Under-nutrition, as a silent emergency, haunts the lives of millions of Indian children. Several facts reveal the magnitude and severity of the nutritional crisis facing the country. Close to two million children below the age of five die in India every year. Of these, over a million deaths can be attributed to under-nutrition and hunger. Available reports place the number of annual child deaths because of under-nutrition in Maharashtra alone one of Indias most prosperous States at 45,000. Sadly, only a handful of starvation and nutrition-related deaths get reported by the media. Most of the times, child deaths and suffering because of poor nutrition go unnoticed. That India reports among the highest levels of child under-nutrition has been rightly termed by Prime Minister Manmohan Singh as a national shame.
Stunting (deficiency in height for age) affects close to 195 million children under five years of age in the developing world. Of these, around 61 million the largest number live in India. Wasting (deficiency in weight for height) affects around 71 million children under five in the developing world. Of these, some 25 million are in India. And an estimated 129 million children under five in the developing world are underweight (that is deficient in weight for age a composite measure of stunting and wasting). Of these, close to 54 million are children in India. In 2005-06, 43 per cent of Indian children below five years of age were underweight and 48 per cent were stunted. In China, only 7 per cent of similar children are underweight and 11 per cent are stunted. The corresponding levels of child malnutrition are much lower in Africa where 21 per cent of children below five years are underweight and 36 per cent are stunted.
The high proportion of child under-nutrition, combined with the large population base, has made India the country with the largest number of stunted, wasted and underweight children in the world. According to a recent United Nations Childrens Fund (UNICEF) estimate, India accounts for 31 per cent of the developing worlds children who are stunted and 42 per cent of those who are underweight.
There are several reasons why India should do something about child under-nutrition. Most significantly, being well-nourished is the right of every child, and the state has the obligation to ensure proper nutrition for all children. Scientific evidence offers other justifications as well. Undernourished children have significantly lower chances of survival than children who are well-nourished. They are much more prone to serious infections and to die from common childhood illnesses such as diarrhoea, measles, malaria, pneumonia, and HIV and AIDS. The risk of dying increases with the severity of the under-nutrition. For instance, a child suffering from severe acute malnutrition is nine times more likely to die than children who are not undernourished.
Nutrition is important to ensure proper brain formation and development, which starts in the womb: development of the brain goes on during early childhood. Evidence suggests that children who are stunted often enrol late in school, complete fewer grades and perform less well in school. This, in turn, affects their creativity and productivity in later life. Iodine deficiency is known to affect a childs Intelligence Quotient (IQ) adversely. It has also been established that children with deficient growth before age two are at an increased risk of chronic disease as adults, especially if they gain weight rapidly in the later stages of childhood. A low birthweight baby, who is stunted and underweight in its infancy and gains weight rapidly in childhood and adult life, is much more prone to chronic conditions such as cardiovascular disease and diabetes.
It is indeed unfair and unjust that so many millions of children should suffer and die from under-nutrition especially when the economic performance of the country has been impressive for close to two decades now. Particularly disconcerting has been the extremely slow pace of improvement in the nutritional status of children.
Equally unjust are the levels of inequality that characterise the nutrition situation. Levels of child under-nutrition vary widely across the country. In general, in India, undernourishment is higher among rural than urban children. For instance, in 2005-06, the proportion of underweight children in urban areas was 36 per cent as against 49 per cent in rural areas. Similarly, levels of stunting and wasting are higher in rural than in urban areas (see Table 1).
Levels of child under-nutrition vary widely across Indian States. Less than 22 per cent of the children below five years are underweight in Sikkim and Manipur whereas the proportion is 57 per cent in Jharkhand and 60 per cent in Madhya Pradesh. Similarly, the proportion of underweight children is highest 55 per cent among those belonging to the Scheduled Tribes, 48 per cent among those belonging to the Scheduled Castes, 43 per cent among Other Backward Class children and 34 per cent among others. Again, though the levels of under-nutrition are not that dissimilar between boys (42 per cent underweight) and girls (43 per cent), it is well established that girls are discriminated against when it comes to access to food, nutrition, health and care.
Several underlying causes explain the prevalence of child under-nutrition. Household income levels and poverty make a difference. In general, we find that levels of child under-nutrition are the lowest in the highest wealth quintile and the highest in the lowest wealth quintile.
Here it is important to view differentials in wealth as an outcome of the inequalities in the distribution of various opportunities economic, social, political and cultural. As a matter of fact, it is the poverty of opportunities that explains under-nutrition much more effectively than the poverty of incomes per se. For instance, levels of child nutrition are better in societies where women enjoy relatively greater opportunities and freedoms and there is greater gender equality. Nutritional outcomes among children are much better where girls have more opportunities to pursue education. Data show that malnutrition among Indian children below three years born to illiterate mothers (52 per cent) is almost three times higher than levels reported among mothers who have completed 12 years of education (18 per cent).
The pathways of influence between womens education and nutritional well-being could be many. More educated women tend to be better informed, they enjoy better opportunities for employment, they tend to be less superstitious, and they seek out modern health care and advice much more readily than less-educated women. Educated women also tend to have a greater say in decision-making within the household, they enjoy greater self-esteem, and they are treated more equally within the household and by society. Along with basic education, the socialising processes of schooling expose girls to several aspects of human life, including the opportunity to make friends, interact, broaden perspectives, consult, and discuss many matters. In the event of an illness or any problem, women who have been to school are in a more advantageous position to find out what is in the best interest of children through a broader process of dialogue and consultations than women who have been denied the freedom to even go to school.
Equally important in understanding nutritional outcomes is household-level food security. Proper food intake determines the nutritional well-being of adolescent girls and mothers and this impacts the nutritional condition of the child, especially at the time of birth. A body mass index (BMI) less than 18.5 kg/m2 is often used as a measure of chronic energy deficiency. More than one-third (36 per cent) of women have a BMI less than 18.5, indicating a high prevalence of nutritional deficiency. And almost 55 per cent of women are anaemic. In the case of children, it is again not so much the quantum of food in the household as much as the quality and access to nutritious diets. Most children in the age group of 6-59 months do not enjoy a proper diet. Almost 70 per cent of children 6-59 months are anaemic, and a high prevalence of anaemia is found across all States. Many poor households just do not have the means to ensure proper wholesome diets to their children.
Interesting patterns and clues to understanding child under-nutrition emerge when we examine nutritional outcomes across Indian States. Let us take two sets of States: Sikkim (20 per cent) and Manipur (22 per cent), which report the lowest, and Jharkhand (57 per cent) and Madhya Pradesh (60 per cent), which report the highest proportions of underweight children. Many factors interact to account for the differentials in nutritional outcomes across the two sets of States.
Income levels and poverty do not seem to explain much of the differentials. Sikkim and Manipur reported a per capita State Domestic Product of between Rs.20,000-21,000 (in 2005-06). Income levels were not very different in Jharkhand (Rs.18,900) and Madhya Pradesh (Rs.17,649). Similarly, both in Sikkim and Madhya Pradesh, 37 per cent of the population lives below the poverty line.
The first clue to explaining differentials in nutritional outcomes occurs from an examination of low birthweights. Low birthweight is closely associated with poor growth not just in infancy but throughout childhood. Estimates for India reveal that 20-30 per cent of babies weigh less than 2,500 grams at birth. Whereas only 10-13 per cent of children are born of low birthweight (less than 2,500 grams) in Sikkim and Manipur, the proportion is as high as 19 per cent in Jharkhand and 23 per cent in Madhya Pradesh. The inter-generational transfer of under-nutrition from the mother to the child in the womb is obvious. While the proportion of women with a BMI less than 18.5 kg/m2 is 10 per cent in Sikkim and 13 per cent in Manipur, it is as high as 42 per cent in Madhya Pradesh and 43 per cent in Jharkhand.
Access to and reach of health services also affect levels of child nutrition. Not surprisingly, provisioning of health services is better in States with relatively low rather than high proportions of underweight children. For instance, the proportion of fully immunised children is 70 per cent in Sikkim and only 40 per cent in Madhya Pradesh.
Equally important is care of the child. Initiation of breastfeeding immediately after birth makes a big difference. Some 43 per cent of children in Sikkim and 57 per cent in Manipur start breastfeeding within half an hour of birth. The proportion is 10 per cent in Jharkhand and 15 per cent in Madhya Pradesh. Failure to introduce adequate and proper supplementary foods at the end of 6-9 months is another major factor accounting for child malnutrition. Breast milk provides vital nutrients throughout the first year of life; but breast milk alone is not sufficient. The energy and calories needed for healthy growth can come only from additional food. Beyond four to six months, infants must be given solid foods to supplement breast milk. The National Family Health Survey reveals that nationally only 21 per cent of the children in the age group of 6-23 months are fed as per the Infant and Young Child Feeding (IYCF) recommendations. The proportion is 49 per cent in Sikkim and 41 per cent in Manipur as against 17 per cent in Jharkhand and 18 per cent in Madhya Pradesh.
The impact of literacy and schooling becomes evident when we compare educational attainments in Sikkim and Madhya Pradesh. Sikkim reports a female literacy rate of 62 per cent, Madhya Pradesh of 50 per cent. Similarly, there is strong evidence to suggest that women in Sikkim enjoy far greater freedoms and autonomy than women in Madhya Pradesh. A larger proportion of women work outside the home in Sikkim than in Madhya Pradesh. Women in Sikkim also have greater access to money, more exposure to the media, and greater freedom to go out of the house than women in Madhya Pradesh.
We find that 71 per cent of women in the 18-29 age group in Sikkim and 86 per cent in Manipur were married after the age of 18 whereas the proportion was 40 per cent in Jharkhand and 47 per cent in Madhya Pradesh. Gender disparities are much lower in Sikkim and Manipur than in Jharkhand and Madhya Pradesh (see Table 2). Available data suggest that men may also have a role to play in preventing child under-nutrition. We find that in both Sikkim and Manipur, the health provider had reached and spoken during pregnancy about the well-being of the mother and child to a much higher proportion of fathers than in Jharkhand and Madhya Pradesh.
The most significant direct intervention designed by India to tackle under-nutrition is the Integrated Child Development Services (ICDS) programme. Most reviews and assessments have established that the more than 30-year-old programme has not succeeded in delivering the desired result of preventing and eliminating under-nutrition. This is what prompted the Prime Minister in his Independence Day address in 2008 to remark: The problem of malnutrition is a curse that we must remove.
What then are the actions needed to ensure the eradication of child under-nutrition?
Several expert groups have offered valuable suggestions on how best to tackle the problem of child under-nutrition. These suggestions fall broadly into three clusters: technical, programmatic requirements, and institutional arrangements.
There is overwhelming evidence to suggest that tackling child under-nutrition requires a life-cycle approach, which implies that different interventions are needed at different stages in the life of a woman (during adolescence and pre-pregnancy as well as during pregnancy and after the birth of the child) and of a child (immediately at birth, up to six months, 6-23 months and 24-59 months). Listed below are such five critical technical interventions.
1. Improve breastfeeding practices in the first six months of life by ensuring that:
All newborns start breastfeeding within one hour after birth (early initiation);
All newborns are fed the nutrient-rich colostrum in the first three-to-four days of life (colostrum feeding); and
All infants are fed only breast milk in the first six months of life (exclusive breastfeeding) and are not fed any other solid or liquid, not even water.
2. Improve foods and feeding practices for children 6-23 months old by ensuring that:
Infants are fed complementary foods beginning at about six months of age while breastfeeding continues until two years and beyond;
Complementary foods are rich in energy, protein, and micronutrients (vitamins and minerals).
3. Control micronutrient deficiencies and anaemia in the first years of life by ensuring that:
All children 6-59 months old are provided with vitamin A supplements twice a year (about six months apart);
All children 12-59 months old are provided with deworming tablets twice a year (about six months apart); and
All children with diarrhoea receive appropriate treatment with zinc supplements and oral rehydration solution (ORS).
4. Control micronutrient deficiencies and anaemia in adolescent girls and women by ensuring that:
Anaemia is prevented in adolescent girls and pregnant women through supplementation programmes with iron and folic acid and deworming tablets;
Iodine deficiency is prevented in adolescent girls and women by ensuring that all salt for direct human consumption contains adequate levels of iodine.
5. Provide quality care for children with severe under-nutrition by ensuring that:
Cases of severe acute under-nutrition are managed at home with simplified protocols and also clinically (wherever required) under appropriate medical supervision.
In terms of immediate actions that can yield quick results, four priorities for the child would be the initiation of breastfeeding within one hour after birth, exclusive breastfeeding in the first six months of life, introduction of appropriate complementary foods after six months, and bi-annual vitamin A supplementation with deworming for children under five.
Reviewing the global experience with reducing child under-nutrition, UNICEF has identified seven programme success factors.
1. Situation analysis: to understand and analyse the local nutrition situation and its determinants.
2. Linkages with other sectors: The package of nutrition interventions need to be implemented in conjunction with relevant health, water and sanitation interventions. Better household food security through strengthened agricultural and social protection programmes is equally essential.
3. Political commitment and partnership: Strong and clear government ownership, leadership, commitment, coordination and clarity of roles and responsibilities of several departments.
4. Capacity-building: Promotion of early initiation of breastfeeding and exclusive breastfeeding; home visits by community health workers; immunisation and weighing sessions; sick child consultations; and services to prevent mother-to-child transmission of HIV; paediatric AIDS treatment. Review, identify opportunities, update knowledge and strengthen the capacity of health workers in order to extend the effective reach and coverage of the health system.
5. Communication and community: Initiate effective large-scale communication strategies and community involvement; offer regular support and counselling of caregivers at the community level; place strong emphasis on quality implementation, monitoring and evaluation.
6. Corporate social responsibility: Engage with the private sector, especially with the marketing of appropriately nutritious foods and compliance with the International Code of Marketing of Breastmilk Substitutes and other relevant standards.
7. Resources: Ensure that adequate resources financial and human are mobilised, allocated and expended on the delivery of nutrition programmes for children.
Several reports and committees have called for more specific suggestions, including an improved system of monitoring through the use of better indicators, implementation of the ICDS in a mission mode, recognising counselling for infant and young child feeding as a service in the ICDS, scaling down focus on food supplementation, supporting innovative child care service delivery options, piloting and universalising a two-anganwadi-worker model in the ICDS, and ensuring better coordination between health and nutrition interventions.
Others have called for transferring the responsibility for nutrition from the Ministry of Women and Child Development to the Ministry of Health and Family Welfare. The Coalition for Sustainable Nutrition Security in India has proposed a five-point charter for overcoming the curse of malnutrition.
1. Institutional structures for public policy and coordinated action in nutrition.
Recognising the need for concurrent attention to food (macro and micronutrients, clean drinking water) and non-food factors (for example, sanitation, environmental hygiene, primary health care, literacy and income security), set up the following consultative, policy, oversight and monitoring structures.
A Council for Freedom from Hunger, selected by gram sabhas and local bodies at the panchayat, nagarpalika and local body levels.
A State-Level Committee on Nutrition Security, chaired by the Chief Minister, with all Ministers concerned and representatives of civil society organisations, the corporate sector and the mass media in every State and Union Territory.
A Cabinet Committee for Nutrition Security, chaired by the Prime Minister at the national level.
2. Learning for success: converting the unique into the universal.
On the basis of evidence and successful programming within India and elsewhere, it will be prudent to place special focus on:
Child nutrition in the first two years of life; and
Womens nutrition throughout the life cycle.
3. Action at local level: community food and nutrition security system.
Setting up of community food and nutrition security systems, including grain, seed, fodder and water banks.
Widening the food basket to include a wide range of millets like ragi, legumes, vegetables and tubers.
Mobilising technology and credit for establishing the grain, seed, fodder and water banks by the proposed panchayat and local Council for Freedom from Hunger support.
Adopting, wherever hidden hunger from the deficiency of iron, folic acid, iodine, zinc and vitamin A in the diet is endemic, food-cum-micronutrient supplementation and appropriate and effective fortification approaches (as for example, iodine- and iron-fortified salt).
4. Action at State level: Coordinating nutrition security initiatives.
The State-level Committee on Nutrition Security, chaired by the Chief Minister, should facilitate the implementation of the numerous ongoing nutrition safety net programmes in a coordinated and mutually reinforcing manner in order to generate synergy and thereby maximise the benefits from the available resources.
State governments should launch a nutrition literacy movement and set up Media Coalitions for Nutrition Security for improved nutrition awareness.
5. Action at national level: Mainstream nutrition in national missions.
Appoint a Nutrition Advisory Board for large national programmes such as the Rashtriya Krishi Vikas Yojana, the National Horticulture Mission and the National Food Security Mission so that cropping and farming systems are anchored on the principle of food-based nutrition security.
Organise the delivery of various nutrition safety net programmes on a life-cycle basis so that integrated attention can be given to the needs of an individual from birth to death.
Open nutrition clinics and a PDS outlet at the NREGS sites.
Add a nutrition component to the NRHM and thereby launch an Integrated National Rural Health and Nutrition Mission.
It is frustrating to pose the question: Why then are we not acting fast to tackle the curse of under-nutrition? Clearly, India has the resources to deal with the problem. It also has the knowledge and the expertise. Most of the solutions are well known. What then explains the slow progress? Clearly, it is insufficient state action.
There are at least three reasons. First, the government needs to walk the talk. Despite identifying under-nutrition as a national shame, nutrition has not been assigned top priority and necessary resources have not been committed. Two, there is a reluctance to restructure, and if necessary dismantle and redesign, the ICDS programme despite several proposals for making it more efficient and effective.
Three, there is a strong resistance to reorganise service delivery in order to ensure better integration of health and nutrition as this will call for redefining responsibilities and reallocating functions between different Ministries and Departments. It is said that in development, it is not knowledge that is lacking, but courage. This underlies the paradoxical situation of under-nutrition that India as an economically resurgent nation faces. Not daring to take bold decisions is resulting in the violation of the rights of millions of children. Nothing could be more detrimental to the future growth and development of the country.
A.K. Shiva Kumar is a development economist and Adviser to UNICEF India.