Policy remake to combat Child Malnutrition in India
Malnutrition – the Challenge
?India has a dream. A dream of building a nation that is developed by 2047, a hundred years after it won its independence. However, to achieve that goal, India needs to overcome major challenges in malnutrition, healthcare, and education, besides others. Malnutrition is the first and foremost challenge, as a stunted child can not become a productive asset to the nation.
? According to a study by Lancet, 68 per cent of the under-5 deaths in India can be attributed to malnutrition. Besides, India is home to nearly half of the world’s “wasted or acute malnourished” (low weight for height ratio) children in the world. Wasting is a critical health condition where a child is nine times more likely to die as compared to a healthy child. According to National Family Health Survey (NFHS)-4 conducted in 2015-16, 21 per cent of children in India under-5 suffered from Moderate Acute Malnourishment (MAM) and 7.5 per cent suffered from Severe Acute Malnourishment (SAM).[i]
According to the World Health Organisation, in 2019 over 8 lakh children under the age of five died in India. In 2020 and the next few years, with the adverse effects of the pandemic in play, this figure could be higher as most of the child mortality is explained by malnutrition. Despite various targeted outreach and service delivery programmes run by the government such as POSHAN Abhiyaan, Supplementary Nutrition and Anaemia Mukt Bharat, to name a few, 16 out of the 22 states and Union territories have still shown an increase in SAM (Severe Acute Malnutrition), as per NFHS-5 conducted in 2019-20. This is also evident from India’s poor ranking, an abysmal 94th out of 107 countries on the Global Hunger Index 2020. COVID-19 has significantly unravelled the system inefficiencies, therefore, bringing to the fore, the need to adopt sustainable solutions aimed at integrated management of acute malnutrition in tandem with mitigating the impact of COVID-19. “Community Management of Acute Malnutrition (CMAM)” has worked well to mitigate the numbers of acutely malnutritioned children in Maharashtra and some other states.[ii]
Funds released under the Poshan Abhiyan Programme, which is aimed at curbing malnutrition in the country, stand severely under-utilised, according to data released by the Women and Child Development (WCD) Ministry. The data shows that out of Rs 5,31,279.08 lakh released for Poshan Abhiyan in the country from Central funds, only Rs 2,98,555.92 lakh has been utilised.[iii]
It is a classic case of poor project management and poor implementation of the schemes related to Child Malnutrition, combined with indifference towards the future generations of the country. Given the importance of this project for our country, it should be managed on a war footing with dedicated teams fanned out in affected states and reinforcing corrective actions on a monthly basis to combat the demon of malnutrition. The development of a nation depends solely on the health of its children and individuals who are able to contribute productively to the nation’s growth rather than being a burden on it. By not acting against this problem on a war footing, we are increasing the burden, both economic as well as social, on our country for the times to come. It has been well established that for every $1 spent towards reducing child stunting, the benefits range from anywhere between $45 to $139. The benefits come in the form of higher per capita income in the future for the children who were saved from stunting. India cannot be a global force to reckon with unless it first brings down the alarming levels of child malnutrition.
The Central Government allocated Rs 20,532 Crores to Integrated Child Development Services (ICDS) in 2020-21, a year before its budget was brought under Poshan 2.0, a revamped version of Poshan Abhiyaan. In 2021-22, the total budget allocated to Poshan 2.0 was Rs 20,105 crore.
It is envisaged that by just allocating 10% of this budget every year for continuous monitoring and evaluation, the balance of the expenses under the budget can be well spent, and optimized for bringing about focused results under the Poshan Abhiyan. But how? It can’t happen with the current system of working through administrative departments of states and lengthy government procedures. We need to think differently to increase the quality and scale of the interventions to combat this problem.
As per the current nutrition targets of 2-3% improvement[iv] on a yearly basis, we are targeting to remove malnutrition from India earliest by 2050. Taking into account the yearly population growth rate of about 1% the targets get further reduced to 1-2% effectively! So how can we think of becoming a developed nation by 2047? These targets are being driven by the results in the past decades working with a fixed set of processes and methodologies through a government framework. However, if we can be a bit innovative in handling this problem, we can surely come up with ways to eradicate this problem from our country within the next five to eight years. In this context, a new policy paradigm is suggested for the successful implementation of this project within a decade. If such a policy is implemented and relevant mechanisms put in place in a project mode, we shall start seeing the results within the next two to three years, i.e. by 2024-25.
Let the Core remain the Core
1.??????Direct nutritional support to children needs to be strengthened. This expenditure should be independent of the expenditure on monitoring the progress of children through the use of various tools. Both the execution and monitoring teams should be separate and focus on their respective tasks to increase their productivity.??
2. The Anganwadi workers need to be encouraged and facilitated in their work, rather than distracting from their regular work by filling in data in the mobile apps and other tools to report their progress. The ultimate outcome of turning children into healthy children shows that the work was done by them. We should focus on the outcomes.
3, Children with moderate malnutrition who need special care to prevent them from becoming SAM children should be provided with supplements. Core principles of nutrition should be taught and made universally applicable to all the processes in the project. ?
4. The literacy rate of Anganwadi workers is low, and they need to focus on the work they can do. Rather their skills should be upgraded in their own domain of providing nutrition, rather than in IT or other technologies for that is what matters most.
5. The data related to progress be collected by independent third parties (say, NGOs and startups working in the domain of healthcare, nutrition and well-being) and analysis of the data also be presented to the Anganwadi workers at regular intervals to make them aware and bring in required course corrections in particular areas.
A new approach
The fact is that Aanganwadi workers in almost all states are working as temporary staff without any minimum wage benefits and provident fund or other insurance covers. They are not even counted among the unorganized sector employees and are bereft of any minimum wage or provident fund or gratuity benefits[v]! There have been court cases and strikes by Aanganwadi workers to air their dissatisfaction with the remunerative and other aspects of their job[vi]. One thing is clear, till the time core worker in the whole scheme of things remains dissatisfied with her job, how can we expect the children to be malnutrition free? It is the Aanganwadi workers who are the chief workforce to combat malnutrition. If we are not taking care of them, what can we really achieve? Yet none in the whole hierarchy of the System wishes to change the approach.
The solution to the malnutrition problem is to create a nutrition ecosystem. How can this be achieved? We have in front of our eyes various ecosystems created in India and policies have been implemented to make them thrive. For example, some successful examples are the Startup ecosystem, the GST ecosystem, the Innovation ecosystem, and the digital payments ecosystem including the Direct Beneficiary Transfer. How many years have we taken to create these ecosystems? Five to eight years maximum to come to a reckoning in the world! However, we have been trying to solve the malnutrition problem the same old way for decades now. We have a National Nutrition Policy that was released about 30 years ago, in 1993! As per NFHS-5 data, after decades of government interventions, more than one-third of the children below 5 years of age in India are still stunted or underweight and approximately one-fifth are wasted (weight for height). Why don’t we try to think of a new and different strategy?
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Albert Einstein said: “Insanity is doing?the?same?thing over and over again and expecting different?results.” Just by changing the nomenclature, funding heads and funding amount, things do not change, if our core processes, people and methodologies to deal with the challenge remain the same, devoid of any new thinking and innovative ways. ?Using technology for monitoring progress is bringing a change in the method of recording measurements, not in the quality and scale of interventions. If the interventions are not regularly reviewed and changed based on the outcome data collected on the ground, things are going to remain the same and return the same kind of results. It has to be a dynamic system. In the present system, only government(s) are responsible for improving the figures for malnutrition-affected children through various interventions in the Society. The communities are treated as passive recipients, not acting on their own to take responsibility for suitable actions to prevent malnutrition. Though both Prime Minister and NITI Aayog have declared it as a Jan Andolan (people’s movement)[vii], the truth is that this has not been able to get translated as a people’s movement on the ground. We need to look for the reasons as to why.
To handle the malnutrition issue of a region effectively it is needed to hand over the reins of managing the malnutrition problem to the Community. Let the Aanganwadi workers be allowed to form their own cooperatives or social startups to handle a particular region or a district. Let these startups or cooperatives be given successive government grants under the Poshan Abhiyan based on their performance on the ground. Give them the flexibility to decide their own job terms within a defined framework, to build a nutrition ecosystem in the community. Let the Corporate Foundations be supported to join the Nutrition movement under CSR activities and they start mega kitchens to prepare fortified meals at scale[viii] and third parties like nutrition startups, and NGOs regularly monitor and report the outcomes of inputs by the Aanganwadi cooperatives and health workers region wise. Rather than running the System itself, the government should become an enabler and facilitator to empower the communities (Social cooperatives, startups, Corporate Foundations) to bring the desired and lasting change. Government should help these actors with funds from Poshan Abhiyan and put other government resources at their disposal at low or no cost, to start with, focusing on making the ecosystem self-sustainable, apart from the government support. Empowering the social actors and Aanganwadi and related workers to excel in their work is a sure way to combat the demon of malnutrition.
The major portion (80-90%) budget of the Poshan Abhiyan can be made available to the social cooperatives, startups and Foundations in various states in the area of nutrition focusing on the explicit job of eradicating malnutrition from a particular region or area, by setting targets. Bring the funds out of the government’s administrative control of sanctions and approvals, and give autonomy to the Cooperatives/startups to use funds for a defined purpose in the community to bring out desired results. We shall not only see the spending on the actual problem-solving increase, but also the performance metrics of various regions improve, which shall compete with each other to create malnutrition-free regions. Let third parties who are engaged in monitoring the progress belong to every state and regularly monitor the social startups’ or cooperatives’ work in the states, different from their home state, at regular intervals, say quarterly, and report the progress on a common web portal.?Let them be paid directly by the government based on their performance metrics. This shall introduce objectivity into the monitoring and evaluation, and lead to corresponding dynamic changes in the interventions.
Social Startups shall themselves come up with innovative ways and means to tackle the malnutrition problem through technology, better nutritional interventions and improved delivery and connections with the affected families. Competition among various regions would lead to more innovation in the methods adopted and, it could turn the malnutrition problem upside down. From currently being a push area for the government to a thriving nutrition ecosystem that takes care of itself, and delivers results that everyone would like to see for India to excel. Various nuances of such an intervention to solve the malnutrition problem can be discussed by involving various stakeholders rather than pushing the systems and processes from the top.
Evidence-based Approach and freedom to excel
It has been my experience that given freedom, responsibility and accountability to do a particular job, the individual and teams excel. But if the same individual or teams are tied up with rules and regulations, they make far less progress in a given time. We all know how projects or schemes start out as one thing but become something else, and what the consequences in terms of social failures are when they retain the same nomenclature that no longer fits the situation on the ground.
Policymakers themselves need to spend much time on the ground to uncover and know the many obstacles mothers and workers face, along with the institutionalized challenges of implementation. And wherever these have been focused upon and corrective actions are taken, those states have excelled in curbing the malnutrition issue to an extent. Changes in intervention coverage and improvements in socioeconomic status (SES) were the main contributing factors to changes in stunting among children (6-59-month-old) in all the four states of Chhattisgarh, Odisha, Gujarat and Tamil Nadu.[ix] Policymakers need to rely more on an evidence-based approach, and amplify it with information campaigns, rather than basing it on assumptions and projected scenarios. ?
I am sure the policymakers in India are thinking seriously about the problem of malnutrition and have set targets to achieve the same. But to get the real outcome of a healthy and nutrition-fortified India by 2030, we need to think differently, and if something has not been working for decades and is only delivering minuscule incremental improvements, we need to change our ways with an aim to leapfrog and conquer the challenge confronting us squarely in our face.
I would like to invite your comments and questions on the approach discussed to refine it further so that we can focus on creating a nutrition ecosystem in India. Our nation requires healthy citizens and only we can help it achieve this goal.
[i] Why community matters in tackling malnutrition, MA Phadake, Indian Express, April 18, 2021
[ii] Explain Speaking: Economics behind India’s rising child malnutrition, Indian Express, Dec 21, 2021
[iii] Funds for malnutrition scheme under-utilised: data, Esha Roy, Indian Express, Dec 2, 2021
[iv] Page 16, Accelerating the progress on Nutrition in India: what will it take? Third Progress Report, NITI Aayog, July, 2020
[v] https://scroll.in/article/1022099/the-historic-injustice-served-to-care-workers-by-indias-highest-court
[vi] https://www.thehindu.com/news/national/anganwadi-workers-struggle-with-centres-order-on-poshan/article35107841.ece
[viii] Midday meal schemes for 1.6 million school children every day by Akshaya Patra Foundation, Hubli, source: God’s own Kitchen by Rashmi Bansal, 2017
[ix] Accelerating the progress on Nutrition in India: what will it take? Third Progress Report, NITI Aayog, July, 2020