The Future of DFID's Programme in India - International Development Committee Contents

Written evidence submitted by Dr Shelia C Vir Senior Public Health Nutrition Consultant and Director, Public Health Nutrition and Development Centre, New Delhi, India

Meeting the Challenge of Malnutrition in India

A.  Need for a Shift in the Programme Focus

The data on child undernutrition of the National Family Health Survey 3, released in late 2006, created unprecedented interest in the country. Four out of every 10 children below the age of five were reported undernourished (measured as underweight for one's age) and a wide variation was noted amongst states—Madhya Pradesh State having almost six children out of 10 underweight compared to two in Kerala. The national survey, for the first time, received remarkable media coverage. The problem was soon recognized politically at the highest level as a "national shame". The challenge for addressing undernutrition gained momentum and reference was invariably made to the immense problem of hunger. The fact that almost 20% of children, even from the highest wealth index group, are underweight in the country went unnoticed. Malnutrition in children, unfortunately, continued to be equated with mere hunger, food insecurity or lack of access to food. The Food Security Act gained momentum and provision of food or nutrition supplement provided under ICDS was viewed as the primary solution to the immense problem of malnutrition in young children. This is far from the desirable strategy that would make a difference in the grim child undernutrition scenario of the country.

The problem of being underweight starts from birth—almost a third of children in the country are born with a low birth weight (less than 2,500 grams) and this underweight situation continues to worsen up to the first two years of life, especially between 9-11 months. Mere unavailability of food at family level is not the primary cause of being underweight—the real problem, in fact, is in not feeding a child adequate amount of food required during this period of accelerated growth. A study of the National Institute of Nutrition indicates that in families where 80% of adult women were consuming adequate calories and proteins, only 30% of young children 1-3 years were in such adequacy category. A child at the age of six months requires semi-solid food in addition to breast milk. At this age, a child cannot eat on its own and needs to be fed. This needs effort and time of the caregivers. The very positive traditional practice of "annaprasan" (meaning introducing food to children) is unfortunately limited only to a community celebration of introduction of a cereal food in child's mouth by a family elder. There is a lack of appreciation that a child needs to be fed semi-solid food not once but at least 2-3 times a day and that the total amount of food fed to a child at this age needs to be adequate to meet the demands of accelerated growth—both physical and mental. Annaprasan celebration is only used as an entry to the world of cereal food—a child is allowed to eat roti or biscuit but is sadly often left to nibble on roti piece or biscuits or rusks of bread to chew on. The absence of crying or silence resulting from the joy of handling an object is accepted as a cue to a child being not hungry or not requiring to be fed. Such traditional opportunities are lost unless special efforts are made to influence child feeding (referred as complementary feeding) and caring practices.

It is time we appreciate the correct causes of undernutrition and shift our mindset and the programme focus from provision of free food to children through universal feeding programme or push the agenda of Food security Act for resolving the problem of malnutrition in children. Active feeding of a young child along with keeping it free from infection and diarrhoea is critical. How often do we refer to safe water and sanitation security when we talk of food security and associated malnutrition in children? How many of us appreciate the fact that only about 30% mothers are reported to wash hands after defecation? Let us not push the problem of undernutrition in children under mere food security or hunger issue. We need to go beyond this and concentrate on issues which hinder mothers from giving birth to a healthy child and feeding these children appropriately in an environment where chances of infection from water borne and vaccine preventable diseases is reduced to near nil. It is time we accord a much greater attention to care of adolescent girls and young women. Adolescent pregnancy—with 30% of girls aged 15-19 in India being married or in union—combined with the common traditional practice of "eating down" during pregnancy for safe and ease in delivery, contributes to the grim scenario of high prevalence of low birth weight and poor start in life. Women's health and nutrition, education and decision making ability as well as increasing time available at hand is essential to enable a mother to perform her child caring tasks more effectively. Studies show that when gains in income are controlled by women, they are more likely to be spent on food and needs of children. By educating our young girls, we empower our future mothers and we amplify benefits across families and generations. It is time we look beyond food subsidy to resolve the issue of underweight or malnutrition in children.

B.  Understanding and Addressing the Gaps

Human resource and Institutional arrangement—The programmes for improving nutrition of women and children in the country is under the purview of the two ministries of the GoI—Ministry of Women and Child Development (MoWCD) and the Ministry of Health and Family Welfare (MoHFW). Both these ministries have functionaries at district, block and village level and need to integrate their actions not only at village level but at central ,state ,divisional and district level to make a difference .MoHFW has a technical wing at the central and state level while the MoWCD lacks such technical support at every level—from the central to district level.

This adversely influences programme planning and implementation. Hence there is a need to undertake a systematic study on the existing institutional arrangement for addressing the problem of nutrition in women and children in the country. Following such a study, effort needs to be made to overcome the existing gap of public health nutritionists and consider establishment of State Nutrition Resource Centres and Divisional Nutrition Resource Centres .In this context, strengthening the Medical and Home Science Colleges based at divisional levels is important.

Zeroing on the "highest risk" population—The nutrition improvement programmes need to focus on under ones instead of under three or under two children—the "highest risk" population groups should include infants, pregnant and nursing mothers and newly weds. Investment in improving adolescent and women's nutrition status is critical. Such a focus will reduce the number of families in a population that would be required to be followed intensively eg in a 1,000 population only about 50 families would fall in the "at risk" category. Interpersonal communication with high risk families through a network of elected community cluster mobilisers/volunteers has proved effective in small scale programmes in India and larger national programmes in Vietnam and Thailand. Such family level inter personal counselling combined with well planned and executed social mobilisation efforts are essential to make a difference in child and maternal nutrition through appropriate care ,feeding, personal hygiene and sanitation practices.

Such a strategy needs to be scaled up and demonstrated to be a workable effective model on a larger scale in India, such as a district. It is critical that district level effective integrated multi-sectoral model for preventing undernutrition (involving ICDS, health ,women's development, hygiene and sanitation sectors ) are planned and implemented with proper monitoring , process documentation and evaluation to facilitate in analyzing and taking the best practices to scale in the states with poor child nutrition indicators.

Additionally, the district level preventive approach needs to be combined with a district level community based approach for the management of severe acute malnourished (SAM) cases—almost 8 million children in India are suffering from SAM .These SAM children are nine times higher chances of dying. For community based management of SAM, development of indigenous therapeutic food product, similar to internationally available RUTF (Ready to Use Therapeutic Feeding), is essential.

How DFID could contribute in making a difference?

DFID is a bilateral agency which is an advantage of working closely with not only one Ministry but at least the three core ministries responsible for improving health and nutrition of children i.e. Ministries and Departments of Health, Women and Child Development, Rural Development (in-charge of community level governance through elected panchayats and also water, sanitation, micro-credit and livelihood programmes). DFID could consider providing support in the following areas for accelerated and sustained improvement in nutritional status of women and children.

Continue advocacy at the highest level for enhancing political support towards accelerating actions for addressing the problem of malnutrition. Shift in programme focus and budget -from mere food supplementation under the Integrated

Child Development Services programme (ICDS) to appropriate feeding including the introduction of micronutrient

supplements for women and children as well as measures for safe water, hygiene and supporting women's development.

Technical and financial support to poor performing states to undertake district level integrated multi-sectoral planning and implementation for sustainable improvements in child nutrition. This would include integrating functioning of sectors such as ICDS of MoWCD and the National Rural Health Mission (NRHM) of MoHFW and water-sanitation (Ministry of Rural development) from central to block to village level First step would be defining sectoral nutrition goals and roles and responsibilities with reference to agreed goals, focusing on evidence based interventions as well as support in block and district level planning and management of programmes implementation. The latter would include experimenting with innovative community based integrated monitoring mechanism and ensuring process documentation and a systematic evaluation.

Undertake a national and state specific assessment study on the existing institutional mechanism for addressing malnutrition in women and children in the country. Based on the emerging scenario and recommendations, support the central and state governments for improving institutional mechanisms and human resource support in the area of public health nutrition.

Longitudinal operational research study on the impact of adolescent and maternal nutrition -health care on birth weight and on the nutritional status of children at one and two years of age. Support to regional Food and Nutrition centres of Home science colleges and Public Health Departments of medical colleges to undertake such joint operational research from the pre-pregnancy stage till the child is two years old. Such research will not only give programme direction but will facilitate in building capacity of institutions to undertake operational research in the subject of public health nutrition.

District level programmes for community based management of severe acute malnutrition (SAM) cases including indigenous production of therapeutic food product through public-private sector partnership.

21 March 2010

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