13

Click here to load reader

Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

Embed Size (px)

Citation preview

Page 1: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

Review Article

Under-nutrition in India – A Forgotten National Nutrition Policy withouta National ProgrammeVEENA S RAO*Advisor, Karnataka Nutrition Mission, State Institute of Health and Family Welfare Building, Room No.4 & 5, 1st Cross, Magadi Road, Bangalore 560 023, India

(Received on 13 May 2016; Accepted on 10 June 2016)

This Paper analyses why and for how long high levels of malnutrition have afflicted India’s population. It does a historicalanalysis of how two centuries of colonial rule created the enabling environment for perpetuation of chronic malnutritionthrough interplay of increasing poverty, decreasing literacy, de-industrialization, an increased agricultural labour force, lowwages, deteriorating health and nutritional status. The paper discusses the James Bhore Committee Report, 1946, firstHealth and Nutrition Survey in India, and the alarming nutrition data it reveals. It examines independent India’s responses- Article 47 of the Constitution, the beginnings of nutrition governance in India, development of nutrition strategies andinterventions in the Five Year Plans, the announcement of the Minimum Needs Programme in 1974, launch of the ICDS in1975, and adoption of the National Nutrition Policy (NNP) in 1993, and evaluates their impact. The paper concludes thatthe problem of under-nutrition in India could decrease faster if its structural causes are programmatically addressed,namely, protein-calorie-micronutrient deficit in about 50% of the people’s diet; its inter-generational character; the informationand awareness deficit in the community about proper nutritional care of infants, children, adolescent girls, and pregnantwomen. Important prescriptions of the National Nutrition Policy, 1993, were never implemented, and India has no nationalprogramme to eradicate malnutrition. The paper concludes with recommendations that the Niti Aayog take charge of thismulti-sectoral subject, and constitute a High Power Committee to revise the NNP and draft the National Nutrition Missionwithin a given time frame.

Keywords: Bhore Committee Report; Inter -generational Malnutrition; Five Year Plans; National NutritionPolicy; Niti Aayog

*Author for Correspondence: E-mail: [email protected]

Proc Indian Natn Sci Acad 82 No. 5 December 2016 pp. 1367-1379 Printed in India. DOI: 10.16943/ptinsa/2016/48873

Under-nutrition in India – A forgotten NationalNutrition Policy without a National Programme

Looking Back – For how long have high levels ofmalnutrition afflicted India’s population?

Let me begin this paper by quoting from the conclusionof the opening chapter of one of the most importantand pioneering reports related to the problem of under-nutrition in India.

“To sum up, the factors responsible for the lowlevel of ill-health in India include, among others, theprevalence of malnutrition and undernutrition amongappreciable sections of the people, the seriousinadequacy of existing provision for affording healthprotection to the community and a group of social

causes consisting of poverty and unemployment,illiteracy and ignorance of the hygienic mode of lifeand certain customs such as early marriage. Thecumulative effect of these factors is seen in theincidence of a large amount of preventable morbidityand mortality in the community. The continuedprevalence of such conditions for many generationshas probably helped to create in the minds of thepeople an attitude of passive acceptance of the existingstate of affairs. This attitude will have to be overcomeand their active cooperation enlisted in the campaignagainst disease, insanitation and undesirable personaland community habits, if any lasting improvement inthe public health is to be achieved.”

This is not a Report of recent years, however

Published Online on 9 December 2016

Page 2: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1368 Veena S Rao

relevant and contemporary it might sound. This is theconcluding paragraph of Chapter 1 of ‘A brief Surveyof the State of the Public Health’ - India’s firstcomprehensive report on nutrition and health - the‘Report of the Health Survey and DevelopmentCommittee’, 1946, headed by Sir Joseph Bhore. Apartfrom stating the universally known connectivitybetween health and nutrition, this Report vigorouslyemphasizes the importance of proper sanitation,(something omitted even in the National NutritionPolicy, 1993) for improving nutritional status, andprovides valuable insights regarding behavioural andsocial practices that negatively impact nutritionalstatus.

The author is particularly impressed by theReport’s comments that, “The continued prevalenceof such conditions for many generations has probablyhelped to create in the minds of the people an attitudeof passive acceptance of the existing state of affairs.This attitude will have to be overcome and their activecooperation enlisted in the campaign against disease,insanitation and undesirable personal and communityhabits, if any lasting improvement in the public healthis to be achieved.” These factors continue to persistin India even today, particularly the attitude of passiveacceptance of an affliction, which they do notunderstand why they have.

It is also important to revisit the findings of thefood surveys conducted between the years 1935 to1948. These are adequately quoted and form the basisof the recommendations of the First Five Year Plan,(1951-1956), regarding nutrition in Chapter 32, Paras25 and 26.

Para 25 reads as: “The average diet of an Indianis lopsided primarily because of its extremely highcereal content. The other noticeable feature is thatthe diet lacks in adequate amounts of protective foodsleading to inadequacy and very often to total lack ofproteins of good quality. Inadequacy of minerals andmost of the important vitamins in more or less varyingdegrees is the other important feature. It has not beensufficiently realized that the inadequacy of B groupof vitamins is of the most serious import in view ofthe large intake of carbohydrates. Intake of vitaminsA and C also is often inadequate”. These surveyshave led to the following observations: “It appearsthat two-thirds of the families did not consume any

fruits and nuts at all. About one-third of the familiesdid not consume sugar and jaggery, meat, fish or fleshfoods, and a quarter of the family groups did notconsume milk and milk products or leafy vegetables.Again, amongst the groups of families consumingparticular foodstuffs the intake of leafy vegetables,other vegetables, ghee and vegetable oil and pulseswas below the desired or recommended level. Onlyin about one-fifth of the groups of families surveyedwas the intake of pulses and other vegetables up tothe recommended level. Though any generalisationon the data presented is not desirable for reasons morethan one, yet it may be stated that in about four-fifthsof the families surveyed the intake of protective foodswas either nil or below standard.

Para 26. “The bulk of the population cannotafford to purchase a satisfactory diet. In terms ofaverage income it would hardly be possible for morethan 30 per cent of the population to feed themselveson an adequate scale” (First Five Year Plan, Chapter32, 1951-56).

Colonialism, the enabling environment forIndia’ s chronic malnutrition and micr onutrientdeficiency

The reports referred to above should remind us thatunder-nutrition and micronutrient deficiency whicheven today afflict more than 50% of our population,is not something that was suddenly acquired becauseof successive natural calamities, food shortages orwar. Clearly, it is one of the outcomes of sustainedsocio-economic deterioration caused by the increasingpoverty in the 19th and 20th centuries under colonialrule, brought about by changed occupations andagricultural patterns enforced by the colonial masters(P. Ponram, 2014) and surging illiteracy resulting fromdepriving the existing and flourishing indigenous systemof education of patronage and funds (Dharampal,1985). Reduced incomes, poverty, compounded byrapidly growing illiteracy, poor health care, and lackof opportunity for upward economic or social mobility,created the most enabling environment for chronicmalnutrition and micronutrient deficiency among thegeneral population of India, the remnants of whichpersist even today.

The conscious policy of the colonial governmentto de-industrialize India, and gradually wipe out anyindustry that manufactured finished products, drove

Page 3: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1369

the unemployed artisan and weaver sector intoagriculture. Simultaneously, there was also a consciouspolicy of converting more and more agricultural landsfor growing cash crops. Starting from 1850, over500,00 acres of the most fertile Ganges basintraditionally growing agricultural crops were convertedinto poppy farms by 1900, for opium trade with China(P. Ponram, 2014).

By the early twentieth century, three out of fourIndians were employed in agriculture, famines werecommon, and food consumption per capita declinedin every decade (ibid). Colonialism reversed India intoan agricultural economy with illiterate unskilled labourand low productivity, and scarcity of skills, capital andknowledge. The intensity of poverty and malnutritionkept increasing during the colonial period, the resultsof which are documented in the Bhore CommitteeReport and the food surveys, 1935 to 1948, cited above.

Independent India was born with a populationhaving the following human development indicators –a per capita income of a meagre Rs 249.6, a literacyrate of 18.33% (with female literacy at 8.86%) (datafrom National Commission on Population), male andfemale life expectancy at 26.91 and 26.56 yearsrespectively, a death rate of 22.8 per 1000, infantmortality rate of 158 per 1000, and maternal mortalityat 20 per 1000 live births, with only one third of thepopulation having the income to feed themselvesadequately (First Five Year Plan, 1951-56).

Independent India’s Response and theBeginnings of a Nutrition Policy

From the above Reports, it is clear that the populationof independent India suffered from high rates of under-nutrition and severe micronutrient deficiencies. Thefirst State response is articulated in the highest law ofthe land, the Constitution of India, in Article 47 of theDirective Principles of State Policy:

“Duty of the State to raise the level of nutritionand the standard of living and to improve public health.-

The State shall regard the raising of the level ofnutrition and the standard of living of its people andthe improvement of public health as among its primaryduties and, in particular, the State shall endeavour tobring about prohibition of the consumption except formedicinal purposes of intoxicating drinks and of drugswhich are injurious to health.”

The Five Year Plans and the National NutritionPolicy, 1993

The National Nutrition Policy (NNP) 1993 is India’sprimary national policy directly governing the subjectof under-nutrition and micronutrient deficiency. It wasfollowed up by the National Plan of Action on Nutrition1995.

Prior to the NNP, the development of India’spolicy regarding nutrition can be gleaned from theFive Year Plans.

The Nutrition Section of the First Five Year Plan(1951-56) starts with the economic dimension ofnutrition - ‘Nutrition is perhaps the most importantsingle factor in the maintenance of health andresistance to disease. The state of nutrition has a directbearing on the productive capacity of an individual.Several studies carried out in different parts of theworld give a direct correlation between calorieconsumption and accomplishment of workers. Thereis reason to believe that both under-nutrition andmalnutrition exist widely in the country.’

This simple but fundamental economiccorrelation between the state of nutrition andeconomic productivity, though highlighted in our veryFirst Five Year Plan, has not yet been grasped in oureconomic aspirations towards faster growth and higherGross Domestic Product (GDP).

The First Plan focused on setting up the basichealth infrastructure for the country and addressingthe more visible, clinical manifestation of malnutritionand micronutrient deficiencies, such as, nutritionalblindness, beri beri, pellagra, marasmus andkwashiorkor.

The Second Five Year Plan (1956-61) whileprimarily addressing food production and food security,entrusted the calculation of nutrition data to the IndianCouncil of Medical Research (ICMR). Foodtechnology for improving nutritive value of foods andproduction of fruits and vegetables was alsoemphasized. Priority was placed for improvingnutrition of vulnerable groups, such as expectant andnursing mothers, infants, pre-school and school goingchildren as its specific objective. It recommended that,‘To the extent milk powder and food supplements likecod liver oil and vitamins are available for distribution,this consideration should be specially kept in view.

Page 4: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1370 Veena S Rao

Efforts to provide mid-day meals for school-goingchildren should also be made.’

The Third Five Year Plan (1961-66) admits that‘ During the first two Plans there has been noconcerted effort to improve nutrition, change foodhabits or create great awareness of the problem. Withthe increase in production and improvement ineconomic conditions envisaged for the Third Plan, asystematic approach to the problem of nutrition shouldnow be feasible.’ (Para 55 of Chapter 32 on Healthand Family Planning) In Para 56, it states that ‘At thepresent stage of development the programme forimproving nutrition falls broadly under two heads,namely, education of the public and of various groupsof workers in nutrition, and measures to meet thenutritional requirements of vulnerable groups withinthe community.’ However, no specific interventionshave been recommended in the Plan.

The Fourth Five Year Plan (1969-74) saw Foodand Nutrition as a separate Chapter, and spelt out anintegrated approach to improve nutrition, thatdevelopment in ‘agriculture, along with animalhusbandry and fisheries, must be regarded as the baseof all effort in nutrition.’

The Mobile Food and Nutrition ExtensionService and Applied Nutrition Programme forimproving consumption by promoting production offruits and vegetables, milk and fish etc, at householdand community levels were important nutritioninterventions during this period. The Plan containedseveral significant interventions to combat protein-calorie-micronutrient under-nutrition among thevulnerable groups, such as production of Balahar, lowcost protein foods and weaning foods, fortification ofwheat and bread, mid day meals for school goingchildren, addressing nutritional anaemia amongmothers and children, and blindness due to Vitamin Adeficiency in children. The Crash Feeding Programmefor pre-school children in rural, urban and tribal areas,the Balwadi Nutrition Programme for bridging thecalorie and protein gap, the National ProphylaxisProgrammes for Nutritional Anaemia and NutritionalBlindness due to Vitamin A deficiency, were launchedin the Social Welfare and Health sectors of theGovernment.

However, the critical interventions for ‘educationof the public and of various groups of workers in

nutrition,’ for creating nutritional awareness andbehavioural change were never initiated, even thoughthey had been repeatedly recommended from theBhore Committee Report, 1946, and the First Planonwards. They have continued to elude a strategyand programme during the last six decades and more.The fact that the percentage of population sufferingfrom malnutrition far exceeds the percentage ofpeople below the poverty line clearly establishes thatunder-nutrition is not merely confined to people livingbelow the poverty line, but also extends to those withpurchasing power, because of lack of information andawareness regarding proper nutritional practice anda balanced diet.

The Fifth Five Year Plan (1974-79). The conceptof an integrated approach for addressing under-nutrition among children and women wasconceptualized in the 5th Five Year Plan (1974-79),and in 1975 the Integrated Child DevelopmentServices (ICDS) was launched in 33 Blocks. TheMinimum Needs Programme (MNP) announced in1974 was considered the core of the social sectordevelopment plan with 8 basic minimum services.These were Elementary Education, Rural Health,Rural Water Supply, Rural Electrification, Rural Roads,Rural Housing, Environmental Improvement of UrbanSlums and Nutrition.

The author believes that the ICDS became thewatershed moment of India’s future policy towardsnutrition. On the one hand, it was a step in the rightdirection for an integrated child developmentprogramme with the five components ofsupplementary nutrition, immunization, health check-up, referral services, pre-school non-formal educationand nutrition and health education. On the other hand,because its objectives did contain among others,‘improvement of the nutritional and health status ofchildren in the age-group 0-6 years,’ and ‘reductionof mortality, morbidity, malnutrition and schooldropout’, the ICDS acquired a mistaken identity of aprogramme to address the general subject ofmalnutrition in India afflicting all age groups and bothsexes among the population, particularly adolescentgirls and boys.

I reproduce below, some extracts from thereferences made in the Minimum Needs Programmeabout Nutrition in the Sixth Five Year Plan:

Page 5: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1371

Nutrition

14.27 “The nutrition programme has twocomponents—(a) Special Nutrition and (b) Mid-DayMeals.

The Special Nutrition Programme (SNP) wasintroduced on the Non-Plan side during 1970-71 andsubsequently was brought into the Fifth Plan as a partof the Minimum Needs Programme. It provides 300calories and 8-12 grams of protein for the age group0-6 for 300 days, and 500 calories and 25 grams ofprotein for the pregnant and nursing mothers for 300days. The eligible target group for this programme ason 1-4-1980 is 70 million children of 0-6 years and 7million mothers.

The Mid-day Meals (MDM) Programme for theage group 6-11 was introduced in 1962-63. It providesfor mid-day meals to these children for 200 days in ayear and 300 calories and 8-12 grams of protein perchild per day. It was made a part of the MinimumNeeds Programme in the Fifth Plan. It will continueas part of the MNP in the Sixth Plan.”

The Planning Commission was clear in its verdicton Nutrition. India’s problem of under-nutrition andmicronutrient deficiencies did not require a nationalprogramme like other MNP components, such as,Elementary Education, Rural Health, Rural WaterSupply etc. The ICDS and the School Mid-day mealsprogramme would suffice to address nutrition problemsafflicting the population.

The result of this has been that all Planssubsequent to the Fifth Five Year Plan have treatedICDS, originally meant to be an integrated childdevelopment programme, targeting children below sixyears and pregnant and nursing mothers, as aprogramme to combat undernutrition in India. Aflawed belief also set in the minds of policy makersand planners that the problem of under-nutrition hadbeen sufficiently addressed by the ICDS and mid-day meal programme, and no further initiatives wererequired. This flawed belief has persisted. From theSixth Plan onwards, the concept of nutrition continuedto be viewed as synonymous with the supplementaryfeeding component of the two national programmes,viz., the nutrition component of the ICDS for childrenfrom 0-6 years and pregnant and nursing mothers,and the Mid Day Meal Programme of the Departmentof Education.

The Chapter on Food and Nutrition Security inthe Tenth Five Year Plan (2002-07) did contain a listof several aspirational initiatives, which included theprescriptions of previous plans, and also provided ageneral assessment of the nutritional status of India’spopulation in a multi-dimensional and inter-sectoralmanner. However, while stating the Goals set for theTenth Plan in Para 3.3.155, the focus remained onunder-nutrition of children below six years, reductionof Anaemia and Iodine Deficiency Disorder (IDD)and elimination of Vitamin A deficiency, all of whichwere covered by on-going programmes. The TenthPlan period saw no new programmes or initiatives toaddress under-nutrition or follow up on any of theaspirations articulated in the Food and NutritionSecurity chapter. This situation has continued till date,with a few ad hoc additions to the ICDS, such asSabla, a scheme for Adolescent Girls announced in2011, and the Multi Sectoral Programme to addressMaternal and Child Malnutrition, being implementedin 200 high burden Districts, without any additionalimplementation support to the Anganwadi.

A Critical Assessment

A critical assessment of the manner in which thesubject of Nutrition has been addressed in the FiveYear Plans would lead one to believe that the plannerswere on the right track until the Fifth Five Year Plan.The ICDS was indeed a step in the right direction forEarly Childhood Development, constituting an elementof supplementary nutrition for children under 6 yearsand pregnant and lactating mothers. But, to considerthe ICDS as a national programme to combatmalnutrition was a step in the wrong direction.

The ICDS did not have a component ofdisseminating nutritional awareness to the generalpopulation that has been abundantly emphasised in allprevious plans and the Bhore Committee Report. Itdid not address the adolescent girl’s nutritional status,the critical link to ensuring the nutritional and healthstatus of the next generation, nor did it have thecapacity or wherewithal to engineer the essentialconvergence of critical indirect interventions, mostimportantly, safe drinking water and sanitation,agriculture, horticulture, fisheries etc. The ICDS couldreach out only to pregnant and nursing mothers andchildren below 6 years, and could not touch thepopulation dimension of India’s under-nutrition, such

Page 6: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1372 Veena S Rao

as the protein calorie micronutrient deficit and ChronicEnergy Deficiency among adults and adolescent girlsand boys, amply brought out in the National NutritionMonitoring Bureau (NNMB) Repeat Surveys[(NNMB Reports of the First, Second and Thirdsurveys; (1988-99), (1988-99), (2011-12)].

The unfortunate result of this was that the largerpopulation dimension of malnutrition, well articulatedin the previous plans, got pushed outside the nutritionagenda, and is presently without any parent ministryto programme for it. So too, the Communication andAdvocacy component highlighted from the time ofthe Bhore Committee Report, 1946, was pushed intothe background. Both these issues remain un-discussed and un-addressed even today, and theabsence of interventions to address them is one ofthe major reasons for the extremely tardy reductionof under-nutrition in India.

Malnutrition has also become a misunderstoodword amongst our Planners. Often, it is consideredsynonymous with food programmes or with hungeror food security. Its vast inter-sectoral dimensions,inter-generational character, its relationship withpoverty and income generation, its economic lossesto the nation, have yet not registered in the processesof economic planning. Malnutrition is still not statedas a major national challenge by the politicalleadership, either at the National or State levels, andeven when it is, it is never prioritized high enough tobe followed up by a meaningful or effective strategyto combat it with requisite programme backup orresource allocation.

There was some hope that there would be areorientation towards the issue of malnutrition afterthe Finance Minister’s Budget Speech of 2012, (Para92) that “following the decision taken by the primeminister’s National Council for India’s NutritionalChallenges, a multi-sectoral programme to addressmaternal and child malnutrition in a selected 200 highburden districts is being rolled out during 2012-13. Itwill harness synergies across nutrition, sanitation,drinking water, primary healthcare, women’s education,food security, and consumer protection schemes”(Budget Speech, 2012-13). However, no newprogramme emerged from this Budget declaration.

The author believes that the Fifth Five Year Plan(1974-79) was the defining moment when Nutrition

missed out on the opportunity of becoming a stand-alone national programme, when all other MNP issuesbecame so. One can only assume that neither thelobby of professional nutritionists, nor the developmentadministrators were able to impress the highestpolitical leadership or the planners and policy makersof its long or short-term consequences on nationaldevelopment.

The National Nutrition Policy, 1993

A Task Force on Nutrition Policies and Programmeswas set up by the Planning Commission in 1980 towork on inclusion of a nutrition component in sectoralpolicies and programmes. The Task Force realizedthe need for a Nutrition Policy for the country, andthe Department of Women and Child Development,created in 1985, constituted an Expert Working Groupin 1990 for formulating a Policy. The InternationalConference on Nutrition (ICN) jointly organised bythe Food and Agriculture Organisation and WorldHealth Organisation in December 1992 at Rome alsodirected all member countries to adopt a NationalNutrition Policy and develop a National Plan of Actionon Nutrition.

The National Nutrition Policy was adopted bythe Government of India under the aegis ofDepartment of Women and Child Development in 1993and laid in both the Houses of Parliament. TheNational Nutrition Council was set up in the PlanningCommission in 1994 under the Chairmanship ofHon’ble Prime Minister.

The NNP advocates a comprehensive,integrated and inter-sectoral strategy for addressingthe multi faceted challenge of malnutrition, which alsoincludes the prescription of the previous Five YearPlans.

The Policy prescribes the following Direct andIndirect interventions:

Direct Interventions

l Expanding safety nets for children

l Triggering behavioral changes amongmothers

l Reaching the adolescent girls

l Ensuring better coverage of pregnantmothers so as to prevent low birth weight

Page 7: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1373

l Fortification of essential foods withappropriate nutrients

l Popularization of low cost nutritious foods

l Control of micronutrient deficiencies amongvulnerable groups

Indirect Interventions

l Food security

l Improvement of dietary pattern

l Poverty alleviation programmes andstrengthening of Public Distribution System

l Land reforms

l Nutrition surveillance

l Monitoring and research

l Equal remuneration

l Communication

l Minimum wage administration

l Community participation

l Education and literacy

l Improved status of women

The National Nutrition Policy 1993, even today,is one of our soundest policy documents, though itdoes require some updating after 23 years. Itsprinciples are grounded in the inter-sectoral, inter-generational approach and remain as valid today asthey were in 1993. Certainly, a great deal of newdata and evidence regarding under-nutrition andmicronutrient deficiency has emerged since 1993, andmany new policies and development programmes thatimpact the nutrition environment have beenannounced since 1993, for example, the NationalHealth Policy 2002 and the National Policy for theEmpowerment of Women, 2001, (both currently underreview). These policies have defined the life-cyclecovering the girl child, adolescent girl and the adultwoman; stated that nutrition is a continuum coveringthe life-cycle, and should not be compartmentalized;and emphasized essential inter-sectoralcomplementarities between health, nutrition, sanitation,drinking water, education, women’s empowerment,and agriculture.

Volumes of nutrition data have poured in fromthe National Family Health Surveys, 1992-93, 1998-1999, 2005-06, and the NNMB Repeat Surveys, 1988-

90, 1996-97, 2011-12, and the National Sample SurveyOrganisation (NSSO) 68th Round, which give us theprogressive nutritional and consumption profile of ourpeople. New research findings have been publishedestablishing the correlation between open defecationand stunting (Spears D, 2013). The NNP must berevised to include this new data and the criticalimportance of safe drinking water and sanitation forimproving nutritional status, presently absent in it.

While several prescriptions of the NationalNutrition Policy were existing as NationalProgrammes, such as, Vitamin A Programme, and theAnaemia Prophylaxis Programme, the ICDS,some other prescriptions which would have hadimmediate and far reaching positive impact onimproving nutritional status of our population wereignored, such as “Fortification of Essential Foods”and “Popularization of Low Cost Nutritious Foods”;bringing about behavioural change through “BasicHealth and Nutrition Knowledge” and“Communication”; and ”Improvement of Dietarypattern through Production and Demonstration.”

These omissions have cost the nation dearly incombating malnutrition among those under-nourishedsections of the general population not covered by theICDS or the midday meal programme, both in termsof lost time and wasted generations. This pointbecomes even more significant, given the fact thateven though the per capita income has more thanquadrupled in the last decade, and the ICDS, MDM,and the Public Distribution System have been inoperation for decades, all NNMB Reports, the lastbeing NNMB Technical Report No. 26, 2012,continuously show a large dietary deficit in terms ofprotein, calorie and micronutrients among more than50% of our population of both sexes and all age groups(NNMB 3rd Repeat Survey, 2011-12). And despitethe ICDS having been in operation for the last fourdecades, early data emerging from the NFHS- 4Factsheets (2015-16) covering 17 States (Fig. 1),informs us that the percentage of children from 6-23months receiving an adequate diet ranges from ameagre 5.9% to 31.1%. Clearly, there is highercorrelation of dietary deficit with an awareness/information deficit and with absence of appropriate,affordable complementary foods in the market, thanthere is with poverty or lack of purchasing power.And this in spite of the fact that recommendations for

Page 8: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1374 Veena S Rao

nutrition education, and popularizing of low cost foodshave existed in our Plans and in the National NutritionPolicy, 1993.

In retrospect, the National Nutrition Policy, 1993,though still alive on our policy books, can unfortunatelyonly be viewed as a forgotten or inert policy. Itsimplementation was to be done by an Inter-ministerialCoordination Committee in the Department of Womenand Child Development, overseen by the NationalNutrition Council headed by the Prime Minister. TheNational Nutrition Council never met and the Inter-ministerial Coordination Committee turned out to benon-functional. No sectoral programmes were drawnup in accordance with the NNP, and consequently nobudgets were allocated. The National Nutrition Policy,though a most holistic and comprehensive document,failed to get implemented into programmes, and anopportunity to highlight malnutrition as a priority andgap area in India’s development agenda was missed.

However, the NNP, though it requires someupdating in the light of new research, data andevidence, fundamentally remains relevant even today,even though it has been rendered inert without anational programme or political will to back it.

Why Ar e Our Nutritional Indicators NotImproving Faster?

This question can be answered very simply - becausethe primary causes of under-nutrition and micronutrientdeficiency in India have not yet been addressed.Enough research has been generated in India, postindependence that informs us that:

l At least 50 % of our population suffers fromchronic protein calorie micronutrient deficiency(ibid). This factor has never been acknowledgedby our policy makers or programme managersfor finding solutions, nor taken into account forpolicy making or structuring strategies to addressthis deficit.

l Malnutrition in India is deeply rooted in the inter-generational cycle. However, the current policiesand programmes do not address the issue inter-generationally by addressing the nutritional needsof the girl child, the adolescent girl and theexpectant mother simultaneously.

l There is inadequate awareness and informationregarding proper nutritional practices amongstthe population, particularly regarding nutritionalcare of infants, children, adolescents, andpregnant women. Yet, as stated above,programmes for nutrition education andbehavioural change, particularly among thevulnerable sections of the community that suffermost from under-nutrition, were neverconceptualized and initiated.

l Crucial prescriptions of the National NutritionPolicy, 1993, that could have had positive andsustainable impact on the nutritional status ofthe general public were not translated intoNational Programmes, viz., popularization of lowcost nutritious foods, reaching the adolescentgirl, fortification of essential foods and controlof micronutrient deficiencies.

l India has no comprehensive National Programfor the eradication of malnutrition. In generalperception, the ICDS originally designed with amandate for providing, inter alia, some nutritionalservices for children below six and pregnant andnursing mothers, is mistakenly seen as aprogramme to address malnutrition in India.

In India’s complex, contemporary socio-economic transition, manifested diversely and unevenlyin different parts of the country, the gap in addressingunder-nutrition lies not in lack of a Policy, but in theintent of translating its provisions into programmesbacked by budgets. Ideally, the essential interventionsof the NNP should have been woven into a nationalprogramme to combat under-nutrition long ago, witha definite implementation template of workable

Fig. 1: Percentage of children aged 6-23 months receivingadequate diet (Source: NHFS-4 (2015-16: Factsheets)

Page 9: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1375

interventions on the ground. But the political will, orofficial initiative and skill to make that happen appearto have been absent.

Though some interventions included in the NNPdo form core components of national programmes,such as, immunization, Vitamin A and Iron and FolicAcid, (IFA) administration, and national programmesfor sanitation and safe drinking water were alsoinitiated, there is no system in place to ensure thatthese critical inter-sectoral interventions operatesimultaneously with full coverage of target groups.

Further, real-time monitoring systems, concurrentmonitoring and evaluation, to ensure complete targetgroup coverage by inter-sectoral interventions, andmeasure impact do not form part of the ICDS, ornational health, water or sanitation programmes.

Without a national strategy and programme tocombat under-nutrition, additional interventions, suchas proposed in the Multi-Sectoral Programme toaddress the Maternal and Child Malnutrition inselected 200 high burden districts, or of the Sablascheme, have over the last two decades been loadedon in an ad hoc manner to the anganwadi, which hasneither trained manpower, nor the capacity orresources to implement them effectively. Hence,gaps, both structural and systemic, show upconspicuously in the disconnect between the causesof malnutrition in India and the interventions withinexisting programmes.

Even though the National Nutrition Policy hascomprehensively covered the structural causes ofunder-nutrition and micronutrient deficiency in India,and made recommendations to address them, severalcritical recommendations remain unattended. Forexample, the most critical life-cycle and inter-sectoralinterventions have not been structured into a singleintegrated template for implementation. There is verylittle advocacy or IEC for dissemination of child/adolescent girl/maternal care or nutrition informationfor the community at grass roots to overcome thenutrition information gap. The protein-calorie-micronutrient deficit, (the most proximate cause ofunder nutrition), prevalent among diverse age groupsamong at least 50% of the population, remainsunaddressed, even though confirmed by successiveNNMB Repeat Surveys, including the latest in NNMBTechnical Report Number, 2012.

What emerges is a visible asymmetry betweenstructural causes of India’s under-nutrition well statedin the NNP, and the ongoing programmes andinterventions, the sum total of which do not addresseven a majority of them.

Even within on going, nutrition-relatedprogrammes and interventions, there are conspicuoussystemic gaps at the cutting edge, community level,where the real interventions against under-nutritionmust happen. Important systemic gaps lie in theprovisioning for anganwadi infrastructure andmanpower, providing a rationalized and practicalcharter of responsibilities to the anganwadi worker,establishing real-time monitoring mechanisms andaccountability systems, creating systems for ensuringcomplete coverage of target groups, for inter-sectoralmechanisms at village level to engineer ‘convergence’,and for effective behaviour change strategies at thegrassroots.

The minimum, basic inter-sectoral convergencefor combating under-nutrition requires that everytargeted family must simultaneously receive thefollowing benefits - calorie-protein micronutrientsupplementation to bridge the dietary deficit; completeimmunization of children; IFA for addressing anaemiaamong children, women, and adolescent girls; safedrinking water; and hygienic sanitation. Four of theseinterventions already form part of nationalprogrammes. Unfortunately, there is no villagefunctionary in the present implementation system, whois tasked with the responsibility of ensuring that thetargeted households receive this complete packagesimultaneously, which alone can create positivetransformational impact on reducing under-nutrition.Consequently, we have no data at the national, stateor district level regarding the same; and inter-sectoralprogrammes instead of operating simultaneously,remain scattered.

Social Sector policies and programmes in Indiagenerally result from Constitutional commitments orcommitments at international bodies, or throughsustained internal demand or activism. Politicalgovernance in States is either demand driven orelection driven. Popular demand for addressingmalnutrition from the afflicted is absent, as thecommunity lacks information and awarenessregarding their own affliction or its causes. Andabsence of a national programme further inhibits

Page 10: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1376 Veena S Rao

community knowledge about undernutrition, whichcould have created demand. Clearly, a chicken andegg situation. Experience shows that public awarenessand information dissemination on social anddevelopment issues is largely generated through themedium of strong national programmes, thatthemselves become the strongest advocacy toolstaking the messages down to the grassroots, forexample, the health, education and women’sempowerment programmes. Information andawareness regarding malnutrition has no suchmedium. Hence, the vacuum in information atgrassroots within families, community organizations,Panchayat Raj Institutions (PRIs) and field staff ofNon Government Organisations (NGOs) andGovernment, regarding critical issues like preventingchild under-nutrition, proper maternal nutritional careto ensure adequate pregnancy weight gain and preventlow birth-weight babies, (first casualties to neo-natalmortality), and nutritional care of adolescent girls, (themost under-nourished in the world), who are futuremothers.

This lack of information and awareness is a majorcause for the absence of capacity creation at all levelsand stages of the participation/implementation process,and more importantly, it leads to absence of demandfor nutritional services from the afflicted population,simply because they have no knowledge or awarenessregarding their affliction. All these factors put togetherperhaps explain why there are hardly any think tanks,research or capacity building institutions at State orDistrict Levels; no journals or information in locallanguages to inform rural populations, NGOs or localinstitutions about the subject, not even vernacularequivalents for terms like ‘body mass index’ or‘chronic energy deficiency’.

The above factors cascade into the absence ofan enabling environment for a united and vocalnutrition lobby with strong leadership to influencegovernment, as exists in other sectors. There isnegligible presence of Public Health/Nutritioncurricula in research and medical institutions in Statecapitals and none at all in District/Block institutions,where the action really lies. Besides, the nutrition lobbyis disunited, often deflecting attention from the urgencyof addressing under-nutrition holistically, by generatingadversarial debate on issues like food fortification,and low cost complementary food, not sparing even

double fortified salt, or the Vitamin A prophylaxisprogramme. A strong, united nutrition lobby, providinginnovation and working models could have acquiredgreater clout to prevail upon government to announcea national programme to address malnutrition, sourgently required in the country.

There has also been sustained prejudice againstprivate sector cooperation in India’s strategy tocombat undernutrition or engage with them. TheGovernment must motivate the private sector to takesome measure of responsibility for making availableappropriate low-cost energy foods for poor, under-nourished and anaemic children, women, adolescentgirls and boys, the sick, aged and infirm, in rural andurban markets. The numbers are large enough tosupport a viable business proposition, and this is theonly sustainable solution for enabling the under-nourished percentage of the population to bridge theirmacro and micro nutritional deficit for the presentgeneration. There is a huge market vacuum in thisrespect, unfortunately filled up by forcefully advertisedlow-cost junk foods and tobacco products, which areconsumed by the poor without any nutritional benefit.The presence of high cost energy foods for women,children and the general population, mostly marketedby global companies, is expanding in the market, andare consumed by middle class and higher incomefamilies. Why deny similar, more affordable productsto the poor, who are most in need of them? (Rao V S,2016).

What Needs to be Done?

To conclude, the problem of under-nutrition in Indiastems from lack of serious implementation of itsNational Nutrition Policy, 1993, which contains mostof the prescriptions of the Five Year Plans. This in asituation of lack of demand, requires strong politicalwill to implement it.

The silent under-nutrition crisis in India is oneof alarm, particularly regarding children andadolescents, the potential work force of the country,who constitute 40% of the population, and Governmentresponse is urgently required. The NNP must berevisited and updated, and should address the problemholistically with reference to the latest demographicand epidemiological data, as reflected in the NNMBReports covering all age groups of the population.

Page 11: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1377

Nutrition data of the 1970s and 80s, the ICDSera, related mostly to women and children. This isperhaps the reason why India’s pandemic under-nutrition, even today, is persistently viewed as a womenand children’s issue by government, NGOs,researchers, and academia. Undoubtedly, women andchildren are the worst sufferers, and hapless carriersof undernutrition, and require highest priority in anational programme. But additionally, the under-weightand stunting data of school going children above sixyears, of adolescent girls and boys, Chronic EnergyDeficiency and micronutrient deficiency rates amongadult men and women, is equally alarming and justifiesthat the problem of malnutrition be treated as a seriouspopulation issue. Inflation and price rise of food itemshave reduced food intake among the poor, furtherdeteriorating their nutritional status. Direct evidencefor this is forthcoming in the Karnataka NutritionMission Pilot Projects’ data, confirmed by the NSSO68th Round, “Nutritional Intake in India” (2011-12)and NNMB Technical Report Number 26 (NNMB3rd Repeat Survey, 2011-12).

What India urgently needs is the political will toaddress under-nutrition through a national programmebased on the NNP, backed by effective programmesand adequate financial allocations that address thestructural and systemic causes, with monitorabletargets, real-time monitoring and evaluationmechanisms, and accountability systems.

The good news was that the Finance Ministerannounced in his Budget speech on July 10, 2014,that “A national programme in Mission Mode isurgently required to halt the deteriorating malnutritionsituation in India, as present interventions are notadequate. A comprehensive strategy including detailedmethodology, costing, time lines and monitorabletargets will be put in place within six months” (BudgetSpeech 2014).

The bad news is that the National Programmein Mission Mode to address malnutrition has not yetbeen formulated, even as in May 2016, as I writethis. The Ministry of Women and Child Developmenthas been grappling with the National Nutrition Missionfor the past two years, but has not yet been able toproduce a blueprint, or conceptualize a strategy toaddress the inter-sectoral and the population dimensionof malnutrition. Strangely, there appears to be nopublic debate on the issue, and no questions have been

raised in the public domain as to why this has nothappened.

A national programme to combat undernutrition andmicronutrient deficiency is perfectly doable, andshould be based on the following principles:

l Bridging the protein-calorie-micronutrient deficit,which affects at least 50% of the population, bysupplementation, either through governmentprogrammes or the market.

l Covering the entire life cycle of women andchildren so as to break the inter-generationalcycle of malnutrition within the shortest possibletime.

l Converging the multi-sectoral interventions atfamily and community levels to simultaneouslyaddress all or majority of direct and indirectcauses of malnutrition simultaneously, many ofwhich exist in ongoing programmes.Interventions include Direct Interventions, basedon adequate food and micro-nutrients,immunization, Vitamin A and IFAsupplementation, use of iodized or double fortifiedsalt, and Indirect Interventions, addressing issuesof health, education, water, sanitation and socio-cultural factors, like female literacy, latemarriage, feeding children of both sexes equally,that are critical to eradicate malnutrition on along term, sustainable basis.

l Initiating a sustained general public awarenesscampaign, through the multi-media andinterpersonal communication mode to reach thegeneral public, especially at the grass-root level,regarding proper nutritional practices in thefamily, and proper child, adolescent and maternalnutritional care.

l Establishing effective monitoring mechanismsand accountability through intensive and real-time monitoring of nutritional indicators(Karnataka Comprehensive Nutrition Mission,2012 and Rao V S, 2008).

Lastly, we must note that drafting andimplementing the National Nutrition Programmewould require inter-sectoral coordination betweenmajor Ministries, most importantly, Ministries ofWomen & Child Development, Health & FamilyWelfare, Food, Agriculture, Rural Development,Drinking Water & Sanitation, and Human Resource

Page 12: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

1378 Veena S Rao

Development, and with State Governments. Can theMinistry of Women and Chid Development or anyother single Ministry in the Government of Indiaeffectively steer such mega coordination betweenthese major Ministries, which already have verysubstantive primary mandates of their own?

Experience of the last six decades starting fromthe First Five Year Plan, has established that theGovernment has not been able to come to grips withimplementation of most of the multi-sectoral Planprescriptions on nutrition, through a single Ministry.The Food and Nutrition Board (FNB) was establishedin the Department of Food, Ministry of Agriculture in1964, with the objective of addressing the populationdimension of nutrition, namely, diversifying Indian dietfor improving the nutritional status of the people,development and popularization of subsidiary andprotective foods, nutrition education, extension andfood management, conservation and efficient utilizationof food resources, and food preservation andprocessing. The FNB was transferred to theDepartment of Women and Child Development in 1993in pursuance of the National Nutrition Policy.Thereafter, it has been completely eclipsed by the

ICDS, and has become an appendage to it, completelylosing its population dimension described in theobjectives stated above. Today, these objectives donot holistically form the mandate of any Ministry orDepartment of the Government of India. This is oneof the major reasons why undernutrition andmicronutrient deficiency in India is not reducing faster.

Clearly, no single Ministry can handle thisextremely multi-sectoral subject. The national inter-sectoral programme to combat under-nutritionannounced in the Budget speech, 2012, requires aMission Mode, under a strong overarching, inter-sectoral authority. The highest inter-sectoral institutionin the country, with a mandate for providing strategyand blueprints for addressing critical socio-economicand development issues, is now the Niti Aayog.

The Niti Aayog must take charge of this long-orphaned subject, and constitute a High PowerCommittee headed by an eminent Social Scientist torevise the National Nutrition Policy, 1993 and preparethe blueprint for the National Nutrition Mission withina given time frame. And, those of us who arecommitted to this cause must work towards this.

References

Budget 2014-2015 Speech of Arun Jaitley, Minister of Finance

(2014). http://indiabudget.nic.in/ub2014-15/bs/bs.pdf

Dharampal, Collected Writings, Volume III, The Beautiful Tree:

Indigenous Indian Education in the Eighteenth Century

(1983) http://www.arvindguptatoys.com/arvindgupta/

beautifultree.pdf

First Five Year Plan (1951-56), Chapter 32: Health http://

planningcommission.nic.in/plans/planrel/fiveyr/

welcome.html

Second Five Year Plan (1956-61), Chapter 25: Health http://

planningcommission.nic.in/plans/planrel/fiveyr/

welcome.html

Third Five Year Plan (1961-66), Chapter 32: Health and Family

Planning http://planningcommission.nic.in/plans/planrel/

fiveyr/welcome.html

Fourth Five Year Plan (1969-74), Chapter 10: Food and Nutrition

http://planningcommission.nic.in/plans/planrel/fiveyr/

welcome.html

Fifth Five Year Plan (1974-79) http://planningcommission.nic.in/

plans/planrel/fiveyr/welcome.html

Sixth Five Year Plan (1980-85) Chapter 22: Health, Family Planning

and Nutrition http://planningcommission.nic.in/plans/

planrel/fiveyr/welcome.html

Tenth Five Year Plan (2002-07) Chapter 3.3: Food and Nutrition

Security http://planningcommission.nic.in/plans/planrel/

fiveyr/index1.html

NNMB First Repeat Survey (Rural) (1988-99) http://

nnmbindia.org/NNMB-PDF%20FILES/Report_OF_1st%

20Repeat_Surveys88-90.pdf

NNMB-Report of the Second Repeat Survey (Rural) (1996-97)

ht tp : / /nnmbind ia .org /NNMB-PDF%20FILES/

Report_OF_2nd%20Repeat_Survey-96-97.pdf

NNMB-Report of the Third Survey: “Diet and Nutritional Status

of Rural Population. Prevalence of Hypertension and

Diabetes among Adults and Infants and Young Child

Feeding Practices” (2011-12) http://nnmbindia.org/

1_NNMB_Third_Repeat_Rural_Survey___Technicl_Report_26.

pdf

NSSO 68th Round-”Nutritional Intake in India” (2011-12) http:/

/mospi.nic.in/mospi_new/upload/nss_report_560_

19dec14.pdf

Page 13: Under-nutrition in India – A Forgotten National Nutrition ...insa.nic.in/writereaddata/UpLoadedFiles/PINSA/2016_Art112.pdf · the problem of under-nutrition in India could ... and

A Forgotten National Nutrition Policy 1379

National Commission on Population, Ministry of Health and

Family Welfare, Government of India http://population-

commission.nic.in/Publication/19_4.aspx

National Family Health Survey 4 (NFHS-4) (2015-16): Factsheets

http://rchiips.org/nfhs/factsheet_nfhs-4.shtml

Ram P (2014) Life in India https://books.google.co.in/books?id=

OjT4BQAAQBAJ&pg=PA318&lpg=PA318&dq=

nutrit ion+of+the+people+of+india+in+mughal+

t i m e s & s o u r c e = b l & o t s = r A Z 4 r R O P E Z & s i g =

K7IcEWYCKO_T2QN0MK CzOvmdUmc&hl=en&sa=

X&ved=0ahUKEwjt6fcnbbMAhUnMaYKHXkw

CY84ChDoAQhMMAg#v=onepage&q=nutrition%

20of%20the%20people%20of%20india%20in%

20mughal%20times&f=false

Rao V S, Malnutrition, an Emergency, What it Costs the Nation,

(2008) CAPART

Rao V S, Undernutrition and Public Policy in India (2016)

Routledge, Chapter 8, Undernutrition in India: A Case of

Public Policy Inertia

Report of the Health Survey and Development Committee (1946)

http://www.nhp.gov.in/sites/default/files/pdf/Bhore_

Committee_Report_VOL-1.pdf

Shah D (2012) The beautiful tree, a historical perspective of

Dharmpal in two parts http://bharatkalyan97.blogspot.in/

2012/12/the-beautiful-tree-historical.html

Strategy Paper, Karnataka Comprehensive Nutrition Mission

(2012) http://www.karnutmission.org/Strategy%20Paper-

%20KARNATAKA%20COMPREHENSIVE%

20NUTRITION%20MISSION.pdf

Spears D (2013) How Much International Variation in Child

Height Can Sanitation Explain? http://sanitationdrive

2015.org/wp-content/uploads/2013/09/sanitation-

height.pdf.