Tuesday, 28 February 2017

India: Human development and nutrition

Dr. Devendra Kothari
Population and Development Analyst
Forum for Population Action

India must convert its young population to a competitive advantage, and nutrition is one of the most important stimulants to that outcome.

Nutrition plays a critical role in human resource development since deficiencies in essential nutrients lead to malnutrition, which affects an individual's mental and physical state, resulting in poor health and poor work performance. In addition, a hungry, malnourished child may have mild to serious learning disabilities, resulting in poor school performance; a sick, poorly nourished individual will not respond well to treatment, could lose many working hours and may continue to drain family and national resources. Thus, malnutrition may undermine investments in education, health and other development sectors.

The Ministry of Health and Family Welfare, Government of India has released the results from the first phase of the National Family Health Survey-4 (NFHS-4), conducted in 2015-16. The results indicate that fewer children are dying in infancy and early childhood. After the last round of National Family Health Survey in 2005-06, infant mortality has declined for which trend data are available. All States/Union Territories have rates below 51 deaths per 1,000 live births, although there are considerable variations. [1]

However, NFHS-4 reveals that India’s high economic growth rate in the past decade has not been fully reflected in the health status of its people with 20 per cent of its population undernourished. More than half of the children and women are still anaemic.

The “Global Nutrition Report 2016” collaborates the findings of the NFHS-4. It once again demonstrates India’s slow overall progress in addressing chronic malnutrition, manifest in stunting (low weight for age), wasting (low weight for height), micronutrient deficiencies and over-weight. “Our track record in reducing the proportion of undernourished children over the past decade has been modest at best, and lags what other countries with comparable socio-economic indicators have achieved”, as noted by  Vinita Bali, Director, Alliance for  Improved Nutrition.[2]

According to the Report, in a ranking of countries from lowest to highest on stunting, India ranks 114 out of 132 countries, with the incidence of stunting at 38.7 per cent, compared with Germany and Chile at 1.3 per cent and 1.8 per cent, respectively. Even Bangladesh and Nepal rank marginally higher than India. On wasting, India ranks 120 out of 130 countries, at 15.1 per cent, compared with Australia and Chile at number 1 and 2, with 0 per cent and 0.3 per cent, and South Sudan at 130 with 22.7 per cent. On the prevalence of anaemia in women of reproductive age, India ranks 170 out of 185 countries at 48.1 per cent, compared with Senegal which is the worst at 57.5 per cent and the U.S. which is the best at 11.9 per cent.

The segments most at risk continue to be adolescent girls, women and children, and among them Scheduled Castes and Tribes are the worst off, reflecting the insidious economic and socio cultural deprivation so prevalent in India. The most important national effort is yet to address these deficiencies in India.Despite being one of the biggest producers of food supplies, India is home to 25 percent of the world’s hungry poor, according to a U.N. agency.

The International Food Policy Research Institute (IFPRI) [3] makes the annual calculations of Global Hunger Index (GHI). Basing its readings on the most recent data, the 2016 GHI for India was derived from the fact that an estimated 15 per cent population is undernourished - lacking in adequate food intake, both in quantity and quality. the report states that “Countries worse than India include extremely poor African countries such as Niger, Chad, Ethiopia and Sierra Leone besides two of India's neighbors: Afghanistan and Pakistan. Other neighbors Sri Lanka, Bangladesh, Nepal and China are all ranked above India”.[4]

According to the Report that the malnutrition is a complex problem that contributes to 45 per cent of deaths among children under the age of five in India annuall. Chronically malnourished children are, on average, nearly 30 percent less literate than those who have a nutritious diet. The share of under-5 children who are `wasted' is about 15% while the share of children who are `stunted' is a staggering 39 percent. This reflects widespread and chronic lack of balanced food. This is partially reflecting the fatal synergy of inadequate nutrition and unhealthy environments.

Although India runs two of the world's biggest children's nutrition programmes, the ICDS for children under 6 years  (launched  in 1975) and the mid-day meal programme (1995) for school going kids up to the age of 14, malnutrition    continues to haunt India.

No doubt, nutrition is a big issue. Many health problems could be resolved by proper nutrition. For example, a tuberculosis control strategy that is merely treatment-based would be ineffective unless under-nutrition, which compromises immunity and leads to the latent TB infection turning active in millions, is addressed. Prof Anurag Bhargava, who has been working for decades on TB, pointed out that in India where 40 per cent of the population or about 500 million is estimated to have latent TB infection, it would be logistically impossible to treat them with drugs for 6-9 months. It is always malnutrition and vitamin deficiency that leads a person to TB. A body must have adequate vitamins, minerals and other natural substances in the food it takes to avoid TB. In other words, TB is a nutritional disease, argues Prof Bhargava, that can be prevented by placing nutrition (including adult nutrition) at the heart of the global developmental and public health agenda and implementing appropriate economic and agricultural policies, social protection measures and targeted nutritional interventions". [5]

One of the reasons for persistent under nutrition in India, despite the creation of the Integrated Child Development Services (ICDS) in 1975 and national coverage of the Mid-Day Meal Scheme in 1995, is that there is no structure for multi-sectoral coordination which is essential to address the inter-generational and multifaceted nature of malnutrition. Both schemes should be revamped looking to the needs of beneficiaries.[6]

Of these, the intent to revamp the ICDS has already been announced by the Government and must move into action mode quickly. This must include streamlining the work in the 1.34 million anganwadi centres by investing in training the 2.5 million workers and helpers at these centres, standardizing the nutrition component of the supplementary food offered and focusing on the overall dissemination of information and education to pregnant and nursing mothers on healthy eating habits, hygiene and sanitation,

Similarly, the mid-day meal is an excellent structure to reach 120 million children with continuity and regularity. A single intervention in that scheme to focus on nutrition in addition to food will make a critical difference. This can easily be accomplished by the addition of micronutrients to cooked food or by adding universally liked and accepted products such as milk, biscuits, etc. fortified with micronutrients as a mid-morning or afternoon snack. Therefore, extend large-scale food fortification beyond salt to other staples like flour, oil, dairy, etc. and establish mandatory standards by category.

In addition, endemic poverty coupled with growing number of unwanted childbearing,[7] unemployment, lack of sanitation and safe drinking water, and lack of effective healthcare are main factors for the sorry state.
The human dividend or demographic dividend on which we are banking is actually a huge liability given that one out of every three children is born underweight and unable to realize the full potential for physical growth and cognitive development, leading to lower levels of productivity. The World Bank estimates that India loses 2-3 per cent of its annual GDP by way of lower productivity, the underlying cause of which is malnutrition.

In sum, the need to systemically address underlying causes of malnutrition in India is an urgency that cannot be postponed. Poor nutrition will fracture the dreams and aspirations of India to become a global player in manufacturing and other sectors. Hope policy makers are listening!

[1] Refer: National Family Health Survey 2015-16 (NFHS-4): states fact sheets, International Institute of Population Studies, Mumbai, 2016.

[2] Refer article by Vinita Bali: We need a Nutrition Mission at: http://www.thehindu.com/opinion/lead/We-need-a-Nutrition-Mission/article14503108.ece

[3] The International Food Policy Research Institute (IFPRI) makes the annual calculations of GHI.

[4] For details, refer article at:, http://www.ifpri.org/news-release/india-ranked-97th-118-global-hunger-index-times-india. Also see: http://timesofindia.indiatimes.com/india/India-ranked-97th-of-118-in-global-hunger-index/articleshow/54822103.cms 

[5] Refer article: To control TB, under nutrition must be tackled’ by Rema Nagarajan (2016) at: http://timesofindia.indiatimes.com/india/To-control-TB-undernutrition-must-be-tackled/articleshow/55216307.cms

[6] For further  details, see article by Vinita Bali: We need a Nutrition Mission at: http://www.thehindu.com/opinion/lead/We-need-a-Nutrition-Mission/article14503108.ece

[7] Kothari, Devendra. 2014. “Managing Unwanted Fertility in India: Way Forward”, Institute of Economic Growth (ed.):   National Rural Health Mission: An Unfinished Agenda, New Delhi: Book Well, pp.25-36. Also refer, author’s post entitled - India: Why population matters? at http://kotharionindia.blogspot.in/2015/04/india-why-population-matters.html