|Ending Malnutrition by 2020: An Agenda for Change in the Millennium - Final report to the ACC/SCN by the commission on the nutrition challenges of the 21st century (ACC/SCN, 2000, 104 p.)|
A report on a meeting of the Commission
Asian nutrition advocates, managers and scientists
held in Chennai 23 - 24 November, 1998.
Prepared by staff of the MS Swaminathan Research Foundation
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 undernourished.
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 of development.
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 diseases.
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 undernutrition.
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 whole.
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 situation.
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 deprived.
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 sections.
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 entitlement card.
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 living.