India’s claim to be an economic superpower can be threatened by its over 35 million of underweight children under five years of age, even as India stares at rapidly rising obesity among middle and higher-income groups.
The BJP’s manifesto says: “One of our main targets will be to eradicate the curse of malnutrition. We will do so by revamping existing programmes and launching a multi-pronged war against malnutrition across the nation, especially in the under-developed areas, with the help of state governments. All resources will be provided to achieve this goal.”
While eradication of malnutrition may not be possible in a short time, reforms in governance can change the way we deal with the problem. For that, India needs reforms in governance at the top and we can learn from Brazil. For reforms at the family/community level, we can learn from Thailand. Both countries have successfully fought against malnutrition over the past 2-3 decades. India would need to invest its resources as well.
An Indian success story
India carved a success story in 1992 and 2003 by enacting the “Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003”, which bans promotion of baby foods for children under the age of two years. It led to restriction of sales. Market analysts have found that from 2008 to 2012, sales of milk formula in India grew from 24,428 tonnes to 27,783 tonnes compared to China where it grew from 294,800 tonnes to 560,000 tonnes. This success is because China does not have a similar law. This restriction of sales increases breastfeeding, and use of milk formula exposes the present generation of children to an increased risk of obesity and diabetes later in life. Can India afford to lose this protection under the pressure of market forces? Is anybody thinking in such a long-term sense about nutrition and how decisions are made?
Ad-hoc decision in whose interest?
Joseph Stiglitz, the Nobel laureate economist defined governance as: “How decisions are made in whose interest”. With this principle in mind, India needs a major reform in governance because currently the nutrition agenda is ruled by ad-hoc decisions and action. After the NDA took over, the Government of India organised a “Consultation on National Nutrition Mission in India: Accelerating Essential Nutrition Actions”. This led to development of a “draft nutrition strategy” which was discussed with several states. The Niti Aayog is developing a new one now. Similar exercises were conducted earlier. I have been a part of all of these. “Technological interventions” that were not even recommended in the national or regional consultations are now being actively pursued like, for example, processed “ready to eat foods”, “fortified foods” or even providing Tablet/iPads to workers for monitoring.
At the recent launch of the “India Health Report” by private players, a pitch was made to bring India under the SUN (Scaling up Nutrition movement) umbrella. SUN, which has no official standing so far, typically introduces its “SUN business network” into the countries. In an editorial on this report, Bill Gates and Ratan Tata did not forget to include that foods should be fortified. It’s anybody’s guess who will benefit from fortified foods, my guess is it is the “business network” for sure. However, Brazil has so far refused to be a part of SUN as it has been unwilling to “bring business into nutrition”. There have been calls from some quarters for “friendly” legislations earlier, and fresh voices have been raised on repeal of existing law on protection of breastfeeding.
The problem of hunger and malnutrition is created by structural poverty and inequality resulting in severe food insecurity. Almost half the people of India earn their livelihoods from agriculture, but the sector has been facing unprecedented crisis. Several programmes run by the Government of India in this direction are either inadequately funded or asphyxiated due to poorly skilled workers or lack of workers. Technological interventions like ready-to-use (therapeutic) foods or food fortification, deal with specific problems related to “micronutrient deficiencies” and “severe acute malnutrition”, not with the root of the problem. Fortification, in any case, has debatable impact on micronutrient deficiencies of populations. Food would have to be mechanised, centralised, and then labelling and standards come into play. Industrially processed foods would be more expensive for poor people, which will perpetuate poverty and undernutrition. It can contribute to higher incidence of non-communicable diseases. Such issues only take the debate away from real issues of hunger and undernutrition, water, sanitation, or universalisation.
Strategic capacity issues
Lack of strategic and operational capacity on nutrition in the ministries is well documented and pushes them to rely on “outside consultants”. Many organisations have their own interests, including micronutrients (which are of course necessary) without even ensuring basic food and nutrition for babies.
Convergence or lack of it
There is a lack of convergence within two nodal ministries of health and women and child development, let alone with others like agriculture, food supplies, labour, trade, and finance. There is a lack of coordination at the level of policy and plan development, which is not good as far as the issue of nutrition is concerned.
Bridging the governance gap
India can learn from Brazil and set up an institution like the “National Nutrition Council or Commission” through an Act of Parliament, with a chairperson and members who work full-time and are of proven integrity. They can be chosen from the fields of health, economics, nutrition, anthropology, administration, planning, field experience, etc. There should be a mechanism to avoid and manage conflict of interest in this organisation. It should have representation from civil society from all the states.
This empowered body should work on areas of oversight, technical decisions, clearing house, and planning and lead to demonstrate a political will, mobilising nationwide action around nutrition. It should ensure a coordinated response nationwide and across all the states, and gather public opinion to build recommendations. It should also be responsible for formulating public policies to guarantee the human rights to healthy and adequate food, looking at the WTO and Codex policies that affect the nutrition of people. Acting as a think tank, and monitoring plans of action of key ministries and states, it should achieve improved decision-making and convergence of policy and programmes.
It should report to the Prime Minister and its recommendations should be forwarded to an “Inter-ministerial council on Nutrition” for implementation, again set up by law, to ensure a coordinated response on child malnutrition by multiple ministries. Its major task would be to implement recommendations of the National Council. This would have members who are officials from all the ministries responsible for nutrition action. Needless to say, India desperately needs this governance reform to ensure nutrition. India should invest in this.
Bridging the gap at the family level: Focus on infants
Focus on early nutrition also means focus on scaling up breastfeeding rates, and other nutrition interventions at the family level, particularly in low-income families. For families which need food, we need to implement the Food Security Act in letter and spirit.
For food security of infants, breastfeeding is the key and women need support systems. Breastfeeding within one hour, exclusive breastfeeding for the first six months, and good complementary feeding along with breastfeeding for 6-24 months should be scaled up. This requires support systems for women to ensure this food security during the first two years. Maternity leave needs to go up to nine months. The Indira Gandhi Matritva Sahyog Yojana (IGMSY) scheme needs to be expanded to the universal level without conditions. There is a need to appoint “skilled breastfeeding counsellors”. At the same time, the Infant Milk Substitutes (IMS) Act should be enforced strictly to protect breastfeeding practices.
New evidence reveals that if India scaled up breastfeeding interventions, annually it could reduce 13% of all under-5 deaths (156,000 child deaths), 3900,000 episodes of diarrhoea, 3436,560 episodes of pneumonia, and 4,915 deaths due to breast cancer. Over and above this, it would add about Rs 4,300 crore to the Indian economy through the addition of three points to the IQ of all children, rich or poor. Further, it will reduce obesity by 26% and prevent one in three incidents of new cases of Type -2 diabetes.
Is this evidence not compelling enough to invest in this intervention? For nutrition interventions, India depends a lot on Integrated Child Development Services (ICDS). The CAG report in 2013 showed more than 50% of ICDS can’t even reach infants and young children. How do we expect a change when malnutrition has already set in? We need to reform this programme design flaw to reach all children under three, and lessons can be learnt from Thailand. Thailand provided high level of coverage through high worker intensity, intensive growth monitoring and health and nutrition education. Why can’t we invest?
Malnutrition can be eradicated; it takes time, meticulous planning, but ad-hoc decisions delay this process. India needs governance reforms, programme design reform and investments in its workforce, apart from effective implementation of related legislations. India should be proud of its trusted scientists and the opinion-based policy research relevant to India, not the “magical solutions” being offered currently.
The BJP should fulfill its promises and lead from the front. The Prime Minister has an obligation to initiate the change. Like action on Swachh Bharat, nutrition needs an action of similar nature, if not bigger. Otherwise, as Prof. Irwin Corey said once, “If we don’t change the direction soon, we will end up where we’re going”.
Dr Arun Gupta is a pediatrician, and Regional Coordinator of International Baby Food Action Network (IBFAN), recipient of the 1998 Right Livelihood Award (also known as the Alternative Nobel Prize). He is a member of the PM’s Council on India’s Nutrition Challenges.