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Insights into Editorial: No child left behind
India is home to the largest number of malnourished children in the world, a report, advocating that the country needs to frame policies with a focus on reducing health and social inequities.
- The urgency to address poor nutrition in India, especially among children, adolescent girls and women is compelling, and re-confirmed in virtually every survey — from NFHS-4 in 2015-16, to the Global Nutrition Report 2016 and the Global Hunger Index (GHI) 2017, which ranks India at 100 out of 119 countries, with a low overall score of 31.4.
- Among children less than 5 years, wasting (low weight for height), continues to be 21% in the 2017 index — it was 20% in 1992.
- There has been a reduction in stunting (height for age) – from 61.9% in 1992 to 4% in 2017, reported in the GHI 2017.
- Mortality among children less than 5 years old has declined to around 5% from 11% during the same period, according to both the GHI and the NFHS.
However, 25% of India’s children less than 5 years old are still malnourished.
The fact is that around 190.7 million people in India sleep hungry every night, and over half of adolescent girls and women are anaemic, and the conclusion is obvious — despite a 7% compound annual growth rate over the last decade and the various programmes to improve nutrition, levels of under-nutrition are unacceptably high.
No time to waste: Need to address immediately:
This grim reality lead to a renewed emphasis to address the various forms of poor nutrition: stunted, wasted, anaemic and underweight children; anaemic girls and women, especially in the 15-49 age group.
The recently announced flagship program of the Ministry of Women and Child Development will be anchored through the National Nutrition Mission (NNM), or Poshan Abhiyaan, with its own specific budget of ₹9,046 crore and a proposed World Bank loan of $200 million, to ensure convergence among the various programmes of the government.
Additionally, NITI Aayog has worked on a National Nutrition Strategy (NNS), isolated the 100 most backward districts for stunting and prioritised those for interventions.
Address the structural and systemic issues:
The optimistic view says that exploring new models to address the structural and systemic issues on a priority basis, learning from what has worked or not, and single-minded focus on implementation will be critical to delivering better nutritional outcomes and meeting the Sustainable Development Goals, to which India is a signatory.
Initiatives like Swachh Bharat Abhiyan, where implemented, will contribute positively to nutrition outcomes, and well-structured public-private partnerships could be the catalyst.
The overhaul of capacity and capability in three existing programmes, designed to reach populations most at risk, should be the first priority — namely:
- Integrated Child Development Services (ICDS), with its network of 1.4 million Anganwadi Centres, reaching almost 100 million beneficiaries who include pregnant and nursing mothers and children up to 6 years;
- Mid-day meals (MDM) that reach almost 120 million children in schools; and
- Public Distribution System (PDS) that reaches over 800 million people under the National Food Security Act.
The National Nutrition Strategy (NNS) has set very ambitious targets for 2022 and the Poshan Abhiyaan has also specified three-year targets to reduce stunting, under-nutrition and low birth weight by 2% each year, and to reduce anaemia by 3% each year.
Both the NNS and the NNM have recognised the criticality of working collaboratively across Ministries; yet both are silent on the constructive role that the private sector, development agencies and civil society can and must play in realising these ambitious goals.
Success in this domain will be driven by coordinated action on multiple fronts, but there are at least three urgent priorities.
Key Nutrition strategies and interventions:
IYCF(Infant and Young child feeding), Food and Nutrition, Immunization, Institutional Delivery, WASH(Water, Sanitation and Hygiene), De-worming, ORS-Zinc, Food Fortification, Dietary Diversification, Adolescent Nutrition, Maternal Health and Nutrition, ECCE(Early Childhood care and Education), Convergence, ICT-RTM(Information and Communication. Technology enabled Real Time Monitoring), Capacity Building.
Convergence between different Ministries will be a crucial aspect in making the mission successful.
Way Forward: Three priorities that will improve the present situation:
One, to adequately re-engineer the ICDS, MDM and PDS for greater effectiveness.
- This is an ideal initiative for public-private partnerships as the strength of good private sector companies is in creating and designing frameworks, structures, processes and metrics for action, implementation and tracking.
- For example, involving the best nutritionists to work with local communities on calorie and nutrition dense supplementary foods, using easily available local ingredients that are within the ICDS and MDM budget guidelines, and produced by self-help groups, could easily be anchored by the relevant private sector and development agencies, working with State governments, and considered a corporate social responsibility initiative.
- The key advantages of this disaggregated supply model are that it engages local communities, generates employment and ensures minimal leakage as it works with and inside the community.
- This will also ensure that space and other constraints of lack of hygiene at Anganwadi Centres do not become impediments in the supply of nutritious food.
Two, To mandate and scale staple food fortification comprising edible oil, wheat, rice and dairy products, in addition to salt.
- There is persuasive evidence from several countries of the efficacy and cost-effectiveness of large-scale staple food fortification to address “hidden hunger” or micro-nutrient deficiencies.
- The success of micro-nutrient fortified food is that it does not entail a change in behaviour. Considerable work will also have to be done to make fortified rice and wheat available through the PDS.
- This requires addressing the supply chain capability to deliver — another excellent PPP initiative, that has been piloted in several States for edible oil and wheat flour and can easily be replicated.
- Mandatory fortification with micro-nutrients often sparks to think about it is that these universally consumed staple foods become the carriers of vitamins and minerals that people need but do not get in sufficient quantity from the food they consume.
Three, multiple campaigns designed to inform, communicate and educate on nutrition-specific and nutrition-sensitive behaviours like breast feeding, diet diversity, hand-washing, de-worming, safe drinking water, hygiene and sanitation.
Nutrition has to be “marketed” and made interesting, engaging, simple and personally relevant and this is an expertise where the private sector can meaningfully contribute.
The approach, commitment and resources therefore have to be inter-generational, multi-sector, multi-dimensional and multi-year.
To simplify a complex issue, the challenge for India is to simultaneously address insufficient and poor diets, inadequate hygiene and sanitation and better management of disease and infections.
Nutrition is complex, and therefore its delivery must be simplified through greater awareness and actions.
The delivery models must be collaborative across domains, with clear decision rights and hard-wired processes, enabled by technology and a significant investment in strengthening people competencies.
Unless economic growth improves social and human development, it cannot be sustained. Equally, economic growth itself is impeded by low levels of productivity in an under-nourished and malnourished population.
To address the problem of child under-nutrition, and disease there should be early life-cycle interventions targeting the first 1,000 days of a child’s life.
ICDS, Mid day Meal and PDS should be re-worked upon for greater effectiveness. Public-Private partnership in this domain should be encouraged. This would ensure that leakages, space and other constraints of lack of hygiene, delay in supply of food etc do not hinder delivering nutritious food.