In 2017, fewer than one in five children, six to 24 months of age, in the world ate a minimally accepted diet. More than half of them in the same age group did not get the recommended number of meals, and only two-thirds of the infants from six to eight months ate any solid food at all. In short, the burden of malnutrition, globally, was very high. South Asia was home to 38.9 per cent of the world’s stunted children, while India, Nigeria and Pakistan accounted for half of all the stunted children. India was also home to 25.5 million “wasted” (low weight for height) children. India, Nigeria and Indonesia were home to the largest number of children in the “wasted” category. These and other dismal statistics are part of the 2018 Global Nutrition Report , the outcome of a multi-stakeholder initiative started in 2013.
At the other end of the spectrum, the report says, there was an exponential growth in infant formula sales; globally, it went up from 7.1 kilograms an infant in 2005 to 11 kg an infant in 2017, marking a 54.9 per cent increase. The growth in sales of formula milk food in the follow-up months of infancy, including the toddler stage, was also high and happened despite the World Health Organisation’s (WHO) position that such food was unnecessary and should not supplant breast milk.
The report says that a faulty diet composition was one of the major reasons for the high prevalence of malnutrition and that 37.8 million children affected by stunting were in low-income countries where the daily average income was less than $2.80 per person a day. Another 101.1 million stunted children belonged to countries where incomes were less than $11 per person a day. Rural areas contributed a higher proportion of stunted and wasted children than urban areas.
The discourse on nutrition had picked up since 2014 following the Second International Conference on Nutrition. The following year marked the declaration of the 2016-25 period as United Nations Decade of Action on Nutrition in order to accelerate implementation of the Sustainable Development Goals.
According to the report, malnutrition was responsible for ill health more than any other cause and good health was impossible without good nutrition. On the face of it, these seem like platitudes, but what is important here is the decreased levels of commitment by countries in addressing malnutrition on the one hand and the increased levels of private interventions with regard to it, the latter being fraught with various implications.
In recent years, the reasons for widespread hunger and disabilities caused by that have been a matter of intense debate. Solutions to these have ranged from categorising various kinds of malnutrition to prescribing antidotes that include micronutrients and fortified food. This has, in turn, spawned an entire industry.
The most common cause of malnutrition among children under five was a suboptimal diet compounded and, perhaps, preceded by inadequate breastfeeding. Inadequate breastfeeding itself was a function partly of the ignorance of its benefits and also an outcome of the malnourished status of the mother.
The report also mentions other determinants such as access to water, sanitation, hygiene, income, education and quality health services as mitigating or contributing to malnourishment. It falls short of advocating better income distributive policies though there are sufficient indications in the report of a link between poor income and stunting and wasting among children below five years of age.
Undernutrition accounted for 45 per cent of the deaths among children below five years of age in low- and middle-income countries while overweight contributed to 7.1 per cent of all deaths among children. The report says that while diet alone is not necessarily enough to address malnutrition, it is necessary to reduce disability and death from malnutrition across all ages and income brackets.
Only around 39 per cent of the countries had reported that their nutrition policies were accompanied by operational plans that were financially provided for. Even where they were “costed”, or financially provided for, they were not fully funded. Tanzania, for example, which had a Multi-sectoral Nutrition Action Plan (2016-21) including an ambitious two-year action plan to reduce the burden of malnutrition, could not find adequate funding to implement it.
China has in place a National Nutrition Plan that includes delivering a multivitamin package to women and children in poorer regions. This plan links agriculture to nutrition. In addition, the country has a National Health Commission that takes stock of the nutritional challenges.
“Spotlight”, or case studies that form part of the report, argues that there is a need to break away from existing “silos”, such as wasting versus stunting, treatment versus prevention, and severe wasting versus moderate wasting. This perhaps indicates a positive shift in thinking and approach, from creating categories of malnutrition to looking at the problem of hunger and nutrition more holistically. It was evident that the larger the number of categories, the more the number of “solution silos”, says the report.
The Indian scenario
Stunting and wasting, says the report, ought to be looked at together rather than as two separate categories. Combined, they contributed to the highest mortality rates among a potentially larger proportion of children compared with wasting. India alone contributed to 31 per cent of the global burden of stunting. There were, however, geographical and spatial variations. A study by the International Food Policy Research Institute that looked at district-level data aggregated from the National Family Health Survey revealed that stunting varied greatly from district to district, ranging from as low as 12.4 per cent to as high as 65.1 per cent. As many as 239 of 604 districts had stunting levels above 40 per cent, the national average.
Stunting among children was from multicausal factors such as maternal education, age at marriage, antenatal care, diet of children, assets, open defecation and household size. In short, all these contributing factors at an individual level were directly or indirectly linked to the economic status of the pregnant mother.
In 2017, the Government of India launched the National Nutrition Mission (NNM), which is more about convergence and monitoring and less about identifying the real causes of poor diet among the affected sections. Significantly, most of the districts covered under the first phase of the NNM are from the States of Uttar Pradesh, Rajasthan, Maharashtra, Madhya Pradesh, Chhattisgarh, Jharkhand, Gujarat, Bihar and Odisha.
On November 2 this year, the Central government introduced the guidelines for the implementation of POSHAN Abhiyaan, a programme to improve nutritional outcomes for children, adoloscents, pregnant women and lactating mothers. It aims to reduce malnutrition and bring down stunting in children in the 0-6 age group from 38.4 per cent to 25 per cent by 2022. Nearly 600 districts are covered under the NNM, but as the emphasis is on monitoring by devices such as smartphones, the efficacy of such an approach is highly debatable. It is more so because allocations for child-feeding programmes were slashed significantly in the 2018-19 Union Budget.
The global nutrition report expresses concern about low “nutrition-specific spending”. Interestingly, nutrition-specific investment is low even as donor-spending commitments on obesity and non-communicable diseases, both of which are problems associated with the well-to-do, have seen a modest increase. Domestic spending was “opaque” or, in other words, difficult to track and varied from country to country, says the report. It advocates financing of nutrition interventions other than from public sources.
Social determinants
Where one may disagree with the report is in its assessment that public funding alone will not be enough for nutrition financing. The report does not sufficiently and critically assess the impact that private funding can have on nutrition outcomes, leave alone policy directions. For instance, there has been legitimate criticism over decisions to involve the private sector in nutrition-specific interventions. Increasingly, there has been a push in this direction too, but the report does not touch upon the consequences of this. In fact, rather than nutrition-specific interventions, countries appeared to be better off with nutrition-sensitive interventions which conceptually included greater investments in health, social protection, agriculture and education—the social and economic determinants of nutrition.
The push to include the private sector in supplementary nutrition has been accompanied by either modest or no increases in government allocations for such nutrition schemes. The Integrated Child Development Services (ICDS) and the Mid Day Meal (MDM) Scheme in India are perhaps the largest child feeding programmes in the world. Delivered mainly through rural women workers, the ICDS has a large network of centres across the country that provides nutrition, health and education for children under six years of age. The MDM Scheme caters to schoolgoing children.
There has been a drop in the allocation to the Supplementary Nutrition Programme, which is among the core ICDS services. The share for anganwadi or ICDS centres out of the total budget for the Ministry of Women and Child Development, the nodal ministry for the conceptualisation and delivery of preschool education as well as supplementary nutrition programmes for women and children, also decreased from 72 per cent in 2017-18 to 66 per cent in 2018-19. Besides, it was found that the revised allocations were 64 per cent of what was recommended by the Expenditure Finance Committee.
According to a budget brief by the accountability initiative wing of the Centre for Policy Research, a New Delhi-based think tank, a large number of posts of Child Development Project Officers and Supervisors were reported as lying vacant as on March 2017. Accompanying this was the increase in the malnutrition levels of ICDS beneficiaries. The drop in the allocation in the Pradhan Mantri Matru Vandana Yojana in the 2018 Budget too has been disappointing. Under this, each pregnant and lactating mother would be provided Rs.6,000 to compensate for wage loss during pregnancy and the lactating period. This was one programme that formed part of the NNM. Further, attempts to privatise the ICDS or to provide packaged food instead of hot cooked meals to children under six at the ICDS centres have also come in for criticism from various quarters.
The MDM Scheme of providing supplementary nutrition to children in schools, mainly government schools, has also been outsourced to private organisations that have been allegedly found to flout calorie norms laid down by government institutions such as the National Institute of Nutrition. The Jan Swasthya Abhiyaan, a broad front of individuals working on public health, has raised valid concerns at the refusal by a non-governmental organisation to add onions and garlic in the midday meals provided by it in government schools in Karnataka. The NGO, which provides midday meals to 4.43 lakh children in Karnataka alone, refused to include them citing reservations of a religious nature. There are specific guidelines regarding the dietary composition of the MDM as per the National Food Security Act too.
It is also a point of concern that the prevalence of stunting among Scheduled Caste and Scheduled Tribe children in Karnataka is as high as 39 per cent and that of wasting is 40 per cent. Undernutrition levels were at 28 and 25 per cent respectively for S.C. and S.T. children.
There is also a yawning gap between experience on the ground and policy. On December 12, Prime Minister Narendra Modi launched “Partners Forum 2018”, an international multi-stakeholder consultation on improving maternal and child outcomes. The forum, which has been around since 2005, involves the private sector as well. The two-day consultation in India comprised representatives from 82 countries. The Prime Minister also released a coffee-table book called Proven Paths which outlined the best practices in maternal, child and adolescent health. However, multi-stakeholder approaches have often been about private stakes rather than about the public good, more so in the absence of enhanced public spending.
Even as reports monitoring global nutrition levels remain good initiatives and global partnerships such as Partners Forum serve as a reminder of the commitments elected representatives have towards their people, they always fall short of examining critical factors such as enhanced public spending that ultimately determine the levels of hunger and nutrition.
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