Looking at the critical need to end malnutrition in India in the light of the Global Nutrition Report
The fifth edition of the Global Nutrition Report was released in Bangkok, Thailand, on November 29, 2018 during the event titled ‘Accelerating the end of hunger and malnutrition’, which saw participation from key decision-makers, researchers and practitioners from institutions such as the Food and Agriculture Organisation (FAO) of the United Nations, the World Health Organisation (WHO), the European Union and the UNICEF. The report is the principal publication on the status of malnutrition around the world. It assesses the state of nutrition globally, regionally and country-wise with recommendations and policy prescriptions to enhance nutrition. It charts progress on global nutrition targets, ranging from diet-related non-communicable diseases (NCDs) to maternal, infant and young child nutrition. The report highlights that ‘malnutrition is unacceptably high and affects every country in the world’. However, the authors of the report also point out to ‘an unprecedented opportunity to end it’.
In order to tackle the problem, one needs to understand the complexity of the burden of malnutrition. It can take many forms and affects most of the global population, regardless of location, age, wealth or gender. The WHO defines malnutrition as “…deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients”, and classifies malnutrition into two broad groups of conditions. One is ‘undernutrition’, which comprises stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The second group includes conditions of being overweight or obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and cancer). The causes of malnutrition are multifarious. Sub-optimal diet is a leading cause, but other factors also influence the state of nutrition, including food security, health status, education, social and gender relations, sociocultural and behavioural characteristics, environmental and economic conditions, political situations, technology and infrastructure.
The burden of malnutrition is particularly high for the South Asian region with more than half of the world’s children (26.9 million) impacted by wasting living in South Asia. In addition, of the 38.3 million children globally overweight, 5.4 million live in South Asia – a direct impact of the growing consumption of packaged foods. While significant steps are being taken to address malnutrition globally, Asia experienced the largest reduction in a region in stunting prevalence from 2000 to 2017 – from 38 percent to 23 percent.
Reflecting many other social welfare and human development indices, India’s nutritional report card does not read well. While overall health indicators such as infant mortality rate, maternal mortality rate and life expectancy have vastly improved in the case of India since independence, strong economic growth over the past two decades and a stronger push for social sector expenditure from both central and state governments has not translated into better nutrition for India’s teeming young population.
The report points out that one third of the world’s stunted children under the age of five years, estimated at 46.6 million, live in India. Further, a quarter of the children display wasting as well. The report also points to the double burden of anaemia and stunting which is severely affecting children in India. While the larger picture appears rather dismal, district-level data reveals the wide disparity based on regional location. Central and northern India showed higher prevalence rates of high and very high levels of stunting at more than 30 percent and 40 percent respectively, compared to less than 20 percent in southern India. This is a clear indicator of the importance of political commitment, measures for good governance, literacy and other socio-cultural factors in the efforts to reduce child malnutrition.
A key policy response to address infant and young child malnutrition in India has been the Integrated Child Development Services (ICDS) scheme, which was originally launched in 1975. The programme aims to provide basic education, health and nutrition services for early childhood development. The ICDS comprises six services: Supplementary Nutrition Programme (SNP), non-formal pre-school education (PSE), nutrition and health education, immunisation, health check-ups, and referral services.
Various evaluative studies have indicated that the ICDS has failed to reduce malnutrition, and that it does not uniformly target vulnerable areas. As per government reported data, the proportion of ICDS beneficiaries who are malnourished has been constantly increasing. Fifteen percent of ICDS beneficiaries were malnourished as of March 2015. This increased to 22 percent by March 2016 and even further to 25 percent by September 2017. In addition, budgetary outlays for the scheme have reduced from Rs 16,562 crore in 2014-15 to Rs 16,335 crore in 2018-19. Expenditures on the Supplementary Nutrition Programme have also been reducing. It decreased by 6 percent from Rs 14,403 crore in 2015-16 to Rs 13,514 crore in 2016-17.
To address these gaps the NITI Aayog in 2017 published the ‘Nourishing India: National Nutrition Strategy’ document, which envisions a “Kuposhan Mukt Bharat”, or an India ‘free from malnutrition, across the life cycle’ by 2022. It also lays down in detail the national framework to improve nutrition. In focusing on a life cycle approach, the key guiding principles include: providing early preventive action, promoting a rights based approach that is inclusive and gender sensitive, community empowerment and ownership through better trained and equipped Accredited Social Health Activists (ASHAs), greater recognition and value for anganwadi workers, promotion of decentralisation through ownership at the panchayat or urban local body level, and decision-making informed by scientific evidence.
In light of the Global Nutrition Report, it is imperative that the central and state governments work in tandem to improve nutrition for children on a high priority basis. While the national framework to improve nutrition already exists, mere technocratic interventions without a more holistic understanding of malnutrition which goes beyond food-based problems and solutions will weaken policy efforts. The centre and state governments also have to take into account increasing evidence for improving the quality of nutrition – through promotion of varied diets that cover whole foods and include cooked meals over packaged and processed foods. The importance of collecting disaggregated data including geospatial, socioeconomic status and gender data cannot be emphasized enough in designing more effective and context specific action plans to tackle malnutrition. There is also a definite need to scale up and diversify financing for nutrition-specific and sensitive programmes.
At the global level, commitments to improve the state of malnutrition have been made through the UN Decade of Action on Nutrition of 2016–2025, the Milan Global Nutrition Summit in 2017, and the 2018 UN High-Level Meeting on NCDs. In the context of the Sustainable Development Goals (SDGs), optimal nutrition is essential for achieving several of the SDGs, while many SDGs impact nutrition security. Therefore, nutrition is closely linked to goals and indicators beyond SDG 2 which aims to ending hunger and malnutrition by 2030.
As the former UN secretary general Ban Ki-moon pointed out, “Nutrition is both a maker and a marker of development. Improved nutrition is the platform for progress in health, education, employment, empowerment of women and the reduction of poverty and inequality, and can lay the foundation for peaceful, secure and stable societies.” In order to ensure every child enjoys a healthy future, there is a compelling need for concerted efforts to tackle malnutrition at the national and state levels in India.
Vivek is a PhD research scholar at the department of political science, University of Hyderabad.
(The article appears in January 15, 2019 edition)