Nutrition policy and action in India is finally on the move and commitment is increasing at the central government level — this was clear from the recent Delhi launch of the Global Nutrition Report 2015 and the India Health Report 2015. But if malnutrition reduction is to be further accelerated, changes at the State level need to occur.
Here are a few examples of how States could lead the way, based on my experience in Maharashtra.
First, the Ministry of Women and Child Development (MWCD) needs to recognise stunting and wasting and to measure height. We know that early childhood stunting causes irreversible damage to lifelong health, IQ and productivity; at least allow state WCD departments to start measuring height gain for under- 2 children.
In addition, as a proposal to the states, should we ask the Ministry of Health to deal with wasting (including community level management of SAM based on MUAC measurement) and the curative aspects of malnutrition, while the MWCD should be tasked with addressing stunting and preventive aspects? This division of roles might help in achieving greater clarity and coherence, given that the departments tend to work in silos.
Second, there are no clear guidelines or prescribed nutrient dense recipes on how to treat severely underweight children (very low weight for age) which is the only indicator that MWCD recognises (it does not recognise the global standard of Severe Acute Malnutrition based on weight for height). At present, ICDS centres provide extra food to SUW children, but only in quantity, not in quality or density.
Third, agriculture policy is often at variance with nutrition policy. There is no policy to discourage cultivation of sugarcane, cotton (and other cash crops with no nutritive value but which are resource intensive, risky and lead to farmer indebtedness) and to encourage pulses or vegetable cultivation instead. Indians don't need so much sugar in their diet anyway, given the spread of diabetes even among the poor. Agriculture policy today is mostly about cash crops and increasing production and yields for the market, with no space for multi-cropping and cultivation of local crops for self-consumption.
Fourth, should the National Employment Guarantee Scheme (MNREGS) fund vegetable cultivation/ kitchen gardens by paying for the wages of the caretaker? Since funds are always scarce in the nutrition sector, why not tap MNREGS?
Fifth, since malnutrition has it's roots in adolescence, the training of adolescent boys and girls in health, nutrition and life skills must be given higher priority and budgets. There is no point in launching adolescent training schemes if there are no budgets for training state and district level master trainers.
Sixth, the Public Distribution Scheme (PDS) for subsidised food focuses exclusively on carbohydrates, while protein and micronutrient deficiencies are unaddressed. The PDS needs to include pulses and fortification of wheat flour. In addition the ration cards of migrant workers (construction workers, brick kiln labourers, sugarcane cutters) need to be made 'mobile' so that they can access PDS rations at the place of work. Labourers are away from their native place for almost 6 months every year, and buying wheat or rice at market prices is a huge drain on their resources—the children of migrant workers come back home every year more malnourished than before and migrant women and children have no access to health and ICDS services.
Seventh, government departments that give licenses to brick kiln owners or builders could easily insist that employers must provide basic creche services, toilets and drinking water facilities.
Finally, I note that the Government of India is not in favour of joining the global Scaling Up Nutrition (SUN) movement. This is a missed opportunity. The Government seems to think SUN membership is mere posturing or some kind of succumbing to a movement that has little legitimacy (56 countries think otherwise!). Maharashtra's experience is that attending SUN events provides an opportunity for state level and middle level nutrition stakeholders (from within and outside the government) to get sensitised about, and to take ownership of, nutrition issues. Equally importantly, it provides a way of rewarding and encouraging good performers by giving them learning and profiling opportunities. Government systems are not designed for providing out of turn rewards or performance-based increments. Where else do middle level health and ICDS workers get an opportunity to attend world-class events and to interact with nutrition experts? They come back renewed with energy and determination to work for nutrition.
As the examples in this blog have shown, there are plenty of opportunities for the statesto innovate around nutrition. This innovation should be supported by the national government. This combination is what is needed if India is to build on its recent progress and accelerate reductions in malnutrition.