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Chapter # 31. Nutrition

Objectives 

Under POSHAN Abhiyaan, achieve the following outcomes by 2022-23, compared to the baseline of 2015-16 (National Family Health Survey-4):

  • Reduce the prevalence of stunting among children to 25 per cent or less.
  • Reduce the prevalence of underweight in children (0-6 years) to 25 per cent or less.
  • Reduce the prevalence of anaemia among young children (6-59 months) to 43 per cent or less.
  • Reduce the prevalence of anaemia among adolescent girls and women (15-49 years) to 38 per cent or less.

Current Situation

Under-nutrition is the prime risk factor in over 40 per cent of under-five child deaths. Children with under-nutrition, anaemia and iodine deficiency will have low IQ scores and productivity as adults. A World Bank estimate1 indicates that reducing stunting can raise India’s GDP by 4-11 per cent.

The prevalence of stunting declines by an estimated 3.2 per cent for every 10 per cent increase in income per capita. Similarly, a 10 per cent rise in income per capita translates into a 7.4 per cent fall in wasting. Thus, increasing per capita incomes through rapid and equitable economic growth is a necessary condition for improving nutrition outcomes. 5-06) & NFHS 4 (2015-16)

Although progress has been made, according to National Family Health Survey-4 (NFHS-4), 2015-16, over one-third of all under-five children are stunted (low height-for-age), every fifth child is wasted (low weight-for-height), and more than 50 per cent of the children are anaemic.

Other emerging economies such as Brazil (stunting– 6.1 per cent, wasting – 1.6 per cent), China (stunting – 6.8 per cent, wasting – 2.1 per cent) and Mexico (stunting – 13.6 per cent, wasting – 1.6 per cent) fare far better on nutrition indicators compared to India.

Ironically, at the same time, India is also grappling with the rising menace of ‘over-nutrition’. Nearly one fifth of India’s adults are either obese or overweight as per NFHS-4 data, leading to an increased risk of diabetes and cardiovascular disorders.

India can leverage its demographic dividend only if its citizens attain optimum levels of health, nutrition and cognition.

Recognising this, the government launched the POSHAN Abhiyaan in March, 2018 to provide police and programmatic guidance to high burden states and districts, facilitate multisectoral planning, catalyse resource mobilisation and develop a surveillance system for nutrition.

Constraints

  1. Multidimensional determinants of under-nutrition are inadequately reflected in policymaking
  • Inadequate and poor-quality food is an important, but not the only, cause of under-nutrition.
  • The underlying causes of malnutrition are multifaceted and rooted in economic and social factors like low levels of female literacy, lack of access to clean drinking water and sanitation.
  • At a more proximate level, nearly half of childhood under-nutrition is attributable to illnesses (in particular, diarrhoea, pneumonia and measles) and foetal growth restriction that results in low birth weight due to maternal nutrition, maternal health, pregnancy complications and epigenetic factors.
  1. Design limitations of the Integrated Child Development Services (ICDS)
  • The design of the ICDS programme has an important limitation – its focus on the first 1000 days of the child’s life is inadequate. Over 80 per cent of brain growth occurs during the first 1000 days of a child’s life. This has a significant bearing on work capacity, productivity and IQ in adulthood. Hence, nutrition programmes in the country must accord the highest priority to this critical period of life.
  • However, the ICDS programme’s most prominent activities are focused on the delivery of pre-school education and hot cooked meals as well as growth monitoring at anganwadi centres for children between 3 and 6 years. Only 10% of children between 6 and 13 months received an adequate diet in 2015-16 (NFHS-4).
  1. ICDS programme implementation
  • The ICDS programme is beset with persistent challenges such as shortage of staff and field workers, poor monitoring, instances of food pilferage and poor quality of services.
  • Given the complex nature of the challenge, a multi-dimensional approach is a must. NITI Aayog has already detailed a possible action agenda in its National Nutrition Strategy,2 which needs to be urgently implemented.

Way Forward 

  1. Address policy and governance issues
  • Provide greater flexibility to states under the POSHAN Abhiyaan to adapt programmes for context-specific implementation and to experiment with innovative approaches to attain high coverage, quality, equity and better outcomes.
  • Establish an institutional mechanism, outside the government, to conduct independent annual audits of the programme to achieve implementation improvements.
  1. Ensure convergent action at all levels  
  • Develop and implement Annual Integrated Health, Nutrition and Swachh Bharat Mission (SBM) action plans for all districts under the POSHAN Abhiyaan.

o Ensure accountability of the local administration.

o Actively engage panchayati raj institutions, the public distribution system (PDS) and public health engineering departments for delivery of the action plans.

  • Integrate health, SBM and nutrition services at the village level through the Village Health, Sanitation and Nutrition Committees and by ensuring regular observance of Village Health Sanitation and Nutrition Days (VHSNDs).
  • Develop an implementation guide for integrated action for nutrition (‘a cook book’) for district administrators.
  • Establish a state-level convergence mechanism for nutrition under the chief secretary/ equivalent officer and corresponding structures at the district and block levels.
  1. Implement mission mode action in districts with a high burden of malnutrition under POSHAN Abhiyaan 
  • Set up convergence mechanisms at the state, district and block levels; develop action plans specifying timelines; ensure sufficient budgetary allocation; strengthen monitoring systems; galvanize coordination; demonstrate change guided by annual surveys and intensively monitor implementation by NITI Aayog.
  1. Refine programme interventions Focus on first 1000 days 
  • As envisaged under the POSHAN Abhiyaan, devise a strategy for additional home-based contacts under the home-based young child care initiative with:

o Mothers having children in the age group of 3 months to 2 years to ensure compliance with infant and young child feeding practices as well as healthy behaviours.

o   Mothers having a child with moderate or severe malnutrition for regular follow-up.

o These home visits should be conducted by accredited social health activists, a second auxiliary nurse midwife or community infant and young child feeding counsellors.

  • Replace the food-centric approach with more broad-based action that includes healthcare measures (special care of low birth weight in-fants and immunization), birth spacing, delaying age of marriage, exclusive breastfeeding for 6 months, and timely and adequate access to complementary food interventions.
  • Focus on immunization including Rota Virus and Pneumococcal Vaccines; target the vaccines preferentially to high focus districts.

Fortification

  • Consider mandatory fortification of staples produced in the organized sector and provide incentives to the industry to do so.
  • Incorporate fortified food grains and double fortified salt within government programmes such as ICDS, mid-day meal scheme, and PDS.
  • Explore approaches to bio-fortification of grains for micronutrient deficiencies.

Research

  • Create a national nutrition surveillance system to track food quality and consumption patterns and nutritional deficiency profiles for all age groups in different regions.
  • Conduct implementation research studies to inform improvements in the programme.

o Key research areas include assessing the effectiveness of conditional cash transfers/ vouchers in improving child nutrition and the optimum formulation of supplementary nutrition for young children.

o Evaluate ICDS programme in depth and suggest reforms for greater effectiveness.

  • Track changes in birth weight and prematurity rates at the population level; conduct long-term cohort studies on changes in body composition and early biomarkers of metabolic disorders.
  • Review and redesign nutrition programmes targeted at adolescent girls; link these with pre-pregnancy interventions.
  • Test approaches to prevent childhood and adult obesity at the population level.
  1. Scale-up nutrition MIS and strengthen monitoring mechanisms
  • Establish an IT-based real time monitoring mechanism by rolling out the Common Application Software (CAS) developed by the Ministry of Women and Child Development on a countrywide basis.
  • Undertake joint health and nutrition reviews in the field as a standard practice.
  • Establish accountability with defined responsibilities at all levels – state, district and field.
  1. Make ‘POSHAN Abhiyaan’ a Jan Andolan
  • Make POSHAN Abhiyaan a community-led movement with adequate political backing.
  • Develop behavioural change communication modules and ensure its use by all frontline workers, especially during VHSNDs; emphasise individual as well as group counselling.
  1. Galvanize the National Anaemia Control Programme 
  • Implement the revised strategy for the anaemia control programme based on evidence; incorporate home, community, school and facility level action; embed the strategy in the activities of the emerging health and wellness centres.

Consider ‘screen and treat’ as a part of the anaemia control intervention package.




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Chapter # 40. Optimizing the Use of Land Resources

Optimizing the Use of Land Resources-Ensuring that land markets function smoothly, through efficient allocation of land across uses, provision of secu

Chapter # 39. Modernizing City Governance For Urban Transformation

Objective  City Governance For Urban Transformation To transform our cities into economically vibrant and environmentally sustainable habitats that p

Chapter # 38. Civil Services Reforms

Objective  civil-services-reforms To put in place a reformed system of recruitment, training and performance evaluation of the civil service to ensur

Chapter # 37. Legal, Judicial and Police Reforms

Objective To ensure the safety and security of citizens and ensure access to effective legal systems and speedy delivery of justice. Current Situation

Chapter # 36. The North-East Region

Objectives The North-East Region (NER) should: Have adequate road, rail and air connectivity, waterways, internet connectivity and financial inclusion

Chapter # 35. Balanced Regional Development: Transforming Aspirational Districts

Objective  Balanced Regional Development: Transforming Aspirational Districts Achieve balanced development in India by uplifting 115 districts, curre

Chapter # 34. Scheduled Castes (SCs), Scheduled Tribes (STs), Other Backward Classes (OBCs), Other Tribal Groups and Minorities

SCs, STs, OBCs, De-Notified Tribes (DNTs), Nomadic Tribes (NTs) and Semi-Nomadic Tribes (SNTs) Objective  To accelerate the socio-economic developm

Chapter # 33. Senior Citizens, Persons with Disability and Transgender Persons

SENIOR CITIZENS  Objective To ensure a life of dignity, social security and safety for senior citizens, enabling them to actively participate in econ

Chapter # 32. Gender

Objective  To create an enabling environment, sans institutional and structural barriers. To enhance the female labour force participation rate to at

Chapter # 31. Nutrition

Objectives  Under POSHAN Abhiyaan, achieve the following outcomes by 2022-23, compared to the baseline of 2015-16 (National Family Health Survey-4):

Chapter # 30. Universal Health Coverage

Objectives  On the strong platform of Pradhan Mantri – Jan Arogya Yojana (PM-JAY): Attain a coverage of at least 75 per cent of the population

Chapter # 29. Human Resources for Health

Objectives  Achieve a doctor-population ratio of at least 1:1400 (WHO norm 1:1000) and nurse-population ratio of at least 1:500 (WHO norm 1:400) by 2

Chapter # 28. Comprehensive Primary Health Care

Objectives  Under Ayushman Bharat, scale-up a new vision for comprehensive primary health care across the country, built on the platform of health an

Chapter # 27. Public Health Management and Action

Objectives  To revamp radically the public and preventive health system in the nation through the following strategic interventions: Mobilize public

Chapter # 26. Skill Development

Obejctives  For harnessing the demographic advantage that it enjoys, India needs to build the capacity and infrastructure for skilling/reskilling/up-

Chapter # 25. Teacher Education and Training

Objectives There cannot be a quality education system without quality teachers. Therefore, a thorough revamp of the entire ecosystem of teacher educat

Chapter # 24. Higher Education

Objectives  Increase the gross enrolment ratio (GER) in higher education from 25 per cent in 2016-17 to 35 per cent by 2022-23. Make higher education

23. School Education

Objectives Universal access and retention: o Hundred per cent enrolment and retention at elementary education and secondary education levels; achieve

Chapter # 22. Sustainable Environment

Objective  The objective is to maintain a clean, green and healthy environment with peoples’ participation to support higher and inclusive economic

Chapter # 21. Water Resources

Objectives By 2022-23, India’s water resources management strategy should facilitate water security to ensure adequate availability of water for l

Chapter # 20. Swash Bharat Mission

Objectives The key objectives of the Swachh Bharat Mission include: 1. Making India Open Defecation Free (ODF) by October 2, 2019. 2. Carrying out ext

Chapter # 19.Smart Cities for Urban Transformation

Objectives  Leverage the ‘Smart Cities’ concept in select urban clusters to: Drive job creation and economic growth. Significantly improve effici

Chapter # 18. Digital Connectivity

Objectives Given the relevance of digital connectivity to economic growth and the need to eliminate the digital divide by 2022-23, India should aim to

Chapter # 17. Logistics

Objectives Achieve multi-modal movement of cargo on par with global logistics standards. Reduce the logistics cost to less than 10 per cent of GDP fro

Chapter # 16.Ports, Shipping and Inland Waterways

Objectives  Double the share of freight transported by coastal shipping and inland waterways from 6 per cent in 2016-171 to 12 per cent by 2025. Incr

Chapter # 15. Civil Aviation

Objectives Enhance the affordability of flying to enable an increase in domestic ticket sales from 103.75 million in 2016-171 to 300 million by 2022.2

Chapter # 14. Railways

Objectives By 2022-23, India should have a rail network that is not only efficient, reliable and safe, but is also cost-effective and accessible, both

Chapter # 13. Surface Transport

Objectives Increasing the coverage and quality of roads and highways is critical to enhancing connectivity and internal and external trade. By 2022-23

Chapter # 12. Energy

Objectives The government’s on-going energy sector policies aim “to provide access to affordable, reliable, sustainable and modern energy”. At t

Chapter # 11. Minerals

Objectives Double the area explored from 10 per cent of obvious geological potential (OGP) area to 20 per cent.1 Accelerate the growth of the mining s

Chapter # 10. Travel, Tourism and Hospitality

Objectives  Increase India’s share in global international tourist arrivals from 1.18 per cent to 3 per cent. Increase the number of foreign touris

Chapter # 9. Housing For All

Objectives Provide every family with a pucca house, with a water connection, toilet facilities, and 24×7 electricity supply and access. Build 2.9

Chapter # 8. Financial Inclusion

Objectives Banking for the unbanked  o Bank accounts: Ensuring universal access to bank accounts, which are a gateway to all financial services.  o

Chapter # 7.Doubling Farmers’ Income (III): Value Chain & Rural Infrastructure

Objectives • Transform the rural economy through the creation of modern rural infrastructure and an integrated value chain system. • Leverage the

Chapter # 6.Doubling Farmers’ Income (II): Policy & Governance

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Chapter # 5.Doubling Farmers’ Income (I): Modernizing Agriculture

Objectives • Modernize agricultural technology, increase productivity, efficiency and crop diversification. • Generate income and employment throu

Chapter # 4.Industry

Objectives Double the current growth rate of the manufac-turing sector by 2022. Promote in a planned manner the adoption of the latest technology adva

Chapter # 3. Technology and Innovation

Objectives India should be among the top 50 countries in the Global Innovation Index by 2022-23.1 Five of our scientific research institutions should

Chapter # 2.Employment and Labour Reforms

Objectives Complete codification of central labour laws into four codes by 2019. Increase female labour force participation to at least 30 per cent by

Chapter # 1 Growth (India @ 75)

Objectives Steadily accelerate the gross domestic product(GDP) growth rate to achieve a target of about 8 per cent during 2018-23 This will raise the

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