India today faces a unique development paradox of being in the front rank of fast growing global economies, with vibrant economic growth rates and yet, in stark contrast, around 35 percent of India’s children under three years of age are undernourished. Undernourished children majorly belong to poor households and socially disadvantaged groups, but there is also undernourishment among children and women in the higher monthly per capita expenditure groups in rural India. This means that, besides income and access to food, there are several other determinants of under-nutrition.
The important determinants other than food and micronutrient intakes include factors such as access to healthcare, hygiene, environment, and caring practices. Health interventions related to antenatal care, institutional deliveries, prevention and management of common neonatal and childhood illness (respiratory infections, diarrhea), timely and complete immunization, requisite vitamin A and IFA (iron and folic acid) supplementation, de-worming and regular monitoring of child growth and development contribute to improvements in nutrition outcomes. Cultural and behavioural practices with respect to child rearing too influence child nutrition, survival and development.
The Government of India, in recognition of the complex determinants of under-nutrition, has, over a period of time, been moving in the direction of multi-sectoral interventions for promoting maternal and child nutritional well-being. But, the progress has been very slow. India has one of the highest incidences of malnourishment among children in the world, despite the fact that India has a vibrant democracy, a fast growing economy, and a free and responsible Press, grows enough food, has very extensive public distribution system, and runs the world’s largest maternal and child healthcare and nutrition programme.
Government initiatives, judicial interventions and civil society activism
The government prepared the National Nutrition Policy (NNP) in 1993. In 1995, it drafted the National Plan of Action on Nutrition (NPAN). In 2003, the National Nutrition Mission was set up for effective coordination of the various nutrition-related interventions, and it launched a pilot project in 51 nutritionally deficient districts to provide free of charge grains to children and lactating mothers belonging to the below-poverty-line (BPL) households through the Targeted Public Distribution System (TPDS).
Nutrition assumed the place of a central concern in the development discourse with the setting up of the Prime Minister’s National Council on Nutrition Challenges in 2008. In 2010, the National Advisory Council within the PMO constituted a special group on food security and Integrated Child Development Services (ICDS) reforms, and also drafted the National Food Security Bill in 2011. In 2013, the government enacted the National Food Security Act to provide food and nutrition security as legal entitlements.
It may be noted here that in the shaping and evolution of the nutrition policy, the activism of civil society organizations and judicial interventions have had a major influence. In particular, the Jan Swasthya Abhiyan, the Right to Food Campaign and the Citizens Alliance Against Malnutrition have been instrumental in bringing under-nutrition on to the public policy agenda of the government and sensitizing citizens to the consequences of malnutrition.
Thrust Areas of Nutrition Challenge
In the backdrop of a vigilant Supreme Court, its observations and directives as well as the issues flagged by civil society organizations, the Prime Minister’s National Advisory Council in 2010 formulated a framework of strategic interventions for meeting the nutrition challenge. This framework also underpinned the 12th Five-Year Plan strategy to meet the nutrition challenge. It has four key thrust areas where interventions are called for: (a) strengthening and restructuring the ICDS; (b) prioritizing nutrition in the various sectoral programs of different ministries; (c) introducing multi-sector programmes in selected 200 high-burden districts; and, (d) conducting nation-wide campaigns to raise awareness of malnutrition and its consequences.
Integrated Child Development Services (ICDS) was to be restructured and strengthened because it is the mainstay of the government’s initiatives to foster children’s nutritional well-being. Henceforth, it was to have special focus on the needs of pregnant and lactating mothers, and children under three, who as past experience had shown, generally remained outside the coverage of ICDS. Secondly, ICDS was to actively promote optimal infant and young child feeding practices that inter alia stressed on breastfeeding and discouraged bottle-feeding with milk substitutes. Thirdly, the ICDS was to focus on combating micro-nutrient deficiencies by encouraging its use and supplying nutritional supplements, and keep a record of nutrition and health-related data. Further, as part of strengthening ICDS, the numbers of Anganwadi Women Workers (AWWs), Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwifes (ANMs) in the 200 high-burden districts were to be increased and given skills training. Restructuring ICDS also implied that, henceforth, there would be programmatic convergence with programs run by other departments such as the Ministry of Health and Family Welfare and the Ministry of Rural Development.
The second thrust area was to prioritize the nutrition component in the various sectoral programs of different ministries. For instance, the programs of the Ministry of Health and Family Welfare with relevance to preventing and reducing under-nutrition were to be focused upon, such as (i) Immunization Programme; (ii) newborn care; prevention and management of common neonatal and childhood illnesses including diarrhea and Acute Respiratory Infections; (iii) care of the sick child – at the community level through ASHA and, at the institutional level, through primary healthcare facilities; (vi) Vitamin A administration; (v) Anemia management and pediatric de-worming; (vi) school health programmes with supervised weekly IFA supplementation and six-monthly de-worming; and, (vii) Nutrition Rehabilitation Centers – for sick and severely malnourished children.
Third, since nutrition is a complex issue, which cuts into many sectors, such institutional mechanisms and implementation platforms were to be set up that could bring about effective convergence of direct nutritional and indirect multi-sectoral interventions. While at the national level there was to be the PM’s National Nutrition Council, with executive committee headed by the Minster of Health and an empowered committee to plan, implement and oversee multi-sectoral convergence, at the state level and below it, Chief Minister’s Nutrition Councils, District Nutrition Council, Village Health Sanitation Nutrition Committee (VHSN) were to be formed, where they were hitherto non-existent. These nutrition councils at the state and district levels had to prepare the Nutrition Plan at the relevant level, and oversee its implementation and monitor progress. The panchayat raj institutions with its Gram Sabhas (Village Councils) and VHSN committees on the ground were to be the cutting edge of all multi-sectoral interventions.
And, lastly, as there was little public awareness and understanding of the consequences of malnutrition, the government had decided to launch a nationwide campaign against malnutrition. For this, a national communication strategy framework was to be developed through strategic partnership with CSOs, professional networks, voluntary groups, community colleges and other actors.
Nutritional status today
The progress on the nutrition front since 1992-93 is presented below in Table 1 and Table 2.
The extent of malnutrition, however, varies greatly across India. The NFHS figures (1, 2, and 3) are national averages. In poorer states and among socially and economically deprived groups, the malnutrition figures are more appalling.
Besides, the NFHS-4 survey results, which are only for half of the country and, therefore, to that extent limited, there is another data source – Rapid Survey of Children (RSOC) which conducted the survey in 2013-14 along with UNICEF. Jean Dreze, the development economist, regards it as some sort of a substitute for the NFHS-4, whose work is not yet complete. RSOC data fills in the huge gap in India’s social statistics, and fortunately it is modelled on the NFHS, which makes possible comparison of data with NFHS-3.
According to RSOC, there is marked improvement in many aspects of maternal and child nutrition between 2005-06 and 2013-14. But, progress is on the whole slow and uneven across different indicators. The areas of progress relate to safe birth deliveries, vaccination and breastfeeding.
There are several reasons for the slow and uneven progress. The Right to Food Campaign finds that though social sector financial outlays have increased significantly since the 10th Five-Year Plan, it still remains far short of what is needed to fight the scale of malnutrition among children in India. Then, there are governance issues related to problems in horizontal coordination among different ministries and between state and non-state agencies in producing convergent action in the fight against malnutrition. Further, the mode of delivery and implementation remains centralized and bureaucratized, while peoples’ involvement through panchayat raj institutions remain perfunctory. Above all, health and nutrition have still not become public issues over which electoral battles are fought.
The author is Associate Professor at Aryabhatta College, University of Delhi. He teaches Political Theory and Indian Government, and Politics. His research interests include rural development, public policy, and identity politics. He is author of Constitutional Democracy in India: Institutions at Work (2015) and has edited two books: Introduction to Political Processes in India (2016) and Development Process and Social Movements in India (in press).
Published in the ISSUE 3 of CHINA-INDIA DIALOGUE