Every once in a while, a discussion or debate starts on malnutrition. On a debated issue, precision is desirable. Initially, there were several discussions on the word “malnutrition”, which can technically mean over-nutrition, as well as under-nutrition. But now, there is global consensus on three terms. First, for a given reference age, the under-weight phenomenon is moderate when the weight is two standard deviations below median weight. Moderate moves to severe if it becomes three standard deviations or goes even below. Second, similarly, there is moderate stunting if height is two standard deviations below median; three standard deviations or below makes it severe stunting. Third, one looks at the weight-to-height ratio. Wasting is moderate if it is two standard deviations below median ratio; three standard deviations or more makes wasting severe. We loosely use the word malnutrition, but there are three specific indicators—under-weight, stunting and wasted, though they are correlated. SDGs (sustainable development goals) have been accepted worldwide now, targeted to be met in the lead up to 2030. The second of these is on hunger, food security, nutrition and sustainable agriculture. I should specifically quote targets 2.1 and 2.2. Target 2.2 states, “By 2030, end hunger and ensure access by all people, in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficient food all year round.” Target 2.3 adds, “By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.”
Notice the obvious, this isn’t only about children. The year 2025 is a reference to global nutrition targets. There are six of these. For our purposes, with a focus on children, three are relevant—40% reduction in number of under-5 stunted children; 30% reduction in low birth weight; and reduction to and maintenance of childhood wasting at less than 5%. However, malnutrition doesn’t work in silos. Therefore, despite the focus on children, two more are also important: Increasing the rate of exclusive breast-feeding in first six months to at least 50%, and 50% reduction of anaemia in women of reproductive age. (The last of global nutrition targets relates to over-weight children.) Goals lead to targets and targets lead to indicators that are monitored. We don’t yet know what indicators will be used to monitor SDG performance. But, that is a general comment. For malnutrition, it will obviously be weight, stunting and wasting, for specific ages. Other than birth, the standard age is under-5. However, there are data constraints, relating to both availability and time-lags. For instance, health-related data may be available for those who are under-3, rather than under-5. This has been the problem across various National Family Health Surveys (NFHS). For the record, the last NFHS (NFHS-3) is only for 2005-06.
In February 2015, the ministry of statistics and programme implementation (Mospi) published a country report on India’s progress towards MDGs (Millennium Development Goals), precursor to SDGs. This said, “It is estimated that in 1990, the proportion of underweight children below 3 years was 52%. In order to meet the target (MDG), the proportion of under-weight children should decrease to 26% by 2015. The National Family Health Survey shows that, the proportion of under-weight children below 3 years declined from 43% in 1998-99 to 40% in 2005-06. At this rate of decline, the proportion of underweight children below 3 years is expected to reduce to 33% by 2015, which indicates India is falling short of the target… The prevalence of underweight among children < 3 years of age is significant in most of the States and varies considerably between the States. The problem is severe in Madhya Pradesh (57.9%), Bihar (54.9%), Jharkhand (54.6%), Chhattisgarh (47.8%), Meghalaya (42.9%), Uttar Pradesh (41.6%), and Gujarat (41.1%), where the proportion of underweight children < 3 years is more than the national level estimate (40%) in 2005-06.”
Later, there was the 2013-14 rapid survey on children (RSOC). This gave us a moderate stunting figure of 38.7%, severe stunting of 17.3%, moderate wasting of 15.1%, severe wasting of 4.6%, moderate under-weighting of 29.4% and severe under-weighting of 9.4%.
How much do such all-India figures help us? Indeed, how much do state-level figures help us? I think something like the 2011 HUNGaMA (Hunger & Malnutrition) survey is more useful. It ensures focus on districts, which district-level household surveys (2012-13 is the last) also do. There are other numbers on ICDS (Integrated Child Development Services) beneficiaries. In this data clutter over NFHS, DLHS (with some states not covered), AHS (Annual Health Survey, with limited coverage of states), RSOC and ICDS and time-lags in data and periodicity of surveys, I think everyone will agree more disaggregated the data, better the intervention. This leads to another issue. Does ICDS, the primary scheme directed against malnutrition, work well? Probably not, otherwise, National Nutrition Mission (NMM) wouldn’t have started. However, with health being a state subject, something like NMM, or its counterpart, needs to not only zero-in on broadening ICDS (despite some complaints about its geographical coverage), but also ensure focus on specific districts (you can take your pick on whether the number is 100 or 200) and under-3 malnutrition. We need counterparts not just at state level, but also at the district, block and even angandwadi levels. The report of the Sub-Group of Chief Ministers on centrally-sponsored schemes was submitted in October 2015 and that too, clearly contemplates a broadening of ICDS.
The author is Member, NITI Aayog. Views are personal