A 'malnourished' plan

A December 1, 2017 press release states that the Union Cabinet approved the setting up of a National Nutrition Mission (NNM) with a three-year budget of Rs 9,046.17 crore, starting 2017-18. Limited information in the public domain indicates that the NNM is not an executive mission like the National Health Mission.

Rather, it appears to be a national committee to monitor, supervise, fix targets, map schemes addressing malnutrition, introduce convergence mechanisms, ICT-based real-time monitoring system, digitalisation of the Anganwadi, social audits, Nutrition Resource Centres, Jan Andolans. Or a mission for measurement of malnutrition, with no hint about its methodology, institutional mechanisms or additional field workers for any new grassroots interventions.        

This is at wide variance from the Union Budget speech announcement on July 10, 2014, 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, timelines and monitorable targets will be put in place within six months."

The NNM's mandate appears to be based on the premise that no new nutrition-related interventions are required; that there is "no dearth of schemes directly/indirectly affecting the nutritional status of children (0-6 years), and pregnant and lactating mothers"; that malnutrition levels in the country are high because of "lack of synergy and linking the schemes"; and that "NNM through robust convergence mechanism and other components would strive to create the synergy." It believes that a strategy of setting targets and achieving them by convergence, synergy and real-time digital monitoring is adequate for reducing India's malnutrition.

It is disappointing that NNM does not identify and analyse the fundamental causes for why our nutritional indicators are not improving faster. For example, why has child underweight dropped by only 6.8% between National Family Health Survey (NFHS) 3 and 4, when per capita income almost quadrupled during the same period; why has wasting/severe wasting increased by 2%? Why do more than 50% of our women and children continue to be anaemic, despite iron-folic acid (IFA) programmes for women and children for decades?

Data from NFHS 4 Factsheets (2016-2017) indicates that only 9.6% children between 6-23 months (11.6% in urban areas, 8.8% in rural areas) receive an adequate diet. Adequacy of infant diet, whether through supplementary nutrition from the Anganwadi or in the household, is the mandate of the Integrated Child Development Services (ICDS), either through supply of protein-calorie-micronutrient enriched supplementary food at the Anganwadi or through behaviour change in the household by educating caregivers about timely and adequate complementary food for infants.

On both counts, present interventions have failed, resulting in loss of potential cognitive and physical growth of children, a burden carried for life. The NNM however, provides no transformational strategy or new interventions in this regard.  

The mission also makes no attempt to acknowledge or analyse the significant dietary deficit which afflicts at least 50% of our population of all age groups and both genders, despite our three major food programmes - ICDS, Midday Meal Programme and the Public Distribution System (PDS) -- having been in operation for decades. This dietary deficit is the most proximate cause of India's calorie-protein-micronutrient malnutrition.

It is compounded by information deficit in the household about basic dietary practices for children, adolescents and mothers, such as what is a balanced diet within limited budgets, age at which an infant should be given complementary feeding, how to ensure proper growth of adolescent girls and boys, adequate pregnancy weight gain, importance of sanitation. This information deficit is highest among the most vulnerable, such as agriculture/construction labour families (where almost all wasted children are found).

Lack of strategy

Behaviour change and dietary diversification through information and awareness at community/family level have repeatedly been recommended since the Bhore Committee Report, 1946, and the First Five Year Plan onwards.

However, this powerful intervention continues to elude a strategy and programme even after six decades. Evidence from the Karnataka Multi-Sectoral Nutrition Pilot Projects establishes that just behaviour change through a strong communication strategy over a period of one year can bring about a substantial decrease in underweight and wasting of children, improvement of adolescent girls' body mass index (BMI), pregnancy weight gain, and reduction in low birthweight babies. Unfortunately, the NNM has not listed this as a priority. India's malnutrition could reduce much faster if an effective nutrition information campaign targeting households is launched.  

The mission does not touch other critical prescriptions of the National Nutrition Policy, 1993, that could have brought about sustained reduction of India's malnutrition over time, had they been converted into programmes, particularly 'Fortification of Essential Foods', and 'Popularization of Low Cost Nutritious Foods'. While there is some momentum regarding fortification, the latter remains an orphan subject and does not form the mandate of any ministry. It is precisely because no low-cost nutritious foods are available in the market that the poor of all age groups are unable to bridge their calorie-protein-micronutrient deficit.  

Addressing these primary causes of India's malnutrition is perfectly doable and is being piloted in two of the most backward blocks - Devadurga, Raichur district, and Chincholli, Kalaburagi district- under the Karnataka Comprehensive Nutrition Mission. The nutritional status of children, adolescent girls and women in these blocks has improved dramatically.

Ironically, just a week before announcing NNM, the Ministry of Women and Child Development on November 23 discontinued several administrative costs of the ICDS and reduced the Centre's share for staff salaries to 25% from the existing 60%, effective from December 1. This is bound to cause serious financial dislocation in the states, just as the financial year is closing, and cannot be a good start for the NNM, or whatever is left of it.  

(The writer is a retired IAS officer and Advisor, Karnataka Comprehensive Nutrition Mission)