By Dr Amrit Patel:
Prime Minister Dr Manmohan Singh, while chairing the full Planning Commission meeting on April 21, 2011, said “The 12th plan objective must be faster, more inclusive and also sustainable growth. We need to identify the critical areas where existing policies and programs are not delivering results and should, therefore, be strengthened or even restructured”. In this context, since policies and programs on child nutrition and their implementation could not deliver expected results during the 11th Plan which achieved an annual growth rate of 8.2%, need to be re-looked and new initiatives are called for to tackle them during the 12th Plan when the Prime Minister has agreed to work towards a growth target of 9.0% to 9.5%. This paper highlights the alarming state of child nutrition in the country and suggests focused attention during the twelfth plan to ameliorate the deteriorating situation in light of experiences of China, Brazil, Thailand and Vietnam.
Children who are under-nourished have substantially lower chances of survival. They are prone to suffer from serious infections and are more likely to die from common childhood illness, such as diarrhoea, pneumonia, and measles. Nutritional intervention is a sine qua non when mothers are pregnant and during children’s first two years of life, after which the opportunity for child’s development potential is lost forever. Provision of universal preventive health services and nutritional interventions for children under two and their mothers during pregnancy and lactation can reduce under-nutrition by 25% to 36%. Assured access of poor to pulses and cooking oils at affordable rates can reduce protein and calorie deficiency among the poor.
Alarming Scenario: National Nutrition Week is celebrated in September every year to create mass awareness about the nutrition programs. However, the child under-nutrition in India is a major threat to child’s survival, growth and full development potential. According to third National Family Health Survey of 2005-06, in India 20% of children under five-years-old were wasted [too thin for their age] due to acute under-nutrition and 48% were stunted [too short for their age] due to chronic under-nutrition and 70% of children between six months and 59 months were anaemic. The percentage of children below five years of age who are underweight is 42.5% as compared with 4% in Brazil and 6% in China. More than a third of all deaths in children aged five years or younger can be attributable to under-nutrition. Infancy deaths were 53 per 1000 live births in 2008.The Prime Minister Dr. Manmohan Singh had once referred to under-nutrition as a ‘matter of national shame’.
The Global Hunger Index [2010] identified child under-nutrition as a major contributory factor behind ‘persistent hunger’. According to Washington-based International Food Policy Research Institute India is among 29 countries that face ‘alarming’ situation of hunger. Malnutrition among children under two years of age is one of the serious challenges to reduce hunger, which if not timely attended can cause lifelong harm to child’s health, productivity and earning potential.
Plethora of Schemes: India, acknowledging that the problem of malnutrition is multi-dimensional, multi-sectoral and inter-generational in nature, and that a single sector scheme cannot address the multifaceted problem, introduced a number of schemes to improve nutrition needs of children and pregnant mothers from time to time under different Ministries, such as [a] Ministry of Women and Child Development: [i] Integrated Child Development Services [ii] Kishori Shakti Yojana [iii] Nutrition Program for Adolescent Girls [iv] Rajiv Gandhi Scheme for Empowerment of Adolescent Girls; [b] Ministry of Human Resource Development [i] Mid-day Meals Program [c] Ministry of Health and Family Welfare [i] National Rural Health Mission [ii]National Urban Health Mission [d] Ministry of Agriculture [i] National Food Security Mission [ii] National Horticulture Mission [e] Ministry of Rural Development [i] Rajiv Gandhi Drinking Water Mission [ii] Total Sanitation Campaign [iii] Swaranjayanti Gram Swarojgar Yojana [iv] Mahatma Gandhi National Rural Employment Guarantee Program; [f] Ministry of Food [i] Targeted Public Distribution System [iii] Antyodaya Anna Yojana [iii] Annapoorna. These schemes have had limited success to improve nutritional status, due to fragmented leadership and coordination and reflecting Nutrition is nobody’s responsibility. They need to be re-looked and a more focused and comprehensive effort is called for.
Real per capita GDP in India has grown by nearly 4% per annum over the past 15 years whereas over the same period, the malnourished infants reduced from 52% to 46%. The report ‘Lifting the Curse: Overcoming Persistent Under-nutrition in India’ by Lawrence Haddad reflects a failure of governance at several levels of implementation and identifies a number of shortcomings in nutrition service delivery system, such as [i] services are not provided where they are badly needed [ii] some really deserving groups of citizens are systematically excluded from services [iii] services are of low quality [iv] accountability for service providers is weak [v] leadership and coordination is fragmented [vi] awareness of the public to demand services is poor [vii] annual nutrition data are not available to enable monitoring of progress. Nutrition is nobody’s responsibility. The Government is expanding funding to the ICDS, the main program tasked with malnutrition reduction among infants but without governance reforms. The World Bank’s study on the working of ICDS [2005] highlighted three important mismatches, namely [i] the gap between design and implementation, [ii] the neglect of the poorest and the most vulnerable, and [iii] the poor quality of services.
Public policy even needs to be reordered to improve nutrition right from the period spanning —9 months to +24 months [ from conception to the second birthday] as against past policies targeting children under the age of five. Besides, as malnutrition is a consequence of multiple deprivations a comprehensive policy addressing all related issues impacting multiple deprivations is needed to tackle malnutrition effectively. This is evident from a study by the Oxford Poverty and Human Development Initiative, which showed that while 38.9% of the poor in India were under-nourished they were also faced with severe deprivations in other specifically related areas, such as cooking fuel [52.2%], drinking water [12%] and sanitation [49.3%]. Efforts to fight creeping nutrition insecurity accompanied by poverty and gender inequality have to be redoubled.
Field studies and observations by experts on the current implementation of programs suggest, inter alia, to [i] undertake social audits of the ICDS with reference to effectiveness of services delivered [ii] monitor the Government’s role & action on nutrition by empowered authority [iii] to simplify implementation of ICDS as there are too many interventions and too many age groups. It is complex to implement, especially in relation to several and different contexts. At present, it tries to do many things for many people and in the process it can satisfy none. [iv] put in place an effective cross-ministry mechanism to deliver food, care and health in combinations that work. Efforts to lift the curse of malnutrition must be unified. [v] involve historically excluded groups in the design, outreach and delivery of nutrition programs, reaching out to women from these groups in particular [vi] devise simpler but more frequent monitoring of nutrition status mechanism so that civil society and the media can hold the Government and other implementers to account for year on year slippage and reward them for good progress [vii] develop new ways of teaching and doing research on how to improve nutrition.
Successful Experiences: Experiences of successes in China, Brazil, Thailand, Viet Nam and other countries suggest [i] according top priority to child nutrition with adequate investments in nutrition interventions and related critical areas impacting multiple deprivations [ii] targeting nutrition interventions to prevent and moderate under-nutrition and treat severe under-nutrition as a part of continuum of care for children, particularly among the most vulnerable children, the youngest, the poorest and the socially-excluded [iii] strengthening community-based primary health care to facilitate wider and deeper coverage through community-based frontline workers [iv] strong supervision, monitoring and evaluation of the effectiveness of policy, programs and budgetary allocations to yield expected outcomes and provide timely documented feedback to re-look policy, programs and budgetary action [v] reducing malnutrition calls for serious concern for poor, strong political will to commit, good governance and accountability [vi] Cash Transfer Scheme to be effective need to be supported by adequate staff and infrastructure for public sector health facilities.
With serious concern and commitment China reduced child under-nutrition from 25% to 8% between 1990 and 2002, Brazil from 18% in 1975 to 7% in 1989, Thailand from 50% in 1982 to 25% in 1986 and Viet Nam from 45% to 27% between 1990 and 2006. India has the financial & human resources as well as administration and managerial capabilities to address, once and for all, the challenge of child under-nutrition. Let the prevention and treatment of child under-nutrition in the first two years of life be a national development priority and let National Nutrition Week be celebrated in September every year to create mass awareness about the programs and exercise right to hold implementers accountable. Only by effectively tackling governance of malnutrition, the Government can lift the curse and raise the stature of its children.