PUBLIC HEALTH

Cosmetic measures

Print edition : May 11, 2018

A midday meal at an Anganwadi centre in Gadahumma village of Odisha’s Ganjam district in January 2018. Photo: Biswaranjan Rout

Vitamin A for children below five, at a special camp in Vellore, Tamil Nadu. Photo: V.M. MANINATHAN

The National Nutrition Mission, with all its hype, is confined very much to fixing targets, and its focus does not seem to consist in addressing the causes for the high prevalence of malnutrition, stunting or wasting among children.

ON March 8, Prime Minister Narendra Modi launched the National Nutrition Mission (NNM) and announced the pan India expansion of the Beti Padhao Beti Bachao (BPBB) scheme from Jhunjhunu district in Rajasthan, where Assembly elections will be held this year. While the NNM was approved by the Union Cabinet in December 2017, with a three-year budget of Rs.9,046.17 crore to be shared in a 60:40 ratio between the Centre and the States, the BPBB scheme was launched in January 2015. Both schemes were aimed at the girl child, women and children in general.

The NNM, with all its hype, is confined very much to fixing targets, “intense” monitoring and guiding nutrition-related interventions across Ministries. Its focus does not seem to consist in addressing the causes for the high prevalence of malnutrition, stunting or wasting among children in a district like Jhunjhunu, where it was launched from. It is, rather, confined to mapping various existing schemes; introducing convergence mechanisms (a Convergence Action Plan, to be more precise incentivising States and Union Territories to meet targets; incentivising Integrated Child Development Services (ICDS) scheme workers to use IT-based tools; measuring the height of children at ICDS centres; conducting social audits; and setting up nutrition resource centres. Interestingly, the NNM appears to have been conceived very much on the line of the National Health Protection Scheme targeted at a section of the population and announced in the Union Budget without any specific idea of the contours of the scheme itself. The NNM outlines the targets of reducing stunting, undernutrition, anaemia (among young children, women and adolescent girls) and correcting low birth weight. That apart, it has little to offer except an emphasis on the need for a “synergy” among various schemes as levels of malnutrition remain high despite a number of schemes for pregnant women, children and lactating mothers. (This admission comes in a government release.) Targeted responses seldom work, if the example of the targeted public distribution system is anything to go by. The NNM then only seeks to replicate what is already being mapped by various government bodies, including the National Nutrition Monitoring Bureau (NNMB), which maps nutritional levels in the various population segments.

An official release from the Press Information Bureau, which is incidentally the only available information about the NNM, states that “in the last three years, there has been significant work done on several key determinants of nutrition”. What, then, explains the national average of 38.4 per cent stunting in children? Data from individual States and districts show even higher percentages of stunting. Available information tells us that what the NNM seeks to do is to “bring together all the initiatives targeted towards districts with a high burden of malnourishment through diagnostic analysis at the level of each district, focus on the first thousand days in the development of the child, measuring the nutritional status of children through a real time ICT-enabled system in anganwadis by providing smartphones which (will) ease their work by replacing 8.2 kg of paper register with 173 gram smart phone”. This, says a brief note on the NNM, “leads to an enhanced self-esteem of the anganwadi but also enables paradigm shift in the overall service delivery and monitoring mechanism”.

Recognition as government employees and regular salaries and pensions are long-standing demands of ICDS workers. Successive Central governments, whether led by the Congress or the Bharatiya Janata Party, have remained deaf to these demands.

Key determinants

Notwithstanding the government’s claims of significant work on the determinants of nutrition, some key determinants, identified by the government itself, have not been adequately addressed. For instance, the government has underscored the link between open defecation and gut infection, diarrhoea and levels of nutrition, and supplementary nutrition available to pregnant women and lactating mothers and the health of the mother and child. Yet, the budget for the Swachh Bharat Mission has been reduced this year. The connection between clean water and gut infections is also well known.

According to the latest report of Water Aid released on the occasion of World Water Day on March 22, India had the largest number of people in the world without access to drinking water at a source close to their home. Fifty per cent of malnutrition, as per World Health Organisation (WHO) estimates, is associated with repeated diarrhoea or intestinal worm infections caused by unsafe drinking water, inadequate sanitation or inadequate hygiene. Only 56.3 per cent of rural India has piped water supply. The Pradhan Mantri Matru Vandana Yojana (PMMVY) extends to all women except those in regular employment in the government or the public sector and those who are covered by a maternity benefit scheme in their place of employment. Under it, pregnant and lactating mothers are given Rs.5,000, but only for the first living child. Earlier the benefit was extended for two living children. The narrowing of the scope of the benefit has indirectly encouraged sex selection in a society where male offspring is preferred anyway.

According to a government release, as of March 16, a total of 17.6 lakh women had enrolled in the PMMVY, with around 50,000 applications received every day. While the idea of giving Rs.5,000 as maternity benefit to compensate for a partial wage loss may be welcome, the money is not enough to either make up for the wage loss or meet the nutritional requirements of the pregnant and lactating mother. It also falls way short of the monthly wage for unskilled labour given by various State governments. Moreover, daily wage-earning women in the unorganised sector often end up losing pay completely in the event of pregnancy and complications related to it.

The NNM focusses on behavioural change alone. The only available “background” note on it, hastily drafted, says that the mission focusses on “social and behavioural change”. Further, the note says, “community based [ sic] events envisaged to improve linkage between community and front line workers and by wide public participation convert this into a Jan Andolan to make New India as ‘Suposhit Bharat’”.

In the first Budget of the National Democratic Alliance (NDA) government in 2014-15, the Finance Minister said 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.” The national programme finally arrived with less than a year to go before the 2019 parliamentary elections. The NITI Aayog detailed what should be a nutrition strategy in a paper titled “Nourishing India” in 2017. The report coincided with the Union Cabinet’s approval for the Mission in December 2017. The proposal was mooted by the Women and Child Development Ministry, but the strategy was developed by the NITI Aayog through what it claimed was a “consultative process”.

Levels of anaemia had stagnated for women and girls between 15 and 49 over the last one decade (55.3 per cent in National Family Health Survey-3 to 53 per cent in NFHS-4). The largest proportion of undernourished women are in Bihar, Chhattisgarh, Madhya Pradesh and Odisha. Sharp increases in child wasting or acute malnutrition (calculated on the basis of weight relative to height) were noticed in Punjab, Goa, Maharashtra and Sikkim. Infant and young child feeding practices were at suboptimal levels, noted the NITI Aayog report, observing that “major reasons include the aggressive promotion of baby foods by commercial interests, lack of support to women at family and workplaces especially counselling, inadequate health care support and maternity protection”.

Steady decline in intake

According to NNMB surveys, the nutrient intake of preschool children had not shown any significant improvement between 1975 and 2006. Over the last 30 years, the proportion of families where both adults and preschool children had adequate food had declined from 30 per cent to 22 per cent.

A more recent report by the NNMB on the diet and nutritional status of the urban population of India revealed that the average intake of green leafy vegetables, cereals, millets, milk, milk products, sugar and jaggery was lower than the recommended dietary intake. Cereals formed the bulk of the diet of the urban population. The average intake of micronutrients, too, was much below the recommended level, as was the intake of vitamin A. There was a strong correlation of under-nutrition with socio-economic variables.

The NITI Aayog’s strategy report envisaged covering 254 districts in the first phase, 2017-18, and another 254 districts in the next phase, and the remaining in 2019-20 depending on “needs assessment and performance”. As the Mission itself was launched in 2018 instead of 2017 as envisaged by the strategy document, this will entail a shifting of the targets by at least a year.

Even so, the NITI Aayog strategy document appeared to attribute the grim situation largely to a lack of synergy between Ministries. It calculated that there were not more than 39 districts which were common to the Ministries concerned and where efforts could be targeted, and also that there were 100 districts where stunting was acute and which could be the starting point of the Mission. Between the detailed nutrition strategy (based on robust government data and surveys) of the NITI Aayog and the sketchy Mission document, the focus seems to be on social, behavioural change, governance, convergence, targeting and monitoring.

In 2003, too, the then NDA government set up a National Nutrition Mission, which did not take off. It was “rescinded”, according to the NITI Aayog strategy document and was replaced by a Prime Minister’s Council on National Nutritional Challenges in 2008. Four decisions were taken and three implemented, though the multi-sector roll-out programme for some 200 high-burden (maternal and child malnutrition) districts could not take off. This, the strategy document says, will be a part of the new NNM. With less than a year to go before the next Lok Sabha election, it is doubtful whether the NNM will have any meaningful impact, limited as it already is with its narrow mandate.

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