A new approach to reducing child malnutrition

Escaping stunted development

Over 35 per cent of young children in India are stunted, according to the latest data. This marks a reduction from 2005-6, when one in every two young children was stunted, to one in three children now in 2019-21. Nevertheless, in absolute numbers, India continues to have the largest population of stunted children in the world. Child stunting impacts later developmental outcomes for children, including their ability to learn at school. Proper nutrition is essential for healthy brain development. If children are to fulfil their potential, they must be provided adequate care and nutrition in their earliest years. We can and must do better for our children.

There is no silver bullet: malnutrition in children is a complex problem. It requires multiple nutrition-specific and nutrition-sensitive interventions, such as the provision of adequate protein and green leafy vegetables, clean drinking water, toilets, and informed parenting. Reducing malnutrition in children requires a lifecycle approach.

The prevalence of child marriage is unacceptably high in our society: one in four or five girls is still forced into marriage before she is 18. Supporting girls to access secondary education, retaining them in school, and preventing their marriage in childhood will not only reduce the risk of early pregnancy and the prevalence of low birth weight among new-borns but also give the girls a chance to fulfil their potential as educated adults.

Also Read | Crop diversity key to reducing hunger, malnutrition in India

Other important interventions to support good nutrition in children include hot school meals, and residential schools and hostels for children from disadvantaged homes.

To break the inter-generational cycle of malnutrition, we know that there should be a special focus on the first thousand days of a child’s life, which includes the months before birth. The Integrated Child Development Services (ICDS) programme, with its network of nearly 1.4 million Anganwadis across India, is therefore the primary policy intervention to address malnutrition in young children below the age of 6, as well as in pregnant women and breastfeeding mothers.

Nutrition and health interventions before and after a child’s birth are critical. Recognising this, states like Andhra Pradesh, Telangana and Karnataka have replaced the dry monthly rations provided to pregnant women and breastfeeding mothers with a substantial daily hot meal at the Anganwadi, including eggs and milk, supplementing the ICDS cost norms with their own financial resources. The hot meal is not an end in itself, but the first step in a series of layered interventions that can include calcium, iron and folic acid supplementation, deworming, and nutrition education. Independent evaluation has borne out that this policy redesign has yielded benefits in terms of improved birth weight of babies, and improvements in haemoglobin, gestational weight gain, and mental well-being among pregnant women and breastfeeding mothers.

There is an additional weakness in the ICDS supplementary nutrition programme in its present form. National Family Health Survey-5 (NFHS-5) findings show that only 11.3 per cent of children below 2 years received an adequate diet. Infants and toddlers under 3 years of age do not come to Anganwadis for their supplementary nutrition; their families are instead provided with Take Home Rations (THR) as a packaged mix. This packaged mix is often of uneven quality, unpalatable to children, and is thus sometimes used as animal feed, rather than being given to children.

It is time to rethink this aspect of the ICDS supplementary nutrition programme. We know that in low-income households, mothers of children under three need to engage in paid work; these infants or toddlers are often left behind in informal care arrangements, typically with a grandmother or neighbour. However, even in rural areas, elderly women also participate in daily wage labour, and hence the need for childcare is acute. Infant and young child feeding practices are key to improving child nutrition, and these are the years when nutrition and caring practices can have the greatest impact. It is time, therefore, to think of setting up practical and cost-effective creches for these children, where they can be provided with early stimulation as well as supplementary nutrition while their mothers go out to earn a livelihood.

This can be done through the gram panchayats. The rural livelihood programme MGNREGS already envisages the setting up of a creche at any worksite with five or more children below the age of 6 years, with one of the workers being designated as the caregiver.

Funding to run such a creche can come from MGNREGS, as MGNREGS workers would leave their children in its care; with a small modification in the guidelines, even the creche building can be included as a permissible asset creation activity under MGNREGS; and space for the building can be provided by the gram panchayat (GP).

The GP can engage a local women’s self-help group (SHG) to run the creche, selecting the group through the panchayat-level federation of women’s SHGs. Creche workers can be chosen by the SHG from among its members based on defined eligibility criteria. The creche workers can be given appropriate training in childcare, early stimulation and nutrition. The supplementary nutrition can be provided from the ICDS programme by transfer from the ICDS directorate to the gram panchayats, who will in turn make payments to the SHGs based on the number of children served. Cooking arrangements can be shared with the Anganwadi.

In urban areas, as MGNREGS is not available, such creches should be set up in areas where major construction activity takes place, with support from the construction industry. It will be viable to do so in a clustered manner rather than a creche in every worksite. Urban women’s SHGs can manage these creches, and ICDS can provide the nutrition component. Caregivers can be paid from the funds collected in the labour cess/Building and Other Construction Workers’ Welfare Board.

These practical details can be worked out locally. Creches for young children under 3 years will serve many purposes: it will let women seek paid work outside the home; it will provide livelihoods for SHG creche workers; it will lead to greater engagement of rural and urban local bodies in basic childcare services; and above all, it will provide the opportunity for quality nutrition and appropriate early stimulation for children under the age of 3.

The net outcome would be the tremendous benefit that infants and toddlers could be properly cared for, engaged with early stimulation activities, and fed nourishing food with fresh and locally available ingredients during the hours in the creche; their mothers would be able to earn a livelihood, which would further enable them to care for their children better at home. This would truly help India to break the intergenerational chain of malnutrition, empower mothers, and provide a bright future for all children.

(Uma Mahadevan-Dasgupta is the Additional Chief Secretary, Panchayat Raj, Government of Karnataka; Ramani Venkatesan was the former Director-General, Rajmata Jijau Mother-Child Health & Nutrition Mission, Government of Maharashtra)