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 (the latest available information), 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 38.4% 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.

Add to this the fact that 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

This grim reality has rightly 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.

A cynical view would be that we have seen such declarations before – after all, the special attention to nutrition was highlighted in 2008 when the Prime Minister’s National Council on India’s Nutrition Challenges was constituted. A detailed report, “Addressing India’s Nutrition Challenges”, was submitted in 2010 by the Planning Commission, the convergence of an extensive and multi-sector consultation. But nothing changed significantly.

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. Additionally, initiatives like Swachh Bharat Abhiyan, where implemented, will contribute positively to nutrition outcomes, and well-structured public-private partnerships could be the catalyst.

Seen in this context, the overhaul of capacity and capability in three existing programmes, designed to reach populations most at risk, should be the first priority — namely, the 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 the 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. For purposeful action, it is imperative to have common goals and metrics for improving nutrition, which can then be disaggregated by year, State, district, etc., into a nutrition dashboard, with metrics that are clear and measurable and a real-time tracking mechanism, much like we track economic data. It is interesting to note that the National Nutrition Monitoring Bureau (NNMB), established in 1972, was dissolved in 2015.

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. Altering the fundamentals of poor nutrition requires multiple and sustained interventions over a period of time — increased availability and accessibility of nutritious food, potable water, hygiene and sanitation, primary health care, etc. 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.

Success in this domain will be driven by coordinated action on multiple fronts, but there are at least three urgent priorities.

Three priorities

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 effectiveness of iodised salt in significantly reducing iodine deficiency is well-established in India empirically. 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. A case in point is the mandate of July and August 2017 to use fortified oil, salt and wheat flour in the ICDS and MDM by the Ministries of Women and Child Development and Human Resource Development, respectively. In the absence of coordination with industry to create an effective supply chain, this proposed intervention will be another missed opportunity.

Mandatory fortification with micro-nutrients often sparks an emotional debate, and the way 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 — this is an expertise where the private sector can meaningfully contribute.

Awareness and delivery

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.