Every once in a while, a discussion or debate starts on malnutrition. On a debated issue, precision is desirable. Initially, there were several discussions on the word “malnutrition”, which can technically mean over-nutrition, as well as under-nutrition. But now, there is global consensus on three terms.
First, for a given reference age, the under-weight phenomenon is moderate if weight is two standard deviations below median weight. Moderate moves to severe if it becomes three standard deviations and below. Second, similarly, there is moderate stunting if height is two standard deviations below median, and three standard deviations and below makes it severe stunting. Third, one looks at the weight:height ratio. Wasting is moderate if it is two standard deviations below the median ratio and three standard deviations and more makes wasting severe.
We loosely use the word malnutrition, but there are three specific indicators — under-weight, stunting and wasted, although they are correlated. Sustainable development goals (SDGs) have been accepted now, leading up to 2030. The second of these is on hunger, food security, nutrition and sustainable agriculture. I should specifically quote targets 2.1 and 2.2. Target 2.1 states, “By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round.” Target 2.2 adds, “By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.”
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Notice the obvious, this isn’t only about children. 2025 is a reference to global nutrition targets. There are six of these. For our purposes, with a focus on children, three are relevant: One, 40 per cent reduction in the number of under-five stunted children; two, 30 per cent reduction in low birth weight; and, three, reduction and maintenance of childhood wasting to less than 5 per cent. However, malnutrition doesn’t work in silos. Therefore, despite the focus on children, two more are also important: Four, increasing the rate of exclusive breast-feeding in the first six months to at least 50 per cent; and, five, 50 per cent reduction of anaemia in women of reproductive age. (The last of global nutrition targets is on over-weight children.)
Goals lead to targets and targets lead to indicators that are monitored. We don’t yet know what indicators will be used to monitor SDG performance. But that’s a general comment. For malnutrition, it will obviously be weight, stunting and wasting, for specific ages. Other than birth, the standard age is under-five. However, there are data constraints, both availability and time lags. For instance, health-related data may be available for those who are under-three, rather than under-five. This has been the problem across various National Family Health Surveys (NFHS). For the record, the last NFHS for all states (NFHS-3) is still for 2005-06.
In February 2015, the ministry of statistics and programme implementation (MoSPI) published a country report on India’s progress towards the MDGs (Millennium Development Goals), the precursor to the SDGs. This said, “It is estimated that in 1990, the proportion of underweight children below three years was 52 per cent. In order to meet the target (MDG), the proportion of under-weight children should decrease to 26 per cent by 2015. The National Family Health Survey shows that the proportion of under-weight children below three years declined from 43 per cent in 1998-99 to 40 per cent in 2005-06. At this rate of decline, the proportion of underweight children below three years is expected to reduce to 33 per cent by 2015, which indicates India is falling short of the target… The prevalence of underweight among children < 3 years of age is significant in most of the states and varies considerably between the states. The problem is severe in Madhya Pradesh (57.9 per cent), Bihar (54.9 per cent), Jharkhand (54.6 per cent), Chhattisgarh (47.8 per cent), Meghalaya (42.9 per cent), Uttar Pradesh (41.6 per cent), and Gujarat (41.1 per cent), where the proportion of underweight children < 3 years is more than the national level estimate (40 per cent) in 2005-06.”
Later, there was the 2013-14 rapid survey on children (RSOC). This gave us a moderate stunting figure of 38.7 per cent, severe stunting of 17.3 per cent, moderate wasting of 15.1 per cent, severe wasting of 4.6 per cent, moderate under-weighting of 29.4 per cent and severe under-weighting of 9.4 per cent.
How much do such all-India figures help us? Indeed, how much do state-level figures help us? I think something like the 2011 HUNGaMA (hunger and malnutrition) survey is more useful. It ensures focus on districts, which district level household surveys (DLHS, 2012-13 is the last) also do. There are other numbers on ICDS (Integrated Child Development Services) beneficiaries. In this data clutter over NFHS, DLHS (with some states not covered), AHS (annual health survey, with limited coverage of states), RSOC and ICDS, and time lags in data and periodicity of surveys, I think everyone will agree that the more disaggregated the data, the better the intervention.
This leads to another issue. Does the ICDS, the primary scheme directed against malnutrition, work well? Probably not, otherwise, the National Nutrition Mission (NNM) wouldn’t have started. But with health being a state subject, something like the NNM or its counterpart needs to not only zero-in on broadening the ICDS, despite some complaints about its geographical coverage, but also ensure focus on specific districts (you can take your pick on whether the number is 100 or 200) and under-three malnutrition. We need counterparts not just at the state level but also at the levels of the district, block and even anganwadi. The report of the sub-group of chief ministers on Centrally sponsored schemes was submitted in October 2015 and that, too, clearly contemplates a broadening of the ICDS.