The international nutrition system is broken. Leadership is absent, resources are too few, capacity is fragile and emergency response systems are fragmentary. New governance arrangements are urgently needed. An agency, donor, or political leader needs to step up to this challenge. There is a fabulous opportunity right now for someone to do so. But who?
—Richard Horton in the introduction to the five-part series on maternal and child undernutrition, The Lancet, January 17, 2008
It may be worthwhile for the finance minister to look at the recent Lancet series on maternal and child undernutrition before he allocates money to the Integrated Child Development Scheme (ICDS), the only government programme in the country that is designed to cater to the nutritional requirements of children under six. In the Lancet study — a global, scientific report by a team of public health scientists — he may not find a single fact that he has not heard from experts in India. And herein lies a sad tale.
Among the 20 countries where four-fifths of all undernourished children live, India is home to the largest number. The country is a perfect example of the trend pointed out in the study: nutrition slipping through the gaps even as the portfolio of interventions increases. The last round of the National Family Health Survey (NFHS 3) shows that malnutrition has reduced by just one per cent (from 47 per cent to 46 per cent) in the last eight years. This just means every second child under six years of age is underweight, a statistic worse than that in sub-Saharan Africa.
The Lancet study has pointed to the “golden interval of intervention” that ranges from pregnancy to two years of age. After the age of two, undernutrition would have caused irreversible damage to the child’s development. This should not come as a surprise either: it is a fact that has been pointed out by countless studies and nutrition experts within India.
Does the government have a plan in place to help the faces behind these alarming statistics? The ICDS, which works towards the promotion of maternal and child health and nutrition, includes a range of other interventions — health, immunisation and early education needs of those under six along with nutrition supplements for pregnant and adolescent girls. It operates through an aanganwadi centre in every village manned by an aanganwadi worker.
Despite the Supreme Court playing a key role in monitoring and prodding the government, the status of the programme is far from encouraging. According to the latest reports of the Supreme Court-appointed commissioners, only 35.5 per cent children under six receive supplementary nutrition under the ICDS. Only about 25 per cent of the eligible pregnant women and nursing mothers are being reached under this programme. The worst states are Assam, Madhya Pradesh, Bihar and Jharkhand, where aanganwadis barely exist.
In respect to the golden interval of intervention pointed out by The Lancet, the ICDS programme is flawed. There is virtually no stress on children below three. The programme focuses on the supplementary nutrition component, which mainly reaches the 3- to 6-year age group. Even this food tends to be erratic, of poor quality and unimaginatively prepared. Reports of the SC-appointed commissioners have pointed out that the 0-3 age group should have access to not just foodgrain, but specially prepared weaning foods made from nutritious locally grown cereals, fortified with essential micro-nutrients.
The Lancet series shows that there are proven effective interventions to reduce stunting and micronutrient deficiency. Among the most effective measures listed are breastfeeding, Vitamin A supplements and fortification. For maternal nutrition, it is iron, folic acid and calcium supplements. The series says immunisation of pregnant women may have a larger impact compared to a school-meal programme.
In India, not only is the reach poor but also there is complete lack of clarity on how and what to give as supplementary nutrition. For years, the debate has been whether these children should be provided hot cooked meals or micronutrients in a packet. The commissioners have often written to the government complaining about how the entire supply of food had passed into the hands of private contractors. They not only supply ready-to-eat food powders that were not only culturally inappropriate and calorifically inadequate, but in many cases never reached the ICDS centre at all.
Most of these debates are a part of Supreme Court hearings on the issue. The court had passed an order in 2006, saying every child, adolescent girl and pregnant woman should be covered under the programme. It also asked the government to provide an aanganwadi centre in every habitation. This would translate into 14 lakh aanganwadi centres. Two years later, four lakh centres are yet to be sanctioned. The ones sanctioned last year exist only on paper.
The Lancet study points out that there are no technological silver bullets to solve the problem of undernutrition. Long-term investments are a prerequisite. While no one in the government would disagree with this, the money does not match their verbal pledges. If every child under six in 14 lakh aanganwadis has to be covered, the government will have to increase its budgetary allocation to the programme by 71 per cent. The government is spending less than a rupee on every child when it should be spending Rs 2.
The Lancet journal says these 20 countries lack the political will to get nutrition on their list of priorities — and keep it there. As a ray of hope, a group of young politicians cutting across party lines have formed a Citizens’ Alliance on Malnutrition to push the government for a national policy and action plan. They go from one state to the other looking at how state governments are dealing with undernutrition.
They have already found interventions that could be scaled up: fortification in Gujarat or the self-help groups in Orissa. The Lancet study speaks of the commendable work done in Kerala and Tamil Nadu. To a large extent, the mid-day meal programme for older children has taken off. In a model of public-private partnership, Naandi Foundation feeds lakh of school children every day from their 14 centralised kitchens.
There is no paucity of nutrition champions and entrepreneurs in the country. The finance minister could send a signal by making an allocation that shows that he is ready to take the challenge thrown up by the global study.