09 September, 2019

‘Any strategy that tackles malnutrition in India has to work at multiple levels’

Madhusudhan Rao, who heads the Nutrition portfolio of the Tata Trusts, explains why the Trusts have adopted a multi-layered approach to tackling the challenge of malnutrition in India.

India is quite unique in terms of the malnutrition challenges she faces, having a heavy burden of undernutrition, but now also with a developing burden of over-nutrition or obesity in its cities. Undernutrition is one of India’s biggest problems, particularly in its children and this presents the single largest contributor to under-five mortality, accounting for nearly half of all deaths in that age range.

Ensuring adequate nutrition during early childhood has important implications for the nation’s economic development and movement out of poverty, as it affects cognitive development, economic productivity in adulthood and long-term health.

The challenge is that poverty and hunger occur together, and these are difficult problems to solve, as no single solution exists. Thus, progress towards combating undernutrition has been uneven and slow, and the 2018 Global Nutrition Report showed that while progress against <5y stunting had happened to some extent, almost none had occurred for other problems, such as <5y wasting or anaemia in women of reproductive age. The statistics speak for themselves – less than 10% of children across India have adequately nutritious diets , and nearly 60% of children and 50% of pregnant women are anaemic. A majority of India’s population still lives in its villages, and according to a 2006 World Bank report, 50% of India’s villages are severely affected by malnutrition.

Undernutrition not only includes overt hunger and symptoms like stunting and wasting in children, but also hidden hunger or micronutrient deficiency. Tackling these is an uphill task as it is a combination of several factors that need to be addressed. There is no single magic bullet. Poverty, which includes inadequate poor purchasing power and access to nutritious foods, lack of knowledge about the need for diverse, nutritious diets, inadequate maternal care, and lack of water and sanitation are some of the multi-faceted factors that need to be addressed simultaneously. Then there is the factor of the timing of undernutrition in the life-course. Undernutrition occurs at all ages, but when it occurs early in life, it has its most devastating and profound effects that last well into the lifespan, as well as into the next generations. The first 1000 days of a child’s life, including 9 months of pregnancy, and 24 months of postnatal life, are critical when designing interventions that address malnutrition in all its forms.

There is little doubt that no single intervention will be able to achieve impact at the scale that India needs; to bring about lasting change, we need cohesive, multidisciplinary strategies that help generate critical momentum and sustainable change.

The Trusts’ multi-layered approach, both in strategy and time of intervention, focuses on long-term sustainability, and is based on the three foundational pillars of product, platform and policy. It focuses on early life initiatives for nutrition, and involves the strengthening of existing delivery platforms with appropriate modifications, along with data-based advocacy with policy makers at multiple levels.

An example of ‘platform’ led initiatives is the Trusts’ work to strengthen the implementation of Poshan Abhiyan, the Government of India’s flagship initiative to address malnutrition, in the states of Maharashtra, Rajasthan and Andhra Pradesh. India’s Integrated Child Development Services (ICDS) is arguably the world’s most unique early childhood development programme that encompasses the main components of early childhood development – health, nutrition and education. In India, the Government of India’s ICDS programme reaches out to 19 million pregnant and lactating mothers and 84 million children through a network of anganwadis (centres) run by 1.3 million anganwadi workers.

Giving due importance to early life initiatives, the Trusts have made it a priority to work with state governments to strengthen the ICDS platform to focus on nutrition of young children. The Trusts’ strategy to strengthen the function of the ICDS in Maharashtra, Rajasthan and Andhra Pradesh uses a combination of interventions to improve the programme’s service delivery, modify supplementary food rations and improve awareness amongst young mothers. It includes refurbishing anganwadis, building the capacities of frontline workers, working with communities and panchayati raj institutions to generate awareness, improving the quality of supplementary nutrition, and influencing policy through data-based research. In short, it is a set of interventions that include collaboration with various civil society organisations and central, state and local administrations.

Hidden hunger, or micronutrient deficiency, is another equally important aspect of malnutrition and the Trusts are tackling this issue through ‘products’. The Trusts are working to undertake translational research to develop micronutrient fortified foods at scale, like salt, milk, oil, wheat and rice. These products are designed in line with existing government schemes or channels for appropriate scale-up with the view to strengthen specific delivery platforms. They are being distributed in various states through multiple platforms such as school midday meal schemes and the ICDS anganwadi network. Where required, the Trusts step in to provide technical support to the states to develop fortified foods.

Another component of the work involves developing affordable and tasty nutritious food products for growing children. An example of this is GoMo, a legume-based food specifically designed for the growing school child.

Separately, the Trusts have also been working closely with the Government of Maharashtra to establish centralised kitchens that can supply hygienic wholesome and complete nutritional meals for schoolchildren. The goal is to provide food security and to improve the health and nutrition outcomes in children who come from impoverished backgrounds with limited access to healthy food. Impacting approximately 22,000 children spread across 54 districts in Maharashtra, the biggest success of this programme has been the significant reduction in the prevalence of underweight children (9%) and in their levels of anaemia (10%) in the pilot districts.

Finally, data-based advocacy helps inform all stakeholders and creates a framework for the use of evidence and data to drive actions. The Trusts work with NITI Aayog on data-driven research and presentation of decision-helping dashboards to mobilise policy to strengthen or modify existing schemes.

Going forward, the Trusts plan to focus on the implementation findings and the potential impact they can make in bringing about possible solutions and future policies. The objective is to upscale scientifically researched ideas and various advocacy initiatives at multiple levels, with the understanding that this requires a sustained and consistent effort. The learnings from the present will influence the Trusts’ future actions towards strengthening India’s nutrition parameters and embedding processes for healthier children.