Annex 3: Ending Undernutrition in India by 2020
A report on a meeting of the Commission
Asian nutrition advocates, managers and
held in Chennai 23 - 24 November, 1998.
Prepared by staff of the MS Swaminathan Research
Qualitative and quantitative dimensions
Developmental transition in India has been taking place over the
last 50 years since independence. We have moved from the famine situation of the
1940s to one of self-sufficiency in food production, at the prevailing level of
purchasing power, due to major initiatives like the Green Revolution. However,
we still have over 200 million children, women and men in our country who are
The question that arises is whether developmental transition
resulting in increased food availability has translated into nutritional
transition characterised by opportunities for a productive and healthy life for
all. If not, is there a need for a change in strategy? Changes have been taking
place, but they have made the nutrition problem greater than ever in the context
Four stages of nutritional transition can be identified during
the course of development in a country:
Famines - This was the stage that
India was in just after independence (1949). Food grain production was
insufficient to meet the country's needs. Survival strategies were required.
There was also need to decrease infant mortality rates and calorie shortages
through initiatives such as the Green Revolution for augmenting food production.
Famines under control - This is the stage when a
nation moves from a high prevalence of clinical undernutrition to moderate
undernutrition, resulting in phenomena like intrauterine growth retardation and
stunting. As far as India is concerned, only the tip of the iceberg of
undernutrition has been eliminated.
Normalcy - This is the stage when a nation
achieves a degree of nutritional stability and increased productivity.
Over-nutrition - This is the affluent stage when
dietary imbalances set in and faulty lifestyles lead to chronic
India is now moving to a stage beyond basic child survival. It
is in the second stage of nutritional transition i.e. moderate undernutrition,
and needs to move quickly out of this. In the transitional stage not all
sections of the population move together in the same way. On one hand there is a
burgeoning middle class due to acquired affluence by the group born in poverty.
On the other hand there is a population that suffers from moderate
undernutrition. We are burdened with problems at both ends of the spectrum. What
we need, therefore, is to adopt strategies that go beyond survival.
After independence, the country needed survival strategies. The
application of health technology through measures such as oral rehydration
therapy reduced infant death rates. The Green Revolution resulted in increased
per capita calories, and famines disappeared. However once the first stage was
conquered policy-makers become complacent. They need to be alerted to the second
stage, since this relates to human productivity. We must move to the next stage
quickly in order to improve the quality of the Indian peoples' life.
A series of measures need to be adopted for the country as a
whole. There is a need to go beyond chronic starvation to ensuring the nutritive
quality of food. In India, where most of the population is vegetarian either by
compulsion or choice, this is an important measure. Pulse production, which has
decreased over the years, needs to be increased, as does the production of
fruits and vegetables. There is great scope for research in the areas of food
and micronutrient availability.
The major problems that demand attention today are low
birthweight in infants, and iron, iodine and vitamin A deficiencies. The problem
of low birthweight is an issue of concern. Low birthweight is common in India.
This results in slower growth. In the past, many infants with low birthweight
succumbed to diarrhoea and respiratory infections. However, due to the improved
management and control of such infections in recent years, there has been a
steep decrease in child mortality in poor communities. From 146 infant deaths
per 1,000 live births at the time of independence, child mortality has almost
halved to 71 per 1,000 in 1997.
Child survival, however, is not synonymous with good child
nutrition; the inputs needed for the latter are far greater and need to be more
sustained than those for the former. Decline in child mortality without a
corresponding improvement in 'child nutrition has resulted in an expanding pool
of undernourished survivors, and this is reflected in the high prevalence of
stunting in under-fives in poor communities.
The problem of low birthweight cannot be looked at in isolation.
There is a need to look at the nutritional status of the mothers, which in turn
is linked to their status in society and the degree of empowerment that they
enjoy. Improving maternal health and ante-natal care, especially during the
first and second pregnancies should be considered a mother's right.
In the post-independence era, the nutritional deficiency
diseases have disappeared, giving way to hidden hunger or micronutrient
deficiencies. Though stunting was once attributed to protein energy
undernutrition or PEM, the role of micronutrients such as zinc, iron and folic
acid is now also recognised. In many instances micronutrient deficiency might be
the first limiting factor to growth. With the gradual correction of gross energy
deficits in diets, micronutrient deficiencies may emerge as the major factor
responsible for growth retardation in poor communities.
The role of good nutrition in healthy ageing is another issue of
concern. Increased life expectancy has led to a large elderly population.
Therefore management of the elderly population forms an important aspect in
formulating any strategy towards ending moderate undernutrition.
There is a need to strengthen nutrition research capability by
building more laboratories. Research findings need to be translated into policy,
into programmes, and then back to research in the field. Developing countries
need to have resources to make their own decisions and to resist approaches of
the developing countries. Solutions to the problem of undernutrition can come
only through local action and cannot come from outside sources.
India emerged from colonial rule with a heavy backlog of
under-development. It is not yet totally free from the legacies of the colonial
past or of the effect of an inequitable world economic order. However it has
successfully engineered and ensured that at least food grain availability kept
pace with population growth - no mean achievement. This remarkable change was
brought about not through programmes consisting of the distribution of synthetic
vitamins, drugs or special formulation but through improvements in the
traditional diets of the people and through parallel improvements in their
socio-economic and health status.
Therefore policies for combating undernutrition must be firmly
rooted in a food-based rather than a drug-based approach. We need the help of
farms rather than pharmacies for the solution of our nutrition problems. This
can be achieved through greater linkage between agricultural research and
nutrition research. Nutrition research laboratories and institutions need to be
partners with agricultural and women's universities in order to bring about
changes and synergy in agricultural policies and food production. Thus the
country would be empowered to have a food base that attacks moderate
Lessons learnt from ongoing programmes
India, and in particular Tamil Nadu, has had a long, rich and
varied tradition in implementing health and nutrition programmes. The Integrated
Child Development Services Programme (ICDS), aimed at improving the nutritional
status of pregnant and lactating mothers as well as fostering improvement in the
nutritional status of children up to six years old, is implemented throughout
the country. The primary healthcare system and several health intervention
programmes at the grassroots level aim at improving the health of the population
in general and that of the mother and child in particular. Noon meal programmes
in schools have tried to address the problem, of undernutrition in school aged
children and in reducing drop-out rates from schools.
While these efforts have not entirely succeeded in reducing
undernutrition on a large scale, the valuable lessons learnt from these
experiences have provided important insights into prioritising activities and in
adopting a multi-pronged approaches.
1. The ICDS was initially conceived to foster better
growth and development in children up to six years old. However, the programme
largely focuses on children above the age of three years and is not equipped to
cater to the needs of children younger than two years of age.
2. With a well-designed programme it is possible to eliminate
severe undernutrition. However, causes of undernutrition vary from one area to
another. In the Indian State of Orissa, for example, causes ranged from
inadequate care due to both the parents being involved in income-generating
activity, to malaria and poverty. Therefore a common blueprint for action cannot
be recommended as a solution to the nutrition problems of the country as a
3. Eliminating severe undernutrition might be an objective in
emergency situations; however, the problem of mild to moderate undernutrition
should be tackled on a long-term basis. This can be done only through addressing
the needs of women, who are the primary caregivers to children.
4. In general there is very poor appraisal of the social causes
of undernutrition. Thus services need to be modified to respond to the changing
5. Eliminating undernutrition is not a priority on the political
agenda. At the moment the problem is visible only to professionals and not to
politicians. There is a need to convince policy-makers, through cost benefit
studies and sustained advocacy, about the importance of investing in early
intervention programmes which lead to substantial saving on supplementary
feeding at a much later date.
Suggestions for an action plan
The primary focus of attention is adolescent girls, who are the
mothers-to-be, and pregnant and lactating women. The vulnerable period in the
life-cycle is from conception to two years of age, and so includes the pregnant
woman, the breastfeeding mother and her child. Prevention of low birthweight is
an important aspect of improving nutrition. While breast-feeding is still a
common practice, complementary feeding practices are poor and need to be
addressed through appropriate communication channels.
The efficiency of the delivery of services needs to be improved.
No progress in child health can be achieved unless undernutrition is eliminated.
Common elements of success and failure in different parts of the country need to
be discussed before changes and policies are made. More innovative,
region-specific short-term measures, with a sharp focus on high risk, are
needed. Outreach of medical facilities and the manpower base at the grassroots
level is poor -and needs to be improved. There needs to be improved
co-ordination between doctors and nutritionists in programme implementation.
There is an urgent need to reduce childhood morbidity rates.
Since its inception in 1974, the ICDS programme has not changed
in response to changing needs. Restructuring the ICDS is essential to improving
the programme's efficiency. Training and communication support to the workers is
essential in order to improve the quality of services. Changes which aim at
reducing the time spent on administrative work by functionaries, such as
reduction in the number of records to be maintained, and providing incentives
would go a long way in improving the quality of services provided.
There should be a population-based approach to improving the
nutrition problem in India because the number of afflicted people is very high.
There should also be better appraisal of adult undernutrition and the problems
of the emerging affluent class.
While achievement in food security at the national level is
impressive, at the household level it still is not satisfactory. A mix of
strategies, both long-term and short-term, is needed. The long-term goals should
aim at influencing agricultural and food policies towards an equitable
distribution of resources, while the short-term ones could include measures such
as double fortification of salt with iron and iodine.
Fortification technology should be affordable. Synergy between
various sectors such as Government, NGOs and private bodies is essential. For
example, in less than 10 years the global community has succeeded in providing
iodised salt and addressing the problem of iodine deficiency. This was possible
only because of the co-ordination between government and private agencies.
In order to solve the problem of undernutrition there is a need
to look for solution beyond food. Non-nutritional problems which cause
undernutrition need to be addressed on a priority basis by fostering convergence
and synergy among different sectors. Adequate sanitation, innovative approaches
for improving horticulture and a specially targeted public distribution system
for the disadvantaged should receive priority attention. Development initiatives
such as low-cost investment in bio-manure and recycling of waste for energy
production need to be extended.
Safe drinking water, which plays a vital role in the prevention
of gastro-intestinal disorders, should be easily accessible and freely available
to the population.
The prevailing systems for monitoring and surveillance in any
programme, and the priority accorded to these issues in any action plans, are
inadequate and need to be improved. There is a need to indicate the processes
through which changes are attempted.
Social mobilisation needs to be attempted on a large scale to
generate community awareness for better articulation of demands and to enable
the public to participate and deliberate on the services provided.
Child-care support for women is an important issue in empowering
women to take care of children. Most women from the lower socio-economic
categories are employed in the informal sector which has no provisions for
child-care services. Many of the children are under the care of older siblings
while their mothers are away at work. If the mother is away at work and is
unable to provide complementary food the child may become nutritionally
Micro-credit interventions at the village level through
self-help or women's groups help women to gain a better status within the
family. Providing credit to women's groups for consumption or for production
would result in increasing their income, which would have direct bearing on the
nutritional status of the family. Women belonging to these groups could also be
targeted in nutritional and non-nutritional interventions.
In India there are a number of development programmes being
implemented by various governmental departments. However, in most cases there is
no co-ordination in implementation; in many cases, the target groups are not
even aware of their entitlement. The poorest among the poor get left out of the
programmes and the benefits reach only the relatively well off among the poorer
Effective implementation needs to ensure that all programmes
reach those for whom they are meant. This can only be achieved through
information empowerment. One strategy for ensuring effective implementation of
all development programmes at the grassroots level could be through a household
The entitlement card, listing all the development programmes for
the region - by age, gender and occupation - could be made available to the
Panchayat at the village level for distribution to the poor households. It would
help in empowering people with information about developmental programmes. It
would de-mystify the complicated bureaucratic process of applying for
assistance, and make it closer to the people.
The system of decentralisation through the Panchayat Raj system
could be another method of improving implementation of various programmes.
Panchayat Raj brings democracy closer to people as it consists of elected
representatives chosen from the local area who tackle issues of local concern.
Since 33% of the Panchayats are women, involving them in implementation of
programmes for women and children would result in better functioning. Panchayat
Councils for the Elimination of Malnutrition should be set up at the village
level in order to tackle the problem at the regional and local level.
Measurement and monitoring tools
The implementation of various programmes and their impact on the
nutritional status of the population should be systematically monitored and
evaluated. Beginning with maternal mortality rate, several indicators for
assessing progress in children's health and nutritional status can be used.
Maternal mortality rate would
indicate the availability of safe motherhood practices and obstetric care within
the healthcare system.
Infant mortality rate is reflective of
the morbidity pattern, overall health care facilities, feeding practices and the
socio-economic situation of the family.
An imbalance in the male-female sex ratio
would be suggestive of survival threat to the girl child in the form of
selective abortion, infanticide or neglect.
Low birthweight of children would be a
measure of assessing the poor health and nutritional status of mothers and
intra-uterine deprivation for the fetus.
An increase in the average life span is
indicative of improvement in the quality of life and standard of