India must convert its young population to a competitive advantage, and nutrition and health are foundational to that outcome.
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 inter-generational 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 build-up 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 intergenerational 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 large-scale 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 nutritionspecific 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.