malnutrition tackling child india

tackling child
Rachel Palmer
Raghu Rai/Magnum for Save the Children
MDG 4 – TO
India is home to one-third of the world’s poor, with over
one-fourth of the population – about 410 million people
– living in poverty, 60% in the seven lowest-income states.1
One-third of children are born with low birthweight, 43%
of under-fives are underweight, 48% are stunted, 20% are
wasted, 70% are anaemic and 57% are vitamin A deficient.2
There are wide and increasing disparities across different
states and economic groups.3
Progress towards reducing undernutrition has been limited,
particularly in the last two decades.4 But nutrition security
has remained a leading issue in political and policy debates.
In 2001, the Supreme Court of India pronounced the Right
to Food as an implication of the Fundamental Right to
Life enshrined in the Indian Constitution. This order also
converted the eight nutrition-related state schemes into
legal entitlements.5,6 The government enacted the 2005
National Rural Employment Guarantee Act after immense
mobilisation and pressure by civil society, non-governmental
organisations, and social and labour movements. These
groups have also been leading a nationwide Right to Food
Campaign since 2001.7 The National Food Security Bill 2011
has been approved by the Union Cabinet and is likely to
be placed before Parliament in the coming session.8 The
Prime Minister’s Council on Nutrition has also prioritised
Kate Redman
malnutrition. The Coalition for Sustainable Nutrition Security
in India, formed in 2008 and now chaired by Save the
Children, is a high-level committee that brings together
various actors such as the government, the development
sector, the media, policy-makers, bureaucrats, scientists
and the private sector to work collaboratively towards
overcoming malnutrition. In addition, the forthcoming 12th
Five Year Plan proposes a restructuring of the national
Integrated Child Development Services programme. There
are other complementary policy frameworks and schemes
in education, health, water, sanitation and agriculture.9
“...malnutrition is a matter of national shame.
Despite impressive growth in our GDP, the level of
undernutrition in the country is unacceptably high.”
Prime Minister Manmohan Singh, speaking at the launch of
the 2011 HUNGaMA Survey Report, 10 January 2012
the issue
the solutions
There is no streamlined targeting of nutrition-related
programmes for pregnant women and children under
two – both critical periods to avoid undernutrition.
The below poverty line targeting model practised
in some schemes like the Public Distribution System
does not encompass a large percentage of poor
people due to opaque bureaucratic enrolment
procedures, inadequate selection criteria and lack
of consideration of the seasonality of poverty.10
The model promotes a ‘management’ rather than
‘prevention’ approach to nutrition, and is detrimental
to social inclusion and solidarity.11 Those who are
most marginalised (women, Dalits, Adivasis, landless
or displaced rural poor, migrant workers, urban
slum-dwellers and people who are homeless or
displaced, women-headed households, children under
two) are still largely excluded.12
•Universalise and ensure inclusiveness in all
nutrition-related state schemes with commitment
to ‘universalisation with quality for all’.13
•Improve selection criteria and procedures for
the below poverty line model, so that it defines
nutritional entitlements as per Indian Council for
Medical Reform14 norms, takes into account the
multidimensional nature of poverty and engages
local bodies like the Gram Sabha, female self-help
groups and community-based organisations.15
•Launch a drive to bring rapid access to the poorest
people and scale up the Antyodaya Scheme,
especially provision of standard, state-of-the art
feeding and care for children with severe acute
•Increase coverage and central funding to schemes
in poor performing states.
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the solutions
Implementation, Coordination
and Capacity
Despite a series of progressive welfare schemes, these
are marred by misappropriation or under-utilisation of
financial assistance. Service delivery mechanisms are
weak and inefficient (eg, irregular cereal-stock delivery
to Public Distribution System outlets or Aaganwadi
the issue
rotting grain in state warehouses).16 Lack of
coordination between various central, state and local
departments and bodies mean that links across the
health, education, water, sanitation and agriculture
sectors, which could improve the implementation
of many schemes, do not exist.17 Grassroot-level
workers are overburdened, under-trained, underpaid,
demotivated and ill-equipped.18 Bureaucrats lack
adequate understanding of the issues and there
is no specialised nutrition post at the central
ministry level.19 The current approach to reducing
undernutrition thus fails to take into account the
complex and multifaceted nature of the issue, which
is dependent on a host of economic, environmental,
agricultural, health, cultural, political and administrative
•Decentralise service delivery, management and
response, eg, so that food entitlements through
the integrated child development services and
public distribution system can be procured locally
and farmers also benefit from assured minimum
•Restructure Integrated Child Development Services
to include children aged 0–2 years and increase
focus on preschool education.
•Encourage community ownership of management
and monitoring of schemes, involve Panchayati Raj
Institutions and other village-level committees, and
promote participatory planning.21
•Mobilise local, state and national-level citizen action
for enhanced transparency and accountability, use
innovative approaches like social audits, the right to
information, community vigilance groups, workers’
and women’s collectives, etc.22
•Strengthen the knowledge and skills, as well as
support systems, for community-level workers
(especially Anganwadi Workers, Accredited Social
Health Activists, Auxiliary Nurse Midwives and
teachers) and primary-level providers
and counsellors.
•Recommend and support the process of
convergence between various government
ministries, programmes and non-state actors;
prevent integrated cross-cutting schemes from
creating parallel mechanisms.
•Support the government to establish
comprehensive and coordinated national-level
nutrition training, monitoring, redress, accountability
and a data analysis mechanism, and to adopt an
evidence-based approach to the design and
revision of key nutrition programmes.23
•Strengthen the focus on improving nutrition
through a leadership and coordination mechanism
with clear authority and responsibility, working from
local to national levels (possibly through a ministry
or nutrition authority).
•Mainstream nutritional goals, criteria and
support programmes in ongoing agricultural
and employment guarantee schemes.24
•Initiate a comprehensive and coordinated
national nutrition education and behavioural
change programme.
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the solutions
India has one of the highest proportions of
malnourished women in the developing world.
As many as 35.6% of adult women (15–49 years)
suffered from chronic energy deficiency in 2006;25
and 70% of non-pregnant and 75% of pregnant adult
women were anaemic in 2000.26 A large proportion
of these women are from the poorest sections of
society.27 Patriarchal norms that propagate gender
inequality and practices like child marriage trap
adolescent girls and women in a cycle of malnutrition
and ill-health,28 which has severe development
implications, including low birth weight, child
malnutrition and chronic diseases.29
•Emphasise empowering women, collectivisation and
access to resources, and address the socio-culturalpatriarchal issues that affect women.
•Focus on combating child marriage and adolescent
pregnancy, empowering and meeting the nutritional
needs of married and unmarried adolescent girls.
•Introduce a national scheme for maternity
entitlements in the informal sector, including cash
support of Rs1,000 (US$19.50) per month for six
months without any exclusions for age or number
of children.30
•Promote awareness of infant feeding practices31 and
build capacity of accredited social health
activist volunteers as community ambassadors
for women’s rights.
•Expand the focus on girls’ and women’s nutrition
within existing national programmes.32
the issue
the solutions
Political Will
Despite rhetorical commitment to tackling
undernutrition, strong commitment and political will
is lacking. As a result, food and nutrition has become
a hotly debated issue. The proposed National Food
Security Bill has been severely criticised by the Right
to Food campaign for being half-hearted.33 Recent
budgetary allocations to child nutrition have been
grossly inadequate.34 The push towards cash transfers,
debates around ready-to-eat vs cooked meals in the
mid-day meal programme or centralised fortified
food production vs decentralised food procurement,
and autonomy or feeding-practice awareness vs baby
food, highlight the contentious issue of corporate
involvement in food policy.35The government has
no clear conflict of interests policy to address these
concerns, except the Regulation of Production, Supply
and Distribution Act 1992.36 The state approach to
nutrition has also been limited mainly to a technical
one and has not paid sufficient regard to the effects
of socioeconomic structural changes.37
•Enact a comprehensive National Food Security Bill
2011, and make appropriate budgetary allocations
in nutrition that meet the requirements of the
Supreme Court April 2004 Order.
•Focus on the work of the Coalition for Sustainable
Nutrition Security in India to assist the government
to develop a strong programme based on proven
•Keep the ‘best interests’ of children in mind when
deciding on nutrition interventions.
•Enact a ‘conflict of interests’ regulation in child
health programmes consistent with the World
Health Assembly resolutions.38
•Promote nutritional food entitlements like pulses,
milk, eggs, oil, etc, in addition to cereals, and the
indigenous production and provision of therapeutic
foods rather than expensive ‘medicalised’
micronutrient supplements.39
•Develop strong local accountability mechanisms.
•Seek to better understand the link between
undernutrition and socioeconomic changes, such as
increasing urbanisation, structural transformation of
the economy, displacement and agricultural crisis.40
Our goal is that Millennium Development Goal 4 –
a two-thirds reduction in child mortality rates
by 2015 – is achieved. Improving child nutrition is
key to achieving this goal. It will save many lives
and give all children the chance of a good start
in life so they can grow up to fulfil their potential.
“If you eat well you can feed
your child well”
“It was a hard pregnancy. I was diagnosed with
anaemia from the first month. I don’t know why
I became anaemic. I was weak beforehand but I
didn’t bother checking with a doctor until I was
pregnant. I had monthly check-ups then, though,
and saw the doctor about 10–15 times.
“I learned from my delivery that if you eat well
then you can feed your child well. And I think
mothers should go to hospital when they’re
pregnant because the support you get there
is far better than the type of care you get at
home. Next time I have a baby I will feed him
properly – no bottled milk, and no water. I can’t
imagine what would have happened if I hadn’t
had the support I had for my child.”
Kate Redman
Gulnaf (pictured right with her son, Sanya) in
Rajasthan, where Save the Children is working
with Anganwadi workers, accredited social
health activists and auxiliary nurse midwives
to reduce infant mortality and malnutrition
among children, increase the percentage of
babies delivered in hospitals or clinics, improve
postnatal care and immunisation coverage, and
promote early and exclusive breastfeeding. The
districts chosen for the project have a high
concentration of scheduled castes and
tribes, eg, Dalit and Adivasi populations.
1United Nations Development Programme, Human Development
Report 2010, United Nations, New York (2010) p.98: http://hdr.
2B Fenn (2011) Research for Save the Children’s report, A Life Free
From Hunger:Tackling child malnutrition
3 P K Pathak and A Singh (2011) ‘Trends in malnutrition among
children in India: Growing inequalities across different economic
groups’, Social Science & Medicine,Vol 73, No. 4, pp. 576-585; K
R G Nair (2007) ‘Malnourishment amongst Children in India: A
Regional Analysis’, Economic and Political Weekly, Issue No. 37
4 P K Pathak and A Singh (2009) ‘Geographical variation in poverty
and child malnutrition in India’ in K K Singh, R C Yadava and A
Pandey (eds), Population, poverty and health: Analytical approaches (pp.
183-206), New Delhi, India: Hindustan Publishing Corporation
5 Public Distribution System (PDS); Antyodaya Anna Yojana (AAY)
aimed at the poorest one crore [10 million] ‘hungry’ families;
National Programme of Nutritional Support to Primary Education
(‘mid-day meal scheme’); Integrated Child Development Services
(ICDS); Annapurna Scheme for senior citizens; National Old Age
Pension Scheme (NOAPS); National Maternity Benefit Scheme
(NMBS); and National Family Benefit Scheme (NFBS)
6 Supreme Court of India Order of November 28, 2001; Item No.
6, Court No. 2 Section PIL A/N Matter Supreme Court of India
Record of Proceedings, Writ Petition (Civil) No 196 OF 2001,
People’s Union for Civil Liberties Petitioner(s)-Versus-Union of
India & Ors. Respondent(s).
8 Ibid
9 For example, National Rural Health Mission, Horticulture Mission,
Jawaharlal Nehru National Urban Renewal Mission, Rajiv Gandhi
National Drinking Water Mission, Sarva Siksha Abhiyan (Education
for All), Bharat Nirman programmes, Prime Minister’s Nutrition
10Report of the Expert Group to advise the Ministry of Rural
Development, Government of India on the methodology for
conducting the Below Poverty Line (BPL) census for 11th Five Year
Plan chaired by N C Saxena, August 2009
11Working Group on Children Under Six (2007) ‘Strategies for
Children Under Six’, Special Article, Economic and Political Weekly,
Vol 42, No.52, pp. 93–94
12M Gragnolati et al (2005) ‘India’s Undernourished Children:
A Call for Reform and Action’, Health, Nutrition and Population
(HNP) Discussion Paper, World Bank; J Ghosh (2010) ‘The Political
Economy of Hunger in 21st Century’, Economic and Political Weekly,
Vol 45, No. 52; U Patnaik (2007) The Republic of Hunger and Other
Essays, Three Essays Collective: New Delhi
R Khera (2011) ‘Revival of the Public Distribution System:
Evidence and Explanations’, Economic and Political Weekly,Vol 46,
Nos. 44 & 45; J Dreze (2006) ‘Universalisation with Quality: ICDS
in a Rights Perspective’, Economic and Political Weekly,Vol 41 No. 34
14Indian Council for Medical Research (2009) Nutrient Requirements
and Recommended Dietary Allowances for Indians: A Report of the
Expert Group of Indian Council of Medical Research, National
Institute of Nutrition, Hyderabad
15Saxena (2009) op cit
17 Gragnolati et al (2005) op cit, note 12
18Citizens’ Initiative for the Rights of Children Under Six (2006)
Focus on Children Under Six Report, New Delhi;
Working Group on Children Under Six (2007)
19Gragnolati et al (2005) op cit
20M Gragnolati et al (2006) ‘ICDS and Persistent Under-nutrition:
Strategies to Enhance the Impact’, Economic and Political Weekly,Vol
41 No. 34
21Gragnolati et al (2006) op cit; S Sinha (2006) ‘Infant Survival: A
Political Challenge’, Economic and Political Weekly,Vol 41, No. 34
22D Sinha (2008) ‘Social Audit of Mid-Day Meal Scheme in AP’,
Economic and Political Weekly,Vol 43, No. 44; M Chatterjee (2006)
‘Decentralized Child Care Services: The SEWA Experience’,
Economic and Political Weekly,Vol 41, No. 34
23A Deaton and J Dreze (2009) ‘Food and Nutrition in India: Facts
and Interpretations’, Economic and Political Weekly,Vol 44, No. 7
24These schemes include the National Horticulture Mission, the
National Food Security Mission, Rashtriya Krishi Vikas Yojana and
the National Rural Employment Guarantee Act. The National
Horticulture Mission should be implemented in such a manner
that for every nutritional malady, an appropriate horticultural
remedy is introduced.
25S Jose (2011), ‘Adult Under-nutrition in India: Is there a Huge
Gender Gap’, Economic and Political Weekly,Vol 46, No. 29
26 J Mason et al (2005) ‘Recent Trends in Malnutrition in Developing
Regions:Vitamin A Deficiency, Anaemia, Iodine Deficiency, and
Child Under-weight’, Food and Nutrition Bulletin,Vol 26,No 1, pp
27K Sethuraman K and N Duvvury (2007) ‘The Nexus of Gender
Discrimination with Malnutrition: An Introduction’, Economic and
Political Weekly,Vol 42, No. 44
29S Jose and K Navaneetham (2008) ‘A Factsheet on Women’s
Malnutrition in India’, Economic and Political Weekly,Vol 43, No. 33
30Working Group on Children Under Six (2007)
31S Ghosh (2006) ‘Food Dole or Health, Nutrition and Development
Programme?’, Economic and Political Weekly,Vol 41, No. 34.
32For example, the National Rural Health Mission, the Public
Distribution System, National Rural Employment Guarantee
Scheme, Sarva Siksha Abhiyan, and Bharat Nirman programmes.
34htpp://, Resource Allocation in the Union Budget
2005-06: Is It Sufficient to Fulfil the Rights of India’s Children?
35A Gupta and N S Khaira (2008) ‘Flaws in Child Nutrition and
Health Governance’, Economic and Political Weekly,Vol 43, No.
17; A Gupta (2008) ‘Manipulation by Assistance: Undermining
Breastfeeding’, Economic and Political Weekly,Vol 43, No. 36; Working
Group on Children Under Six (2007)
36Gupta (2008) ibid
37Editorials (2006) ‘Child Malnutrition: Behind the Numbers’,
Economic and Political Weekly,Vol 41, No. 18
38Gupta (2008) note 35; Gupta and Khaira (2008) op cit, note 35
39Working Group on Children Under Six (2007)
40Ghosh (2010) op cit, note 12
This briefing is part of a set of eight country briefings produced
by Save the Children and the Institute of Development Studies
to accompany Save the Children’s report, A Life Free from Hunger:
Tackling child malnutrition.
To see the full report, visit
Save the Children, February 2012
Registered Charity No: 1076822