The “Global Nutrition Report 2016” once
again demonstrates India’s slow overall progress
in addressing chronic malnutrition,
manifest in stunting (low weight for age),
wasting (low weight for height), micronutrient
deficiencies and over-weight. Our
track record in reducing the proportion of
undernourished children over the past decade
has been modest at best, and lags what
other countries with comparable socio-economic
indicators have achieved.
In a ranking of countries from lowest to
highest on stunting, India ranks 114 out of 132
countries, with the incidence of stunting at
38.7 per cent, compared with Germany and
Chile at 1.3 per cent and 1.8 per cent, respectively.
Even Bangladesh and Nepal rank marginally
higher than India. On wasting, India
ranks 120 out of 130 countries, at 15.1 per cent,
compared with Australia and Chile at number
1 and 2, with 0 per cent and 0.3 per cent,
and South Sudan at 130 with 22.7 per cent. On
the prevalence of anaemia in women of reproductive
age, India ranks 170 out of 185
countries at 48.1 per cent, compared with Senegal
which is the worst at 57.5 per cent and
the U.S. which is the best at 11.9 per cent.
Breaking the cycle
Aggregate levels of undernutrition in India
remain shockingly high, despite the impressive
reduction in stunting in the last decade.
The segments most at risk continue to
be adolescent girls, women and children,
and among them Scheduled Castes and
Tribes are the worst off, reflecting the insidious
economic and sociocultural deprivation
so prevalent in India. According to the most
recent United Nations Population Fund
(UNFPA) report, nearly 50 per cent of women
in India are married before they turn 18, in
violation of the law. The poor nutritional status
of adolescent girls, combined with child
marriage and multiple pregnancies even before
becoming an adult, lead to another dismal
fact, that 30 per cent of all children are
born with low birth weight. So we add approximately
seven million, potentially wasted
and stunted, to our population every year!
For India to be healthy and break the intergenerational
cycle of malnutrition, we have
to focus on the health, nutrition and social
status of children, adolescent girls and women
as a priority.
Undernutrition — both protein energy
malnutrition and micronutrient deficiencies
like iron deficiency anaemia — among nearly
70 per cent of school-going children challenges
the capacity for physical growth and
cognitive development.
The past decade has seen a steady buildup
of momentum around nutrition with the
setting up of the SUN (Scaling Up Nutrition)
secretariat in the UN; the World Health Assembly
adoption (in 2012) of the 2025 global
targets for maternal, infant and young children’s
nutrition, and the 2015 Sustainable
Development Goals which centre-stage the
ending of all forms of malnutrition for all
people by 2030, to name a few. India’s progress
clearly lags behind what is needed to
eliminate malnutrition by 2030.
Maharashtra was the first State in India to
launch a nutrition mission, in 2005, followed
by five other States, Madhya Pradesh, Uttar
Pradesh, Odisha, Gujarat and Karnataka,
covering a total population of 300 million. In
all six States the focus of the nutrition mission
is inter-sectoral coordination to improve
child nutrition in the first 1000 days.
The problem and solution framework are
correctly identified, but there are hardly any
targets or financial commitments or concrete
and specific programmes and processes
to accomplish this goal. Systemic development
is a long process that requires
continuity, consistency, excellence in execution
and a measurement of process, output
and outcome/impact metrics, and so far at
least, much of this seems to be missing for
converting intent to action.
One of the reasons for persistent undernutrition
in India, despite the creation of Integrated
Child Development Services (ICDS)
in 1975 and national coverage of the mid-day
meal scheme in 1995, is that there is no structure
for multi-sectoral coordination which is
essential to address the inter-generational
and multifaceted nature of malnutrition.
The announcement therefore from the Ministry
of Women and Child Development last
week of plans to overhaul the ICDS is welcome
and much needed.
Poor nutrition is poor economics
The need to systemically address underlying
causes of malnutrition in India is an urgency
that cannot be postponed for the following
reasons: One, poor nutrition is poor
economics. The World Bank estimates that
India loses 2-3 per cent of its annual GDP by
way of lower productivity, the underlying
cause of which is malnutrition. The Ministry
of Finance in its Economic Survey 2015-16
says, “Imagine the government were an investor
trying to maximise India’s long-run
economic growth. Given constraints on fiscal
space and the state’s capacity to deliver
public services, where would it invest? This
chapter argues that some of the highest economic
returns to public investment in human
capital in India lie in maternal and
early-life health and nutrition interventions.”
The Copenhagen Consensus has
identified twice several nutrition interventions
as some of the most high-yielding of all
possible development assessments.
Two, poor nutrition will fracture the
dreams and aspirations of India to become a
global player in manufacturing and other industries.
The human dividend on which we
are banking is actually a huge liability given
that one out of every three children is born
underweight and unable to realise the full
potential for physical growth and cognitive
development, leading to lower levels of
productivity.
Three, poor nutrition is poor humanity.
Article 47 of the Constitution mentions the
“duty of the state to raise the level of nutrition
and the standard of living and to improve
public health. The state shall regard
the raising of the level of nutrition and the
standard of living of its people and the improvement
of public health as among its primary
duties.” We cannot have this broken
promise nearly six decades after the Constitution
was written.
Harnessing positive factors
Right now there is a confluence of positive
factors that must be harnessed for impactful
and positive transformation. Several programmes
already announced by the government
like Swachh Bharat, ‘Beti Bachao, Beti
Padao’, etc. are critical nutrition-sensitive
factors that address hygiene, sanitation and
education. For the nutrition-specific areas,
India already has the infrastructure and
mechanism for reaching people most at risk.
These have to be urgently revamped and
made more effective.
The three structures that must be prioritised
are: the ICDS, which caters to the needs
of pregnant and nursing mothers and children
under the age of six; the mid-day meal
scheme, which directly feeds approximately
120 million schoolchildren every day; and
the public distribution system, which makes
available subsistence rations to above and
below poverty line families. All three are also
excellent platforms for public-private
partnerships to improve the level and quality
of service and could be considered as specific
areas for collaboration in CSR programmes.
Of these, the intent to revamp the
ICDS has already been announced and must
move into action mode quickly. This must
include streamlining the work in the 1.34 million
anganwadi centres by investing in training
the 2.5 million workers and helpers at
these centres, standardising the nutrition
component of the supplementary food offered
and focussing on the overall dissemination
of information and education to pregnant
and nursing mothers on healthy eating
habits, hygiene and sanitation, etc. CARE India
has recently created a “job aid” which is a
piloted mobile application that helps anganwadi
workers plan, schedule and better coordinate
their work. This and other relevant
applications must be disseminated quickly
to enhance the productivity and effectiveness
of the anganwadi workers.
Similarly, the mid-day meal is an excellent
structure to reach 120 million children with
continuity and regularity. A single intervention
in that scheme to focus on nutrition in
addition to food will make a critical difference.
This can easily be accomplished by the
addition of micronutrients to cooked food or
by adding universally liked and accepted
products such as milk, biscuits, etc. fortified
with micronutrients as a mid-morning or afternoon
snack. There is compelling evidence
from around the world that largescale
food fortification is one of the best
ways to address micronutrient deficiency.
The standards of the cooked meal could be
changed to using only fortified flour, fortified
oil and iodised salt. A large number of
children suffer from both insufficient calories
and inadequate micronutrients. The
most compelling argument for focussing on
this group is that it is targeted, there is continuity
and regularity and the impact of any intervention
is measurable over a period of
time.
Borrowing from best practice in countries
that have made quick and significant progress
in combating malnutrition, it is recommended
that a Nutrition Mission be created
to orchestrate and sequence the work both in
nutrition-specific and nutrition-sensitive areas
so that the impact from each of these is
embedded in positive and productive outcomes.
There is enough evidence from other
countries, especially those which have
adopted a multi-sectoral framework, that the
results are tangible and specific.
There are other proven interventions like
large-scale food fortification (flour, oil, milk,
etc. in addition to salt) that are inexpensive
and effective and must be mandated into
food standards.
Steps to change outcomes
The immediate actions to step change nutrition
outcomes could be summarised as
follows: One, create a Nutrition Secretariat
as part of the Prime Minister’s Office with responsibility
for ensuring multi-sectoral
alignment on priorities, sequencing and
timelines. This would include both nutrition-specific
and nutrition-sensitive initiatives.
Agree on a dashboard of nutrition metrics
to be tracked, just as we track economic
metrics.
Two, make the nodal Ministries accountable
for revamping the ICDS, MDM, PDS
with clear goals, timelines and resources.
Open these up for public-private partnerships
and make these CSR-eligible.
Three, extend large-scale food fortification
beyond salt to other staples like flour,
oil, dairy, etc. and establish mandatory standards
by category.
Four, invest in information and education
about good nutrition practices, extending
from a diverse diet to deworming, breastfeeding,
hygiene and sanitation, etc. Nutrition
is complex and therefore needs to be
simplified in behavioural terms
India must convert its young population to
a competitive advantage, and nutrition and
health are foundational to that outcome.
Vinita Bali is Independent Director and Chair, Global
Alliance for Improved Nutrition. Views expressed are
personal.
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