Nutrition nation

…that’s what India has to work towards becoming, and the only way forward is by ridding the country of the malnutrition scourge

India has made remarkable progress on many fronts since its independence. The country has big global ambitions and expects to become a $5-trillion economy in the near future. The first cannot be achieved and second will not materialise if malnutrition is not tackled on a war footing.

Malnutrition, especially among women and children, remains one of India’s most intractable public health challenges. We have the largest number of stunted, wasted and underweight children in the world. Our impressive economic progress has not touched countless citizens at the bottom of the pyramid, in particular the nearly 35 million children under the age of five who are stunted because they are not getting enough, or the right kind, of nutrition.

India is a conundrum when it comes to economic growth coinciding with high poverty rates. The eight poorest states of India, accounting for more than a third of the population, have poverty rates comparable with 26 of the poorest countries in Africa. Despite being self-sufficient in agricultural output and becoming the largest producer of milk globally, our rates of malnutrition and stunting are shocking. This is a silent emergency.

Malnutrition is a global challenge with huge social and economic costs. It can take many forms and is often split into two broad groups of conditions: one, undernutrition, including stunting (low height for age), being underweight (low weight for age), wasting (low weight for height) and micronutrient deficiencies (deficiencies of vitamins and minerals); and two, excess weight, obesity and diet-related noncommunicable diseases.

Well-nourished children are better equipped to fend off diseases, do better in school and grow up to become more productive members of society
Well-nourished children are better equipped to fend off diseases, do better in school and grow up to become more productive members of society

Malnutrition affects people in every part of the world. It is estimated that, globally, some 2 billion people have micronutrient deficiencies. About 144 million children under the age of five are stunted, 47 million are wasted and 38 million are overweight or obese. Adding to the burden are the 528 million — or 29% of women of reproductive age around the world — affected by anaemia.

While the aggregate levels of malnutrition in India are outrageously high, they hide more than they reveal. There are significant inequalities across states and socioeconomic groups (rural areas, the poorest, girls, and scheduled tribes and castes are the worst affected). In the midst of the gloomy statistics, it is encouraging that nearly all Indian states have recorded declines in malnutrition, proving that progress is possible across the board.

Why invest in nutrition?

It is a moral imperative. The enhancement of health and nutrition is a constitutive part of development. Adequate nutrition is, simply put, one of the foundational building blocks of life. Every child has a right to optimum nutrition so that he or she can develop to his or her true potential. Well-nourished children are better equipped to fend off diseases. They do better in school. And they grow up to become more productive members of society.

Dr Rajan Sankar

Dr Rajan Sankar
heads the India Nutrition Initiative of the Tata Trusts

ICDS and the National Health Mission (NHM) have unmatched reach and are intended to help the most vulnerable. Together, they are structured to deliver the health and nutrition inputs that children need. The country also has various other programmes that focus on the various underlying causes of malnutrition. However, many of these are not delivering. Poor targeting and haphazard implementation are the major problems. Lack of community ownership and participation is another impediment. The Covid pandemic has added to our woes, with a significant surge in the number of malnourished women and children.

India needs to accelerate, and quickly. At the current crawl, the country will not meet either the United Nations’ Sustainable Development Goals or the World Health Assembly targets. Aware of the urgency, the government had launched the National Nutrition Mission, or Poshan Abhiyaan, in 2018. It is a well-conceived, multi-sectoral project designed to address malnutrition in all its forms. Mass mobilisation is an important component of the mission.

Convergence needed 

India has the necessary infrastructure — ICDS, NHM and a number of safety net initiatives — and together they address the immediate and hidden causes of malnutrition. The reality, though, is that universal programmes with low coverage exclude a large number of beneficiaries, people who need a nutrition boost the most. What is needed is a convergence of nutrition-specific and nutrition-sensitive interventions, capable of being delivered to vulnerable populations in underserved geographies.

Business as usual will not result in reaching those in urgent need of these interventions. Focusing on improving the diet of women and children, ensuring maternal, infant and child nutrition, empowering women, improving the health system to make it more responsible and effective, strengthening the public distribution system, and creating access to clean water and sanitation will go a long way in reducing the burden of malnutrition.

We have to engineer a shift so that the malnutrition problem and its solution can be reappraised in terms of consumer perceptions and attitudes. The creation of demand is necessary. If people do not want and do not demand, then even limited supplies and services can prove superfluous. The wrinkle here is that our nutrition programmes are ‘hardware heavy’, concentrating as they do on the supply factor, with the assumption that demand is thereby automatically appeased. Community mobilisation to increase demand and ownership is critical in the circumstances.

Government and more

The government has to be in the driver’s seat, of course, but collaborations and partnerships with all relevant sectors and players, and civil society as a whole, are of the essence to deal with the malnutrition crisis. The government should promote multisector partnerships, and there are several existing examples of successful solutions that show the way.

Beyond the convergence of interventions, we have a lot more to do: improve the diet of women and children; continue to focus on staple food fortification; employ policy instruments to make agriculture more nutrition-sensitive; consolidate the gains of the Swachh Bharat Abhiyaan (clean India mission) to improve water, sanitation and hygiene; and use real-time data from anganwadis to drive action.

The key challenge is to collaborate to create and implement sustainable solutions at scale and at speed. Poshan Abhiyaan offers the right platform to do this.

Every child has a right to optimum nutrition to realise their true potential