India is home to 31% of all stunted children and half of all wasted children across the globe. Lately it took a major step in the direction of holistically addressing the mammoth multidimensional problem of malnutrition – the National Nutrition Mission to achieve the goal of malnutrition-free India by 2022. In this post, Shweta Khandelwal outlines various aspects of the programme which need brainstorming, and the challenges that it might encounter.
Public health and nutrition are undeniably the key elements or indicators of the holistic development of a nation. Nutrition has a direct impact on the cognitive ability of an individual, and thus impacts their productivity. In fact, many intergenerational cohort studies (Fardet and Rock 2014, Mozaffarian 2016, Viljoen et al. 2018, Wahl et al. 2017) show that the benefits accrued by wholesome, balanced diets, and active lifestyle are extendable to 2-3 generations. Several recent reports including the Global Nutrition Report 2018 have also shown huge economic benefits of investing in nutrition (US$16 return for every 1$ invested). The past decade has been hugely nourishing and exciting for the nutrition agenda globally, including India. Multiple high quality reports including the most recent Global Nutrition Report 2018 and advocacy briefs especially from UN agencies were seen coming out lobbying for high quality nutrition for all, strengthened food systems, demand for intersectoral collaboration and action including increased funding, and political attention towards tackling multiple forms of malnutrition (MOM).
Nutrition issues India is grappling with
India is simultaneously battling several nutrition issues – undernutrition on the one hand, and rising prevalence of overweight and obesity on the other. Latest figures reveal that out of the total 150.8 million stunted (low height for age) children in the world, India is home to 31% of them (~47 million), while half of all ‘wasted’ (low weight for height) children (~25.5 million) across the globe are also in India. This is further exacerbated by the wide prevalence of multiple micronutrient deficiencies in both the abovementioned clusters of malnutrition. There is considerable variation across districts (from 12.4% to 65.1%) – 239 of the 640 districts in India have stunting levels above 40% and 202 have prevalence of 30–40%. All these conditions are bound to compromise immunity and cognitive abilities of our future citizens.
A granular analysis of NFHS-4 (National Family Health Survey) data shows alarmingly spiraling overweight, obesity trends and not even a single state in our country (of 29 states and 7 union territories (UTs)) has been found to report a decline in overweight/obesity in the past few years. It’s well known that all these MOM predispose us to the non-communicable diseases, and shorten our productive years of life and overall health. Diabetes, hypertension rates are soaring especially among the younger populations and pushing them towards earlier cardiovascular morbidity and mortality.
National Nutrition Mission
India grapples with an ironical situation – even with an impressive bouquet of comprehensive programmes and policies in the area of maternal and child health (more than 30 MCHN (maternal and child health and nutrition) government programmes/schemes under various ministries and departments – often operational in isolation), India is one of the poorest performer when it comes to MCHN indicators. This has not gone unnoticed thankfully. India has taken a major step in the direction of holistically addressing the mammoth multidimensional problem of malnutrition. On the occasion of International Women's Day in 2018, Prime Minister Narendra Modi launched the National Nutrition Mission (NNM) or POSHAN Abhiyan covering all 640 districts of the country. The mission is backed by a National Nutrition Strategy (NNS) prepared by the NITI Aayog with the goal of attaining “Kuposhan Mukt Bharat” (malnutrition-free India) by 2022. For this, the targets outlined are: to prevent and reduce undernutrition (underweight prevalence) in children (0-3 years) by 3 percentage points per annum from NFHS-4 levels; to reduce the prevalence of anaemia among young children, adolescent girls and women in the reproductive age group (15-49 years) by one-third of NFHS-4 levels.
The political will to addressing this huge problem of MOM especially in our vulnerable population has been fragmented and it was high time that a NNS needed to be drawn up and implemented urgently in our country. This is somewhat like orchestrating a choir – all lyrics and tunes have to be in perfect sync and harmony for the audience to enjoy the end result of wonderful music. Extending this analogy to critically discuss the S-A-A-R-E-G-A-M-A of NNM may provide us useful insights for improved functionality, better planning, strengthening preparedness to take next steps, and for delivery of committed actions to ensure improved public health and nutrition of our masses. Some questions are listed, not necessarily followed by solutions or answers as this may require a more collective brainstorming to appease the raised concerns.
- Sustainability (especially financial): The first question which comes to mind is how will NNM operate and continue to do so for several years in a sustainable fashion. The Centre has committed funds for NNM but also requests states to match investments flexibly. The modes of sharing, funding and costing for each state will depend on their socio-demographic profile, current level of health and nutrition indicators, motivation levels, incentive schema etc. How will inter- and intra-state variations in prevalence of MOM play out in planning interventions? Will higher burden translate into more funding for the state? Will things change with change in political leadership? Overall, the commitment for sustained funding needs to be a given, around which regular expected expenses and scale-up activities can be planned. It will also be useful to have diversified financing for nutrition from several developmental programmes.
- Accountability: Who is going to be the lead body at the Centre and subnational levels responsible for steering this through? If it is the NITI Aayog, how will it ensure state participation and who will be the contact points in different states? Prior experience of multi-sectoral panels/council of experts showed limited success (for example, Prime Minister’s Council on Nutrition). How will previous experience guide next steps in the accountability issue?
- Alignment with other stakeholders: Nutrition sector requires nourishment from several domains which directly or indirectly determine its outputs. Nutrition in India has largely been oscillating between Ministry of Health and Ministry of Women and Child Development for past several decades. What is the proposed mechanism of action under NNM? Efforts should be made to break down silos and develop a comprehensive programme which will propel the mission towards attaining its envisioned goals.
- Research and operational capacity strengthening: The mission requires a huge human resource input including from the research community. But it’s important to think through some basic requirements, such as, who and how many people will be required to contribute to the mission? What will be the mechanism of recruitment? How often will they be trained? What will their terms of reference and modes of contract be? What will be the backup for those quitting? Since this programme entails a variety of tasks – both technical and non-technical – numerous levels/types of personnel may be required. Who will be responsible for data collection and quality check, and how will they liaise with the research team reviewing the data? All efforts should be made to prioritise and invest in the data needed and strengthen capacity to utilise the collected information.
- Education: How can we rope in early education system in preschools or schools to colleges to better sensitise students to the issue of investing in health and nutrition? Children can be the change agents for their families and vice versa. What about workplace education? This component needs to run in parallel with other capacity building and strengthening activities.
- Grievance redressal and conflict of interest: This is an important piece in a programme of a huge size and role, operational at multiple (national and subnational) levels. How are processes of recruitment, vendor empanelment, procurement, contracting, etc. planned and ensured to be free from corruption? A centralised call center is unlikely to suffice for the massive programme with diverse features. Level of preparedness in and motivation of all states/UTs where the mission is yet to be implemented will be a critical factor for running this smoothly. Besides identification of eligible households to be covered under various heads, preparedness would also include necessary strengthening of infrastructure and human resource to ensure effective and timely delivery of entitlements under the programme. Processes should be fair and transparent so as to avoid errors of inclusion and exclusion. The mechanism of vigilance committees at various levels should be strengthened and effective grievance redressal mechanism should be developed. Such reforms measures are crucial to ensure a leakage- and diversion-free PDS (public distribution system) and that no needy person is denied benefits.
- Awareness or Jan Andolan: Participatory programmes (especially those with local accountability and ownership) usually have a better rate of success and longevity than top-driven initiatives. This feature is one of the top USPs of the programme but it needs to integrate the nudging of public at regular intervals and make it interesting for them to participate and want to stay engaged with it. There is a flip side too – people may demand too much, too fast, with too little understanding of participatory development and its implications. How will the process of empowering masses be rolled out?
- Monitoring: This seems to be the biggest challenge for any programme’s optimal delivery and long-term efficiency. For NNM, advanced technology including real-time monitoring and follow ups, has been envisaged. In a low-and-middle-income-country with challenges around power supply, literacy, handling technology sensitively and sensibly may require a long period of hand-holding and capacity building. Motivating people to report and collect data ethically will also need to be emphasised.
- Evidence to policy to improved Action: Overall our focus should be to make healthy diets accessible and affordable to drive better nutrition across the life-course with special consideration for the vulnerable stages like pregnancy, childhood, adolescence etc. This should resonate strongly with NNM’s mission and planned activities at all stages. Just desiring longevity may not suffice. Trying to get our children to live and attain their full neurocognitive potential needs a paradigm shift. In this regard, how will the collected data be collated and processed by researchers to be used by policymakers to inform and improve action in a continued manner?
The purpose of this article is not to find flaws but to outline some challenges NNM might encounter, so that the level of preparedness can be amped up for this massive programme and vision. Many of the above issues may be resolved in phased manner and that is okay but it is hoped that a comprehensive vision document or manual of operations/guidance is thoroughly prepared to help in times of crisis. In all its spirit, NNM is set out to be one of the seminal steps in the history of any nation’s efforts to improve public health and nutrition but it needs better preparation and surveillance mechanism to bear the desired fruits. Let us all contribute in all our sincerity and capability to help match the dream of Kuposhan Mukt Bharat with concerted action to make it a reality.
- Fardet, Anthony and Edmond Rock (2014), “Toward a new philosophy of preventive nutrition: From a reductionist to a holistic paradigm to improve nutritional recommendations”, Advances in nutrition, 5(4):430-46.
- Mozaffarian, Dariush (2016), “Dietary and Policy Priorities for Cardiovascular Disease, Diabetes, and Obesity: A Comprehensive Review”, Circulation, 133(2):187-225.
- Viljoen, Karien, Ricardo Segurado, John O’Brien, Celine Murrin, John Mehegan and Cecily C Kelleher (2018), “Pregnancy diet and offspring asthma risk over a 10-year period: the Lifeways Cross Generation Cohort Study, Ireland”, BMJ Open, 8(2):e017013.
- Wahl, Deborah R, Karoline Villinger, Laura M König, Katrin Ziesemer, Harald T Schupp and Britta Renner (2017), “Healthy food choices are happy food choices: Evidence from a real life sample using smartphone based assessments”, Scientific Reports, 7(1):17069.