Public health

A vicious cycle

Print edition : October 26, 2016

At an ICDS centre in Kinnaur, Himachal Pradesh, a growth-monitoring exercise. Photo: REETIKA KHERA

Inter-State variation in the percentage of children enrolled in the supplementary nutrition (SNP) component, 2002

Relationship between the percentage of underweight children and the percentage of children who are ICDS beneficiaries, by State.

Relationship between State underweight prevalence and public expenditure allocations by the Government of India and the States, 1998-99.

There seems little hope of India ending hunger and ensuring a disease-free life for its citizens as it continues to put its public health stakes on private care in the face of data showing stunting, wasting and loss of weight among large sections of its children.

THE connection between nutritional status and a disease-free environment is not adequately recognised, surprisingly so even in public health-related measures and policy initiatives. Proper dietary intake alone cannot ensure improvements in a child’s nutritional status. It is only one of the determinants. Both dietary intake and absence of infection need to be addressed alongside. Inadequate dietary intake and infectious diseases constitute a vicious cycle, which is the major cause of high morbidity and mortality among children in developing countries.

When there is insufficient dietary intake, the immune response gets compromised, rendering children prone to infections. Infectious diseases, on the other hand, result in a catabolic loss of body nutrients rapidly because of the cycle of reduced consumption, poor absorption of nutrients and increased demands of the body to fight the disease. Studies in Africa and South Asia, including India, have found that children developed diarrhoeal infections around the time of their weaning from breast milk to other foods and became more susceptible to infectious diseases, and that their growth was compromised. Recurring bouts of infection without adequate food intake have been found to be the primary cause of poor growth among children in developing countries. Infections lead to weight loss because it can take weeks before the child returns to the pre-infection state, resulting in a lower weight than the accepted average for the child’s age. Frequent infections result in higher rates of undernutrition and loss of weight. When there is no accessible public health care to speak of, such situations in already impoverished families result in further reductions in purchasing power and push them into the twin trap of poverty and ill health.

The findings of the 2016 Global Hunger Index (GHI) report of the International Food Policy Research Institute (IFPRI) with regard to India should hardly surprise anyone. One already knows this from the National Family Health Surveys (NFHS). Data from the survey (NFHS-3) conducted during 2005-06 is the latest in consolidated form that is available. Figure 1 shows the percentage of under-five children who are (a) stunted, (b) wasting (a child being too thin for his/her height), and (c) underweight. NFHS-3 data show that almost half of the children under five (48 per cent) are too short for their age or stunted. One out of every five children under the age of five in India is wasted. Forty-three per cent of the children under five are underweight for their age.

Stunting and wasting indicate chronic and acute malnutrition

Stunting is an indicator of chronic malnutrition (including malnutrition in the mother during the pre-natal period) and is regarded as a good long-term indicator of the nutritional status of a population. This is because it does not vary appreciably by the season of data collection or other short-term factors such as epidemic illnesses, acute food shortages, or shifts in economic conditions. Wasting is an indicator of acute malnutrition, particularly due to recent causes such as food deprivation and serious illness. Underweight status is a composite index of chronic or acute malnutrition (equivalently stunting or wasting, respectively) and is often used as a basic indicator of the status of a population’s health.

A comparison of the health survey data in 41 countries (taken in the same manner between 2003 and 2007) by the 2009 India Nutrition Report (INR) of the Ministry of Health and Family Welfare showed (Figure 2) that (i) the prevalence in children of the condition of being underweight was higher in India than in any of the other 40 countries, though only slightly higher than the prevalence in Bangladesh and Nepal. Also, the percentage of the underweight condition in children in India (48 per cent) was almost twice as much as that for the 26 sub-Saharan African countries (25 per cent).

Poor child nutrition

In 2014, the Indian government commissioned the United Nations Children’s Fund (UNICEF) to carry out a nationwide Rapid Survey on Children (RSoC) during 2013-14. The survey reveals a similar nutritional profile of children under five. Although not strictly comparable with the NFHS data as the data sets are different and methodologies differ slightly, the data provide an indication of trends in the nutritional status of children in the country (Table 1). There is a significant reduction in all the indicators—9, 5 and 14 percentage points in stunting, wasting and underweight, respectively. This drop is actually more than the decrease between NFHS-2 (1998-99) and NFHS-3 (2005-06) when stunting and underweight decreased by 3 per cent but wasting actually increased by 3 per cent.

While this reduction is good news, India’s performance in ensuring child nutrition remains extremely poor, as, indeed, both the INR of 2009 and the GHI of 2016 reveal. Again, GHI indices are not strictly comparable with the data of the NFHS and the RSoC. The GHI evaluates both under-five child mortality rate and the fraction of undernourished people (both children and adults) in the population. India’s GHI has certainly improved since 1992 (46.4 in 1992, 38.2 in 2000, 36.0 in 2008 and 28.5 in 2016). But so has that of other countries, and India’s rank of 97 among 118 countries is a sad commentary.

In fact, India fares poorly in the rate of decline of its GHI as compared with some of the poorest countries faced with extreme hardships such as war and poor governance and severe economic crises. It indicates a broad systemic failure in all the determinants of nutrition and nutrition security, particularly public health.

Nutritional well-being

In a perceptive article in The Hindu (September 15, 2009), the British economist Lawrence Haddad asked if India was an economic powerhouse or nutritional weakling. India’s per capita gross national product or GNP (on PPP) is lower than only that of South Africa and Angola among the sub-Saharan countries. But if one compared the RSoC data on levels of stunting in India (the latest) with comparable data from the sub-Saharan African countries, the rate (39 per cent) is higher than the average (38 per cent) for the sub-Saharan region (Table 2). India’s performance is only better than that of eight countries and worse than that of 11 countries despite its per capita GNP being two to five times higher than that of most sub-Saharan countries. The reason, as Haddad rightly observed, is that nutrition seems to be no one’s baby within the government. This reality prompted the medical scientist Jacob John to write an editorial in The Indian Journal of Medical Research (June 2010) on the public health interventions required to tackle the double nutritional burden, malnourishment and obesity (a reflection of the perpetrating of inequity arising out of the neoliberal policies followed by government after government). The editorial was titled “Nutrition Security in India: Who exactly is in charge?”

“India,” Jacob John noted, “is no longer a ‘poor’ country that cannot afford nutrition security as well as health security. However, India does not have a national level mechanism or programme to integrate all necessary interventions for optimum nutrition for good health. This deficiency has to be corrected urgently and imaginatively.” But in these six years nothing seems to have changed. In fact, the situation is in regression.

The National Nutrition Monitoring Bureau (NNMB), which was established in 1972 under the Indian Council of Medical Research (ICMR) and was the source of critical nutrition-related information, was inexplicably wound up by the Health Ministry last year. Of course, the Bureau functioned all along in project mode and its operations were restricted to nine States. It should rather have been made an integral and permanent programme of the Ministry’s activities on the nutrition front and expanded to cover all the States. Now, according to Soumya Swaminathan, Director General of the ICMR, the Council plans to recreate the programme entirely under its own aegis and establish nutrition monitoring stations across the country, which would be a step in the right direction. The National Institute of Nutrition (NIN), Hyderbad, also runs under the aegis of the ICMR.

As John pointed out in his editorial, the Ministry’s efforts to ensure nutrition security have been piecemeal. All policy measures so far—the National Nutrition Policy (1993), the Nutrition Plan of Action (1995), the National Nutrition Mission (2001) and nutrition-specific recommendations in the various Five-Year Plans —have remained ineffective because nutrition has never been an integral component of public health care services.

ICDS: strengths and weaknesses

The Integrated Child Development Services (ICDS) programme of the Health Ministry, however, is a reasonably well-conceived programme that can address the gamut of issues linked to child malnutrition. However, a World Bank study in 2006 pointed out that more attention had been given to increasing coverage than to improving the quality of service delivery and to the distribution of food rather than to changing family-based feeding and caring behaviour. This has limited the programme’s impact, the study noted.

It is intended to target the needs of the poorest and the most undernourished and also the age groups that offer significant “windows of opportunity” for nutrition investments —children under three and pregnant and lactating women. But the study found a mismatch between the programme’s objectives and its implementation. Specifically, it found that the dominant focus on food supplementation was to the detriment of other tasks envisaged in the programme that are crucial for improving child nutritional outcomes. For example, not enough attention was being given to improving child-care behaviours and on educating parents on how to improve nutrition using the family food budget, the study report said.

The study also found greater participation in the programme of older children (between three and six years of age) and of children from wealthier households than children from poorer househholds. It said that the programme failed to preferentially target girls, backward castes or the poorest villages, groups that were at a higher risk of undernutrition than others. Although the programme’s growth was greater in underserved areas than in well-served ones during the 1990s, the poorest States and those with the highest levels of undernutrition continued to have the lowest levels of funding under the programme and coverage by ICDS activities, the study noted. Interestingly, it also noted that the (per child) expenditure by State governments under the ICDS (spent on the supplementary feeding component) was lowest in the States with the highest percentages of underweight children and highest in States with the lowest percentages. (See Figures 3, 4 & 5.)

Operational challenges

The programme also faced substantial operational challenges such as inadequate worker skills, shortages of equipment, poor supervision and weak monitoring evaluation, the study found. Community workers were overburdened because they were expected to provide preschool education to four-to-six-year-olds as well as nutrition services to all children under six. As a consequence, most children under three—the most malnourished group—did not get micronutrient supplements, and most of their parents were not reached with counselling on better feeding and child-care practices.

According to the report, other studies had shown that the presence of ICDS centres or anganwadi centres (AWCs) had no significant impact on the nutritional status of children in villages that had them compared with those that did not. One such study, which covered six States, found that, except in Kerala, children who lived in villages with AWCs were not less likely to be underweight or ill than other children. There is also not much evidence, the World Bank study said, that ICDS had been successful in attaining its goal of improving the coverage of specific child health interventions such as deworming, providing micronutrient supplementation such as vitamin A, and encouraging mothers to adopt appropriate child-care and feeding behaviours such as breastfeeding, weaning and ensuring a proper diet.

The skills of the anganwadi workers (AWWs) and their capacity to mobilise the community to support the ICDS and recruit eligible children are central to quality service delivery, but their performance reflects poor quality of training and the pressures of a large and diverse workload. Indeed, AWWs have been demanding higher wages, and the amounts they demand are not unreasonable. Often, however, it is found that even the designated wages are not disbursed regularly. In the final analysis, the study observed that “regardless of the indicator of ICDS coverage used, access to ICDS programme appears to be poorest in the States with the worst nutrition indicators”

Need for multiple interventions

Therefore, the imperative today is to strengthen and integrate the steps into a cohesive inter-Ministerial framework for coordinated and planned multiple interventions cross-cutting issues of nutrition and health. These, as John outlined in his editorial, include (i) the health of mothers and children; (ii) the connection between nutrition and infection; (iii) the role of nutrition of girl children in future pregnancies; (iv)the intrauterine growth of the foetus and the postnatal risk of obesity in the offspring; and (v) the high prevalence of anaemia among girls and women. It is necessary to combat malnourishment across the country on a war footing. But, clearly, health and nutrition do not seem to be priorities for the government.

The 71st National Sample Survey (NSS) data, collected in 2014 and released in April this year, clearly bear testimony to that. The data bring home once again the fact that an increasing number of people access health care in private facilities. This proves to be an enormous financial burden, particularly for the poor. The government is increasingly abrogating its responsibility to provide affordable and quality health care to all. According to the data, there is considerable variation among the States. Andhra Pradesh, Gujarat and Maharashtra have the most privatised health systems.

The data show that 71.7 per cent of the people in rural areas and 78.8 per cent in urban areas access private facilities for health care, which included both outpatient care as well admission into hospitals. Only 11.5 per cent of the rural population and 3.9 per cent of the urban population approach public primary health care facilities such as dispensaries and primary health centres (PHCs). This is a reflection of the poor accessibility of public health utilities.

The trend of decreased use of public utilities has continued since the mid 1990s. While in rural areas the number of hospitalised patients in public facilities has remained virtually constant to around 40+ per cent, in urban areas there has been a steady decline from 43.1 per cent in 1995 to 38.4 per cent in 2004 and 32 per cent in 2014. This is true not just of the relatively better-off sections, both rural and urban. Among the poorest sections, 42.5 per cent in rural areas and 52 per cent in urban areas access private hospital care.

Catastrophic burden on the poor

According to the NSS data, the average expenditure per incident of hospitalisation for the poorest economic class (with monthly household consumer expenditures below Rs.800 in rural areas and below Rs.1,182 in urban areas) is Rs.11,805 and Rs.12,516 in rural and urban areas respectively. This obviously imposes a catastrophic financial burden on poor families. The poorest families also spend an average of about Rs.524 per episode of illness on out-patient treatment. In rural India, 67.8 per cent of families reported that they financed these expenses from savings, 24.8 per cent reported that they were forced to borrow, and 0.8 per cent said that they had to sell assets such as jewellery.

With the public health system progressively failing and the government reposing faith in neoliberal policies even for social security systems such as health care, India cannot hope to achieve the Sustainable Development Goal-2 (SDG-2) of “Ending hunger, achieving food security and improved nutrition, and promoting sustainable agriculture” even by 2050, 20 years later than 2030, the deadline targeted by the United Nations.

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