The problem

INDIA’S battle against malnutrition has been long and arduous. Despite some recent improvements, India is amongst countries with the highest proportion of stunted and wasted children. According to the National Family Health Survey (NFHS-4, 2015-16), 38.4% of children under five years of age are stunted (low height for age) and 21% are wasted (low weight for height).¹ In addition, we now face a triple burden of malnutrition – undernutrition, micronutrient malnutrition and low but increasing levels of overweight and obesity.² As is well known, malnutrition is a multidimensional problem, affected by a number of factors, proximate as well as underlying. While the immediate causes of malnutrition are lack of adequate and appropriate diets and poor health, there are also several underlying structural factors such as poverty and gender disparities.

Although we have made much progress in terms of food security in the country, there are still pockets of hunger and starvation that reflect the deep structural inequalities we face. Further, diets are very poor among all age groups. Only 9.6% of children in the 6-24 months age group get an adequate diet that meets World Health Organization (WHO) norms for complementary feeding,³ according to NFHS-4 data. Even among adults, the diets of a majority of the population are largely cereal based, with very little consumption of pulses, animal foods, fruits and vegetables.⁴ There is a decline in absolute poverty, but where access to better diets is limited, the vulnerability of households continues to be high. The policy emphasis in this context has solely been on making foodgrains available through the public distribution system (PDS), whereas many continue to face cost and availability barriers with respect to other foods. The prices of pulses and vegetables, for instance, are very volatile, with periods of high inflation.

While there is no denying the importance of behaviour change communication, especially for infant and young child feeding, we must not lose sight of the significance of improving people’s livelihood security as a factor in addressing malnutrition. Linkages between agriculture and nutrition are also important. In order to take all of this into account, the Committee on World Food Security of the UN has called for a food systems approach.⁵

Another structural factor that makes a huge difference to malnutrition is the status of women. The significance of women’s status has been recognized by several studies, including Ramalingaswami et al,⁶ who cited poor women’s status as one explanation for the South Asian Enigma.⁷ Women’s status is not only important because of biological factors and the inter-generational nature of malnutrition, but also because in most societies women are the primary caregivers. In the UNICEF conceptual framework on malnutrition, inadequate care for women and children constitutes one of the underlying causes of malnutrition.⁸ In resource constrained contexts, where most women are also workers, some arrangements for childcare, in the form of creches or daycare centres, can also become an important part of responding to malnutrition.

The Integrated Child Development Scheme (ICDS) in India, which has been the central platform for all responses to malnutrition, provides essential services such as supplementary nutrition, growth monitoring and nutrition education for children under the age of three through anganwadis, but these centres are not equipped to play the role of full-fledged childcare centres. Enhancing the capacities of anganwadis in terms of human resources, space and additional funding could go a long way in reaching out to the young child. Additionally, maternity entitlements, which include antenatal care and nutrition as well as wage compensation, can contribute to healthier pregnancies and enable exclusive breastfeeding, both of which are critical for better nutrition outcomes for children.

The significance of broader reforms towards women’s empowerment, including promoting women’s education, preventing child marriages, and working towards changing patriarchal social norms, cannot be underestimated either.

Recent research has also highlighted the role of sanitation in preventing malnutrition. High prevalence of open defecation can offer further explanation for high malnutrition rates in India.⁹ Exposure to open defecation can lead to diseases such as diarrhoea, which contributes to malnutrition through reduction in food intake, and decrease in absorption of nutrients.¹⁰

Efforts under the Swachh Bharat Abhiyan may have improved this situation, but we need to see what gaps remain. Measures for prevention and cure of infection, including diarrhoea, pneumonia and malaria, also need to be stepped up. On the other end of the spectrum, there is a lack of regulations and guidelines on ultra-processed foods and therapeutic nutrition.

Recognizing that multifactorial interventions are required to address malnutrition in the country, the Poshan Abhiyaan or National Nutrition Mission, launched in 2017-18, works towards ‘mapping of various schemes contributing towards addressing malnutrition’ and ‘introducing a very robust convergence mechanism’.¹¹ However, in the first three years of its implementation, the focus seems to have been largely on setting up the ICDS-CAS (common application software) mechanism for real-time monitoring of anganwadi services, and on conducting public awareness campaigns on malnutrition. While this has helped bring the issue to the forefront, a comprehensive response to malnutrition calls for much more. The budgetary allocation for the Poshan Abhiyaan is only about Rs 9,000 crore over three years, which translates to a meagre Rs 200 per child under six per year, not nearly enough for a problem of this scale.

Budgetary inadequacy is especially important considering that anganwadi services, the platform on which the Poshan Abhiyaan is based, have been massively underfunded from the outset. While the number of anganwadi centres in the country has more than doubled over the last 10 to 12 years, with a commensurate increase in budgets, the allocations for supplementary nutrition, wages of anganwadi workers and helpers, educational material and infrastructure continue to be very low.

The Poshan Abhiyaan needs to be made more comprehensive, ensuring convergence of services and functioning as a platform where multi-sector interventions, including food systems, gender and childcare, can be regularly monitored at a decentralized level, along with nutritional outcomes. Such a strategy, backed by resources, is even more important now, with the Covid-19 pandemic and the lockdown related livelihood and hunger crisis still unfolding.

DIPA SINHA

 

* Seminar wishes to acknowledge the help of Global Health Strategies and Anubha Bhonsle in putting together this issue.

Footnotes:

1. NFHS-4 data, http://rchiips.org/NFHS/pdf/NFHS4/India.pdf

2. J. Meenakshi, ‘Trends and Patterns in the Triple Burden of Malnutrition in India’, Agricultural Economics 47(S1), 2016.

3. Complementary feeding means complementing solid/semi-solid food with breast milk after child attains age of six months. After the age of six months, breast milk is no longer sufficient to meet the nutritional requirements of infants. Age appropriate complementary feeding for children 6-23 months, while continuing breastfeeding. Children should receive food from four or more food groups [(i) Grains, roots and tubers, legumes and nuts; (ii) dairy products ; (iii) flesh foods (meat fish, poultry); (iv) eggs, (v) vitamin A rich fruits and vegetables; (vi) other fruits and vegetables] and fed for a minimum number of times (two times for breasted infants 6-8 months; three times for breastfed children 9-23 months.

4. On poor dietary diversity see V. Prasad and D. Sinha, ‘Dietary Deprivation: Diets Sans Diversity’, Frontline, 8 November 2019, https://frontline.thehindu.com/cover-story/article29766073.ece

5. http://www.fao.org/cfs/home/activities/nutrition/en/

6. V. Ramalingaswami, U. Jonsson and J. Rhode, ‘Malnutrition: A South Asian Enigma’, in Malnutrition in South Asia: A Regional Profile. UNICEF Regional Office for South Asia, 1997.

7. Of malnutrition levels in South Asia being higher than poorer countries in sub-Saharan Africa.

8. P. Engle, M. Bentley and G. Pelto, ‘The Role of Care in Nutrition Programmes: Current Research and a Research Agenda’, Proceedings of the Nutrition Society 59(1), 2000.

9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774764/

10. https://www.ncbi.nlm.nih.gov/books/NBK219100/

11. https://icds-wcd.nic.in/nnm/NNM-Web-Contents/UPPER-MENU/AboutNNM/PIB_release_NationalNutritionMission.pdf