A public health management perspective on malnourishment
The article has been authored by Dileep Mavalankar, director and Ritu Rana, Indian Institute of Public Health Gandhinagar (IIPHG).
Unfortunately, malnutrition numbers in India are worse than many poorer countries in Sub-Saharan Africa. Wasting, which is low weight for height is 19.3 % in under five children as per the last National health survey. For stunting – low height for age, this number is 35.5 % nationally. India cannot be a super power if so many children are malnourished. The situation of nutrition has not improved much between the last two national surveys. Why is this?
There are many explanations for persistent malnutrition in India - low income, illiteracy, traditional culture and associated feeding practices etc., which may be all true partly. The government has three major programmes for nutrition. Firstly, the large public distribution system (PDS) for subsidised grains to ensure that even the poor can afford to buy food grains. Then there is Integrated Child Development Services (ICDS), which provides take home ration (6 months-3 years) and morning snack and hot cooked meal (3-6 years) for children at the Anganwadi centre. This programme is run by the women and child development (WCD) department of the government. We also have facility-based management of children with severe malnutrition in the form of NRCs or CMTCs run by the health department. Finally, we have the mid-day meal scheme to provide meals in the schools for children. On top of this, both the health and WCD departments do health education about nutrition so that people’s habits change for the better and child nutrition improves. Government launched the POSHAN Abhiyan in 2018 – a special initiative to improve nutrition nationally with the vision to ensure attainment of malnutrition free India by 2022. In spite of all these efforts, Indian children remain malnourished. Why?
Here we present a public health management perspective on this issue. We feel that firstly nutrition is not receiving the required political support as is received by industry, defense, space science or infrastructure. The budget allocation for nutrition programmes are not adequate. ICDS provides about eight rupees per day per child. This low allocation is a reflection of low political priority. Secondly, the nutrition programmes are divided in various departments – WCD, health and education. Hence inter-departmental coordination becomes a major issue. Another key issue is the absence of nutrition experts in these programmes management. WCD department has very few technical nutrition experts in the whole government system. Nationally the apex technical institution is National Institute of Public Cooperation and Child Development (NIPCCID) and not National Institute of Nutrition (NIN) which is an Indian Council for Medical Research (ICMR) institute.
Nutrition is also a neglected area in health departments as their major attention is on medical colleges and hospitals. In the directorate of public health, there are no technical experts on nutrition ─ unfortunately, it is largely staffed by doctors, often not trained in nutrition. Even in medical colleges there is no department of nutrition or no linkages with universities where there are departments of nutrition. Hence there is lack of nutrition expertise for large nutrition programs in the country. Education department which runs the mid-day meal scheme also has very little nutrition expertise. Also the main purpose of this scheme is to attract poor children to school and not improve the nutrition. Budget for mid-day meal is also much less. Akshaya Patra Foundation, an NGO providing mid-day meal services to the government has to raise donations to run the programme.
The monitoring of the nutritional status in India is also not robust. ICDS has its own service statistics that show very low levels of malnutrition, while independent national surveys always show much higher levels of the same indicators. The national surveys only happen every 5-10 years and hence do not provide regular data on nutritional status of children for data-driven policy and actions. Some states have conducted their own nutrition surveys but these are also few. The National Nutrition Monitoring Bureau (NNMB), under which 10 state level units were set up, which were supporting continuous data collection on diet and nutritional status of population has now been discontinued. Some independent studies on a small scale happen via some universities or funded research projects but they are not representative of district-, state- or national-level data, and hence of limited use for policy-makers.
To remedy this situation, we propose the following solutions. First is to create a national level nutrition related central services on lines with the IAS, IPS etc. These officers should staff all nutrition-related programmes such as ICDS, mid-day meal and management of children with severe malnutrition etc starting from block or taluk level. All these programmes to be brought under one ministry of nutrition headed by cabinet level minister and senior secretary. There has to be adequately staffed nutrition departments in each state and central level with administrative and technical officers in the directorate of nutrition. NIN should have a much larger technical role in ICDS, mid-day meal and other nutrition programmes.
NNMB should be revived and expanded to do annual independent nutrition surveys. Adequate budget should be allocated for nutrition programmes. States should put in funds and technical staff to plan, implement and monitor the nutrition programmes in districts. Each of the nutrition programmes should be periodically monitored by the chief secretary and CM. The ministry of nutrition should have a large well- developed division of communication as about 60-70% of nutrition work has to be done by families in the home - how to cook and how to feed the children, how to maintain food hygiene and prevent diarrheas. This needs massive communication efforts.
Unless, we, as a nation take nutrition seriously and provide adequate budget as well as administrative and technical support, Indian children will continue to suffer from malnutrition, which will have a grave negative impact on the knowledge economy of the tomorrow. Malnutrition hampers brain development and physical growth of the individual. With our children being malnourished, we will suffer setbacks going forward.
The article has been authored by Dileep Mavalankar, director and Ritu Rana, Indian Institute of Public Health Gandhinagar (IIPHG).
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