India needs to rethink its nutrition agenda

Context: Poor nutritional outcomes in NFHS-5 show that a piecemeal approach does not work.

• The Ministry of Health and Family Welfare has released data fact sheets for 22 States and Union Territories (UTs) based on the findings of Phase I of the National Family Health Survey-5 (NFHS-5). The 22 States/ UTs don’t include some major States such as Tamil Nadu, Rajasthan, Punjab, Uttar Pradesh, Jharkhand, Odisha and Madhya Pradesh.
• While the national picture will only be clear when the survey is completed and data are released for all the States and UTs, what we have so far paints a troubling picture in relation to nutrition outcomes.

Worrying findings

• Of the 22 States and UTs, there is an increase in the prevalence of severe acute malnutrition in 16 States/UTs (compared to NFHS-4 conducted in 2015-16).
• Kerala and Karnataka are the only two big States among the six States and UTs where there is some decline.
• The percentage of children under five who are underweight has also increased in 16 out of the 22 States/UTs.
• Anaemia levels among children as well as adult women have increased in most of the States with a decline in anaemia among children being seen only in four States/UTs (all of them smaller ones — Lakshadweep, Andaman and Nicobar Islands, Dadra and Nagar Haveli and Daman and Diu, and Meghalaya).
• There is also an increase in the prevalence of other indicators such as adult malnutrition measured by those having a Body Mass Index of less than 18.5kg/m2 in many States/ UTs.
• What is also a matter of concern is that most States/UTs also see an increase in overweight/obesity prevalence among children and adults, once again drawing attention to the inadequacy of diets in India both in terms of quality and quantity.
• The data report an increase in childhood stunting (an indicator of chronic undernutrition and considered a sensitive indicator of overall well-being) in 13 of the 22 States/UTs compared to the data of NFHS-4.
• Among the remaining nine States, five see an improvement of less than 1 percentage point (pp) in this five-year period.
• Sikkim (7.3 pp), Manipur (5.5 pp), Bihar (5.4 pp) and Assam (1.1 pp) are the four States which see some improvement although even these are below the goals set by the government.
• There was a 10 pp decline in stunting among children under five (low height for age) between 2005-06 (NFHS-3) and 2015-16 (NFHS-4), from 48% to 38%, averaging 1 pp a year.
• Although in the right direction, this was considered to be a very slow pace of improvement.
• Poshan Abhiyaan, one of the flagship programmes of the Prime Minister, launched in 2017, aimed at achieving a 2 pp reduction in childhood stunting per year.
• All indications from these initial results of NFHS-5 are that we are likely to see an increase in prevalence of childhood stunting in the country during the period 2015-16 to 2019-20.
• This is extremely alarming and calls for serious introspection on not just the direct programmes in place to address the problem of child malnutrition but also the overall model of economic growth that the country has embarked upon.
• The World Health Organization calls stunting “a marker of inequalities in human development”.
• Over the last three decades, there have been phases where India has experienced high rates of economic growth.
• But this period has also seen increasing inequality, greater informalisation of the labour force, and reducing employment elasticities of growth.
• Some expansion in social protection schemes and public programmes such as the Mahatma Gandhi National Rural Employment Guarantee Scheme, the Public Distribution System, the Integrated Child Development Scheme (ICDS), and school meals have contributed to reduction in absolute poverty as well as previous improvements in nutrition indicators.
• However, there are continuous attempts to weaken these mechanisms through underfunding and general neglect.
• For instance, in a response to a parliamentary question in December 2019, the Minister for Women and Child Development presented data which showed that only about 32.5% of the funds released for Poshan Abhiyaan from 2017-18 onwards had been utilised.
• The last few years particularly have been bad with slowdown in economic growth, stagnant rural wages and highest levels of unemployment.
• This is also reflected, for instance, in the rising number of reported starvation deaths from different parts of the country.
• Volunteers of the Right to Food campaign have listed over 100 starvation deaths based on media and/or verified fact-finding reports since 2015.
• While these data present a bleak picture as far as nutrition is concerned, what is worrying is that the situation would be even worse now as a result of the pandemic and lockdown-induced economic distress.
• Field surveys such as the recent ‘Hunger Watch’ are already showing massive levels of food insecurity and decline in food consumption, especially among the poor and vulnerable households.
• In the Hunger Watch survey carried out in 11 States, two-thirds of the respondents reported that the nutritional quality and quantity of their diets worsened in September-October compared to before the lockdown.
• All of this calls for urgent action with commitment towards addressing the issue of malnutrition.
• The NFHS-5 fact sheets, which also present data related to health, nutrition and other socioeconomic indicators, show some positive trends as well.
• There are some improvements seen in determinants of malnutrition such as access to sanitation, clean cooking fuels and women’s status – a reduction in spousal violence and greater access of women to bank accounts.

A piecemeal approach

• What these overall poor nutritional outcomes therefore also show is that a piecemeal approach addressing some aspects (that too inadequately) does not work.
• Direct interventions such as supplementary nutrition (of good quality including eggs, fruits, etc.), growth monitoring, and behaviour change communication through the ICDS and school meals must be strengthened and given more resources.
• Universal maternity entitlements and child care services to enable exclusive breastfeeding, appropriate infant and young child feeding as well as towards recognising women’s unpaid work burdens have been on the agenda for long, but not much progress has been made on these.
• At the same time, the linkages between agriculture and nutrition both through what foods are produced and available as well as what kinds of livelihoods are generated in farming are also important.
• Overall, one of the main messages is that the basic determinants of malnutrition – household food security, access to basic health services and equitable gender relations – cannot be ignored any longer.
• An employment-centred growth strategy which includes universal provision of basic services for education, health, food and social security is imperative.
• There have been many indications in our country that business as usual is not sustainable anymore.
• It is hoped that the experience of the pandemic as well as the results of NFHS-5 serve as a wake-up call for serious rethinking of issues related to nutrition and accord these issues priority.

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