Prime Minister Manmohan Singh recently released a report prepared by a private organization on the state of childhood malnutrition in India and he called it our National Shame. Ironically, he chairs the Prime Minister’s National Council on Nutrition Challenges which itself has met only once in the last 3 years. The report mentioned that 42 percent of children in India below 5 years are malnourished. Some other more credible agencies put the figure closer to between 52 and 54 percent.
Thinking about these figures, my mind was drawn to my visit to Sahebganj district of Jharkhand more than 6 years ago. I was traveling through the district trying to understand the problems of malaria there on the request of the World Bank. Being deeply concerned about tribal issues, I had opted to focus on the hilly and difficult areas in which they lived. It was around lunchtime that we reached a very remote tribal settlement and I walked into a hut where the tribals were getting ready to have lunch. I found a family of seven – 3 adults and 4 children – hovering around an aluminum plate filled with 4 thick rotis. Slices of onion and 3 long chillies were lying on the ground beside the plate. This was lunch for this family and I was shocked to learn that this was their largest meal of the day. With seven people helping themselves to this meal,what else other than malnutrition could one expect! While the statistic by itself may not mean much to the average Indian, it has become an everyday reality to millions like this family across the nation.
Malnutrition is more common in India than in Sub-Saharan Africa. One in every three malnourished children in the world lives in India. Malnutrition limits development and the capacity to learn. It also costs lives; about 50 percent of all childhood deaths are attributed to malnutrition. According to UNICEF, around 46 percent of all children below the age of three are too small for their age, 47 percent are underweight, and atleast 16 percent are wasted. Many of these children are severely malnourished. The prevalence of malnutrition varies across states, with Madhya Pradesh recording the highest rate (55 percent) and Kerala among the lowest (27 percent).
We need to understand that malnutrition in children is not affected by food intake alone. It is also influenced by access to health services, quality of care for the child and pregnant mother as well as good hygiene practices. Girls are more at risk of malnutrition than boys. Malnutrition in early childhood has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults, at greater risk of disease and early death. Around one-third of all adult women are underweight. Inadequate care of women and girls, especially during pregnancy, results in low birth-weight babies. Nearly 30 percent of all newborns have a low birth-weight, making them vulnerable to further malnutrition and disease.
The global community has designated halving the prevalence of underweight children by 2015 as a key indicator of progress towards the Millennium Development Goal (MDG) of eradicating extreme poverty and hunger. Economic growth alone, though impressive, will not reduce malnutrition sufficiently to meet the nutrition target. If this is to be achieved, difficult choices about how to scale up and reform existing nutrition programs or introduce new ones have to be made by the Government of India and other agencies involved in nutrition in India.
Approximately 60 million children are underweight in India. Given its impact on health, education and productivity, persistent under-nutrition is a major obstacle to human development and economic growth in the country, especially among the poor and the vulnerable, where the prevalence of malnutrition is highest. The progress in reducing the proportion of undernourished children in India over the past decade has been modest and slower than what has been achieved in other countries with comparable socioeconomic indicators. While aggregate levels of under-nutrition are shockingly high, the picture is further exacerbated by the significant inequalities across states and socioeconomic groups – girls, rural areas, the poorest and scheduled tribes and castes are the worst affected – and these inequalities appear to be increasing.
In India, child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices, and has its origins almost entirely during the first two to three years of life. However, the commonly held assumption is that food insecurity is the primary or even sole cause of malnutrition. Consequently, the existing response to malnutrition in India has been skewed towards food-based interventions and has placed little emphasis on schemes addressing the other determinants of malnutrition. India’s main child development intervention, the Integrated Child Development Services (ICDS) program, has been sustained for about 30 years and has been successful in many ways. However, it has not yet succeeded in making a significant dent in child malnutrition. This is mostly due to the priority that the program has placed on food supplementation rather than on nutrition and health education interventions, and because of the fact that the program targets children mostly after the age of three when malnutrition has already set in. Interventions to address good caring behaviors, which have been proven to be cost-effective in many places including India, require substantial development of the skills of grass-root workers and an efficient management system. Although there has been progress towards providing training and skill development, much of the emphasis has been on universalizing the program rather than on strengthening the quality of its implementation and monitoring in a way that increases its impact. Transforming ICDS into an intervention that effectively combats under-nutrition will yield huge benefits for India, both in terms of human development and economic returns, but will require substantial changes in the program’s design and implementation.
In particular, public investments in ICDS should be redirected towards the younger children (0-3 years) and the most vulnerable population segments in those states and districts where the prevalence of under-nutrition is higher. The focus should be on those ICDS components that directly address the most important causes of under-nutrition: improving mothers’ feeding and caring behavior, improving household water and sanitation, strengthening the referral to the health system and providing micronutrients. While designing nutritional interventions, we need to keep in mind cultural sensitivities and engaging communities in the planning and implementation of the programs. Instead many States including Karnataka seem to be focusing on providing pre-packaged foods that are not only irrational but also against the Supreme Court directions in this matter. What we need is the political and bureaucratic will to tackle this problem head-on instead of spending time on creating more and more vertical structures which only benefit the people administering these programs rather than the people for whom it is meant. We need to act now if we are truly intent on building India into a thriving Knowledge Economy that all of us keep talking about.