The Prime Minister has often talked of 125 crore Indians and promotes “Sabka Saath Sabka Vikas”. Once he said, “Our children must not only be healthy but also receive proper education”. To fulfil his vision, enormous work is cut out as the results of National Family and Health Survey 4 reveal that there are more than 44 million undernourished and unhealthy children under 5. This number is arrived at with the addition of millions each year. Unless we check this, under-nutrition will continue to impact child survival negatively, as health and nutrition are inextricably linked.
Between NFHS 3(2005) and now, under-5, the prevalence of stunting is reduced from 48% to 38.4%; and that of underweight reduced from 42.5% to 35.7%. However, children who are severely wasted increased from 6.4% to 7.5%. These figures leave 44 million children chronically undernourished, which is often irreversible and thus far more tragic. With an annual reduction of underweight and stunting to be less than 1%, India might take 35-40 years to eradicate it.
Important ingredients to address child undernutrition in a sustainable manner include food security at household level, protecting, promoting and supporting breastfeeding, optimal complementary feeding; preventing early child bearing; strengthening preventive and curative health systems and care of children, especially the capacity of frontline providers; enhancing literacy; and improving water supply and sanitation. All these have to be applied at universal level.
The National Health Mission has made strides on child health indicators. Immunisation has improved the most. Other indicators make us think hard e.g. prevalence of diarrhoea is 9.2%, children with diarrhoea receiving ORS: 50.6%; mothers who received postnatal care: 62%; and just 24.3% children received a health check up within two days of birth. On infant feeding front, out of about 26 million born today, 41.6% babies are able to begin breastfeeding within one hour, meaning 15 million do not. 54% babies are able to exclusively breastfeed for the first six months. Less than 10% kids at 6-8 months receive adequate diet, i.e. solid foods from four food groups required to meet their growing needs. This means about 23 million kids are not optimally fed during 6 to 24 months.
This 2017 data points out for serious re-thinking how we deal with child health, care and under nutrition.
It is a fact that child undernourishment occurs almost entirely during pregnancy and the first two years of life and is directly related to higher morbidity and mortality during infancy. Its degree also depends on various types and amount of food available to the family and the family’s awareness about what and how to give. Younger children also depend on their parents for breastfeeding, food, and home hygiene and caring practices.
The vikas (development) of millions of under-nourished children is based on how they are fed and cared during the first two years as brain development is almost 85%-90% complete by this time. The current situation, therefore, calls for a deep focus on stronger infrastructure for healthcare and nutrition outcomes of under 2s and ensuring every child is reached at home. Yet, in practice, the focus is only on treating severely wasted children or on nutrients, not on food. States are harping on treatment of wasted children with ready to use therapeutic foods (RUTF), although even recent Indian trials have not shown any advantage of RUTF over home foods. The problem is provision of enough food from locally available sources through education and awareness, rather than supplementing nutrients in the form of RUTF. The clamour for RUTF shifts the focus and displaces resources. No wonder the market is cheering this chorus.
KEY STEPS NEEDED
Keeping the above in mind, following strategic steps are placed before the Prime Minister to urgently consider:
1. Re-engineered Health and Nutrition Infrastructure at Block Level: Existing health and nutrition system at the block level could be re-engineered with a strong team of at least four members, which is technically capable of dealing with child health, development, and nutrition. If existing system cannot be spared, a new team may be put in place in all 6,600 plus blocks. It will cost just Rs 1 crore per district annually. Specific responsibility of the team may include mentoring support and supervision for every newborn, postnatal care, counselling on feeding, growth monitoring of under 2s, prevention and management of diarrhoea, and other relevant indicators. The block team should be capable and ensure growth monitoring, analyse the cause and take action at the earliest. In a block with population of 100,000, there are about 200 new births monthly and a team of four persons should be able to handle this. This action could be part of the “National Action Plan for Reduction of Maternal and Infant Mortality by 2019”.
2. Institutionalising a countrywide nutrition surveillance system to give results on child nutrition indicators every year, including large-scale nutrition surveys, periodical small surveys at national/state level, sentinel surveys to monitor trends, school surveys, growth monitoring and finally surveys during emergency situations.
3. Establishing an empowered national council under the PM’s leadership. Housed in the social sector of Niti Aayog as “single window governance”, this council may be set up by a law of Parliament. This will act as a “think tank” to focus on the under-2 for health and nutrition outcomes, apart from strong central leadership. To mobilise action, coordinate, monitor, and ensure cooperation and convergence between the ministries could be its major functions. With a full time team of senior advisors or advisors from different fields, it could serve as a clearing house also. The council should be free from any conflicts of interests. If India succeeded in bringing down HIV infections, it was with a NACO set-up in place, and nutrition needs no less within the health system.
4. Investigating into the gaps in food and nutrition security for the youngest kids: As poverty is so deep and with food prices going up, leading to shrinking food at home, it makes anybody vulnerable to child under-nutrition. Real diverse food in the hands of the people and that to be given to the under-2s is big challenge.
A strong political will is required to defeat child malnutrition. For rapidly reducing the numbers of unhealthy children, Prime Minster Modi has to take big decisions. By 2022, he may like to demonstrate acceleration in reduction of child under-nutrition.
This action fits with the BJP manifesto and makes economic sense. Today’s children are the workforce of tomorrow. Therefore, improving the health and nutritional status of today’s infants is the key to India’s emergence as an economic power.
According to Keith Hansen, the Global Practices Vice President at the World Bank “…gains from early childhood nutrition are forever. And to a large extent, many of them are free because they have come pre-packaged in this unbelievable intervention called breastfeeding.”. Hansen further says “…Children who avoid under-nutrition are not only much more likely to survive, but also stay in school and are therefore more likely to escape poverty—about 33 percent more likely on an average.”
Mr Prime Minister, the vikas of millions of children is in your hands.
Dr Arun Gupta MD, who is a senior paediatrician, works on child health and nutrition policy. He is the Regional Coordinator for Asia, of International Baby Food Action Network (IBFAN), which is a 1998 Right Livelihood laureate (also known as the Alternative Nobel Prize).