster response. From this view, the principle of providing first responder training was well supported. The National Health Policy 2017 aimed to increase the number of ‘health volunteers’ in communities who may act as first responders for health concerns. The National Disaster Management Plan 2016 and West Bengal State Disaster Management Policy and Framework also required community members, especially local leaders, to be trained in first response to respond to accidents and natural disasters. However, no specific government programs to provide First Responder training had been introduced in West Bengal based on these national directions.
Comprehensive programs
However, three valuable programs that may play facilitative or implementation roles across all four drowning interventions were also identified.
Firstly, Self-Help Group (SHG) programs, including the National Bank for Agriculture and Rural Development (NABARD) Self-Help Group Bank Linkage Program and the National Rural Livelihoods Mission, were identified as possible facilitators for program delivery. These programs formed support groups in villages for the provision of loans, mostly with women. The National Policy for the Empowerment of Women 2001 had identified SHGs as a mode through which social and economic development programs can be implemented in communities.
Secondly, the Accredited Social Health Activist (ASHA) program was mandated in the National Health Mission 2013 policy. The ASHA program trained and deployed community-based maternal and child health workers to act as the interface between the community and public health system. They were tasked with educating and mobilising communities on health issues through household visits and community meetings.
Thirdly, the National Health Mission 2013 detailed the establishment of Village Health, Sanitation and Nutrition Committees (VHSNCs), which were sub-committees under the local government (Gram Panchayats) tasked with overseeing programs related to health and its social determinants.
Equity considerations in policy
Particular barriers faced by women was mentioned in 67% of the policy documents (See Fig. 2). Place of residence was acknowledged in 61% of policies and socio-economic status in 50%. Social capital, educational background, occupation and religion were rarely discussed. Only two policies acknowledged more than half of the PROGRESS-PLUS groups: the National Health Policy 2017 and the National Policy for the Empowerment of Women 2001 (Fig. 2).
Based on the Equiframe Framework, 78% (n = 14) of policies acknowledged that programs should be tailored to meet the needs of underserved groups, and 72% (n = 13) recognised that underserved groups were capable and had a right to be involved in decision making. 61% (n = 11) of policies also recognised explicitly that underserved groups were productive contributors to society, and 56% (n = 10) supported underserved groups’ physical, economic, and information access to services. However, few policies aimed to protect the privacy of underserved groups’ information, ensured programs were tailored to the person’s characteristics, or acknowledged the role of family in the impact of services. See Table 3 for the number of policies that addressed each Equiframe domain.
Policies that linked to supervision-based interventions were more likely to protect the rights of underserved groups. For example, both the Early Childhood Care and Education Policy 2013 and the National Population Policy 2016 catered to 80% (n = 12) of the applicable Equiframe criteria, and MGNREGA and catered to 77% (n = 10) of the applicable criteria. However, water and disaster-related policies, which often considered First Responder training and barriers and fencing, included few or no equity considerations. Health-related policy reflected only half of the Equiframe criteria.
Table 3
Domain | Number of policies |
Does the policy support the rights of underserved groups with equal opportunity in receiving services? | 9 |
Does the policy support the rights of underserved groups with individually tailored services to meet their needs and choices? | 14 |
Does the policy indicate how underserved groups may qualify for specific benefits relevant to them? | 5 |
Does the policy recognize the capabilities existing within underserved groups? | 13 |
Does the policy support the right of underserved groups to participate in the decisions that affect their lives and enhance their empowerment? | 10 |
Are underserved groups protected from harm during their interaction with health and related systems? | 5 |
Does the policy support the right of underserved groups to be free from unwarranted physical or other confinement? | 5 |
Does the policy support the right of underserved groups to consent, refuse to consent, withdraw consent, or otherwise control or exercise choice or control over what happens to him or her? | 6 |
Does the policy address the need for information regarding underserved groups to be kept private and confidential? | 1 |
Does the policy recognize that underserved groups can be productive contributors to society? | 11 |
Does the policy recognize the value of the family members of underserved groups in addressing health and safety needs? | 6 |
Does the policy recognize that individual members of underserved groups may have an impact on the family members, requiring additional support from health or other related services? | 2 |
Does the policy ensure that services respond to the beliefs, values, gender, interpersonal styles, attitudes, cultural, ethnic, or linguistic aspects of the person? | 5 |
Does the policy specify to whom, and for what, services providers are accountable? | 9 |
Does the policy support underserved groups’ physical, economic, and information access to services? | 10 |
Implementation of programs with linkages to drowning reduction
As discussed above, a range of government programs were identified in policy that may be leveraged in support for drowning reduction. The following reviews what is known about the implementation of these programs in West Bengal based on a systematic review of the peer-reviewed literature.
Integrated Child Development Scheme (ICDS)
The Integrated Child Development Scheme (ICDS) is delivered through community-based Anganwadi centres. A trained female Anganwadi worker and assistant are responsible for running the centre four hours per day from 7 to 11am. They are tasked with providing early childhood education (ECE) and nutritionally-sufficient meals (28, 29). In West Bengal, the lowest tier of local government, the Gram Panchayat, is responsible for implementing the ICDS program (30). Anganwadi workers are paid a stipend and are considered volunteers (31).
Overall, 88% of villages in West Bengal have access to an Anganwadi centre, compared to 45% nationally (32). However, cross-sectional survey data in two districts found that 27% of centres documented as operational were not running (33). The true coverage of Anganwadi centres is likely to be lower than reported.
Implementation of ECE in Anganwadi centres is variable across the state, with only 60–85% of centres in each district providing this service (29, 34–36). A cross-sectional study found that where provided, the duration of ECE activities averaged at only 60 minutes, below the 120 minutes prescribed in policy. In addition, only 10% of centres had sufficient floor space for indoor activities, 33% did not have any materials for activities, and none ran activities that were age appropriate. One study found that only 33% of children enrolled at the centre remained to participate in ECE (37).
A key barrier to implementing ECE in Anganwadi centres was the lack of an educational curriculum against which the services could be assessed. In addition, Anganwadi workers had limited resources and time to run ECE activities between their other responsibilities, and viewed the service as effortful (31, 34, 38). Anganwadi centres may require additional resources in order to provide these services (39).
The ICDS program suffers from poor supervision and administration. Funding is often inadequate for rent, food and materials, and corrupt practices in higher levels of administration have occurred (31). Furthermore, there is limited capacity to provide ongoing training, supervision and support of Anganwadi workers in managing on-ground implementation (40). Although many Indian policies highlight ECE as a right, little emphasis is placed on ECE activities by supervisors (34).
Shishu Aloy
In 2015, the West Bengal government launched the Shishu Aloy program to set up enhanced Anganwadi centres that focused on early childhood education with a structured curriculum. However, there is no data available on this program’s coverage and implementation success.
Self-help Group (SHG) programs
The National Bank for Agriculture and Rural Development (NABARD) Self-help Group Bank Linkage program and the National Rural Livelihoods Mission are two programs centred on supporting mainly women through support groups. Although these two programs are independent, the basic models are similar (41, 42). Village-based self-help groups are formed by partnering NGOs and banks and linked to a financial institution for the provision of loans (43). They also become involved in the provision of non-public services, such as providing training on agricultural techniques and providing childcare and healthcare (44, 45).
West Bengal has one of the greatest reaches of SHG programs in the country, with 51–75% of rural households being covered (46–49). SHGs in West Bengal have been found to be effective in increasing women’s income, providing better access to credit, reducing reliance on local money-lenders, reducing physical labour for members, increasing members’ autonomy, increasing employment, improving access to health information and services, reducing rural poverty and empowering women with decision making power in their families and communities (18, 46, 50–58).
Nevertheless, challenges are evident. Firstly, there is often inadequate mentorship from the linked banks and NGOs for navigating the financial system (50, 51, 59, 60). This is attributable to the absence of a clear chain of authority and accountability in funding structures (51, 61). Secondly, women still bear the brunt of domestic work in rural communities, which may inhibit their ability to be involved in community activities (52, 62). Operational issues have also been reported, where regularity of meetings and coordination between members may be poor (50).
The benefits and function of SHGs varies across religious and caste groups. Economic and political benefits have been found to be higher for upper caste Hindus than scheduled caste Hindus or Muslims, as they start with greater social mobility, higher incomes and better access to markets and technologies (18, 50). Muslim women in particular see fewer improvements in business profits or health outcomes compared to Hindu women, possibly due to greater restrictions on women’s roles and mobility (63).
Village Health, Sanitation and Nutrition Committees
The National Rural Health Mission set up Village Health, Sanitation and Nutrition Committees at the village level. These are sub-committees to the Gram Panchayat that coordinate collective actions on issues related to health and its social determinants. This includes overseeing the functioning of Anganwadi Centres and facilitating the work of front line health workers in the community (64). 29.4% of villages in West Bengal have VHSNCs, similar to the national average (65, 66). However, there is no information on their effectiveness and involvement in on-ground implementation in rural West Bengal.
Rajiv Gandhi National Crèche Scheme for Working Mothers
This program seeks to open crèche services for working mothers within communities. A key difference between these crèches and Anganwadi centres is that they run for 7.5 hours each day, rather than half days. Currently there are 1,636 crèches operating in West Bengal under this scheme, serving 40,900 children. However, the coverage of centres is low due to insufficient funding for these centres, and delays in payments to implementing agencies (67).
Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
In West Bengal, 33% of the labour employed through MGNREGA are women (58). However, evidence from surveys conducted in West Bengal indicate that few workplaces have functioning childcare facilities available for use, and women are not aware of their right to request these services. Gram Panchayats also do not view the provision of childcare services a priority and are not taking actions to ensure set up (58, 68, 69).
Accredited Social Health Activist (ASHA) program
The Accredited Social Health Activist (ASHA) program is part of the National Health Mission strategy. In 2016, there were 47,204 ASHAs employed in West Bengal at a population density of 1 per 1,317 population. This is 77% of the target of 1 per 1,000 population (70). ASHAs in West Bengal perform above average compared to the other states, showing higher members of visitations to households and greater involvement in sanitation education and toilet construction (71). However, ASHAs in West Bengal are rarely fulfilling maternal support duties, with 7% of ASHAs escorting women to health centres at the time of delivery, and only 14% visiting on the first day of birth. One study in the Howrah District of West Bengal found that half of ASHA workers were overburdened. In addition, Muslim ASHAs showed lower performance due to lower educational attainment and less support from Anganwadi workers (72).