Why India needs a national nutrition strategyBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6687 (Published 11 November 2011) Cite this as: BMJ 2011;343:d6687
- Lawrence Haddad, director
- Accepted 9 October 2011
Over the past 15 years India’s economic growth rate has been unprecedented. The International Monetary Fund reports an average growth in real gross domestic product (GDP) of nearly 6% in the 1990s and of 8% in 2000-10.1 The economic growth has not, however, been associated with corresponding reductions in the rates of childhood undernutrition.2 The National Family Health Survey, which provides India’s most authoritative statistics on nutrition status, showed that 43% of children under 5 years old were underweight for age in 1998-9; by 2005-6 the percentage had only dropped to 40%.3 At that rate of progress India will not reach its millennium development goal target (to halve the proportion of underweight children by 2015) until 2043.4 By contrast, China has already met its goal and Brazil is expected to do so by 2015.5
What is undernutrition?
Undernutrition is the outcome of interactions between inadequate food intake and repeated infectious diseases
Preschool children experience undernutrition if they are stunted (low height for age), underweight (low weight for age), or wasted (low weight for height)
Moderate undernutrition is experienced if a child’s height or weight is more than 2 standard deviations below the median value for age drawn from a healthy population (World Health Organization growth standards)
Undernutrition is responsible for 35% of deaths among children under 5 and 11% of the total global disease burden.6 It also reduces schooling attainment: an improvement in height for age z scores of 1 is a predictor of an extra half a year of schooling7 and substantially increases the likelihood of being poorer later in life since less schooling is a predictor of lower wages (46% in a longitudinal study from Guatemala) and lower lifetime incomes.7
During 1981-2005 India’s poverty rate fell from 60% to 42%. This decline is similar to China’s more lauded poverty reduction (a fall from 40% to 29%) over the same period. Yet unlike China, India is not reducing undernutrition. Given the importance of childhood nutrition it is important to ask why high levels of undernutrition are so persistent in India.
Challenges to improving rates of undernutrition
The Unicef model of undernutrition articulates three levels of determinants: fundamental, underlying, and immediate.8 Economic growth and governance are key fundamental drivers. Underlying factors include agriculture and food security, women’s power in decision making, the provision of food to infants, health and psychosocial needs, clean water and sanitation, and access to effective and affordable health services. Immediate determinants include diet and infection. I will start by focusing on the underlying determinants.
Agricultural growth is usually linked to improved nutritional status of children because it has a stronger effect on poverty than other sources of growth.9 Agricultural growth also improves food availability. But agricultural growth in India does not seem to have improved infant undernutrition. We don’t know why this is the case. It could be that agricultural investments are focused in the wrong regions or on the wrong crops and animals or on the wrong size of farm. In the absence of well functioning food markets, a focus on increasing production of nutrient rich crops by smallholders in areas with high levels of undernutrition is likely to enhance agriculture’s effect on undernutrition. A recent systematic review on the effect of agricultural interventions that set out to improve nutrition offers a few clues on how to make agriculture more pro-nutrition.10 The review highlights several success stories from the region and elsewhere that can point the way towards making agriculture more nutrition sensitive, ranging from homestead gardening, livestock and dairy interventions that incorporate programmes to change nutrition behaviour, and enhancing fruit and vegetable productivity to the biofortification of staple crops with iron, zinc, and vitamin A. One of the studies, on the effectiveness of an orange flesh sweet potato intervention, found an increase in serum retinol in the intervention group (compared with those growing regular sweet potatoes) equal to 10% of the lower acceptable serum retinol threshold.11
Food security programmes
Food security is promoted by three national government programmes: the targeted public distribution system, the national rural employment guarantee act, and the midday meal scheme. An evaluation of the targeted public distribution system by the Indian Planning Commission in 2005 concluded that 57% of subsidised grain does not reach its intended recipients through a combination of technical targeting errors and deliberate diversion.12 Although a recent household survey points to improvements in the system,13 full information is not yet available.
Some experts have suggested that cash transfer programmes to poorer households would improve the transparency and accountability of food programmes.14 The new national employment guarantee programme, which guarantees rural households 100 days of unskilled manual work a year at a given wage, has the potential to improve food consumption, but the two high quality impact studies so far show contrasting effects on household expenditure (one positive and one negative).15
The midday meals scheme, which covers 139 million children aged 4-14 in school has significantly reduced stunting and underweight rates among 4-5 year olds,16 but it does not help younger children, who are most vulnerable to the effect of undernutrition.
Low status of women
Discrimination against women in South Asia is thought to be one of the main drivers of infant undernutrition in the region.17 Multi-country multivariate analysis shows that differences in the levels of women’s status relative to men between South Asia and sub-Saharan Africa is responsible for a substantial share of the difference in infant undernutrition rates between the two regions.18 Within India, women tend to have higher status in the states that have better rates of nutrition (such as Tamil Nadu), but the time series data at state level are insufficient to assess this association more rigorously.
Weak public health system
India’s health system is ranked below that of Bangladesh and Sri Lanka.19 Spending on the public health system is low (less than 1% of GDP) and over 80% of health expenditure is out of pocket. There have been recent calls on the government to increase public sector spending to 6% of GDP by 2020 and to act to strengthen the system.20
Access to clean water and sanitation
Childhood nutritional status is linked to infection rates and therefore unsanitary conditions. Access to piped drinking water remains low in India, increasing from 19% in 1990 to 22% in 2008, although 88% had access to “improved” water sources.21 However, sanitation practices remain largely unimproved. Unicef and WHO estimate that 640 million Indians still practise open defecation, accounting for 56% of the world’s total.21 Wider promotion of the cost effective Community Led Total Sanitation intervention could help increase use of latrines.22
Discrimination against certain castes and groups remains strong in many Indian states. Low caste is associated with poor access to services and therefore poor nutrition and health outcomes, even after education and welfare levels have been taken into account.23 Longitudinal analysis from Andhra Pradesh finds that children from a scheduled caste or a backward tribe have a substantially increased probability of being stunted.24
National nutrition interventions could be improved
The Integrated Child Development Services (ICDS) programme is the main national nutrition related programme for infants. The latest evaluation showed that it reduces stunting among children under 3 years by 6%, yielding a 3.75-fold net return on investment.25 This is low compared with community based nutrition promotion efforts elsewhere (such as Thailand), which attain ratios of 12.5 to 1.26 The evaluation shows the programme’s effects are weaker for under 2s, girls, and those with the most severe stunting and that the centres are not always placed where they are most needed.
The programme could be made more efficient by allowing different districts to adapt it to circumstances, employing more staff so that each age group (0-2 and 3-6 year olds) can receive tailored attention, reaching out to excluded castes, and making centres more accountable to the people they serve.27
Other essential nutrition interventions have low coverage.28 For example, infant and young child feeding interventions cover only 25% of vulnerable children and vitamin A supplementation covers 30-40%. The new accredited social health activist programme pays community health workers to improve these coverage rates and service delivery. So far no data are available to assess its impact on nutrition status, but other evaluations suggest stronger recruitment and support systems need to be put in place.29
Governance refers to the capacity, accountability, and responsiveness of society in dealing with the challenges it faces. Because India has a federal government, it is inevitable that governance will vary by state. Undernutrition levels and their rate of fall also vary by state.30 Unfortunately, there are too few data series at the state level to begin exploring statistical associations between undernutrition rates and features of state governance.
High levels of capacity are required to invest coherently in reducing undernutrition. Investments in health, sanitation, agriculture, women’s status, and food and nutrition programmes need to be not only effective but also coordinated because any weak link in the chain will undermine all other investments. India’s focus therefore needs to be coordination and prioritisation: new mechanisms for cross-departmental working need to be developed, and India’s expertise in prioritising investments to spur economic growth through new diagnostic tools could be transferred to prioritising investment in nutrition.
High levels of accountability are also required because infants aged 0-2 years are particularly sensitive to poor quality services and because undernutrition is so invisible, not only to parents and nutrition workers but also to politicians and the media. To strengthen accountability, new community feedback mechanisms on the performance of nutrition interventions could be piloted and scaled up. There should also be greater transparency about where nutrition resources go so that the cost effectiveness of nutrition interventions can be analysed accurately.
Finally, high levels of responsiveness are required to deal quickly with rapidly emerging shocks such as droughts, floods, and infection. One step would be to collect data on nutritional status more frequently—at the moment they are collected only once every five to seven years.
Successful governance requires a national nutrition strategy backed by strong national leadership. Brazil, another federal government, has done this successfully. In 2003 President Lula da Silva announced Zero Hunger as the major social policy programme of his newly elected government. A new ministry, directly linked to the president’s office, was created, coordinating the work of other ministries towards an overall set of food and nutrition goals. Food and nutrition security was a declared a priority of the federal government’s social policy.31 Combined with economic growth, this strong leadership has greatly reduced hunger and child undernutrition.5
Economic growth in India is reducing poverty, and this should help reduce undernutrition in the long run. But the current environment is not as supportive to nutrition as it could be. The box gives some actions that could help to change this. The most important of these is to establish a national nutrition strategy with government leadership to ensure that undernutrition is given the priority it deserves.
Actions to support better nutrition in India
Focus agriculture on what people living in poverty grow, eat, and need nutritionally
Experiment with cash based alternatives to the targeted public distribution system
Promote community led approaches to sanitation
Increase coverage of essential nutrition interventions in the context of a stronger public health system
Focus Integrated Child Development Services resources more on children under 2 years and those with severe undernutrition and locate centres where they are most needed
Continue the fight against gender and social exclusion
Establish a national nutrition strategy with a senior leader within the government empowered to implement it
Cite this as: BMJ 2011;343:d6687
Contributors and sources: LH has conducted research on the intersections of nutrition, agriculture, poverty, gender, and food security over the past 25 years. This article arose from a long series of interactions with researchers, practitioners and policy makers with expertise on the Indian nutrition situation.
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.