Centre must address multidimensional determinants of malnutrition on urgent basis

For holistic nourishment of children and malnutrition-free India by 2030, the govt must address the multi-dimensional determinants of malnutrition on an urgent basis

By Ashok Gulati & Shyma Jose
Prime minister Narendra Modi and home minister Amit Shah launched a campaign declaring September as ‘POSHAN maah 2020’. By inviting citizens to send nutritional recipes, the campaign aims to create awareness about the POSHAN Abhiyan through community mobilisation. But, how far it can help solve India’s massive problem of malnutrition is an open question.

Here, we dive deeper into the issue of malnutrition, especially amongst children below the age of 5 years. We also present some research evidence on its key determinants, and based on that evidence, what policy measures could help India overcome this problem of malnutrition by 2030. Incidentally, ending all forms of malnutrition by 2030 is also the target of Sustainable Development Goal (SDG-2) of Zero Hunger.

Globally, there were 673 million undernourished people, of which 189.2 million (28%) were in India in 2017-19, as per the combined report of FAO, IFAD, UNICEF, WFP and WHO (FAO, et.al. 2020) titled The State of Food Security and Nutrition in the World. Additionally, India accounts for 28% (40.3 million) of the world’s stunted children (low height-for-age) under five years of age, and 43% (20.1 million) of world’s wasted children (low weight-for-height) in 2019.
As a proportion of the overall population, around 14% were undernourished during 2017-19. In China and Brazil, the prevalence of under-nourishment in their respective total population was less than 2.5% (FAO, et al 2020).
In India, the problem has been more severe amongst children below the age of 5 years. As per National Family Health Survey (NFHS, 2015-16), the proportion of underweight and stunted children was as high as 35.8% and 38.4%, respectively. In several districts of Bihar, Jharkhand, Uttar Pradesh, Madhya Pradesh, Rajasthan and even Gujarat, the proportion of underweight children was more than 40% (see map).

The National Nutrition Mission (NNM), also known as POSHAN Abhiyan, aims to reduce stunting, underweight and low birth weight, each by 2% per annum, as also anaemia among children, adolescent girls and women, each by 3% per annum by 2022. However, the Global Burden of Disease Study 1990–2017 has estimated, if the current trend continues, India cannot achieve its targets of reducing stunting, underweight and low birth weight under NNM by 2022.

We have done deeper research using unit-level data of NFHS (2015-16) (with a sample of 219,796 children under five years of age) on the determinants of malnutrition. We find that the mothers’ education, particularly higher education, has the strongest inverse association with under-nutrition. Women’s education has a multiplier effect not only on household food security but also on the child’s feeding practices and sanitation facility.

Despite India’s considerable improvement in female literacy, only 13.7% of women have higher education (NFHS, 2015-16). This is quite below several countries at comparable income levels. Therefore, programmes that promote women’s higher education, such as liberal scholarship for women, need to be accorded much higher priority. Lack of basic facilities in school infrastructure such as separate toilets for girls, as well as distance between school and home, are major factors for higher dropout rates among girls.

State governments need to promote schooling via the provision of separate sanitation facilities for girls in schools. Initiatives like distribution of bicycles to girls in secondary and higher schools could help reduce the dropout rates among girls.

The second key determinant of child under-nutrition is the wealth index, which subsumes access to sanitation facilities and safe drinking water. WASH initiatives, i.e., safe drinking water, sanitation and hygiene, are critical in improving child nutritional outcomes. In this context, it was commendable that the prime minister launched Swachh Bharat Abhiyan in October 2014, with the aim to eliminate open defecation and bring about behavioural change in hygiene and sanitation practices.

In five years of the Abhiyan, as per government records, rural sanitation coverage has gone from 38.7% in 2014 to 100% in 2019 while sanitation coverage in urban areas had reached 99% by September 2020. This remarkable achievement of Swachh Bharat Abhiyan, subject to third-party evaluations, is expected to have a multiplier effect on nutritional outcomes. However, behavioural change towards personal hygiene still needs to be promoted at the grassroot level

The third factor is leveraging agricultural policies and programmes to be more “nutrition-sensitive” and reinforcing diet diversification towards a nutrient-rich diet. Food-based safety nets in India are biased in favour of staples (rice and wheat). They need to provide a more diversified food basket, including coarse grains, millets, pulses and bio-fortified staples, to improve the nutritional status of pre-school children and women of reproductive age. Bio-fortification is cost-effective in improving the diets of households and the nutritional status of children.

The Harvest Plus programme of the Consultative Group on International Agricultural Research (CGIAR) has implemented bio-fortification successfully in many countries around the world. The Harvest Plus programme can work with the Indian Council of Agricultural Research (ICAR) to grow new varieties of nutrient-rich staple food crops such as iron- and zinc-fortified pearl millet, zinc-fortified rice and wheat; iron-fortified beans.

Lastly, the promotion of exclusive breastfeeding and introduction of complementary food and a diversified diet after the first six months is essential to meet the nutritional needs of infants and ensure appropriate growth and cognitive development of children. Access to, and utilisation of, prenatal and postnatal health care services also play a significant role in curbing under-nutrition among children. Anganwadi workers and community participation can bring significant improvement in child-caring practices and antenatal care for mother and child through comprehensive awareness programmes.

For POSHAN maah to contribute towards holistic nourishment of children and malnutrition-free India by 2030, the government needs to address the multi-dimensional determinants of malnutrition on an urgent basis. The challenge has become bigger with the outbreak of Covid-19. Can India meet this challenge? Only time will tell.

Gulati is Infosys Chair professor for agriculture, and Jose is research fellow, ICRIER