India has been able to dramatically reduce the number of people living in extreme poverty from 306 million people living on less than $1.90 (on a PPP basis) a day in 2011 to 48 million today. However, it is puzzling as to why the country has been unable to show a similar dynamism in its record against malnutrition. Despite major government interventions — including providing highly subsidised foodgrains to the poorest 67 per cent of the population under the National Food Security Act (NFSA), a free Mid-day Meal Scheme (MDM) that targets around 100 million students in government schools and a supplementary nutrition programme through the ICDS network — the country is home to the largest number of malnourished children in the world.
In the decade between 2005-06 and 2015-16, stunting declined at the rate of 0.9 per cent per annum. Though anaemia among children has declined, it affects every second child in the country. There has been no perceptible decline in anaemia among 15 to 49-year old women; it affects around 60 per cent of them. This public health emergency needs to be addressed immediately.
Poverty, gender disparity, poor sanitation, low health and nutrition service coverage and poor nutritional intake — particularly an iron-deficient diet — continue to impede our fight against anaemia. The daily consumption of iron rich dark green leafy vegetables has reduced from 64 per cent to 48 per cent of the population in the last decade. Many, in fact, argue that the NFSA’s focus on wheat and rice has forced millets — traditional source for iron and minerals — out of the market. The government’s iron supplementation programme to overcome IDA has led to only 30 per cent of pregnant women consuming iron and folic acid tablets. This compels us to think of simpler and effective strategies like fortification of food staples with essential micronutrients like iron and vitamin.
Food fortification is a largely-ignored, yet critical, strategy which has proved an effective, affordable, scalable and sustainable intervention in many countries. India too has tested this idea when it successfully tackled the widespread problem of goitre by mandating iodised salt in 1962. As there are numerous programmes to address malnutriton, this simple idea of fortifiying meals has the potential to reach every segment of the population.
Policy-makers have recently begun to address this blind spot to change the country’s nutritional landscape. Comprehensive regulations and standards have been framed by the FSSAI on fortification of food. The Women and Child Development and Human Resource Development ministries have issued advisories to the states to mandatorily use fortified wheat flour and edible oil in ICDS and MDM. However, given that fortification of these staples is still relatively new in India, traction has been slow.
Rice is the staple for 65 per cent of the Indian population, most of whom are located in high malnutrition burden states. Supply of fortified rice through a network of fair price shops is a cost-effective intervention to address anaemia across all sections of the population. Evaluations in Odisha’s Gajapati district, which experimented with fortified rice in MDM, found that the incidence of anaemia has reduced by 20 per cent between 2012 and 2015, of which 6 per cent reduction can be directly attributable to fortification.
The Department of Food and Public Distribution, facilitated by the NITI Aayog, has recently launched a centrally-sponsored scheme on rice fortification in PDS. The programme is designed to cover 15 districts, initially. Although the budget is a meagre Rs 147 crore, the implications for the fight against anaemia are huge. Our estimate for a pan-India roll out of rice fortification is around 2,400 crore (about 1.4 per cent of the total food subsidy bill in 2018-19). A successful pan-India scale up of fortification will depend on many factors — the political will of state governments, flexibility to allow states to adapt the fortification model to their procurement and distribution systems and capacity building of different stakeholders. The FSSAI’s role, its enforcement machinery and the quality control labs needs to be strengthened. Lastly and most crucially, sustainability of fortification depends on the regular consumption of fortified food by the consumers and thus a comprehensive state specific strategy should be developed to generate awareness among the consumers.
This article first appeared in the print edition on May 20, 2019 under the title ‘The Salt Example’. The writers are with the Niti Aayog.
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