tackling child malnutrition Rachel Pal m e r Save the C hild r en m fo r Save Rai/Magnu Raghu

DESPITE IMPRESSIVE India is home to one-third of the world’s poor, with over ECONOMIC one-fourth of the population – about 410 million people 1 GROWTH, INDIA – living in poverty, 60% in the seven lowest-income states. HAS HIGH CHILD One-third of children are born with low birthweight, 43% of under-fives are underweight, 48% are stunted, 20% are MORTALITY RATES wasted, 70% are anaemic and 57% are vitamin A deficient.2 AND NEARLY HALF There are wide and increasing disparities across different ITS CHILDREN ARE states and economic groups.3 STUNTED. Progress towards reducing undernutrition has been limited, MDG 4 – TO particularly in the last two decades.4 But nutrition security REDUCE CHILD has remained a leading issue in political and policy debates. MORTALITY BY TWO- In 2001, the Supreme Court of India pronounced the Right to Food as an implication of the Fundamental Right to THIRDS – CANNOT Life enshrined in the Indian Constitution. This order also BE ACHIEVED converted the eight nutrition-related state schemes into WITHOUT TACKLING legal entitlements.5,6 The government enacted the 2005 MALNUTRITION. National Rural Employment Guarantee Act after immense mobilisation and pressure by civil society, non-governmental organisations, and social and labour movements. These groups have also been leading a nationwide Right to Food Campaign since 2001.7 The National Food Security Bill 2011 has been approved by the Union Cabinet and is likely to be placed before Parliament in the coming session.8 The Prime Minister’s Council on Nutrition has also prioritised

1 malnutrition. The Coalition for Sustainable Nutrition Security in India, formed in 2008 and now chaired by Save the ate Red m an K ate Children, is a high-level committee that brings together various actors such as the government, the development sector, the media, policy-makers, bureaucrats, scientists and the private sector to work collaboratively towards overcoming malnutrition. In addition, the forthcoming 12th Five Year Plan proposes a restructuring of the national Integrated Child Development Services programme. There are other complementary policy frameworks and schemes in education, health, water, sanitation and agriculture.9

“...malnutrition is a matter of national shame. Despite impressive growth in our GDP, the level of undernutrition in the country is unacceptably high.” Prime Minister Manmohan Singh, speaking at the launch of the 2011 HUNGaMA Survey Report, 10 January 2012

the issue the solutions

Targeting There is no streamlined targeting of nutrition-related • Universalise and ensure inclusiveness in all programmes for pregnant women and children under nutrition-related state schemes with commitment two – both critical periods to avoid undernutrition. to ‘universalisation with quality for all’.13 The below poverty line targeting model practised • Improve selection criteria and procedures for in some schemes like the Public Distribution System the below poverty line model, so that it defines does not encompass a large percentage of poor nutritional entitlements as per Indian Council for people due to opaque bureaucratic enrolment Medical Reform14 norms, takes into account the procedures, inadequate selection criteria and lack multidimensional nature of poverty and engages of consideration of the seasonality of poverty.10 local bodies like the Gram Sabha, female self-help The model promotes a ‘management’ rather than groups and community-based organisations.15 ‘prevention’ approach to nutrition, and is detrimental to social inclusion and solidarity.11 Those who are • Launch a drive to bring rapid access to the poorest most marginalised (women, Dalits, Adivasis, landless people and scale up the Antyodaya Scheme, or displaced rural poor, migrant workers, urban especially provision of standard, state-of-the art slum-dwellers and people who are homeless or feeding and care for children with severe acute displaced, women-headed households, children under malnutrition. two) are still largely excluded.12 • Increase coverage and central funding to schemes in poor performing states.

2 the issue the solutions

Implementation, Coordination and Capacity Despite a series of progressive welfare schemes, these • Decentralise service delivery, management and are marred by misappropriation or under-utilisation of response, eg, so that food entitlements through financial assistance. Service delivery mechanisms are the integrated child development services and weak and inefficient (eg, irregular cereal-stock delivery public distribution system can be procured locally to Public Distribution System outlets or Aaganwadi and farmers also benefit from assured minimum thecentres, issuerotting grain in state warehouses).16 Lack of theprices. 20solutions coordination between various central, state and local • Restructure Integrated Child Development Services departments and bodies mean that links across the to include children aged 0–2 years and increase health, education, water, sanitation and agriculture focus on preschool education. sectors, which could improve the implementation of many schemes, do not exist.17 Grassroot-level • Encourage community ownership of management workers are overburdened, under-trained, underpaid, and monitoring of schemes, involve Panchayati Raj demotivated and ill-equipped.18 Bureaucrats lack Institutions and other village-level committees, and adequate understanding of the issues and there promote participatory planning.21 is no specialised nutrition post at the central • Mobilise local, state and national-level citizen action 19 ministry level. The current approach to reducing for enhanced transparency and accountability, use undernutrition thus fails to take into account the innovative approaches like social audits, the right to complex and multifaceted nature of the issue, which information, community vigilance groups, workers’ is dependent on a host of economic, environmental, and women’s collectives, etc.22 agricultural, health, cultural, political and administrative determinants. • Strengthen the knowledge and skills, as well as support systems, for community-level workers (especially Workers, Accredited Social Health Activists, Auxiliary Nurse Midwives and teachers) and primary-level providers and counsellors. • Recommend and support the process of convergence between various government ministries, programmes and non-state actors; prevent integrated cross-cutting schemes from creating parallel mechanisms. • Support the government to establish comprehensive and coordinated national-level nutrition training, monitoring, redress, accountability and a data analysis mechanism, and to adopt an evidence-based approach to the design and revision of key nutrition programmes.23 • Strengthen the focus on improving nutrition through a leadership and coordination mechanism with clear authority and responsibility, working from local to national levels (possibly through a ministry or nutrition authority). • Mainstream nutritional goals, criteria and support programmes in ongoing agricultural and employment guarantee schemes.24 • Initiate a comprehensive and coordinated national nutrition education and behavioural change programme.

3 the issue the solutions

Gender DISCRIMINATION India has one of the highest proportions of • Emphasise empowering women, collectivisation and malnourished women in the developing world. access to resources, and address the socio-cultural- As many as 35.6% of adult women (15–49 years) patriarchal issues that affect women. suffered from chronic energy deficiency in 2006;25 • Focus on combating child marriage and adolescent and 70% of non-pregnant and 75% of pregnant adult pregnancy, empowering and meeting the nutritional women were anaemic in 2000.26 A large proportion needs of married and unmarried adolescent girls. of these women are from the poorest sections of society.27 Patriarchal norms that propagate gender • Introduce a national scheme for maternity inequality and practices like child marriage trap entitlements in the informal sector, including cash adolescent girls and women in a cycle of malnutrition support of Rs1,000 (US$19.50) per month for six and ill-health,28 which has severe development months without any exclusions for age or number implications, including low birth weight, child of children.30 malnutrition and chronic diseases.29 • Promote awareness of infant feeding practices31 and build capacity of accredited social health activist volunteers as community ambassadors for women’s rights. • Expand the focus on girls’ and women’s nutrition within existing national programmes.32

the issue the solutions

Political Will Despite rhetorical commitment to tackling • Enact a comprehensive National Food Security Bill undernutrition, strong commitment and political will 2011, and make appropriate budgetary allocations is lacking. As a result, food and nutrition has become in nutrition that meet the requirements of the a hotly debated issue. The proposed National Food Supreme Court April 2004 Order. Security Bill has been severely criticised by the Right • Focus on the work of the Coalition for Sustainable to Food campaign for being half-hearted.33 Recent Nutrition Security in India to assist the government budgetary allocations to child nutrition have been to develop a strong programme based on proven grossly inadequate.34 The push towards cash transfers, interventions. debates around ready-to-eat vs cooked meals in the mid-day meal programme or centralised fortified • Keep the ‘best interests’ of children in mind when food production vs decentralised food procurement, deciding on nutrition interventions. and autonomy or feeding-practice awareness vs baby • Enact a ‘conflict of interests’ regulation in child food, highlight the contentious issue of corporate health programmes consistent with the World involvement in food policy.35The government has Health Assembly resolutions.38 no clear conflict of interests policy to address these concerns, except the Regulation of Production, Supply • Promote nutritional food entitlements like pulses, and Distribution Act 1992.36 The state approach to milk, eggs, oil, etc, in addition to cereals, and the nutrition has also been limited mainly to a technical indigenous production and provision of therapeutic one and has not paid sufficient regard to the effects foods rather than expensive ‘medicalised’ of socioeconomic structural changes.37 micronutrient supplements.39 • Develop strong local accountability mechanisms. • Seek to better understand the link between undernutrition and socioeconomic changes, such as increasing urbanisation, structural transformation of the economy, displacement and agricultural crisis.40

4

Our goal is that Millennium Development Goal 4 – a two-thirds reduction in child mortality rates by 2015 – is achieved. Improving child nutrition is key to achieving this goal. It will save many lives and give all children the chance of a good start in life so they can grow up to fulfil their potential.

“If you eat well you can feed your child well”

“It was a hard pregnancy. I was diagnosed with anaemia from the first month. I don’t know why I became anaemic. I was weak beforehand but I didn’t bother checking with a doctor until I was pregnant. I had monthly check-ups then, though, and saw the doctor about 10–15 times. “I learned from my delivery that if you eat well then you can feed your child well. And I think mothers should go to hospital when they’re pregnant because the support you get there is far better than the type of care you get at home. Next time I have a baby I will feed him properly – no bottled milk, and no water. I can’t imagine what would have happened if I hadn’t had the support I had for my child.” Gulnaf (pictured right with her son, Sanya) in , where Save the Children is working with Anganwadi workers, accredited social health activists and auxiliary nurse midwives to reduce infant mortality and malnutrition among children, increase the percentage of babies delivered in hospitals or clinics, improve postnatal care and immunisation coverage, and promote early and exclusive breastfeeding. The K ate Red m an districts chosen for the project have a high concentration of scheduled castes and tribes, eg, Dalit and Adivasi populations.

5 notes

1 united Nations Development Programme, Human Development 18 Citizens’ Initiative for the Rights of Children Under Six (2006) Report 2010, United Nations, New York (2010) p.98: http://hdr. Focus on Children Under Six Report, New ; undp.org/en/media/HDR_2010_EN_Complete_reprint.pdf Working Group on Children Under Six (2007) 2 b Fenn (2011) Research for Save the Children’s report, A Life Free 19 Gragnolati et al (2005) op cit From Hunger: Tackling child malnutrition 20 M Gragnolati et al (2006) ‘ICDS and Persistent Under-nutrition: 3 P K Pathak and A Singh (2011) ‘Trends in malnutrition among Strategies to Enhance the Impact’, Economic and Political Weekly, Vol children in India: Growing inequalities across different economic 41 No. 34 groups’, Social Science & Medicine, Vol 73, No. 4, pp. 576-585; K 21 Gragnolati et al (2006) op cit; S Sinha (2006) ‘Infant Survival: A R G Nair (2007) ‘Malnourishment amongst Children in India: A Political Challenge’, Economic and Political Weekly, Vol 41, No. 34 Regional Analysis’, Economic and Political Weekly, Issue No. 37 22 D Sinha (2008) ‘Social Audit of Mid-Day Meal Scheme in AP’, 4 P K Pathak and A Singh (2009) ‘Geographical variation in poverty Economic and Political Weekly, Vol 43, No. 44; M Chatterjee (2006) and child malnutrition in India’ in K K Singh, R C Yadava and A ‘Decentralized Child Care Services: The SEWA Experience’, Pandey (eds), Population, poverty and health: Analytical approaches (pp. Economic and Political Weekly, Vol 41, No. 34 183-206), New Delhi, India: Hindustan Publishing Corporation 23 A Deaton and J Dreze (2009) ‘Food and Nutrition in India: Facts 5 Public Distribution System (PDS); (AAY) and Interpretations’, Economic and Political Weekly, Vol 44, No. 7 aimed at the poorest one crore [10 million] ‘hungry’ families; National Programme of Nutritional Support to Primary Education 24 These schemes include the National Horticulture Mission, the (‘mid-day meal scheme’); Integrated Child Development Services National Food Security Mission, Rashtriya Krishi Vikas Yojana and (ICDS); Annapurna Scheme for senior citizens; National Old Age the National Rural Employment Guarantee Act. The National Pension Scheme (NOAPS); National Maternity Benefit Scheme Horticulture Mission should be implemented in such a manner (NMBS); and National Family Benefit Scheme (NFBS) that for every nutritional malady, an appropriate horticultural remedy is introduced. 6 Supreme Court of India Order of November 28, 2001; Item No. 6, Court No. 2 Section PIL A/N Matter Supreme Court of India 25 S Jose (2011), ‘Adult Under-nutrition in India: Is there a Huge Record of Proceedings, Writ Petition (Civil) No 196 OF 2001, Gender Gap’, Economic and Political Weekly, Vol 46, No. 29 People’s Union for Civil Liberties Petitioner(s)-Versus-Union of 26 J Mason et al (2005) ‘Recent Trends in Malnutrition in Developing India & Ors. Respondent(s). Regions: Vitamin A Deficiency, Anaemia, Iodine Deficiency, and 7 http://www.righttofoodindia.org/index.html Child Under-weight’, Food and Nutrition Bulletin, Vol 26,No 1, pp 59-162 8 Ibid 27 K Sethuraman K and N Duvvury (2007) ‘The Nexus of Gender 9 For example, National Rural Health Mission, Horticulture Mission, Discrimination with Malnutrition: An Introduction’, Economic and Jawaharlal Nehru National Urban Renewal Mission, Rajiv Gandhi Political Weekly, Vol 42, No. 44 National Drinking Water Mission, Sarva Siksha Abhiyan (Education for All), Bharat Nirman programmes, Prime Minister’s Nutrition 28 Ibid Council 29 S Jose and K Navaneetham (2008) ‘A Factsheet on Women’s 10 Report of the Expert Group to advise the Ministry of Rural Malnutrition in India’, Economic and Political Weekly, Vol 43, No. 33 Development, on the methodology for 30 Working Group on Children Under Six (2007) th conducting the Below Poverty Line (BPL) census for 11 Five Year 31 S Ghosh (2006) ‘Food Dole or Health, Nutrition and Development Plan chaired by N C Saxena, August 2009 Programme?’, Economic and Political Weekly, Vol 41, No. 34. 11 Working Group on Children Under Six (2007) ‘Strategies for 32 For example, the National Rural Health Mission, the Public Children Under Six’, Special Article, Economic and Political Weekly, Distribution System, National Rural Employment Guarantee Vol 42, No.52, pp. 93–94 Scheme, Sarva Siksha Abhiyan, and Bharat Nirman programmes. 12 M Gragnolati et al (2005) ‘India’s Undernourished Children: 33 http://www.thehindu.com/opinion/lead/article2285546.ece A Call for Reform and Action’, Health, Nutrition and Population (HNP) Discussion Paper, World Bank; J Ghosh (2010) ‘The Political 34 htpp://www.haqcrc.org, Resource Allocation in the Union Budget Economy of Hunger in 21st Century’, Economic and Political Weekly, 2005-06: Is It Sufficient to Fulfil the Rights of India’s Children? Vol 45, No. 52; U Patnaik (2007) The Republic of Hunger and Other http://articles.timesofindia.indiatimes.com/2011-02-28/ Essays, Three Essays Collective: New Delhi india/28641180_1_child-mortality-health-care-health-budget 13 http://www.thehindu.com/opinion/op-ed/article562922.ece; 35 A Gupta and N S Khaira (2008) ‘Flaws in Child Nutrition and R Khera (2011) ‘Revival of the Public Distribution System: Health Governance’, Economic and Political Weekly, Vol 43, No. Evidence and Explanations’, Economic and Political Weekly, Vol 46, 17; A Gupta (2008) ‘Manipulation by Assistance: Undermining Nos. 44 & 45; J Dreze (2006) ‘Universalisation with Quality: ICDS Breastfeeding’, Economic and Political Weekly, Vol 43, No. 36; Working in a Rights Perspective’, Economic and Political Weekly, Vol 41 No. 34 Group on Children Under Six (2007) 14 Indian Council for Medical Research (2009) Nutrient Requirements 36 Gupta (2008) ibid and Recommended Dietary Allowances for Indians: A Report of the 37 Editorials (2006) ‘Child Malnutrition: Behind the Numbers’, Expert Group of Indian Council of Medical Research, National Economic and Political Weekly, Vol 41, No. 18 Institute of Nutrition, Hyderabad 38 Gupta (2008) note 35; Gupta and Khaira (2008) op cit, note 35 15 Saxena (2009) op cit 39 Working Group on Children Under Six (2007) 16 Ibid 40 Ghosh (2010) op cit, note 12 17 Gragnolati et al (2005) op cit, note 12

This briefing is part of a set of eight country briefings produced by Save the Children and the Institute of Development Studies to accompany Save the Children’s report, A Life Free from Hunger: Tackling child malnutrition. To see the full report, visit

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