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  1. 1. Nourishing a Nation ReducingMalnutritionin India Aditya Pratap Singh, Ashishkumar Suryawanshi, Ishwarya Thyagarajan, Priya Singh and Sethulakshmi Vinayan Azim Premji University, Bangalore 05 September 2013
  2. 2. Malnutrition – a few facts • UNICEF definition: Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it also refers to overnutrition. People are malnourished if their diet does not provide adequate calories and protein for growth and maintenance or they are unable to fully utilize the food they eat due to illness (undernutrition). They are also malnourished if they consume too many calories (overnutrition). • Malnutrition majorly contributes to child mortality. Stunting, wasting and underweight of children could be attributed to malnutrition
  3. 3. Malnutrition and development • Malnutrition affects the well being and quality of life of the nation’s population • Has a direct impact on development indicators like morbidity, mortality and literacy levels • Unhealthy population greatly affects productivity • The economic growth and potential of the country comes down • Heavy infrastructure investment in other domains is required to compensate these shortcomings
  4. 4. Malnutrition in India • Two-thirds of the 200 million children suffering from malnourishment live in India. India is currently ranked 65th among 79 countries in the Global Hunger Index of 2012 • The problem is significantly severe in few states like Bihar, Uttar Pradesh, Rajasthan, Orissa etc. • India approximately spends US$2.5 billion for issues relating to nutrition deficiencies • There is a productivity loss of close to US$ 10 million because of malnutrition • Undernourishment of pregnant women, frequent pregnancies, lack of hygiene, sanitation and quality healthcare, accessibility to food, poverty and lack of awareness have been identified as the main causes for malnutrition
  5. 5. Elements other than food intake causing Malnutrition • Accessibility to primary health care • Issues of poor hygiene and sanitary conditions breed diseases • Affordability of basic health care • The food provided under the Public Distribution System focusses more on meeting the calorific requirements rather than emphasizing on nutritional value • Lack of awareness, especially among women regarding issues like child nutrition, health-hygiene etc.
  6. 6. Malnutrition in numbers 0 10 20 30 40 50 60 70 80 1992 1998 1992 1998 1992 1998 Mild Moderate Severe Underweight Stunting Wasting Source: Underweight figures calculated directly from NFHS I and NFHS II data; other figures obtained from StatCompiler DHS (ORC Macro 2004). Note: Figures are for children under the age of three India has not made any significant progress in reducing malnutrition over time. Despite the numbers going down in the recent years, the country has a long way to go
  7. 7. Major Schemes and Policies The following are the main policies and schemes introduced by the Indian government to combat malnutrition: • Integrated Child Development Scheme (ICDS): 1975; targeting children below 6 years of age, pregnant and lactating mothers • Mid-day meals in schools • National Children’s Fund: 1979 • National Plan of Action for Children: 2005 • National Rural Health Mission: 2005
  8. 8. Major flaws in the policies (1/2) Though there are numerous ambitious policies to decrease malnutrition but some of the challenges these policies face in terms of implementation are: • The programmes do not target children below 3 years of age • Agendas like preferential treatment for girls, prioritising poorly performing states have not been met • The focus is on merely expanding the policies for better coverage and not improving the service quality
  9. 9. Major flaws in the policies (2/2) • Lack of judicious funding and resource allocation • The programmes are vertical in nature and are challenged by malpractices like corruption and fraud • There is a very wide gap between policies’ aims and their implementation • Despite being designed to be comprehensive and holistic, results do not reflect this The recently introduced Food Security Bill aims just at curbing hunger and reducing poverty and does not cover the nutrition aspects. States that are already performing well in the distribution domain face serious challenges with the introduction of the bill. Food storage and related infrastructure requires serious revisiting
  10. 10. Challenges • Since the approach followed to address the issue is top-down, there are many governance loopholes in terms of corruption, accountability, lack of proper implementation at all levels , etc. • The quality is mostly compromised to increase the coverage/ quantity. E.g. the recent case of Bihar school children dying due to bad quality of mid day meal • PDS has certain loopholes like it is not reaching to the needy reaching our and serving those really in need of it • Most of the programs do not look at the long term impact but rather focus on immediately measurable outcomes • The policies in place fail to look at factors like gender differentials within the nutrition framework. E.g. prevalence of anemia among girls • Autonomy of the states is constrained by the fiscal incentives of the Centre
  11. 11. Solutions (1/3) • Though expanding PDS shops as a part of the food security bill might be helpful, it is also essential to strengthen the existing systems • Studying the PDS models of states like Tami Nadu where it has been a success and reviewing possibilities of replication • Decentralization has to be made stronger with the states being given more autonomy in decision making and resource utilization • Efficient monitoring at all levels is needed. Evaluation of small scale programs is highly essential • Checks and balances have to designed to keep prevent malpractices. The community and the local NGOs must be involved to enhance accountability and transparency • The ICDS should increase its focus on covering children below 3 years of age and improve the service quality
  12. 12. Solutions (2/3) • Community Participation – awareness regarding health and hygiene should be promoted. The women Self Help Groups at local level should be provided with health education in order to generate health awareness • Increased involvement of school authorities and community in keeping a check on mid-day meal schemes • The policies need to focus on women’s nourishment along with children’s • Programmes should be devised such that they look beyond just calorific value sand should include locally available nutritious food • Judiciously using the budget allocated for programmes related to malnourishment • Focusing more on public health services to improve hygiene and sanitation. It should not be amalgamated with the medical services
  13. 13. Solutions (3/3) • Expansion and enhancing of the public health services for better environmental and preventive health care systems • Integration of the programs with similar agenda for greater, meaningful impact • Similar to village health committees, nutrition committees need to be introduced for designing the dietary plan using local nutritious food • In addition to anganwadi workers there should be staff assigned specifically to work on malnourishment and special training should be provided to the local level workers like ASHAs and ANMs • Tackling malnourishment is not just about improving food intake but also requires efforts in various issues like greater awareness among both male and female population, improvement in sanitation, hygiene and health infrastructure etc.
  14. 14. Key Solutions - a quick look Stronger Decentralization Strengthening PDS System Involving Community Strengthening ICDS Enhancing Public Health System Holistic, Comprehensive Programs Improving Health Education and Awareness
  15. 15. References HUNGAMA, New Delhi, ‘Fighting Hunger and Malnutrition- Survey Report 2011’ online World Bank Report on ICDS, 2012 http://siteresources.worldbank.org/SOUTHASIAEXT/Resources/223546- 1147272668285/undernourished_chapter_2.pdf Mehrotra, S. (2006). Child Malnutrition and Gender Discrimination in South Asia. Economic and Political Weekly, 41 (10), pp. 912-918 Ghosh, S. (2004). Child Malnutrition. Economic and Political Weekly, 39(40), pp. 4412-4413 Payne, P. & Cutler, P. (1984). Measuring Malnutrition: Technical Problems and Ideological Perspectives. Economic and Political Weekly, 19(34), pp. 1485-1487 Ramakrishna T. “Tamil Nadu has it covered, but Food Bill poses new challenge,” The Hindu, 01 September 2013 Sethi Nitin. “Talk about food - The coming battle over beneficiaries,” The Hindu, 01 September 2013 Gupta, M., Shukla, R., Somanathan, T.V. & Datta, K.K (2009). How Might India’s Public Health Systems Be Strengthened? The World Bank Development Research Group