India is booming – so why are nearly half of its children malnourished? (Part 2)

As we discussed in Part 1 of this blog post, India’s impressive, rapid economic growth is not reflected in its dismal nutrition indicators.  Here we discuss more about what is happening in India to address malnutrition, and opportunities for improvement and scale-up.

What is India doing to address its wide nutrition challenges?

High levels of chronic malnutrition in India—particularly among women and children—emphasizes need for long-term, multidimensional interventions.  National programming and social safety nets currently include the Integrated Child Development Services (ICDS) programme, the public distribution system (PDS) for basic subsidies for below-poverty line (BPL) families, the Mid-day Meal Scheme (MMS) in public schools, and nutrition-focused activities within the National Rural Health Mission (NRHM).  However, while these interventions have potential, they have yet to form a comprehensive, multi-sectoral nutrition strategy at national and state levels.

ICDS: the world’s largest village-level nutrition programme

ICDS was launched in 1975 under the Government of India, with assistance by UNICEF and the World Bank.  ICDS operates as a nutrition safety-net program through village anganwadi centres (AWC), and local anganwadi workers (AWW) are sanctioned to provide cooked meals and informal preschool activities for children under 6; supplementary food and nutrition counselling for adolescent girls, pregnant women, and breastfeeding mothers; home visits and growth monitoring of children; and community programming, such as the village health and nutrition days (VHND).

ICDS is considered well designed—and well situated as the only national program operating at village level—to address malnutrition’s multidimensional factors.  However, significant gaps exist between design and implementation, undermining the programme’s potential to address undernutrition effectively, efficiently, and equitably. Longitudinal data from ICDS attendees reports no impact on nutritional status, and coverage is unsatisfactory.

During our team’s many trips to anganwadi centres, few are open (neighbours will often report that they have not been open in months)–and if they are, food supplies are extremely sporadic, children sit in a single room choking with cooking fire smoke, and equipment like growth monitoring scales are often broken or missing. Anganwadi workers do not regularly receive supervision, support, supplies, or training.

In summary, the system is defunct, just about everyone knows it, and creative ideas and true reform has been slow to come.

ICDS is widely criticized for poor targeting, focusing on children from 3-6 years of age instead of the particularly critical window of opportunity from conception to 24 months. Informal preschool activities are often prioritized over health programming, and nutrition interventions focus almost exclusively on the supplementary food provision.  Some of the most effective interventions for child nutritional outcomes—behaviour change around family care and feeding practices—are lost when home visits, counselling, and demonstration-education are not prioritized or supported.  Anganwadi centres are often located in wealthier or more central parts of town, making them poorly situated to target vulnerable children in the poorest households or lower castes living in remote areas.  Centres in priority tribal areas have been difficult to reach and monitor, and ICDS has not been able to fully target girls, poorer households, and lower castes.  Some anganwadi centres are caught in issues around caste.

As Drs. Bajpai and Sachs reported in 2005, there are wide disparities in funding, and the poorest states and states with the highest rates of undernutrition still have much lower levels of funding and programmatic coverage.  States are responsible for procuring supplementary food; while Tamil Nadu spent 167 Rupees ($3.71 today) per child in 1999-2000, states lower on the spectrum spent less than 53 Rupees ($1.18 today).  Even though food procurement and distribution was shifted to the states in an attempt to solve distribution issues, supplies are sporadic, often of poor quality, and largely cereal-based, thereby lacking in essential macro and micronutrients. There is significant need for improved oversight, supportive supervision, focused training, and performance management. Data is not well collected or used (for example, from growth monitoring); Anganwadi workers are tasked with tedious data keeping by hand, and they do not understand how it is being used.

The National Rural Health Mission (NRHM) was also launched in 2005 to facilitate access to nutrition, sanitation, and primary healthcare services for India’s rural masses.  NRHM seeks community-level involvement through the locally elected Panchayat Raj Institutions and community health workers called ASHAs (Accredited Social Health Activist).  However, the nutrition component has not been well-integrated into programming, and has taken a backseat to activities that health workers are remunerated for (for example, they are paid for institutional deliveries – which we certainly won’t argue against, we just want nutrition to be integrated in a proactive, meaningful way).

What’s ahead for India’s nutrition strategy?

Nutrition has not been a national priority and has long lacked political will.  Decision-making in nutrition programming is fragmented among several national ministries and departments, fueling widely acknowledged bureaucratic delays and the lack of central expert leadership.  That said, we hope the Prime Minister convening his first National Council on India’s Nutriton Challenges in November 2010–the creation of which was recommended by Drs. Nirupam Bajpai and Jeffrey Sachs–is promising. Recommendations offered to the Council from the expert Planning Commission, national experts, and our team–including concrete reforms to ICDS and the creation of nutrition leadership bodies in each state government to create state nutrition policies–are moving forward.

Nutrition and health programmes are also ineffectively targeting the critical window for child malnutrition and key vulnerable groups with evidence-based interventions.  There are no guidelines for managing acute malnutrition at the community level, beyond the defunct ICDS supplementary nutrition, and much debate exists around how to treat severe acute malnutrition in the country.  Major programmes–the Public Distribution System and Mid-day Meals, for example–are also plagued with severe operational problems, particularly in governance. The lack of monitoring and evaluation, supervision, accountability, and transparency results in unspent funds, corruption, leakages, and poor reporting.

Considerable investment is required to improve the performance of community delivery modules, including governance, health worker management, reporting and use of data, and supply chains for food, and matched funding for disparities between poor (and the same are poor-performing) states, for example, state spending on food procurements for ICDS.  There are many in the country, including the Model Districts, pushing for technology solutions to some of these issues.

The government will also begin piloting a conditional cash transfer scheme that will give mothers cash if they attend growth monitoring and counselling, ensure their child receives immunizations, and exclusively breastfeeds until 6 months of age.  This will be really interesting to follow and learn from–conditional cash transfers targeting nutrition have been scaled up in Mexico and Brazil, but this is pretty new for India.

A case for Model Districts in nutrition

As is clear and widely reported, India’s national growth-nutrition relationship is unusually weak, and raises a lot of questions. This calls for disaggregation to regional and state models–as we’re setting out to do in the Model Districts–to focus on assessments, innovations, best practices, and scale-up that is regionally significant.  It is a critical time for India to utilize experience from ICDS and NRHM, and international initiatives in nutrition programming, as a springboard for an innovative, targeted national nutrition strategy.

Gender equity, education, legal reform and land tenure, agricultural stimulus, and special efforts to address the needs of vulnerable groups are critically important to making real, sustained pro-nutrition growth in India. Additionally, research on multi-pronged nutrition strategies is strongly needed; while some countries, and even some Indian states, have accomplished nutrition gains, we need to understand more about the innovations, best practices, and requirements for scale-up.  Model Districts hopes to contribute to this research, and we’ll be sharing our ideas and experiences here on the blog.

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