Hope and stasis for malnutrition in India


I have just finished a trip to India to help contribute to the efforts on ending malnutrition. The politicians and media were talking about the sparkling new economic growth and development figures. There was no such attention given to the “other” growth and development figures — those related to child nutrition. These figures are less than sparkling. If current rates of progress in reducing undernutrition are not improved upon, India will reach the U.N. Millennium Development Goal of halving undernutrition by 2043. The target date is 2015. China has already exceeded the target.

There are some glimmers of hope. The State of Karnataka has just adopted a Nutrition Mission which promises to give focus, coherence and urgency to efforts to combat undernutrition. There are some initial indications that the decline in undernutrition rates may be accelerating in one of the worst affected States, Madhya Pradesh. More and more international agencies such as the U.K.'s Department for International Development have ramped up their focus on nutrition. But there are worrying signs at both the national and State levels. It is at least 18 months since the creation of the Prime Minister's Council on Nutrition. It has not met once. The scandal of rotting food grains in the midst of hunger and undernutrition has rightly been getting a lot of media coverage. And we still don't know who in Delhi is responsible for leading efforts to reduce undernutrition.

During my stay I went to Bihar to visit some ICDS Anganwadi centres. The Anganwadi workers in charge of the centres were inspirational in their attempts to make the best out of the resources at their disposal. But the conditions in which they have to teach and feed about fifty 3-6 year olds, do home visits, and monitor child growth are testing and undermining. The centres are understaffed. Many are without toilets, washing facilities, clean drinking water, decent floors or food storage facilities. It is a miracle that the centres have any positive impact on nutrition status. I visited several AWCs in the mid 1990s. Nothing much seems to have changed. More pressure for change needs to be generated.

So how do we make more noise about undernutrition? During my visit I gave a presentation at a conference on “Nutrition: Reaching the Hard Core” organised by the Britannia Nutrition Foundation. For me, there are three key puzzles on how to overcome undernutrition: (a) how to raise the quality and expand the coverage of interventions such as ICDS; (b) how to make investments in various related sectors (such as agriculture) more pro-nutrition; and (c) how to create an environment where it is hard for anyone to neglect malnutrition.

My presentation was on the third area and was entitled “The 7 Habits of Highly Effective Environments for Nutrition”. The 7 habits are: (1) developing new surveillance techniques using mobile technologies to allow the government and civil society to react in real time to the changing nutrition situation, (2) the importance of creative campaigns to reset norms around what are acceptable rates of undernutrition reduction, (3) the need to support and expand the cadre of nutrition champions, (4) the need to learn from success within India (taking advantage of the federal set-up) and internationally, (5) the potential of a new class of “commitment indices” which monitor the nutrition commitments of governments, civil society and businesses, (6) the insights to be gained from adopting the new generation of economic growth diagnostics for nutrition to help prioritise and sequence the laundry list of potential nutrition actions in a given context, and (7) the value added of feedback — asking intended beneficiaries to score existing services and suggest what to do differently. Too little attention has been given to these issues.

Undernutrition is insidious — it sucks the life out of kids before clinical signs show. Undernutrition requires action on many fronts and hence it requires coordination and leveraging. Undernutrition requires scaling up of quality. All of these features — invisibility, scaling, coordination, leveraging — demand leadership. Sometimes leadership just emerges as in Mexico or Brazil or Ghana or Karnataka. But with so many lives being ended or wrecked by undernutrition, we can't afford to wait. We need to make sure nutrition is not easily neglected. And that means putting pressure on leaders throughout society to focus on nutrition. These seven habits will play a big role in doing that.

What should the private sector do?

Despite the aforementioned conference being organised by the Britannia Nutrition Foundation there was little discussion of the roles of the private sector in accelerating undernutrition reduction. Is there a role at all? The provision of nutrition is a prime public good — undernutrition generates negative spillovers for the current and next generation, is often generated through information deficits and affects the poorest — all classic features of a public good provided by the state. But that should not preclude dialogue on the question “are there any overlaps between commercial interests and sustainable and equitable improvements in nutrition?” This is a discussion that many are afraid to have — and not just in India. It seems to me that four things are being mixed up when we talk of the private sector. First, what can business do to make its core activities more supportive of nutrition? This means going beyond corporate social responsibility and making sure for example that advertising is responsible, that legal resources are directed in ways that do not only protect shareholders, that labelling is clear and gives consumers real choice, and that transparency is high on the business agenda so that civil society can hold businesses accountable.

Second, when can business act as a substitute for the state? I am not too optimistic here about the role of business — in the end, nutrition is a public good. But there might be things that the private sector can do better than the state. Would the private sector have handled the supply chain management of food grains as badly as the state seems to have done? Third, when can business be a complement to the state? For example, while fortification of salt and other widely used low cost foods is only a small part of an effective nutrition strategy, international experience has shown that the private sector is usually the best way of implementing it. The fourth and perhaps the most promising area is to work with businesses outside the traditional food and health areas to make the environment more enabling for nutrition. For example, when renewing a contract for mobile telephone operation, could the state build in requirements to set up sms services to remind health workers about childhood vaccinations? And could computing companies be engaged to help improve nutrition surveillance? I don't know the answers to these questions. They can only come through a dialogue that is sorely missing in India and elsewhere.

To be fair to the Government of India, it needs help to combat undernutrition. It is such a huge burden (43 per cent of children are malnourished) that the government cannot do it alone. Civil society, business, and the academic community have to help. International donors have an important catalytic role to play. But nutrition is a public good. Leadership has to come from the government. I still do not see it.

(Professor Lawrence Haddad is director of the U.K.-based Institute of Development Studies and president of the U.K. and Ireland's Development Studies Association.)

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