india tackling child malnutrition Raghu Rai/Magnum for Save the Children Rachel Palmer DESPITE IMPRESSIVE ECONOMIC GROWTH, INDIA HAS HIGH CHILD MORTALITY RATES AND NEARLY HALF ITS CHILDREN ARE STUNTED. MDG 4 TO REDUCE CHILD MORTALITY BY TWO- THIRDS CANNOT BE ACHIEVED WITHOUT TACKLING MALNUTRITION. India is home to one-third of the world s poor, with over one-fourth of the population about 410 million people living in poverty, 60% in the seven lowest-income states. 1 One-third of children are born with low birthweight, 43% of under-fives are underweight, 48% are stunted, 20% are wasted, 70% are anaemic and 57% are vitamin A deficient. 2 There are wide and increasing disparities across different states and economic groups. 3 Progress towards reducing undernutrition has been limited, particularly in the last two decades. 4 But nutrition security has remained a leading issue in political and policy debates. In 2001, the Supreme Court of India pronounced the Right to Food as an implication of the Fundamental Right to Life enshrined in the Indian Constitution. This order also converted the eight nutrition-related state schemes into legal entitlements. 5,6 The government enacted the 2005 National Rural Employment Guarantee Act after immense mobilisation and pressure by civil society, non-governmental organisations, and social and labour movements. These groups have also been leading a nationwide Right to Food Campaign since 2001. 7 The National Food Security Bill 2011 has been approved by the Union Cabinet and is likely to be placed before Parliament in the coming session. 8 The Prime Minister s Council on Nutrition has also prioritised 1
Kate Redman malnutrition. The Coalition for Sustainable Nutrition Security in India, formed in 2008 and now chaired by Save the Children, is a high-level committee that brings together various actors such as the government, the development sector, the media, policy-makers, bureaucrats, scientists and the private sector to work collaboratively towards overcoming malnutrition. In addition, the forthcoming 12th Five Year Plan proposes a restructuring of the national Integrated Child Development Services programme. There are other complementary policy frameworks and schemes in education, health, water, sanitation and agriculture. 9...malnutrition is a matter of national shame. Despite impressive growth in our GDP, the level of undernutrition in the country is unacceptably high. Prime Minister Manmohan Singh, speaking at the launch of the 2011 HUNGaMA Survey Report, 10 January 2012 the issue Targeting There is no streamlined targeting of nutrition-related programmes for pregnant women and children under two both critical periods to avoid undernutrition. The below poverty line targeting model practised in some schemes like the Public Distribution System does not encompass a large percentage of poor people due to opaque bureaucratic enrolment procedures, inadequate selection criteria and lack of consideration of the seasonality of poverty. 10 The model promotes a management rather than prevention approach to nutrition, and is detrimental to social inclusion and solidarity. 11 Those who are most marginalised (women, Dalits, Adivasis, landless or displaced rural poor, migrant workers, urban slum-dwellers and people who are homeless or displaced, women-headed households, children under two) are still largely excluded. 12 Universalise and ensure inclusiveness in all nutrition-related state schemes with commitment to universalisation with quality for all. 13 Improve selection criteria and procedures for the below poverty line model, so that it defines nutritional entitlements as per Indian Council for Medical Reform 14 norms, takes into account the multidimensional nature of poverty and engages local bodies like the Gram Sabha, female self-help groups and community-based organisations. 15 Launch a drive to bring rapid access to the poorest people and scale up the Antyodaya Scheme, especially provision of standard, state-of-the art feeding and care for children with severe acute malnutrition. Increase coverage and central funding to schemes in poor performing states. 2
the issue Implementation, Coordination and Capacity Despite a series of progressive welfare schemes, these are marred by misappropriation or under-utilisation of financial assistance. Service delivery mechanisms are weak and inefficient (eg, irregular cereal-stock delivery to Public Distribution System outlets or Aaganwadi the centres, issue rotting grain in state warehouses). 16 Lack of coordination between various central, state and local departments and bodies mean that links across the health, education, water, sanitation and agriculture sectors, which could improve the implementation of many schemes, do not exist. 17 Grassroot-level workers are overburdened, under-trained, underpaid, demotivated and ill-equipped. 18 Bureaucrats lack adequate understanding of the issues and there is no specialised nutrition post at the central ministry level. 19 The current approach to reducing undernutrition thus fails to take into account the complex and multifaceted nature of the issue, which is dependent on a host of economic, environmental, agricultural, health, cultural, political and administrative determinants. Decentralise service delivery, management and response, eg, so that food entitlements through the integrated child development services and public distribution system can be procured locally and farmers also benefit from assured minimum the prices. 20 solutions Restructure Integrated Child Development Services to include children aged 0 2 years and increase focus on preschool education. Encourage community ownership of management and monitoring of schemes, involve Panchayati Raj Institutions and other village-level committees, and promote participatory planning. 21 Mobilise local, state and national-level citizen action for enhanced transparency and accountability, use innovative approaches like social audits, the right to information, community vigilance groups, workers and women s collectives, etc. 22 Strengthen the knowledge and skills, as well as support systems, for community-level workers (especially Anganwadi Workers, Accredited Social Health Activists, Auxiliary Nurse Midwives and teachers) and primary-level providers and counsellors. Recommend and support the process of convergence between various government ministries, programmes and non-state actors; prevent integrated cross-cutting schemes from creating parallel mechanisms. Support the government to establish comprehensive and coordinated national-level nutrition training, monitoring, redress, accountability and a data analysis mechanism, and to adopt an evidence-based approach to the design and revision of key nutrition programmes. 23 Strengthen the focus on improving nutrition through a leadership and coordination mechanism with clear authority and responsibility, working from local to national levels (possibly through a ministry or nutrition authority). Mainstream nutritional goals, criteria and support programmes in ongoing agricultural and employment guarantee schemes. 24 Initiate a comprehensive and coordinated national nutrition education and behavioural change programme. 3
the issue Gender DISCRIMINATION India has one of the highest proportions of malnourished women in the developing world. As many as 35.6% of adult women (15 49 years) suffered from chronic energy deficiency in 2006; 25 and 70% of non-pregnant and 75% of pregnant adult women were anaemic in 2000. 26 A large proportion of these women are from the poorest sections of society. 27 Patriarchal norms that propagate gender inequality and practices like child marriage trap adolescent girls and women in a cycle of malnutrition and ill-health, 28 which has severe development implications, including low birth weight, child malnutrition and chronic diseases. 29 Emphasise empowering women, collectivisation and access to resources, and address the socio-culturalpatriarchal issues that affect women. Focus on combating child marriage and adolescent pregnancy, empowering and meeting the nutritional needs of married and unmarried adolescent girls. Introduce a national scheme for maternity entitlements in the informal sector, including cash support of Rs1,000 (US$19.50) per month for six months without any exclusions for age or number of children. 30 Promote awareness of infant feeding practices 31 and build capacity of accredited social health activist volunteers as community ambassadors for women s rights. Expand the focus on girls and women s nutrition within existing national programmes. 32 the issue Political Will Despite rhetorical commitment to tackling undernutrition, strong commitment and political will is lacking. As a result, food and nutrition has become a hotly debated issue. The proposed National Food Security Bill has been severely criticised by the Right to Food campaign for being half-hearted. 33 Recent budgetary allocations to child nutrition have been grossly inadequate. 34 The push towards cash transfers, debates around ready-to-eat vs cooked meals in the mid-day meal programme or centralised fortified food production vs decentralised food procurement, and autonomy or feeding-practice awareness vs baby food, highlight the contentious issue of corporate involvement in food policy. 35 The government has no clear conflict of interests policy to address these concerns, except the Regulation of Production, Supply and Distribution Act 1992. 36 The state approach to nutrition has also been limited mainly to a technical one and has not paid sufficient regard to the effects of socioeconomic structural changes. 37 Enact a comprehensive National Food Security Bill 2011, and make appropriate budgetary allocations in nutrition that meet the requirements of the Supreme Court April 2004 Order. Focus on the work of the Coalition for Sustainable Nutrition Security in India to assist the government to develop a strong programme based on proven interventions. Keep the best interests of children in mind when deciding on nutrition interventions. Enact a conflict of interests regulation in child health programmes consistent with the World Health Assembly resolutions. 38 Promote nutritional food entitlements like pulses, milk, eggs, oil, etc, in addition to cereals, and the indigenous production and provision of therapeutic foods rather than expensive medicalised micronutrient supplements. 39 Develop strong local accountability mechanisms. Seek to better understand the link between undernutrition and socioeconomic changes, such as increasing urbanisation, structural transformation of the economy, displacement and agricultural crisis. 40 4
Our goal is that Millennium Development Goal 4 a two-thirds reduction in child mortality rates by 2015 is achieved. Improving child nutrition is key to achieving this goal. It will save many lives and give all children the chance of a good start in life so they can grow up to fulfil their potential. If you eat well you can feed your child well It was a hard pregnancy. I was diagnosed with anaemia from the first month. I don t know why I became anaemic. I was weak beforehand but I didn t bother checking with a doctor until I was pregnant. I had monthly check-ups then, though, and saw the doctor about 10 15 times. I learned from my delivery that if you eat well then you can feed your child well. And I think mothers should go to hospital when they re pregnant because the support you get there is far better than the type of care you get at home. Next time I have a baby I will feed him properly no bottled milk, and no water. I can t imagine what would have happened if I hadn t had the support I had for my child. Gulnaf (pictured right with her son, Sanya) in Rajasthan, where Save the Children is working with Anganwadi workers, accredited social health activists and auxiliary nurse midwives to reduce infant mortality and malnutrition among children, increase the percentage of babies delivered in hospitals or clinics, improve postnatal care and immunisation coverage, and promote early and exclusive breastfeeding. The districts chosen for the project have a high concentration of scheduled castes and tribes, eg, Dalit and Adivasi populations. Kate Redman 5
notes 1 United Nations Development Programme, Human Development Report 2010, United Nations, New York (2010) p.98: http://hdr. undp.org/en/media/hdr_2010_en_complete_reprint.pdf 2 B Fenn (2011) Research for Save the Children s report, A Life Free From Hunger: Tackling child malnutrition 3 P K Pathak and A Singh (2011) Trends in malnutrition among children in India: Growing inequalities across different economic groups, Social Science & Medicine, Vol 73, No. 4, pp. 576-585; K R G Nair (2007) Malnourishment amongst Children in India: A Regional Analysis, Economic and Political Weekly, Issue No. 37 4 P K Pathak and A Singh (2009) Geographical variation in poverty and child malnutrition in India in K K Singh, R C Yadava and A Pandey (eds), Population, poverty and health: Analytical approaches (pp. 183-206), New Delhi, India: Hindustan Publishing Corporation 5 Public Distribution System (PDS); Antyodaya Anna Yojana (AAY) aimed at the poorest one crore [10 million] hungry families; National Programme of Nutritional Support to Primary Education ( mid-day meal scheme ); Integrated Child Development Services (ICDS); Annapurna Scheme for senior citizens; National Old Age Pension Scheme (NOAPS); National Maternity Benefit Scheme (NMBS); and National Family Benefit Scheme (NFBS) 6 Supreme Court of India Order of November 28, 2001; Item No. 6, Court No. 2 Section PIL A/N Matter Supreme Court of India Record of Proceedings, Writ Petition (Civil) No 196 OF 2001, People s Union for Civil Liberties Petitioner(s)-Versus-Union of India & Ors. Respondent(s). 7 http://www.righttofoodindia.org/index.html 8 Ibid 9 For example, National Rural Health Mission, Horticulture Mission, Jawaharlal Nehru National Urban Renewal Mission, Rajiv Gandhi National Drinking Water Mission, Sarva Siksha Abhiyan (Education for All), Bharat Nirman programmes, Prime Minister s Nutrition Council 10 Report of the Expert Group to advise the Ministry of Rural Development, Government of India on the methodology for conducting the Below Poverty Line (BPL) census for 11 th Five Year Plan chaired by N C Saxena, August 2009 11 Working Group on Children Under Six (2007) Strategies for Children Under Six, Special Article, Economic and Political Weekly, Vol 42, No.52, pp. 93 94 12 M Gragnolati et al (2005) India s Undernourished Children: A Call for Reform and Action, Health, Nutrition and Population (HNP) Discussion Paper, World Bank; J Ghosh (2010) The Political Economy of Hunger in 21 st Century, Economic and Political Weekly, Vol 45, No. 52; U Patnaik (2007) The Republic of Hunger and Other Essays, Three Essays Collective: New Delhi 13 http://www.thehindu.com/opinion/op-ed/article562922.ece; R Khera (2011) Revival of the Public Distribution System: Evidence and Explanations, Economic and Political Weekly, Vol 46, Nos. 44 & 45; J Dreze (2006) Universalisation with Quality: ICDS in a Rights Perspective, Economic and Political Weekly, Vol 41 No. 34 14 Indian Council for Medical Research (2009) Nutrient Requirements and Recommended Dietary Allowances for Indians: A Report of the Expert Group of Indian Council of Medical Research, National Institute of Nutrition, Hyderabad 15 Saxena (2009) op cit 16 Ibid 17 Gragnolati et al (2005) op cit, note 12 18 Citizens Initiative for the Rights of Children Under Six (2006) Focus on Children Under Six Report, New Delhi; Working Group on Children Under Six (2007) 19 Gragnolati et al (2005) op cit 20 M Gragnolati et al (2006) ICDS and Persistent Under-nutrition: Strategies to Enhance the Impact, Economic and Political Weekly, Vol 41 No. 34 21 Gragnolati et al (2006) op cit; S Sinha (2006) Infant Survival: A Political Challenge, Economic and Political Weekly, Vol 41, No. 34 22 D Sinha (2008) Social Audit of Mid-Day Meal Scheme in AP, Economic and Political Weekly, Vol 43, No. 44; M Chatterjee (2006) Decentralized Child Care Services: The SEWA Experience, Economic and Political Weekly, Vol 41, No. 34 23 A Deaton and J Dreze (2009) Food and Nutrition in India: Facts and Interpretations, Economic and Political Weekly, Vol 44, No. 7 24 These schemes include the National Horticulture Mission, the National Food Security Mission, Rashtriya Krishi Vikas Yojana and the National Rural Employment Guarantee Act. The National Horticulture Mission should be implemented in such a manner that for every nutritional malady, an appropriate horticultural remedy is introduced. 25 S Jose (2011), Adult Under-nutrition in India: Is there a Huge Gender Gap, Economic and Political Weekly, Vol 46, No. 29 26 J Mason et al (2005) Recent Trends in Malnutrition in Developing Regions: Vitamin A Deficiency, Anaemia, Iodine Deficiency, and Child Under-weight, Food and Nutrition Bulletin, Vol 26,No 1, pp 59-162 27 K Sethuraman K and N Duvvury (2007) The Nexus of Gender Discrimination with Malnutrition: An Introduction, Economic and Political Weekly, Vol 42, No. 44 28 Ibid 29 S Jose and K Navaneetham (2008) A Factsheet on Women s Malnutrition in India, Economic and Political Weekly, Vol 43, No. 33 30 Working Group on Children Under Six (2007) 31 S Ghosh (2006) Food Dole or Health, Nutrition and Development Programme?, Economic and Political Weekly, Vol 41, No. 34. 32 For example, the National Rural Health Mission, the Public Distribution System, National Rural Employment Guarantee Scheme, Sarva Siksha Abhiyan, and Bharat Nirman programmes. 33 http://www.thehindu.com/opinion/lead/article2285546.ece 34 htpp://www.haqcrc.org, Resource Allocation in the Union Budget 2005-06: Is It Sufficient to Fulfil the Rights of India s Children? http://articles.timesofindia.indiatimes.com/2011-02-28/ india/28641180_1_child-mortality-health-care-health-budget 35 A Gupta and N S Khaira (2008) Flaws in Child Nutrition and Health Governance, Economic and Political Weekly, Vol 43, No. 17; A Gupta (2008) Manipulation by Assistance: Undermining Breastfeeding, Economic and Political Weekly, Vol 43, No. 36; Working Group on Children Under Six (2007) 36 Gupta (2008) ibid 37 Editorials (2006) Child Malnutrition: Behind the Numbers, Economic and Political Weekly, Vol 41, No. 18 38 Gupta (2008) note 35; Gupta and Khaira (2008) op cit, note 35 39 Working Group on Children Under Six (2007) 40 Ghosh (2010) op cit, note 12 This briefing is part of a set of eight country briefings produced by Save the Children and the Institute of Development Studies to accompany Save the Children s report, A Life Free from Hunger: Tackling child malnutrition. To see the full report, visit Save the Children, February 2012 everyone.org Registered Charity No: 1076822 6