As India launches the celebrations of its 75th anniversary of Independence, there is much to be proud about; significant advances have been made in science, technology, and medicine, adding to the country’s ancient, traditional, and civilisational knowledge base, wisdom and wealth.
Still, it is disconcerting that even after seven decades of Independence, India is afflicted by public health issues such as child malnutrition (35.5% stunted, 67.1% anaemic) attributing to 68.2% of under-five child mortality. Poor nutrition not only adversely impacts health and survival but also leads to diminished learning capacity, and poor school performance. And in adulthood, it means reduced earnings and increased risks of chronic diseases such as diabetes, hypertension, and obesity.
The good news is that the Government appears determined to set it right — with an aggressive push to the National Nutrition Mission (NNM), rebranding it the Prime Minister’s Overarching Scheme for Holistic Nutrition, or POSHAN Abhiyaan. It has the objective of reducing malnutrition in women, children and adolescent girls.
The Ministry of Women and Child (MWCD) continues to be the nodal Ministry implementing the NNM with a vision to align different ministries to work in tandem on the “window of opportunity” of the first 1,000 days in life (270 days of pregnancy and 730 days; 0-24 months). Global and Indian evidence fully supports this strategy, which prevents the largely irreversible stunting occurring by two years of age. POSHAN Abhiyaan (now referred as POSHAN 2.0) rightly places a special emphasis on selected high impact essential nutrition interventions, combined with nutrition-sensitive interventions, which indirectly impact mother, infant and young child nutrition, such as improving coverage of maternal-child health services, enhancing women empowerment, availability, and access to improved water, sanitation, and hygiene and enhancing homestead food production for a diversified diet.
NHFS data is a pointer
Data from the National Family Health Survey (NFHS)-5 2019-21, as compared to NFHS-4 2015-16, reveals a substantial improvement in a period of four to five years in several proxy indicators of women’s empowerment, for which the Government deserves credit. There is a substantial increase in antenatal service attendance (58.6 to 70.0%); women having their own saving bank accounts (63.0 to78.6%); women owning mobile phones that they themselves use (45.9 % to 54.0%); women married before 18 years of age (26.8 % to 23.3 %); women with 10 or more years of schooling (35.7% to 41.0%), and access to clean fuel for cooking (43.8 % to 68.6%).
But, alarmingly, during this period, the country has not progressed well in terms of direct nutrition interventions. Preconception nutrition, maternal nutrition, and appropriate infant and child feeding remain to be effectively addressed. India has 20% to 30% undernutrition even in the first six months of life when exclusive breastfeeding is the only nourishment required. Neither maternal nutrition care interventions nor infant and young child feeding practices have shown the desired improvement. A maternal nutrition policy is still awaited.
Despite a policy on infant and young child feeding, and a ban on sale of commercial milk for infant feeding, there has only been a marginal improvement in the practice of exclusive breastfeeding (EBF). Child undernutrition in the first three months remains high. Creating awareness on EBF, promoting the technique of appropriate holding, latching and manually emptying the breast are crucial for the optimal transfer of breast milk to a baby. Recent evidence from the Centre for Technology Alternatives for Rural Areas (CTARA), IIT Mumbai team indicates that well-planned breastfeeding counselling given to pregnant women during antenatal checkup prior to delivery and in follow up frequent home visits makes a significant difference. The daily weight gain of a baby was noted to average 30 to 35 grams per day and underweight prevalence rate reduced by almost two thirds.
Another key intervention
NFHS-5 also confirms a gap in another nutrition intervention — complementary feeding practices, i.e., complementing semi-solid feeding with continuation of breast milk from six months onwards. Poor complementary feeding is often due to a lack of awareness to start feeding at six to eight months, what and how to feed appropriately family food items, how frequently, and in what quantity. The fact that 20% of children in higher socio- economic groups are also stunted indicates poor knowledge in food selection and feeding practices and a child’s ability to swallow mashed feed. Where are we going wrong?
So, creating awareness at the right time with the right tools and techniques regarding special care in the first 1,000 days deserves very high priority. We must act now, and invest finances and energy in a mission mode. The Prime Minister can give a major boost to POSHAN 2.0, like he did to Swachh Bharat Abhiyaan, using his ‘Mann Ki Baat’ programme.
There is a pressing need to revisit the system spearheading POSHAN 2.0 and overhaul it to remove any flaws in its implementation. We need to see if we are using opportunity of service delivery contacts with mother-child in the first 1,000 days to the optimum, There is a need to revisit the nodal system for nutrition programme existing since 1975, the Integrated Child Development Scheme (ICDS) under the Ministry of Women and Child and examine whether it is the right system for reaching mother-child in the first 1000 days of life. By depending on the ICDS, we are in fact missing the frequent contacts with pregnant mothers and children that the public health sector provides during antenatal care services and child immunisation services, There is also a need to explore whether there is an alternative way to distribute the ICDS supplied supplementary nutrition as Take- Home Ration packets through the Public Distribution (PDS) and free the anganwadi workers of the ICDS to undertake timely counselling on appropriate maternal and child feeding practices.
We need to systematically review the status, and develop and test a new system that would combine the human resource of ICDS and health from village to the district and State levels. This would address the mismatch that exists on focussing on delivery of services in the first 1000 days of life for preventing child undernutrition by having an effective accountable system.
It is time to think out of the box, and overcome systemic flaws and our dependence on the antiquated system of the 1970s that is slowing down the processes. Moreover, mass media or TV shows could organise discourses on care in the first 1,000 days to reach mothers outside the public health system.
Dr. Sheila C. Vir is a public health nutrition expert and the editor of the book, ‘Public Health Nutrition in Developing Countries’