India is struggling to reduce its rate of undernutrition. What it needs is a national nutrition strategy, with a senior leader within the government empowered to implement it.
Over the last 15 years, India has posted unprecedented economic growth rates. Only China has grown faster. India has emerged as one of the most important rising global powers, but it also has one third of the world's undernourished children and one of the highest rates of child undernutrition in the world. Undernutrition causes 35 per cent of under-5 child deaths, impairs learning outcomes, increases the likelihood of being poor and is linked to illness or death during pregnancy. India is estimated to reach its Millennium Development Goals (MDG) nutrition indicator by 2043. China has already met its goal, halving its 1990 rate of underweight a few years ago. For Brazil, the Goal will most likely be met by 2015. Why is such an economic powerhouse struggling to reduce undernutrition?
Is India's economic growth pro-poor enough?
The decline in India's poverty rates compares well against the more lauded performance of China. Over the period 1981-2005, China's poverty rates declined from 40 per cent to 29 per cent, while India's rates declined from 60 per cent to 42 per cent (both represent about a 30 per cent proportionate decline). Studies find that economic growth continues to reduce poverty, but is not reducing poverty's cousin, undernutrition. Why is it so?
How strong is the enabling environment for undernutrition reduction?
Could it be that India's economic growth is preventing it from reducing undernutrition because of a weak enabling environment for nutrition improvements?
For most countries we would expect agricultural growth to have large impacts on the nutritional status of children. But the latest most authoritative study concludes that agricultural growth in India does not seem to have an impact on child undernutrition.
What about food and poverty programmes? An evaluation of the Targeted Public Distribution System (TPDS) by the Indian Planning Commission in 2005 concluded that the majority of subsidised food does not reach its intended recipients. On the Mahatma Gandhi National Rural Employment Guarantee Act (NREGA), the evidence is mixed. A recent systematic review of employment guarantee schemes finds two studies from India. One of these shows a positive net impact on household expenditures; another shows a negative net impact. The Midday Meals Scheme tends to be evaluated positively in terms of child growth, but it does not help infants in the two-three-year age group who are the most vulnerable to nutrition insults.
Discrimination against women in South Asia has long been thought to be one of the key drivers of the high levels of infant undernutrition in the region — levels that are well above those in most of sub-Saharan Africa. Studies show that low status of women is responsible for a significant, but not a majority, share of the difference in infant undernutrition rates between these two regions.
India has a system that is ranked significantly below those of Bangladesh and Sri Lanka. Professor K. Srinath Reddy and his colleagues note that the Indian public health system spends less than 1 per cent of GDP, and 80 per cent of health expenditures are incurred out-of-pocket. They call on the government to increase spending to six per cent of GDP by 2020 and outline actions needed to strengthen the system.
On sanitation, according to the World Health Organisation (WHO), India accounts for 56 per cent of the world's total cases of open defecation. We know that infection rates are powerfully associated with such unsanitary conditions, leading to an increased need to ingest nutrients and fluids and a depressed appetite.
Social discrimination is a powerful exclusionary factor in many Indian States. Research following children over time finds that being from a Scheduled Caste or a backward tribe substantially increases the probability of a child being stunted — and persistently so.
If the underlying context is not strong for economic growth to generate undernutrition reduction, can India's nutrition interventions overcome these barriers?
How strong are the country's nutrition interventions?
The coverage of key nutrition interventions in India is patchy. Interventions on infant and young child feeding practices cover 25 per cent of the population. Access to iron-rich foods and vitamin A supplementation rates are in the 30-40 per cent range depending on the State. The main nutrition intervention, the Integrated Child Development Services (ICDS), has a positive and significant impact on infant nutrition, but at a cost that is four times higher than elsewhere. The Accredited Social Health Activist (ASHA) programme pays community health workers to reduce infant and maternal mortality, control specific diseases, and improve young child nutrition. So far no evaluations are available to assess its impact on nutrition status, but other evaluations suggest that stronger recruitment and support systems need to be put in place to assist these crucial activists in the fight against undernutrition.
How strong is the governance of nutrition?
Given the multiple opportunities for investing in nutrition and the multiple ways that nutrition status can be undone, it is vital that there is a nutrition strategy backed by strong leadership. Brazil has done this successfully, leading to dramatic declines in hunger and child undernutrition rates. Going by available information, the government is not well supported to do this; and is not sufficiently pushed to act strategically.
First, nutrition data are collected every five to six years. This is too infrequent to track changes and respond to events. Second, because there are so many moving parts in any nutrition strategy, the government needs to use nutrition diagnostic tools to prioritise and sequence action to improve child growth, in the way it does for economic growth. Third, this variation in contexts is also matched by variance in nutrition status. There are many bright spots in the fight against malnutrition (for example, the recent Karnataka Nutrition Mission) but the incentives to analyse and learn from them are weak.
This lack of data and strategic analysis also diminishes the effectiveness of Indian civil society to mobilise around nutrition. For example, the Right to Food Campaign's push for a National Food Security Act makes important demands, but even if some of them are met, they will need transparent monitoring of resource flows to promote accountability of all stakeholders.
At current rates India will meet its MDG target by 2043 rather than 2015. Economic growth is poverty-reducing and this should help undernutrition reduction in the long run. But the current environment is not very supportive to nutrition. Action is needed to:
- make agriculture more pro-nutrition by focussing it more on what people living in poverty grow, eat, and need nutritionally
- experiment with cash-based alternatives to the TPDS
- promote community led approaches to sanitation
- increase coverage of essential nutrition interventions in the context of a stronger public health system
- focus ICDS resources more on children under two, on severe undernutrition and locate centres where most needed
- continue the fight against gender and social exclusion
But most importantly, India needs a national nutrition strategy with a senior leader within the government who is empowered to implement that strategy. Successful implementation needs civil society to play its part, helping shape and deliver the strategy and promoting greater transparency and accountability in the fight against undernutrition.
In the context of rapid economic growth, persistently high levels of undernutrition may seem like a curse but, as has been outlined here, there are many things that can be done to lift the spell. The most important thing is the commitment to do so.
(Lawrence Haddad is Director of the Institute of Development Studies, Sussex, and President of the U.K. and Ireland's Development Studies Association. He is an economist; his main research interests are at the intersection of poverty, food insecurity and malnutrition. He will deliver a detailed version of this argument in an address on September 2 at the 3rd Britannia Nutrition Foundation symposium in New Delhi.)