Malnutrition remains one of the biggest challenges facing India. In the last large survey, the National Family Health Survey of 2005-06, about 42 per cent children under the age of five were underweight. Economic growth has failed to redress this problem. Recently released estimates from the District Level Health Survey for selected states continue to paint a dismal picture.
In the best performing states, like Karnataka and Himachal Pradesh, the proportion of children who are underweight declined by 7 to 8 percentage points between 2005-06 and 2012; in the worst — Maharashtra and West Bengal — there is virtually no improvement. At this rate, it is unlikely that we can achieve the Millennium Development Goal of 28 per cent children being underweight by 2015. Not only is this a blow to India’s core values, it has vast economic consequences.
According to a study by the international non-profit, Save the Children, this cost is expected to be between 1 to 2.5 per cent of the GDP per annum by 2030. In spite of the urgency of the problem, the only solution at hand, the National Food Security Act (NFSA), 2013, appears inadequate to the task of addressing the problem for a number of reasons.
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First, the primary focus of the NFSA is to expand access to cheap cereals, although dietary composition is as relevant to Indian malnutrition as hunger or caloric deficiency. The NFSA’s focus on hunger is bolstered by the observation that successive rounds of the National Sample Survey (NSS) and the National Nutrition Monitoring Bureau surveys document declining caloric consumption among the Indian population. However, as Jean Dreze and Angus Deaton note, most of this decline is observed among upper-income groups, particularly in rural areas. These groups are increasingly moving away from manual labour and hence may need fewer calories.
But malnutrition is not limited to the poor. The National Family Health Survey shows that although 57 per cent of the children in the households with the lowest levels of wealth are underweight, even among the top 40 per cent of households, about 30 per cent of the children are underweight. So it is not simply a question of income or access to food grains, but rather of the composition of food and dietary diversity. The India Human Development Survey (IHDS), organised by the National Council of Applied Economic Research (NCAER) and the University of Maryland, documents that when households consume a diet of cereals, coarse grains, pulses, milk, vegetable, fruits and fat, the percentage of children who are underweight goes down by about 5 percentage points, even when compared to other children from families similar in socio-economic background but with lower dietary diversity.
Second, the NFSA does not take into account the unanticipated effects of the expansion of the public distribution system (PDS), which may well result in a reduction in nutritional quality due to its emphasis on cereals. While the proportion of families obtaining food from ration shops has grown from 25 per cent to over 50 per cent between 2004-05 and 2011-12, careful analysis of IHDS data matching households at the same income level using the PDS and not using the PDS shows that PDS use is associated with greater consumption of cereals but lower consumption of fruit and milk. When caloric needs can be met with cheap cereals, households may not choose to spend money on a diverse food basket. This concern is validated by an excellent analysis of NSS data by Professor Raghav Gaiha and colleagues, in which they document declining dietary diversity between 1993 and 2009.
Third, the NFSA relies on existing programmes like the PDS and the Integrated Child Development Services (ICDS), whose operation is fraught with inefficiencies and leakages. While much has been written about the leakages in the PDS, little attention has been directed to the ICDS programme. By an order of the Supreme Court issued in 2006, this programme was expanded to cover all children, instead of just the poor. The IHDS records that only 23 per cent children in 2004-05 received any ICDS benefits, compared to 46 per cent in 2011-12, but most of the benefits are limited to immunisation. Among the IHDS children under the age of five, only 12 per cent received any food from the ICDS in the month prior to the survey. As many speakers at a recent conference organised by the NCAER, IDS, Sussex and IDRC, Canada, noted, the ICDS has tremendous potential for reducing malnutrition and has been quite successful in some areas. However, without substantial reorganisation, its scope will remain limited.
Fourth, the potential agricultural ramifications of the expansion of government procurement of vast quantities of cereals have received little attention in this discussion, and it is assumed that the current stocks will be sufficient to meet these needs. But the case of millets offers little reason for this optimism. Although it is a welcome departure for the NFSA to include millets in the PDS, little attention is directed towards the challenges of production bottlenecks and storage for millets. Thus, at the moment, it is unlikely that millets can be a major component of food supplied under the NFSA.
Fifth, the NFSA contains no mechanisms for measuring success in reducing malnutrition. Social audits focus on process and not outcomes, and do not replace standardised data on malnutrition and food intake. It is amazing that in spite of the staggering incremental costs of the NFSA, estimated by Prachi Mishra of the International Monetary Fund at between Rs 44,000 and Rs 77,000 crore per annum, we really have no plans for monitoring its outcome in terms of nutrition statistics. Government data collection on malnutrition is sporadic, at best; the last nationwide large survey was done in 2005-06. As of now, there is no nationwide data available. If transparent data collection took place predictably every two years, immediate course correction could be undertaken.
These observations suggest that if we are serious about eliminating undernutrition, we must focus on smarter policy design, effective implementation and increased monitoring and accountability. The BJP manifesto calls for addressing malnutrition in mission mode; disappointing statistics from the District Level Health Survey suggest a need for urgent action.