India waking up to a malnutrition crisis and its dire consequences

By Moin Qazi

Despite the spectacular strides made in economic growth and having a technological boom, India still continues to struggle to attain freedom from hunger. It is bearing witness to a triple burden of malnutrition—the coexistence of undernutrition, micronutrient deficiencies, and overnutrition. According to the Economic Survey (2017-18), child and maternal malnutrition posed the most challenging health risk of our times.

Causes and government response

The scenario of maternal and infant health in India is quite dire; the key reason for this being inequitable growth. India has now grown as an economic powerhouse, but millions of its children are still malnourished—on account of unhealthy diets, poor sanitation and anaemic condition of their mothers. Renowned development economist, Jean Dreze, argues that the most serious nutrition challenge in India is reaching out to our youngest children: “It is well known that if a child is undernourished by age three, it is very difficult to repair the damage after that.”

India accounts for more than 3 out of 10 stunted children globally, largely owing to a lack of good quality food, poor care and feeding practices, inadequate water, sanitation, and health services. Other than increased susceptibility, the chronic impact of long-term malnutrition in human and economic terms is well known. Undernourishment is highly damaging to children and overshadows their childhoods, impairs their mental and physical development, and damages the country’s economic prospects.

The government has been acutely sensitive to India’s standing internationally when it comes to malnutrition and its consequences and is taking the battle against malnutrition and its ravaging run seriously. It has approved a National Nutrition Mission (NNM) and set aggressive goals; targeting issues regarding stunting, undernutrition, anaemia and low-birth weight in infants. The core idea behind this mission is better integration and stronger monitoring of various government programmes for young children as well as adolescent girls and mothers.  A sum of ?9,046 crores has been allocated for the NNM, for a period of three years (2017-2020). More than 10 crore people are expected to be benefitted by the programme. The new approach is well crafted. Although it requires strong political will, if translated into action properly, the programme shows the potential for rich dividends.

Consequences of malnutrition

Malnutrition threatens a child’s physical as well as mental wellbeing for many years to come. For many children, chronic malnutrition begins in the womb, with 20 percent having a low birth weight. 90 percent of our brain develops in the first two years of birth and the quality of nutrition during this stage determines the long-term physical health, learning ability, and future productivity. Undernourishment can lower a child’s IQ, increase the risk of diet-related non-communicable diseases such as diabetes and heart diseases, and reduce productivity.

Going by NFHS-4 results, it appears that 40 percent of our future workforce will be unable to achieve its full physical and cognitive potential. The World Bank estimates this to cost India’s economy $12 billion a year in higher healthcare spending and lost productivity.

Most of the neo-natal undernourishment cases can be attributed to pervasive nutritional deficiencies in Indian women. In India, 33.6 percent of Indian women are chronically undernourished, and 55 percent are anaemic, putting over half the women in the childbearing age at risk. The loss of gross domestic product (GDP) to anaemia was estimated at $22.64 billion (?1.50 lakh crore) in 2016, more than three times the health budget of the country for 2017-18. And at the other end of the spectrum, over-eating is taking a heavy toll on people of all ages.

There are three major heads to be addressed while looking at the challenge of malnourishment: Nutritious food, clean water, sanitation and hygiene practices, and attitudinal change. According to the World Health Organisation (WHO), 50 percent of malnutrition is associated with repeated diarrhoea or worm infestation issues, caused mainly due to unsafe water, inadequate sanitation, and unhygienic practices. These health hazards reduce the capacity of the body to absorb essential nutrients required for growth and development in early infanthood.

Schemes and challenges in implementing them

Schemes like Integrated Child Development Mission (ICDS), National Health Mission (NHM), Swachh Bharat Abhiyan (Clean India Campaign) and National Rural Drinking Water Mission (NRDWM) clearly demonstrate that funding is not the key constraint. Complimenting this will be the Pradhan Mantri Matru Vandana Yojana (Maternity Benefit Scheme)—which facilitates direct cash transfers to pregnant women and lactating mothers upon fulfilment of certain conditions and promotes uptake of health services and behavioural change.

Operating in silos curbs the spillover benefits available out of synergies from these convergences; so, these programmes need to be converged and efficiently implemented at the district level. Under the current ICDS scheme, pregnant mothers and new mothers need to involve local bodies from the Zilla Parishad to the Gram Panchayat as well as local communities for the management of child nutrition.

In the present scenario, the pre-mix gets distributed from the project to the anganwadi but with no control over the quantities that are reaching the anganwadi. The family of a newborn child is entitled to receive ‘Take Home Ration’ worth ?10,332 over a 45-month period, but the scheme is riddled with leakages and poor quality food supplements.

Despite the rise in institutional birth-rates to almost 80 percent, early initiation of breastfeeding (within 1 hour of birth) remains as low as 41.6 percent. A child should be exclusively breastfed for the first six months of its life without any additional food or drink, not even water—there is an imminent need to promote this.

There is also growing evidence of the benefits to mother and child of initiation within 1 hour of birth. Early initiation of breastfeeding ensures skin-to-skin contact, which is important in preventing hypothermia and establishing the bond between the mother and her child. It also reduces a mother’s risk of post-partum haemorrhage, one of the leading causes of maternal mortality.

Colostrums, the milk produced by the mother immediately after delivery, contains antibodies and essential nutrients, which act like the first “natural” immunizers for newborns, boosting the immune system and reducing the chances of neonatal mortality. Continued breastfeeding for two years or more, together with safe, age-appropriate and hygienically prepared foods, starting at six months of age, boosts long-term immunity. All this would require the mother to be withdrawn from her regular chores to be with the child in the first six months.

Recent measures

The recent amendment in National Maternity Benefit Act (NMBA) has provided six months of paid leave to women in the organised sector. However, this policy has no relevance for the women who work in the informal economy. Around 95 percent women workers are in the informal sector, and most poor women tend to get back to their routine work schedule within days of their delivery. In such conditions, it is very difficult to expect them to rest, gain weight, take care of their own health, and then provide the baby with exclusive breastfeeding for six months. In this context, the compensation of ?6,000 under the Pradhan Mantri Matru Vandana Yojana to each pregnant and lactating mother is quite inadequate here.

Proper sanitation facilities are essential to prevent child infections on account of related ailments like diarrhoea and pneumonia, which impair nutrient absorption.  A survey by the Bill and Melinda Gates Foundation in 5 states, comparing ODF (Open Defecation Free) and non-ODF villages, found that, on an average, the number of children with diarrhoea in a non-ODF village was 46 percent more than in an ODF village. The number of children with worms in their stool in a non-ODF village was 78 percent more than in an ODF village and 17 percent more children were stunted and overall 58 percent more children were affected in non-ODF villages.

To successfully address the challenges of nutritional deficiencies, efforts need to be taken to fortify staple food vehicles such as flour, salt, oil, and milk. The full impact of the various interventions can be amplified if we adopt a multi-sectoral and integrated approach looking at maternal and infant health, water and sanitation, poverty alleviation, and behavioural change communications as inter-related challenges.