After an agonising wait of over ten years, the results of the National Family Health Survey (NFHS-4) are finally before us. The fact the data on the nutrition status of India’s children is disquieting is reflected in a recent letter from the NITI Aayog CEO to all Chief Secretaries of states with high under-5 years stunting rates in specific districts. The letter stresses the need for concerted action and setting annual targets in respect of critical maternal and child health and nutrition outcomes.
Unfortunately, there is no mention of the policy framework and systemic changes needed to break the vicious cycle of child under-nutrition.
First, therefore, we need to recognise that the seeds of child malnutrition are sown in the womb. Given the moribund state of health systems in many states, especially in northern India, little attention is paid to the condition of the pregnant woman. NFHS-4 data reveals that the big three problem states – Uttar Pradesh, Bihar and Madhya Pradesh – had very low full ante-natal care (ANC) coverage of mothers.
Incidentally, save for Bihar, six of the seven states with the highest incidence of stunting are ruled by the BJP or the BJP and its allies – Uttar Pradesh, Jharkhand, Meghalaya, Madhya Pradesh, Rajasthan, Gujarat and Bihar.
However, even in states like Maharashtra and Gujarat, where full ANC coverage was over 60 per cent, the position on the ground is that ANC visits are perfunctory in nature and there is no monitoring of physical parameters of pregnant mothers, especially those with low weight, poor weight gain during pregnancy, high blood pressure and a history of obstetric complications. Not surprisingly, most states in India still record distressingly high rates of maternal mortality.
Underweight, unhealthy mothers deliver low birth-weight babies, perpetuating the inter-generational cycle of malnutrition. India’s children, therefore, start with a handicap that is exacerbated by economic and social factors as well as a lack of focused attention from the huge paraphernalia of Public Health and Integrated Child Development Services (ICDS) staff.
Second, social sector administrators stubbornly refuse to use real-time data in policy formulation and implementation. Although the ICDS system mandates a monthly recording of weights of every under-5 year-old child, this requirement is observed more in its breach. Almost no state places data on aggregate ICDS project-wise monthly child weights in the public domain.
The only state doing so regularly, Maharashtra, has uploaded aggregate child weight data on the internet – but only up to December 2016. Without real-time data on child weights, it is not possible to identify the specific pockets of child malnutrition where focused interventions are necessary. More critically, this lack of data absolves the ICDS machinery of accountability for results. It is only when there is media and public furore about “malnutrition deaths” that governments swing into apparent action.
Nutrition and health administrators in Delhi are strangely reluctant to adopt the criterion of height measurement of under-5 children, recommended by the WHO as far back as 2008. Without height measurement, stunting in under-5 children, representing chronic malnutrition, cannot be measured. Stunting leads to impaired physical as well as cognitive development in children, with consequences for their future health and productivity. Wasting in under-5 children, one of the contributors to infant and child mortality, cannot be easily assessed in the absence of height statistics.
There is also policy confusion on what needs to be done to improve child nutrition indicators. This stems from what we may term a “food-centric” approach to an issue like child malnutrition that has wider economic and social ramifications. The ICDS machinery considers their job done if supplementary nutrition, in the form of take-home rations for mothers and under-3 children and cooked meals for pre-primary children attending anganwadis, is provided.
But growth monitoring of children, counselling of mothers on sound infant-feeding practices, home visits to under-3 children and early childhood education services for pre-primary children receive very little attention from anganwadis workers as compared to food distribution.
The 2012 reports of the Commissioners appointed by the Supreme Court have highlighted how administrations in Uttar Pradesh, Maharashtra and Karnataka have twisted Supreme Court orders to favour private parties. But governments will apparently never learn. Even today the central government favours commercial, pre-packaged, fortified food to under-5 children, notwithstanding the unsavoury history of poor quality supplies, widespread corruption and beneficiary apathy.
A recent study by LANSA, an international research partnership involving multi-nation research organisations and voluntary institutions, has detailed the massive siphoning of public finances in the supply of take-home rations and cooked meals in Uttar Pradesh, with no local authority oversight, little community participation and an unresponsive ICDS machinery.
This contrasts with the situation in neighbouring Chhattisgarh, where decentralisation of power to communities and panchayats has ensured far better delivery of ICDS services to mothers and children.
To improve child mortality and malnutrition indicators, the NITI Aayog should:
- Ask state governments to prepare a concrete plan of action, covering both processes and outcomes. Chief Ministers should make the reduction of child malnutrition a top priority and gear up the ICDS and public health machinery to deliver results.
- Develop, at the central level, a rigorous monitoring system, combining the regular flow of real-time data with periodic independent third-party surveys, to assess the ground situation.
The 2016 UNICEF State of the World’s Children Report shows India to be 48th highest out of 193 countries in under-5 child mortality (out of 193 countries). India also fares poorly in under-5 stunting, wasting and underweight indicators in comparison with other emerging economies and even with neighbours like Sri Lanka, Nepal and Bangladesh.
For a country that aspires to be an economic powerhouse and is already one of the largest markets in the world, investing in the health and productivity of its future generation is an imperative which can no longer be ignored.