India needs to bridge the population’s dietary and information deficit if it wants to end malnutrition

Malnutrition in India continues to be the “ghost at the party.” The country needs to find an effective solution to this problem within a generation, particularly if India is serious about achieving Sustainable Development Goal 2, which mandates ending all forms of malnutrition by 2030. Yet data presented by UNICEF, WHO, and the World Bank Group shows that Southern Asia continues to be home to half the stunted and wasted children in the world, with India having the highest percentage of wasted children aged under 5 years (21% of the child population). For other indicators like infant, child, and neonatal mortality, and low birth weight, only Afghanistan and Pakistan are worse than India. India’s Global Hunger Index ranking has dropped from 97 in 2016 to 100 in 2017, and its nutritional indicators are seen as serious or critical in both the 2017 Global Nutrition Report and the Global Hunger Index.

Back in July 2014, India’s finance minister announced in his budget speech that “a national programme in Mission Mode is urgently required to halt the deteriorating malnutrition situation in India, as present interventions are not adequate. A comprehensive strategy including detailed methodology, costing, time lines and monitorable targets will be put in place within six months.”

I suggested then that the government should set up a high level committee to draw a roadmap of the mission and to revise India’s 1993 national nutrition policy. Yet in the three and a half years that followed, it was not very clear what kind of consultations went on within the government until in December 2017, the government announced it would be setting up a National Nutrition Mission (NNM) with a three year budget of Rs 9046.17 crore, commencing from 2017-18.

I was surprised and disappointed to learn, however, that this was not to be an executive mission, which would have the authority to draw up a work plan by integrating all intersectoral, nutrition related interventions under one roof; identify programme gaps and include them in any plans; initiate a strong education and awareness campaign; and, importantly, assign responsibility for achieving targets. Instead, it would merely be an apex body to supervise and monitor the reduction of stunting, undernutrition, and anaemia among children, adolescent girls, and women, and low birth weight babies. It would do this through, among other things, target setting, mapping schemes, creating more collaborations and convergence, a real time monitoring system, and digitalisation of Anganwadi centres, which provide care and support to mothers and children in rural areas. No further nutrition or nutrition related interventions were required, according to the government’s press release.  

The NNM could have inspired greater confidence, had it gone a bit deeper to identify and analyse the root, fundamental causes of why India’s nutritional indicators are not improving at a faster pace, and by giving the mission the powers to try and address this. Why has child underweight dropped by only 6.8% between 2006 and 2016 (according to the National Family Health Surveys) when per capita income has almost quadrupled during the same period? Why has wasting/severe wasting in children increased by 1.2% during that same period, and why do more than 50% of women and children continue to be anaemic? Why do only 9.6% of children between 6-23 months (11.6% urban and 8.8% rural) receive an adequate diet?

Ensuring that infants have an adequate diet is the mandate of the government’s Integrated Child Development Services, which currently works towards this either through distributing protein-calorie-micronutrient enriched supplementary food at anganwadis or through creating behaviour change in the household by educating caregivers about timely and adequate complementary food for infants. Clearly, on both counts, these interventions have failed to tackle India’s problem of malnutrition, resulting in children’s loss of potential cognitive and physical growth—a burden carried for life. It is unlikely that the current deficiencies in infants’ diets will be solved by target setting and providing tablet computers to anganwadis. This can only be improved by ensuring infants receive adequate and timely complementary feeding, which the existing interventions have failed to achieve, and the NNM suggests nothing new.

The mission also makes no attempt to acknowledge, analyse, or address the substantial dietary deficit that afflicts at least 50% of our population of all age groups and both sexes. The “Popularisation of Low Cost Nutritious Foods” intervention, which was mandated by the 1993 National Nutrition Policy, would have provided market access to low cost energy foods for children, women, adolescents, as well as sick and older people. This would have helped to bridge this dietary gap, and could have brought about a sustained reduction of India’s malnutrition over time. But even today, this remains an orphan subject, which is not the responsibility of any one ministry.

It is precisely because no low cost nutritious foods are available in the market that the poor of all age groups, but particularly the most vulnerable, are unable to overcome their calorie-protein-micronutrient deficit, leading to morbidity, lower productivity and incomes, and perpetuating the cycle of poverty. It’s good that the NNM will monitor the problem and try to get various bodies to work more collaboratively, but it cannot substitute for the hard macro and micronutrient deficit that affects about 50% of India’s population.   

This dietary deficit is compounded by a lack of accessible information for the public about basic dietary practices for children, adolescents, and mothers. For example, what is a balanced diet on a limited budget, the age at which an infant should be given complementary feeding, the proper growth of adolescent girls and boys, adequate pregnancy weight gain, and why is sanitation so important. This information deficit is often highest among the most vulnerable, for example, among families who work in agriculture/construction labour, where almost all wasted children are found.

The scale of malnutrition in India would have been best addressed by the NNM working out a strategy for bridging both the dietary and information deficit in households—perhaps through an effective education campaign reaching the most vulnerable households. Unfortunately, the NNM has ignored both.   

At best, the National Nutrition Mission can be termed a Mission for Measuring Malnutrition—without a clear roadmap, it’s unlikely to do much else.     

Veena S Rao is adviser, Karnataka Nutrition Mission.

Competing interests: I work closely with the Government of Karnataka, World Bank, Global Alliance for Improved Nutrition, and some universities. I have nothing further to declare. The views expressed in this piece are my own.