Malnutrition has been India’s scourge for several years now. A month-long POSHAN Utsav may be good optics, but is no substitute for painstaking everyday work. The need of the hour is to make addressing child malnutrition the top priority of the government machinery, and all year around. An estimated 9,27,606 severely acute malnourished children from six months to six years were identified across the country till November last year. The Global Hunger Index (GHI) 2022 has brought more unwelcome news for India, as far as its global ranking on a vital indicator of human development is concerned. India ranked 107 out of 121 countries. The Government of India attempted to discredit the index immediately in its attempt to deny the findings of the report, even going so far as to term it a conspiracy against India. As more go hungry and malnutrition persists, achieving Zero Hunger by 2030 in doubt, UN report warns Asia remains home to the greatest number of undernourished (381 million). Africa is second (250 million), followed by Latin America and the Caribbean (48 million). The global prevalence of undernourishment – or overall percentage of hungry people – has changed little at 8.9 percent, but the absolute numbers have been rising since 2014. This means that over the last five years, hunger has grown in step with the global population.

The Challenge & Core Issues

Anemia, caused by iron deficiency, is widespread among preschool and school-age children in low- and middle-income countries, and among women of reproductive age. The prevalence of anemia among children under five is uneven across World Health Organization (WHO) regions—highest in the African region (60.2 percent) followed by South Asia (55 percent). Anemia is particularly high in India. While addressing it is complex, solutions exist, and fortifying school lunches with iron may be one way to lower anemia rates in children, and in turn, improve their health later in life. People with anemia have a lower quantity of hemoglobin, which decreases the oxygen-carrying capacity of blood. In chronic and severe cases, it can cause illness, and even death, among women and children. Globally, about 40 percent of children ages 6 to 59 months were anemic in 2019—equivalent to 269 million children.

Policy Possibilities

The ‘Anemia Mukt Bharat’ program was launched by the Ministry of Health &Family Welfare (MoHFW), Gov. of India to reduce the occurrence of Anemia among children, adolescents, and women. Till now, PHTT has done 3.5 lakh registrations in screening anemia patients.

Despite significant improvements in the standard of life and economic prosperity in India over the past decade, iron-deficient anemia remains a widespread problem, especially in some states and regions. The state of Bihar, for example, is poorly equipped to establish an effective distribution system to deliver fortified food products at scale and at low cost, or to ensure high uptake of fortified products by households.

While potential delivery channels in India include “market institutions” such as retail shops or “non-market institutions,” including hospitals, schools, and government offices, our study shows that school-based distribution of iron through school lunch programs could be an effective delivery channel in reducing iron deficiency among school children. The existing network of public schools can be effectively used to implement health programs that tackle malnutrition among children.

Globally, about 380 million schoolchildren are served school lunches daily and if these school lunches are fortified with iron and other micronutrients, the high rate of micronutrient deficiencies—including iron deficiency—could be reduced significantly in low- and middle-income countries (LMICs).

In 2018, the government of India launched Anemia Mukt Bharat (AMB), or Anemia Free India Campaign, to reduce anemia prevalence among vulnerable groups. The AMB program includes the Weekly Iron and Folic Acid Supplementation Program that administers 100 milligrams (mg) of elemental iron and 500 micrograms (ug) of folic acid to school age girls and boys in grades 6-12 enrolled in public schools. These programs are likely to accelerate anemia reduction among women, adolescents, and children.

Policymakers in India and other LMICs need to recognize that a school-based supply of micronutrients is a low-cost, less burdensome, and effective strategy for tackling malnutrition among children.

Anemia in India

A recent health survey shows an anemia prevalence of 60 percent among children under five in India. The majority of anemia cases in India are due to iron deficiency, from eating foods low in minerals and micronutrients, including iron. This is a significant concern because iron deficiency in early life is strongly associated with impaired cognitive and behavioral development in children, and with decreased educational attainment and work productivity later in life. Against this backdrop, reducing the high prevalence of anemia among children in India and other developing countries is an urgent public health priority.

The link between the consumption of iron-rich or fortified foods and anemia is well-documented, but identifying the most effective distributional channels to provide iron to children remains an uphill task. The uptake of fortified food items has been limited in developing countries. For example, a 2018 study published in the Journal of Development Economics showed that market-based supply or free delivery of iron-fortified salt had no impact on anemia incidence—primarily due to the limited use of iron-fortified salt by households. Households were reluctant to either buy iron-fortified salt from the market or use it in their meal preparations. The puzzling evidence in the study implies that the choice of distribution channel is important in anemia prevention and market-based intervention may not work in a setting where demand for health products is low.

Anaemia is a serious global public health problem that particularly affects young children and pregnant women. It is also a widespread health challenge in India. Anaemia is caused due to nutritional deficiencies, especially iron deficiency, and can be treated by dietary changes and supplements. Anaemia is a condition when the blood does not have enough red blood cells, which leads to a reduced flow of oxygen throughout the body. The main cause for anaemia is iron deficiency, and symptoms may include fatigue, shortness of breath, and skin pallor, weakness, dizziness and drowsiness to impaired cognitive development of children and increased morbidity.

There are many causes of anemia, out of which iron deficiency accounts for about 50% of anemia in school children and 80% in children 2-5 yrs of age. The reduction of anemia is one of the important objectives of the POSHAN Abhiyaan launched in March 2018. Complying with the targets of POSHAN Abhiyaan and National Nutrition Strategy set by NITI aayog, the anemia Mukt Bhartat strategy has been designed to reduce prevalence of anemia by 3 % points per year among children, adolescents and women in the reproductive age group between the year 2018 and 2022.

The GHI is an important indicator of nutrition, particularly among children, as it looks at stunting, wasting and mortality among children, and at calorific deficiency across the population. And this is by no means an international conspiracy — India’s National Family Health Survey (NFHS-5) from 2019-21 reported that in children below the age of five years, 35.5% were stunted, 19.3% showed wasting, and 32.1% were underweight.

The World Health Organisation (WHO) defines severe acute malnutrition’ (SAM) by very low weight-for-height or a mid-upper arm circumference less than 115 mm, or by the presence of nutritional oedema. Children suffering from SAM have very low weight for their height, and are nine times more likely to die in case of diseases due to their weakened immune system. The Covid-19 pandemic left 9.2 lakh children in India severely impacted by acute malnourishment. Uttar Pradesh topped the list with the highest cases while Bihar came second. The government data which was revealed last year in response to an RTI query underscored concerns that the Covid pandemic could exacerbate the health and nutrition crisis among the poorest of the poor.

The data had been collected by the Women and Child Development Ministry which had in 2020 asked all states and union territories to identify SAM children for their early referral to hospitals. But even before the Covid-19 pandemic, The Global Nutrition Index 2018 revealed that India has one-third of world’s stunted children.

Acute Malnutrition: Stunting, Wasting

While data is not updated year on year, NFHS-4 (National Family Health Survey) in 2015-16 showed prevalence of severe acute malnutrition among 7.4 per cent of children from 601,509 households, 699,686 women, and 112,122 men. The survey was based on Information from 265,653 children below age 5 had been collected in the survey.

The subsequent NFHS-5 which was conducted acrossd 6.1 lakh sample households and gave figures for 22 states and UTs, also presented a grim scenario. It said malnutrition increased among children in 2019-20 from 2015-16 in 22 states and UTs. While the malnutrition data had improved from NFHS-4, the new reports found that at least 35.5 per cent of India’s children were stunted. Around 13 states and UTs out of the 22 surveyed recorded a rise in percentage of children under five years who are stunted in comparison to 2015-16; 12 states and UTs recorded a rise in percentage of children under five years who are wasted; 16 states and UTs recorded a rise in the percentage of children under five years who are severely wasted and underweight in 2019-20.

Wasting refers to low weight in children in proportion to their height and is an indicator of acute undernutrition. It is a strong predictor of mortality among children under five years of age.

Govt initiatives

• India already scores low on the Global Hunger Index, ranking just above 13 countries out of a total of 107, including North Korea, Haiti, Afghanistan and others.

• The NFHS-5 data is concerning as it reflects how several states like Kerala, Maharashtra, Goa, Gujarat and Himachal Pradesh which in the previous decade had managed to lower their rates of stunting saw a reversal of the trend. 

• To tackle high persistence of malnutrition in the country, the Centre launched the Poshan Abhiyan programme in 2018 to reduce low birth weight, stunting, undernutrition and anaemia among children, adolescent girls and women.

• NFHS 6, which is set to be conducted in the next year, would evaluate the impact and outcomes of the health schemes implemented by the BJP government such as Ayushman Bharat and Poshan Abhiyan on this population. It might be interesting to know how much impact these schemes have had on the health and nutrition of children.

Indicators of inequality

Seven years since India’s independence, indicators of child and maternal health have improved drastically. With mortality now reduced to 30 per 1,000 live births. The infant mortality rate (IMR) was 145.6/1000 live births in 1947.

However, inequitable resource distribution and benefits of the government’s healthcare policies have led to discrepancies and social gaps. Social and economic inequality overlap with health and nutritional metrics, meaning the most malnourished or undernourished children belong to socially or economically backward sections of the population. In 2019, UNICEF noted that globally about 165 million children under the age of 5 years were stunted (low height for age), 101 million were underweight (low weight for age), and 52 million children were wasted. Further, from the estimates from United Nations (UN), about 6.3 million under age-five mortality occurred in India, of which 45 per cent died due to malnutrition.

A 2019 study on socioeconomic inequality found an inverse relationship between a district’s economic development with childhood stunting and underweight, meaning that economically developed districts have a lower prevalence of childhood malnutrition than less developed districts.Socially depressed sections such as children belonging to Scheduled Castes (SC), Schedules Tribes (ST), and Other Backward Classes (OBC) households report higher levels of malnutrition indicators.

NFHS-4 found 43.8 percent of ST children under the age of five were stunted, 27.4 were wasted and 45.3 are underweight. This is the highest percentage share among all the three categories. Among children belonging to the SC category, 42.8 percent are stunted, 21.2 percent are wasted and 39.1 percent are underweight. The prevalence of Anaemia was also higher among children belonging to SC and ST categories. A 2019 study titled Pathways to Inequalities In Child Health highlighted how disadvantaged SECs suffer from worse health than their more advantaged peers as the pathways through which SECs influence children’s health are complex and interrelated. In general, they are “driven by differences in the distribution of power and resources that determine the economic, material and psychosocial conditions in which children grow up”, the authors of the study noted.

UNICEF’s World Children’s Day 2022 theme was “Inclusion: For Every Child”. The theme reflected the need to commit to striving for a more inclusive healthcare policy. This holds especially true for developing nations battling economic and social inequalities like India where social stigma and discrimination are key impediments to healthcare access.

India is one of the 193 countries that are signatories to the United Nations Convention on the Rights of the Child (UNCRC), which includes promoting healthy lives (addressing survival, nutrition, health care services, etc.) as its first goal.

Any interventions in child healthcare, however, can only succeed in an inclusive sense by creating pathways to cross-sectional development in healthcare infrastructure and access that benefits the weakest section of India’s population.

Status of budgetary allocation for Government Schemes

Gaps in the funding: Experts have suggested several approaches to address the problem of chronic malnutrition, many of which feature in the centrally-sponsored schemes that already exist. However, gaps remain in how they are funded and implemented, in what one might call the plumbing of these schemes.

Saksham Anganwadi:

The Government of India implements the Saksham Anganwadi and Prime Minister’s Overarching Scheme for Holistic Nutrition (POSHAN) 2.0 scheme (which now includes the Integrated Child Development Services (ICDS) scheme), It seeks to work with adolescent girls, pregnant women, nursing mothers and children below three. However, the budget for this scheme for FY2022-23 was ₹20,263 crore, which is less than 1% more than the actual spent in FY2020-21 an increase of less than 1% over two years.

PM POSHAN:

PM POSHAN, or Pradhan Mantri Poshan Shakti Nirman, known previously as the Mid-Day Meal scheme (National Programme of Mid-Day Meal in Schools). The budget for FY2022-23 at ₹10,233.75 crore was 21% lower than the expenditure in FY2020-21.It is clear that the budgets being allocated are nowhere near the scale of the funds that are required to improve nutrition in the country.

Nutrition

What are the hurdles for effective Implementation of such large-scale schemes. Underfunded Nutrition Programme: An Accountability Initiative budget brief reports that per capita costs of the Supplementary Nutrition Programme (one of the largest components of this scheme) has not increased since 2017 and remains grossly underfunded, catering to only 41% of the funds required. Vacant posts of Projects officers and insufficient manpower: The budget brief also mentions that over 50% Child Development Project Officer (CDPO) posts were vacant in Jharkhand, Assam, Uttar Pradesh, and Rajasthan, pointing to severe manpower constraints in successfully implementing the scheme of such importance. Regular controversies over the food served under MDM: While PM POSHAN (or MDM) is widely recognized as a revolutionary scheme that improved access to education for children nationwide, it is often embroiled in controversies around what should be included in the mid-day meals that are provided at schools. Irregular social audits: Social audits that are meant to allow community oversight of the quality of services provided in schools are not carried out routinely.

Volatile food prices effects: The effect of cash transfers is also limited in a context where food prices are volatile and inflation depletes the value of cash.Social factors: Equally, there are social factors such as ‘son preference’, which sadly continues to be prevalent in India and can influence household-level decisions when responding to the nutrition needs of sons and daughters.

Nutrition

Suggestions for the effective delivery of the government schemes.Tracing the reasons behind existing malnutrition: It is clear that malnutrition persists due to depressed economic conditions in large parts of the country, the poor state of agriculture in India, persistent levels of unsafe sanitation practices, etc. Political battles over malnutrition are not going to help; nor is continuing to think in silos.Cash transfers where purchasing poverty is less: Cash transfers have a role to play here, especially in regions experiencing acute distress, where household purchasing power is very depressed. Cash transfers can also be used to incentivize behavioural change in terms of seeking greater institutional support. Targeted supplementation: Food rations through PDS and special supplements for the target group of pregnant and lactating mothers, and infants and young children, are essential.Community participation: Getting these schemes right requires greater involvement of local government and local community groups in the design and delivery of tailored nutrition interventions.Comprehensive social education programs for girls: A comprehensive programme targeting adolescent girls is required if the inter-generational nature of malnutrition is to be tackled. There is a need of comprehensive social education programme.