Reimagining public health
An interview with Rajiv Kumar, Vice Chairperson, NITI Aayog.
We are almost halfway into the stated goal of the Poshan Abhiyaan – to make India malnutrition-free by 2022. What is your assessment of our progress so far?
We have made steady progress over the last five years. The Poshan Abhiyaan was launched on 8 March 2018 (International Women’s Day), by the prime minister. Since then, we have set up the National Nutrition Council, and we are trying to achieve real-time monitoring of the nutrition status of children and women in the country. To that end, all our 11 lakh anganwadi workers are being connected to a dashboard in the Ministry of Women and Child Development (and about 60% have already been connected). I get a weekly report on all the necessary equipment that we need for measuring the height, weight and other relevant parameters of the children in each state. Some of the results are beginning to show. The Comprehensive National Nutrition Survey (CNNS) conducted by UNICEF showed that malnutrition levels have come down from 38.4% in 2016 to 35.7% in 2018. So far, they’ve come down by one percentage point a year, and we want to raise it to three percentage point [decline] per year. We can achieve that 3% reduction – the current pandemic has come in the way – but we will try very hard to achieve the target. The other part of the target is women’s nutrition. Fifty per cent of women are anemic in our country, and that’s harder to [address], but we are trying new forms of food fortification, including rice fortification.
What kind of impact has the outbreak of Covid-19 (and the subsequent lockdowns) had on our nutrition goals?
We are trying very hard that this does not deliver a big setback to our nutrition efforts and nutrition levels. We have tried to convert all anganwadis into supply conduits for take-home rations to mothers and children. Therefore, food that children used to have at the anganwadis is now packed and delivered as dry rations. Since Covid-19 kicked in, 8.3 crore children and 5.1 crore women have been given the take-home rations. Our efforts are very much on to make sure that Covid-19 does not derail our malnutrition targets.
What would a holistic and co-ordinated Covid-19 response strategy look like in your opinion, one that prioritizes and provides for the nutritional needs of vulnerable groups and integrates nutrition? What advice has NITI Aayog been giving ministries on next steps?
Our effort has been to work not just with the state governments but also with panchayati raj institutions, gram pradhans and district administrations. We are specially focusing on the 112 Aspirational Districts, which have historically had the worst malnutrition levels; and in these districts we are also working with development partners and civil society organizations, such as the Bill & Melinda Gates Foundation and the Piramal Foundation. Our CEO has now written to 92,000 civil society organizations registered on DARPAN, the NITI portal for civil society organizations, to encourage them to work with the state governments and local agencies in keeping nutrition at the forefront and making sure that these targets are not set back.
The World Food Programme has warned that the world currently is at the brink of a ‘hunger pandemic’. The United Nations has also called for extraordinary measures because they predict that ‘a spectre of multiple famines looms’ due to the ongoing pandemic. How far is India from a situation like this? What steps is India taking to prevent such a situation?
Thankfully, due to our past efforts, India is very far away from any such catastrophe or any hunger/famine situation. One of our biggest achievements post-independence has been to achieve food security, and also to enact the National Food Security Act (NFSA). I am glad to say that there is a stock of 70 million tonnes of food grain with the FCI [Food Corporation of India], and this is prior to the rabi harvest coming in. This has given us the confidence we need to ramp up our food allocation for the vulnerable sections and also for the migrant workers. As the finance minister announced, 80 crore people have been given an additional five kilograms of food and one kilogram of pulses per month in light of the Covid crisis.
Recently, we have also implemented the One Nation-One Ration Card, and 18 states are already on board. This is a digitized card, linked to the individual’s Aadhaar card, and will be valid for acquisition of food grains at NFS rates across all states. This reflects significant improvement in portability of food entitlements and thereby ensuring availability. The next step, of course, is going to be issuing them, and ensuring that Aadhaar is linked to this ration card. If you are a migrant worker with only your Aadhaar card with you and you have left your ration card behind with your family, you will still be able to access supplies under the NFSA. That’s a big step – a big achievement that has just been completed.
Further, there has been a decision to provide wheat and rice at heavily subsidized prices (actual amount of subsidy is being currently determined) to all NGOs and charity organizations that are providing cooked meals to migrant workers [and vulnerable groups] during these difficult times.
More than 66% of our population is now covered by the NFSA, which means all of them are entitled to these very subsidized rates of food grains. Therefore, both things – purchasing power, which was the cause of the 1942 famine in Bengal, and non-availability of, which was the cause of the 1967 Bihar famine – have been addressed more than adequately. I feel very confident to say that India will never face the spectre of hunger deaths and famines, now or ever in the future.
Agriculture has a key role to play as far as nutrition security is concerned. How well designed do you believe India’s agricultural policies are as far as this is concerned? Do you see any gaps that are being addressed on priority?
Quite often, we mistake nutrition to be the availability of cereals and food grain. Nutrition is more than that; nutrition is about getting the right balance of proteins, vitamins, fat, carbohydrates and other nutrients. These are also produced in the agricultural sector, and a non-diversified agricultural sector will not be able to deliver the necessary amount of fruits, vegetables, poultry products, fish and other forms of proteins. There, I think the good news is that horticulture, fisheries and poultry have seen much higher growth over the last 10 years than they have seen in the past. Our farmers are beginning to diversify. This government is particularly laying emphasis on the procurement of non-wheat-and-rice crops (millets, for example, because they provide much more nutrition than these two crops). We are trying to incentivize farmers to grow higher quantities of millets, lentils and other nutrition-rich crops, and I think we are succeeding.
Our agriculture is diversifying, but we need to reduce the distance between the farmer and the consumer. The longer the supply chain, the more difficult it becomes for the consumer to obtain the necessary nutrition. The recent announcements by the finance minister permitting farmers to sell to anybody they like, and removal of the Essential Commodities Act will further reduce the distance between the farm and the fork. Lastly, as I mentioned earlier, fortification is important. We need to process our agricultural output, fortify it, standardize it, and the government is working on this and you will see results very soon. I think we are making agriculture more nutrition sensitive, more nutrition oriented, than what it was earlier.
The Poshan Atlas, once developed, would be a unique database that maps food consumptions patterns and links them with information on crop varieties. How will this help in addressing malnutrition or the control of non-communicable diseases like obesity and diabetes?
Once completed, it will be an amazing instrument for us. Given our diversity and India’s continental scale, one size will not fit all and we need a very heterogeneous basket of nutritional intake and inputs to be able to achieve our [nutrition] targets. The importance of local varieties of grains, cereals and millets is extremely important. The Poshan Atlas will give a complete breakdown – a very disaggregated picture of all that is being produced in different parts of the country. Once we get that, we can start to make changes at local levels to suit the needs and requirements of the population there. The Atlas would enable us to plan and intervene at a very micro level, where it matters. We will be able to intervene to ensure there are enough supplies of nutritious, locally adaptable food for children, and adults as well. The Atlas will be inherently connected to agriculture, and it will be able to help us improve agricultural productivity and agricultural diversity once we get that data. I am looking forward to the completion of the Atlas and I hope it will be completed within the year.
Centrally sponsored schemes (CSS) have been criticized for their centralized nature and procedural inefficiencies. The current government has also emphasized that it wants to rationalize these schemes. In the specific context of financing nutrition-specific and nutrition-sensitive CSS, what kind of reforms do you believe are needed?
The first part of the question you asked is very important. We need to shift from input-based performance evaluation to outcome-based performance evaluation. The NITI Aayog has given the task to the Development Monitoring and Evaluation Office (DMEO), an affiliate organization of NITI Aayog. DMEO is in the process of completing an output-outcome based performance evaluation of nearly all the 300-odd centrally sponsored schemes. That could bring about a very big change. We have also created a 700-lines output-outcome performance matrix for all the budget heads. This outcome based performance evaluation is likely to increasingly become the basis for allocating budgetary resources to different schemes. So, we are making that move and we will achieve that.
Regarding the second part of the question on financing, we have been allocating sufficient resources from the central budget for these big schemes like the National Health Mission and the Integrated Child Development Scheme. Resources have not been a constraint; the constraint has been the quality and effectiveness of implementation and delivery. Several international foundations and organizations are also interested in helping with financial resources in the nutritional effort. So, financing is not a problem because the central government is committed to providing as much as is required to achieve the target. But if need be, we will not hesitate to go to the multilateral organizations to mobilize more resources.
What kind of reforms does our federal fiscal structure need to maximize the impact of the schemes across states?
My understanding is that we need to financially empower the third tier of government (the urban local bodies and the panchayati raj institutions, which in effect implies the full implementation of Constitutional amendments 73 and 74) and make them accountable. The prime minister has said that the Poshan Abhiyaan should be converted into a Jan Andolan, and unless this is a social movement, we will not get rid of malnutrition, whether of our children or of women. It will happen only if the local leadership and local institutions get involved in it completely. For that to happen, we need to financially empower them and make them accountable by taking surveys and feedback from beneficiaries. I think that’s a governance reform is required to bring the delivery of public services under these schemes to expected levels.
You have in the past urged corporate houses to prioritize nutrition as part of their CSR (corporate social responsibility) initiatives. What are some other ways in which businesses/the private sector can contribute to India’s mission to eradicate malnutrition?
The biggest role corporates can play is to spread awareness [about nutrition]. The Ministry of Women and Child Development in partnership with NITI Aayog and state governments organizes Poshanmelas, Poshanpakhwadas and Poshanmaah in different parts of the country. If the corporates in those regions were to cooperate and partner with the government, give it that extra push and visibility and sustain it for a longer time, it could play an important role.
I am saying this because people still confuse food with nutrition. We need awareness about nutrition, about balanced diets, about the fact that maximum development of the brain happens when a child is between one to three years of age and therefore needs maximum nutrition at that early age, or that mothers/would-be mothers should not be anemic. This, much needed, awareness is still not present. That’s where corporates can do a huge amount of work. I could have easily said that they can provide food packets and so on – but no, I think awareness is something that they can start and sustain. To repeat myself, financial resources are not the problem in this case, as might be in some other sectors because the government is really committed to giving it whatever we can.
The other manner in which corporates can help in the nutrition programme is to provide fortified rice because that’s something which can address women’s anemia very quickly. We are launching the programme in 15 pilot districts and it will hopefully be rolled out across all districts. That – rice fortified with iron and folic acid – by itself can help us eliminate women’s anemia in the next three years. It doesn’t take much more than that. These are two areas in which corporates can help.
The Global Nutrition Report 2020 was released recently, and India continues to bear the largest burden of malnutrition and looks set to miss the World Health Assembly nutrition targets for 2025. How do we fast track our progress?
Well, in these Covid-19 days, we can’t think of fast tracking anything at all. We have to get the state governments much more enthused about nutrition. Luckily, some have shown a willingness to do more than what they’re doing. And as I said earlier, the shortest way to fast track it is to involve the local governments. We should be working with the third tier and empowering it with financial resources, with knowledge, and with accountability.
If CSOs can get involved in and can share my priority, that can be a big factor. I give nutrition the highest priority in my work because I don’t think we can do anything with such a large number of children being undernourished, because that’s the future of the country. In Uttar Pradesh, for example, we had some very good results because of an intervention by Tata Trusts, who sent volunteers for working with the administration in every district. If the corporate world can also share my priorities and direct more and more of their CSR to this critical issue of malnutrition and eliminating it, I think we could achieve our goals sooner rather than later.
Following the Covid-19 pandemic, every day we are seeing reports of struggle, strife, starvation, and even some deaths. What do you believe has been missing in our systems that what was primarily a health crisis is also now a humanitarian one?
I don’t want to accept that this is already a humanitarian crisis because I think the state governments have done a lot in partnership with civil society organizations which have shown tremendous initiative and drive in helping the migrants and vulnerable sections of the population. The central government has itself allocated Rs 13,000 crore to the state governments to try and take care of these population segments.
But let me put it to you in a rather economist way. The statistic from the 2011 Census was that we had 65 million migrants in the country. And that figure I believe has risen to more than 100 million migrants in the country at present. Out of this very large number of migrants, from all available estimates, not more than 10% have tried to return to their villages. Therefore, a large majority of migrant workers are staying where they were and they have not moved back and are unlikely to move back. Not for a minute am I underplaying the tragic images that have come out. But we should take some heart from the fact that it’s still only about a tenth or so of the total number of migrants who have taken journeys back to their states of origins. The two implications of that are – one, thankfully this is not therefore a very large-scale humanitarian crisis, and two, when the lockdown is lifted, there will hopefully be sufficient number of workers available to go back to run the factories, transport or start other economic activities. Surely, the absence of the ten per cent of the workforce will raise wages in regions/states where migrants played a prominent role in economic activities. This might be a blessing in disguise as it will propel productivity improvements and may also help to eliminate the duality between the formal and informal sections of the workforce. The most important take away from this experience is to ensure that we bring the informal sector workers firmly in our policy radar and collect all relevant data and assure them of a minimal safety net.
Could you explain how we have reached this figure of the migrants we are seeing, as hundreds of thousands and not the full arc of 70-72 million?
Let me repeat that any number – in tens or hundreds or thousands – of people making these journeys is unacceptable. I am the last one to underplay or undermine that. The numbers – as there is no data on the number of people moving – are just anecdotal, from what we see and hear. There is no statistic being collected. The number of 72 million is, as I said, extrapolated from the 65 million, which was a hard data from 2011.
How do you see this impacting our social and economic landscape in the immediate future and perhaps in the long-term?
It’s really very difficult, and it depends on so many things. By allocating Rs 40,000 crore more to MGNREGA right away, and making MGNREGA budget now worth more than 100,000 crore, the government is trying to ensure that those workers who return to their villages are quickly absorbed into the rural workforce as soon as possible, therefore not leading to any disruption or strife. The central and state governments are working in tandem in this effort. Civil society organizations have played a stellar role and the government is also extending a helping hand to them.
What in your opinion would a post-Covid-19 India look like?
I don’t think there will be a ‘pre’ and ‘post’ COVID situation, because you’ll have to learn to live with it, like you’ve learned to live with influenza, flu, swine flu or dengue or whatever. But yes, we will have an India that is going to be hugely cognizant of the fact that a continuation of this dualistic structure of our society, where a very large percentage – almost 85-90% of people – are in the informal sector, where they don’t have social safety or health safety nets, or even where labour laws simply don’t exist or apply, that dualism cannot continue to exist.
Therefore, after this particular time, I hope and I think there will be a very sharp rise in the social consciousness of our people that we have to eliminate this dualism, the sooner the better, sooner rather than later. And it is very much pointed towards us, the elite who have chosen to live with it all our lives. We have simply accepted the fate of the rehri-wallahs and the rickshaw-wallahs for whom none of these [safety nets] are available. The Covid-19 shock will tell us that we need to put in place a social safety net, a medical safety net as soon as we can for the entire population. This is the effort under Ayushman Bharat, which will initially cover about 10 crore families and then expand to achieve universal health insurance coverage.
Therefore, this will be an India which will pay much more heed to social sectors and human resource welfare than was done in the past. And I hope that to a certain extent the elites’ indifference towards their own brethren will be much lower than what it used to be. The knock on the window in the car would mean something…
Do you think it’s more visible now to us that we have invisibilized large sections of society?
I think this is the first time that we have the awareness that a large mass of unprotected and informal sector workforce has extensive negative externalities and we cannot isolate ourselves from it. The virus will come to you, whether you are in Lutyens Delhi or in Malabar Hill in Mumbai, or wherever. This is the first time this insularity that the elite has had will hopefully be breached. The virus will not respect any class, caste or communal boundaries. And therefore, public health is a hugely important public good and I think that recognition must and will come about.
I think this is what the prime minister had in mind when he initiated and so passionately pushed forward with the Swachhta Abhiyan. That’s what Gandhiji had said, that swachhta is more important to him than swatantrata. The fact is we have been caught in the midst of our campaign for swachhta and public hygiene, and I think it will be accelerated, as it should be, because of the pandemic.
So, that’s the post-Covid India: an India which is more sensitive towards the requirements of public health, safety and hygiene and also more sensitive towards the welfare of those at the bottom of the pyramid, found mostly in the informal sector.
