India is slipping further on malnutrition, we must act now

A few years ago, I conducted ethnographic research in a tribal village in Rajasthan’s Udaipur district. The community members frequently came to me for all sorts of health problems, mistaking me for a healthcare provider. One day, during a visit to a remote hamlet, a young mother approached me. She worriedly said, “My son cannot see anything at night.” After investigations, we discovered that Ramlu suffered from acute malnourishment (low weight for height) accompanied by micronutrient deficiencies, such as of vitamin A.

These tribal communities often live in remote/inaccessible villages. They lack access to clean water, adequate nutrition and medical care. Often, mothers have to leave infants under the supervision of the elder siblings or grandparents to work in the farms. Mothers and children living in remote hamlets also have limited access to health and nutritional intervention programmes like Integrated Child Development Services (ICDS). Dietary deficiencies among children like Ramlu go undetected due to a lack of proper monitoring and nutritional awareness among the families.

A large proportion of Indian children suffer a similar fate. The recent National Family Health Survey of 2019-20 (NFHS-5) data for 17 states and 5 Union Territories, presents a grim picture. It shows worsening in nutrition indicators among children. Stunting in children below five years has increased drastically in several states, including in the more progressive ones like Kerala and Goa. Even the percentage of wasted children has gone up in most states surveyed; and the figures on underweight children look grim. These figures are undoubtedly a cause for alarm.

The second phase of NFHS-5 was conducted after the Covid-19 pandemic and the lockdown. In all likelihood, the nutrition indicators would have worsened during Covid-19 due to lack of access to mid-day meals, hot cooked meals in Anganwadis (rural childcare) and loss of livelihoods. A rise in malnutrition numbers will have severe consequences for the country.

Children with anthropometric evidence of malnutrition, such as Ramlu, are at risk of developing multiple nutrient deficiencies. These children are more susceptible to opportunistic infections, a significant cause of childhood mortality and morbidity globally. They are at an increased risk of developing stunting and various diseases, disorders, poor educational performance, and low productive life in the later years.

Malnutrition is also a significant contributor to disease burden in India. It dramatically impedes the country’s socio-economic development and the potential to reduce poverty. India continues to have the largest share of the world’s undernourished population, and in the 2019 Global Hunger Index (GHI), the country ranked 102 among 117 countries. In the given circumstances, we will be far from attaining Sustainable Development Goals (SDG) 2, which focus on ending hunger, achieving food security, improving nutrition and promoting sustainable agriculture.

What are the causes of malnutrition in India? A host of interrelated factors are responsible for its occurrence and persistence. These include poverty, lack of access to healthcare, hunger, poor sanitation, women’s status, lack of awareness, and low quality and implementation of nutritional programmes and policies. A study by Harvard Chan School of Public Health identified five top risk factors responsible for two-thirds of India’s malnutrition problem: short maternal stature, extreme poverty, low dietary diversity, and lack of education among mothers.

Despite the gamut of programmes and schemes, India still lags in combating malnutrition. There are many direct programmes, like Poshan Abhiyan, ICDS, PMMVY, and mid-day meals for addressing malnutrition. They suffer from underfunding and inadequacies.

In 2017, the government launched Poshan Abhiyan, its flagship National Nutrition Mission, to improve nutrition among children, pregnant women, and lactating mothers to reduce stunting, underweight, anaemia and low birth weight by 2022. Looking at the recent NFHS data, it seems we are far from achieving our target of Kuposhan-mukt Bharat. We have to wait and see how the recently launched Poshan Mission 2.0 fares.

Since ICDS is the heart of Poshan Abhiyan, we need to strengthen it. The ICDS scheme, one of the leading platforms for delivering nutrition interventions, suffers from numerous bottlenecks, such as inadequate supply of quality food and uniform distribution. Underpayment of Anganwadi workers and helpers, insufficient training and skills are other impediments in effectively implementing it. Lack of physical and social accessibility also impedes the utilisation of the scheme by the poor communities.

The Mid-Day Meal Scheme, which aims to improve children’s overall health, is also afflicted with quality issues and social inequalities. I have witnessed tribal children being discriminated against by upper caste teachers in schools. Even the Public Distribution System (PDS), crucial in providing food security to marginalised populations, lags. There are problems like inaccurate identification of beneficiaries, leakages, inadequate storage capacity, and non-viability of Fair Price Shops.

Since malnutrition has many causes, we need to formulate multiple and synergistic interventions embedded in proper multi-sectoral programmes by considering the varied nature of local-level challenges. Many simultaneous actions are required to address the problem.

First, the allocated budgets for programmes and schemes like ICDS, Mid-Day Meal, PDS and Poshan Abhiyan have to be increased.

Second, strong inter-ministerial coordination between ministries like rural development, public distribution and civil supplies, health and family welfare, women and child development, drinking water and sanitation, agriculture, as envisioned by Poshan Abhiyan, is crucial.

Third, we need robust collection and monitoring of nutrition data in severely affected pockets. The ICDS-Common Application Software (CAS), if appropriately implemented, may prove useful in collecting data from the Anganwadi centres.

Fourth, we need to invest in upskilling health workers, who are the backbone of schemes like ICDS and health programmes.

Fifth, there is a need to spread awareness on malnutrition to target the information lag among vulnerable populations, such as tribal communities. Involving local bodies and women’s groups to deliver the right messages may prove useful. Even nutrition education about locally available protein- and micronutrient-rich plants/resources may prove helpful and sustainable.

Lastly, we have to improve the earning capacity of people in the marginalised populations by investing in social security schemes.

(The writer is a public health researcher, storyteller and children’s writer)