Nutrition matters for a developed India

By Amarjeet Sinha

The Economist, in its July 13 issue, recorded gain in intelligence quotient (IQ) by 2.2 points between 1948 and 2020. However, it pointed out how stunting could cause a 15-point loss in IQ and 25% loss in incomes. With over one-third Indian infants still being stunted and suffering micronutrient deficiencies, nutrition becomes critical for a developed India. China, Vietnam, and Thailand are our Asian peers who managed to tackle under-nutrition effectively in a short span through country-specific approaches. They also have sustainable rates of economic progress, improved learning outcomes, higher per capita incomes, and greater human well-being.

Over 50% of India’s children were stunted and underweight in 1998-99; and one-third in 2019-21. Our demographic dividend, disease burden, human development potential, and sustainable economic progress with better skills and productivity are irreversibly compromised if we fail to make a difference to nutrition. Evidence from a few states tells us that it is possible.

National Family Health Survey (NFHS)-5 data confirms a higher incidence of stunting and underweight among lower quintiles. While poor states like Odisha improved their performance in nutrition with the decentralised management of the Integrated Child Development Services (ICDS), the levels have plateaued in recent years. Incomes matter for food diversity and access to health care. Wages of dignity matters for nutrition as well.

Free food grains alone do not address under-nutrition. Infants, adolescent girls, and pregnant women need a range of vitamins, minerals, and proteins that aren’t available in food grains. Fruits and green vegetables, milk, eggs, pulses, oil, etc. are all integral to food diversity. Early and exclusive breastfeeding, of course, is the way to begin. Let the baby food industry not compromise an infant’s best option.

India’s nutrition standards are aspirational, having been set after a 1997-2003 study, observing the growth milestones of infants born in a few well-off households of South Delhi! These are achievable.

The small, hilly state of Sikkim reduced stunting by eight points between NFHS-4 (2015-16) and NFHS-5 (2019-2021). Besides strengthening the ICDS system and developing locally-produced protein-rich food, Sikkim cleaned spring sheds, delivered piped clean water to every household, and promoted the use of bio-fertilisers from farmer dairy sheds. Incomes rose through cardamom plantations. Convergent community-led action for a functional ICDS, health sub-centre and school, and active women’s collectives and gram panchayats for decentralisation made the difference.

Bihar and Uttar Pradesh also recorded a 5-point and 6.6-point decline in stunting between NFHS-4 and NFHS-5. The Jeevika movement in Bihar promoted dietary diversity. Uttar Pradesh involved women’s collectives in ensuring supply of scientifically prepared high-protein local food. It ensured convergence of accredited social health activists and auxiliary nurse midwives (ANMs) and the ICDS, and made governance improvements.

An analysis of the ICDS since 1975 brings out its “project focus”. The thrust has remained on food for children aged 3-6 years and rudimentary pre-school education. The 0-3 age group, which faces the real challenge, has not received the attention it deserves. A 2006 study pointed out the importance of basic medicines in villages, considering over 50% of the children had some minor ailments — fever, skin rashes, eye infection, diarrhoea — that needed neither a hospital nor a doctor. Anganwadis and ANMs with basic medicines can prevent unattended illnesses that often lead to wasting and stunting.

The life cycle approach needs flexible financing to set up day-care centres for infants, adolescent girls, and pregnant and lactating women. Andhra Pradesh’s pilot community-managed Nutrition-Cum-Day Care Centres (2007-11) led to lower infant and maternal mortality and near negligible underweight babies. The cost was unsustainable under ICDS funding norms. This is unacceptable if India has to transform.

The southern states boast better indicators on nutrition, highlighting the role of women’s collectives, adolescent girls’ education, and the functional health care system. Other factors include better governance of ICDS, and higher disposable income. Decentralisation through panchayats and urban local bodies with professionals, funds, functions, and functionaries becomes imperative.

Wider determinants of health like clean water, sanitation, hygiene, housing, behavioural change, safe cooking, and food diversity play a key role in poor households. Nutrition gains from convergence. It is the surest way to address the unacceptably high nutritional anaemia.

We need to develop institutions of accountability, community-led planning, and implementation. Panchayats and women’s collectives can play a critical role in monitoring every infant to ensure growth does not falter. The Poshan tracker should only accept community validated data for effectiveness.

Backyard gardens, and fruits and vegetables grown on school premises and other public land will create a societal impact on under-nutrition. Under-nutrition also leads us to appreciate mature age of marriage and childbirth, as underage mothers give birth to underweight infants. While the age of marriage has been increasing, we need greater care during adolescence and pregnancy. With more women in panchayats and women’s collectives under the livelihood mission, there is an opportunity for gender justice and equity.

Flexible and well-funded interventions have to be tailored to need. Efforts to make use of monitoring data at the local level for immediate rectification helps. As is the support for immunisation and health services. The greater the interaction of the front-line worker with households, the greater the likelihood of timely interventions. Let us address the curse of under-nutrition through adequately funded, flexible, decentralised, and convergent action. It will make all the difference.

The writer is a retired civil servant.

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