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Abstract

Despite excellent economic growth in the last two decades India continues to suffer from ‘alarming’ hunger, and acute malnutrition amongst children under five. The recently introduced National Food Security Bill tries to address some of these concerns, but its success would depend on several non-legal factors, such as whether we are able to increase food production in backward regions, ban exports and thus increase availability, and identify the real poor correctly with some help from the biometrics-based unique identity (UID) programme. The Government of India also has to improve the design and oversight of central welfare programmes such as the Public Distribution System (PDS), which seeks to distribute subsidised foodgrains to the poor, and the Integrated Child Development Services (ICDS) meant for children under five. However, food alone does not solve the problem of underweight children, which needs a multidimensional thrust in health, hygiene, water quality, and above all a change in cultural practices related to child-rearing.
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Governance challenges to reducing hunger and malnutrition in India
N.C. Saxena
Introduction
High economic growth in India in the last two decades has unfortunately not been
translated into satisfactory progress on reducing hunger and malnutrition. According to the
Global Hunger Index Report, India continues to be in the category of those nations where
hunger is ‘alarming’ (IFPRI 2012). The hunger index in India between 1996 and 2011 has
gone up from 22.9 to 23.7, while 78 out of the 81 developing countries studied, including
Pakistan, Nepal, Bangladesh, Vietnam, Kenya, Nigeria, Myanmar, Uganda, Zimbabwe and
Malawi, have all succeeded in reducing hunger.
The hunger and malnutrition report (popularly known as HUNGaMA) released by the
Prime Minister in January 2012 showed that the number of malnourished children in the
112 rural districts of India was 42 per cent whereas stunting was even higher at 59 per cent
(Hungama 2012). Evidence shows that stunted children enroll later in school, perform less
well and complete fewer grades; this leads to reduced capabilities and income-earning
capacity in adult life and perpetuates the inter-generational cycle of poverty and
deprivation in families and communities. This is an unacceptable loss (Chambers and
Medeazza 2013).
The latest RSOC data however shows modest improvement in several indicators.
Prevalence of stunting as a measure of undernutrition among children under-five in India
got reduced from 48% in 2005 to 39% in 2013. Initiation of breast feeding within an hour
of birth has improved from 25 to 45% during 2005-13 but remains much below the
required threshold of 90% coverage for saving lives and reducing stunting. Current levels
of child malnutrition in India are however still higher than those in sub-Saharan Africa.
India’s age old habit of defecating in the open—which distinguishes it from many other
developing countries—makes matters worse. The proportion of Indians who do this has
fallen from 55% a decade ago to 45%, but that is more than enough to help spread
diseases, worms and other parasites that make it more difficult to absorb nutrients even
when food is abundant. Poor public hygiene may account for much of India’s failure to
make faster improvements in nutrition.
Children also suffer most because of problems of inadequate diet, poor early care practices
and lack of hygiene. With half its child population malnourished and stunted, India’s
demographic dividend - a large young generation being born each year - will not pay off.
Specifically, the return of the investments currently being made in elementary education
will be halved because of undernutrition, which thus remains India’s greatest development
challenge and a question mark on India’s credibility as a global player.
Emerging economies have demonstrated that child undernutrition can be drastically
reduced: Thailand (Garg and Nandi undated) reduced the percentage of underweight
children by half (from 50% to 25%) between 1980 and 1986; Brazil reduced child
undernutrition by 75 percent (from 20% to 5%) from 1990 to 2006; and China reduced
child undernutrition by 68% (from 25% to 8%) between 1990 and 2002 (UNICEF 2009).
Even Viet Nam, a country poorer than India, has seen a reduction in underweight children
from 41% in 1996 to 25% in 20061. Therefore, nutrition improvement at national scale is
possible. However, economic growth is not enough; it needs to be coupled with effective
policy and budgetary action, particularly for the most vulnerable: the youngest, the
poorest, and the excluded.
1 http://www.unsystem.org/scn/Publications/SCNNews/scnnews36.pdf (accessed on 7 July 2014)
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Falling foodgrain and calorie consumption
Hunger and malnutrition is caused by a large number of factors, of which availability and
access to a balanced diet is quite important. NSSO data shows that
per capita cereal consumption in India is lower than the desired norm and it has shown a
decline over time. As regards changes in expenditure on food over the years two trends are
observed. First, while consumption expenditures in both rural and urban regions rose, this
was not reflected in a commensurate rise in expenditure on food. As shown in Table 1, the
growth in food expenditure has been significantly lower than the increase in overall
expenditure on all goods during the period of analysis.
Table 1: Growth in real average per capita expenditure on all goods and on food (in
Rs) at 1993-94 prices
Years Average Per Capita
Expenditure Average Per Capita Food
Expenditure
Rural Urban Rural Urban
1993-94 281.4 458.0 177.8 250.3
2009-10 347.5 637.8 184.8 244.9
Annual rate of growth 1993-94
to 2009-10 1.3 2.1 0.2 -0.1
(Gupta 2012)
Thus the average per capita food expenditure during the period 1993 to 2010 increased only by 0.2
per cent annually in rural India, and fell slightly by 0.1 per cent per annum in the urban areas. One
may argue that this could indicate shift to more sedentary lifestyle needing less calories. However,
the second trend negates this hypothesis for the poor, as the decile-wise data (Table 2) clearly
shows that the hard working poor consume much less cereal (the cheapest form of food) than the
non-poor. It also shows a declining trend in the annual per capita consumption of cereals, for all
classes of people.
Table 2: Changes in per capita cereal consumption (kg per month) in since 1993-94
for different MPCE classes: all-India, rural
year monthly per capita cereal consumption (kg) in population percentile class
0-10 10-
20 20-
30 30-
40 40-
50 50-
60 60-
70 70-
80 80-
90 90-100
1993-94 10.52 12.03 12.63 13.19 13.33 13.72 14.07 14.41 14.59 15.39
1999-2000 10.45 11.64 12.27 12.56 12.89 13.03 13.36 13.45 13.67 13.96
2004-05 10.39 11.33 11.70 11.98 12.16 12.37 12.61 12.77 12.72 13.14
2009-10 10.17 10.63 11.06 11.12 11.48 11.42 11.72 11.75 12.05 12.07
2011-12 10.42 10.80 11.03 11.14 11.49 11.46 11.50 11.58 11.48 11.71
NSS 68th Round, Report No. 555
The above Table2 clearly shows that as India moved to greater prosperity in the last twenty
years the cereal consumption of the rural rich went down, but there was no increase for the
poor. At any given point of time the cereal intake of the bottom 10 percent in rural India
continues to be about 10 to 20 percent less than the cereal intake of the top decile of the
population, despite better access of the latter group to fruits, vegetables and meat products.
Their sedentary life style too should be taken into account while assessing the difference
2 It is likely that eating out for all classes has increased. Cereal content of meals taken outside at own cost or
at public cost is hardly known, and is not captured in the NSSO data.
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between the two groups. Calorie needs of the non-poor may be declining because labour-
saving devices are becoming increasingly available in the household, in the workplace,
and in transportation (NSSO 2014). For the upper segment of population the decline may
be attributed to a diversification in food consumption, easy access to supply of other high
value agricultural commodities, changed tastes and preferences, and consumption of more
expensive non-foodgrain products. Higher economic growth and per capita incomes thus
contribute to reduction in per capita demand for cereals for the rich.
However for those who are around or below the poverty line, this has to be understood as
a distress phenomenon, as with marginal increase in their incomes over time they are
forced to cut down on their food consumption to meet other pressing demands that were
not considered important in the past. For instance, as more schools open, the poor too wish
to send their children to schools, where expenses are incurred on clothes, books, etc.
despite the school fees being met by government. These expenses would thus become a
new item on the household budget, and food expenditure may be curtailed to make room
for it. Fighting sickness leads to another chunk of essential expenses, for which
opportunities did not exist in the past, as there were no doctors in the vicinity. The share of
fuel and light in total consumer expenditure has risen from under 6 per cent to 10 per cent
in both rural and urban areas between 1972-73 and 2004-05. Finally, the rural labouring
masses have to spend on transport in order to earn their livelihoods. The food budget of
the poor has been squeezed out because the cost of meeting the minimum non-food
requirements has increased (Sen 2005). Thus, it is not possible for households around the
poverty line to purchase their initial food basket within their current food budget.
There are also issues at the macro-level. According to the central government, foodgrain
production in India has gone down from 208 kg per annum per capita in 1996-97 to 200
kg in 2011-12, which was a year of bumper production (Economic Survey 2013). From the
reduced production, India has been exporting on an average 7 million tonnes of cereals per
annum, causing availability to decline further from 510 gm per day per capita in 1991 to
439 gm in 2012. This has adversely affected the cereal intake of the bottom 30 percent
which, as shown above, continues to be significantly less than the cereal intake of the top
decile of the population. Their expenditure on health, education, liquor, tobacco, transport
and fuel has also gone up. Food is still needed, but not demanded as they get used to
eating less food and in the process get stunted and malnourished. Endemic hunger (often
hidden) continues to afflict a large proportion of Indian population.
Calorie consumption - As regards calorie consumption, the national average for per
capita calorie intake for the rural region in 2009-10 was 2020 kcal, while it was 1946 kcal
for the urban region (Chandrasekhar 2012). Actual intake in 2009-10 for the rural poor
was 1755 Kcal /person/day whereas the same figure for high income rural households was
2572. These figures for the urban India were 1665 and 2394 kcal respectively for the poor
and the rich. Thus poor households suffered from a daily per capita calorie deficiency of
281 Kcal in urban areas and 265 Kcal in rural areas when compared with the average, and
with greater deficiency when compared with the corresponding figures for the high
income households (Chand and Jumrani 2013).
FAO uses a uniform norm of 1800 Kcal. Even taking the low FAO norm, there is wide
prevalence of undernutrition, as shown below.
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Table 3: Prevalence of Undernutrition in India based on FAO norm
expenditure class % Undernourishment
Rural
Poor 56.9
Middle income 21.3
High income 7.0
All rural 32.3
Urban
Poor 66.7
Middle income 33.7
High income 10.1
All urban 39.5
Rural+Urban 34.2 (Chand and Jumrani 2013)
One-third of the population living in rural households and close to 40 per cent in urban
households were found undernourished based on the FAO norm. More than half of the
rural poor and two-thirds of urban poor consumed less than 1800 Kcal. Such a scenario is
not due to the non-availability of adequate cereals in India. Calorie deficiency of the poor
is because they do not have the necessary income resources to take care of the quantity
aspect of their intakes. Problem is more of access than availability.
Factors other than food that lead to malnutrition
Less well understood than hunger is the nagging problem of under-nutrition amongst children that
leads to their not achieving normal height and weight for their age. The commonly-held belief that
food insecurity is the primary or even sole cause of malnutrition is misplaced. Even the National
Food Security Act, 2013 provides that every pregnant woman and lactating mother shall be entitled
to one free meal a day during pregnancy and six months after the child birth; and maternity benefit
of rupees one thousand per month for a period of six months. Thus the focus is still on food, and
not on health and care related interventions. Consequently, the existing response to malnutrition in
India has been skewed towards food-based interventions and has placed little emphasis on schemes
addressing the other determinants of malnutrition (World Bank 2006).
Child malnutrition starts very early in life, and often it is an inter-generational issue.
Adolescent girls who are themselves underweight give birth to low weight babies. The
child rearing practices in India unfortunately are highly unscientific, as giving colostrum
to the newborn, exclusive breastfeeding for first six months of a child’s life, and
complementary feeding several times a day after six months are not commonly practised.
In the 100 districts studied in the HUNGaMA report 51 per cent mothers did not give
colostrum to the new born soon after birth and 58 per cent mothers fed water to their
infants before six months. Besides, due to bad quality of water and lack of toilets children
are exposed to stomach infections, develop diarrhoea, and start losing weight. At this stage
they need proper medical care which unfortunately is not available. Then the mothers have
to work long hours away from home without any support system, and are unable to afford
healthcare.
Thus, there are other factors too that cause malnutrition and hunger, especially amongst
children (Saxena 2011), such as:
1. Low status of women in Indian society, their early marriage, low weight at
pregnancy and illiteracy leading to low weight of new born babies.
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2. Poor childcare practices, such as not immediately starting breastfeeding after birth,
no exclusively breastfeeding for the first five months, irregular and insufficient
complementary feeding afterwards, and lack of quick disposal of child’s excreta.
3. Poor supply of government services, such as immunisation, access to medical care,
and lack of priority to primary health care in government programmes.
These factors combined with poor food availability in the family, unsafe drinking water
and lack of sanitation lead to high child under-nutrition and permanent damage to their
physical and mental capabilities.
Intervention through government programmes
The Indian State implements massive food, livelihood and social security programmes
some of the largest in the world – which theoretically support vulnerable people from even
before their birth to their survivors after death. For children, government runs in every
village a programme called Integrated Child Development Services (ICDS). As on 31
January, 2013, 13,31,076 centres, called Anganwadi Centres3 (AWCs) are operational
across 35 States/UTs, covering 93 million beneficiaries under supplementary nutrition and
35 million 3-6 years children under pre-school component. The Twelfth Five Year Plan
(FYP) has allocated Rs 1,236 billion to ICDS - a three-fold increase from the previous
FYP.
On paper, expectant mothers are fed in ICDS centres, along with infants, children up to the
age of six, and adolescent girls. Children in school get school meals. As adults, women
receive maternity support, bread earners are guaranteed 100 days of wage employment in
public works; and if identified as poor, they can buy subsidised cereals from a massive
network of half a million ration shops. The aged – and in many states widows and disabled
people are given pensions. And if an earning adult dies prematurely, the survivor is
entitled to a lumpsum payment of Rs ten thousand.
This looks good on paper but the ground reality is different. These programmes are
plagued by corruption, leakages, error in selection, delays, poor allocations and little
accountability. They also tend to discriminate against and exclude those who most need
them, by social barriers of gender, age, caste, ethnicity, faith and disability; and State
hostility to urban poor migrants, street and slum residents, and unorganised workers. In
Rangpur Pahadi, a slum area just two kms away from Vasant Kunj (Delhi), people living
since 1984 have not been given even voter ID or any ration card. Thus their very existence
is denied by the Delhi Government! Therefore, not only do we need to identify the
excluded and run special programmes for them, but improve monitoring and
accountability for all programmes that impinge on hunger.
Supreme Court too has been active to improve malnutrition amongst children. In April
2004, several marathon hearings on ICDS were held in the Court and detailed orders were
issued, followed by further orders on 7th October 2004, in which a few key directions
were made, including: ‘All SC/ST habitations should have an anganwadi as early as
possible. Until the SC/ST population is fully covered, all new anganwadis should be
located in habitations with high SC/ST populations.’ Thereafter the Hon’ble Supreme
Court passed another order on 13th December 2006, where the entitlements of children
under the age of six have been further strengthened, especially in regard to
‘universalisation with quality’ in a time-bound manner. The State Government must
undertake, on war-footing, extensive ‘Health Camps’ in every village to identify every
3 These are generally one or two room structures, where children gather for about four hours every morning
for various ICDS activities.
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malnourished and/or anaemic child, adolescent and all pregnant women and ensure that
they receive proper nutrition and health care. There must be individual monitoring of all of
these persons to prevent any further deaths (Rozario 2013).
These orders of the Hon’ble Supreme Court should have worked as useful wake-up call to
the State government, at least as far as the universalisation of ICDS and provision of
proper nutrition is concerned. Instead, the present situation stands testimony to the failure
of the State to take all the necessary steps, and the results so far unfortunately have been
disappointing.
ICDS- Some evaluations
In addition to general problems of governance and delivery that affect all programmes,
ICDS, the main programme to address malnutrition is particularly doing quite poorly. We
discuss some field studies.
A comprehensive evaluation of ICDS (Planning Commission 2011) concluded that despite
the fact that outlay for the ICDS was increased from Rs 121 billion in the X Plan (2002-
07) to Rs 444 billion in the XI Plan (2007-12), the outcomes were most disappointing.
Only 19 per cent of the mothers reported that the AWC provides nutrition counselling to
parents. More than forty per cent of the funds meant for supplementary nutrition (SN) are
siphoned off, for FY 2008-09 the amount of SN allocation diverted is estimated at Rs 29
billion. Although 81 per cent of children below six years of age were living in an area
covered by the Anganwadi centres only 31 per cent children received SN and only 12 per
cent children received it regularly (Planning Commission 2012). Only 38 per cent of
pregnant women and lactating mothers, and 10 per cent of adolescent girls received
supplementary nutrition.
A recent evaluation of ICDS in Gorakhpur by the National Human Rights Commission
(Saxena 2013) showed that despite Supreme Court orders to provide hot cooked meals, all
centres supplied only packaged ready-to-eat food, containing only 100 calories, as against
a norm of 500 calories, and 63 per cent of food and funds were misappropriated. The food
being unpalatable, half of it ends up as cattle feed. The ready-to-eat food is produced in
poor hygiene conditions. Some of the ingredients shown on the bags containing the
finished product were not found in stock at the time of visit and the stock of maize was
only enough to meet 25% of the daily requirement.
However, such reports, though few, are hardly discussed in state Assemblies, as they meet
now for fewer than 30 days a year. We need a new law making it compulsory for
Parliament and Assemblies to meet for at least 150 days a year.
Comptroller and Auditor General of India’s (CAG) performance audit4 in 2013 revealed
how ICDS was failing to help infants and young children. The audit, covering the period
2006-07 to 2010-11, found that 52% of anganwadis surveyed lack toilets, and 32% don't
have drinking water. Around 61% anganwadis did not have their own buildings and 25%
were functioning from semi-pucca or open or partially covered spaces. Medicine kits are
not available in 33%-49% of anganwadis. The audit also revealed 33%-45% gap between
eligible beneficiaries and actual recipients of supplementary nutrition. CAG also noted
distribution of sub-standard food by the AWCs as ‘ready to cook mixes’ were unpalatable.
Audit found that some of these items had sticky texture which became inedible within
minutes of preparation. ‘In 18 test-checked AWCs, children were reported to have fallen ill
4 http://articles.timesofindia.indiatimes.com/2013-03-06/india/37499356_1_cag-audit-icds-malnourished-
children and http://zeenews.india.com/news/nation/substandard-food-being-distributed-by-
anganwadis_834305.html (accessed on 7 July 2014)
7
after consuming the preparation. The supplier, M/S A. P. Foods (A Government of Andhra
Pradesh enterprise engaged in manufacturing and supplying fortified nutritious food to
ICDS projects), continued to supply these mixes till November, 2011, despite reports
about the beneficiaries disliking the food in two test-checked projects.’ The Audit further
found that there was no system of watching expiry of food items.
A PEEP survey made the following comment on ICDS:
‘In 2004, the Focus On Children Under Six (FOCUS) survey examined the status
of ICDS in six states: Tamil Nadu, Maharashtra, Himachal Pradesh, Chhattisgarh,
Rajasthan and Uttar Pradesh. The first three were found to have reasonably active
and effective anganwadis. The last three, however, were described as “dormant
states”, where the programme was yet to take off. An extreme case of apathy was
Uttar Pradesh, where anganwadis were barely functional. For good measure,
children’s food was supplied across the state by a single contractor a shady
operator who brazenly violated the Supreme Court ban on private contractors to
milk the ICDS programme.
The good news is that some of these dormant states are waking up. Not all of them
Uttar Pradesh is still snoring. But Rajasthan and especially Chhattisgarh have
made serious efforts to revamp the ICDS programme, with significant results. For
instance pre-school education activities, highly valued by parents but rarely seen at
the time of the FOCUS survey, now take place in many anganwadis. Health
services such as child immunization also seem to be in much better shape today,
with a little help from the Accredited Social Health Activists (ASHAs) village
women who have been trained as frontline health workers.
It was a pleasant surprise to find relatively good anganwadis in Odisha – a state not
known for exemplary governance. There were clear signs of real efforts to create a
friendly environment at the anganwadi, both for the child and for the anganwadi
worker. In most of the sample villages, anganwadis were relatively well-equipped
some even had mini-toilets especially designed for small children. Many
anganwadi workers were active and well trained, not just for routine work at the
anganwadi but also for home visits. Children had uniforms, helping to convey that
the anganwadi is not just a parking lot but a centre of learning. And indeed, many
anganwadis had simple pre-school education activities such as games, songs and
counting.’
Governance issues
Although governance has several dimensions, for this paper we restrict our discussion to
its relevance to the capacity of governments to design, formulate and implement policies
and programmes, including accountability of government employees who should be held
responsible for their actions. On all these dimensions the record of ICDS and related
health programmes is quite poor: the design of ICDS is flawed, it is poorly delivered, and
the staff fudges the reported data so as to avoid responsibility for high malnutrition. We
discuss these below.
ICDS design needs a change - The ICDS has not yet succeeded in making a significant
dent in reducing child malnutrition, as the programme has placed priority on food
supplementation rather than on nutrition and health education interventions, and targets
children mostly after the age of three when malnutrition has already set in. Very little of
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the ICDS resources, in terms of funds and staff time, are spent on the under-three child
(Planning Commission 2012), and this low priority must be reversed.
Therefore the focus in ICDS programme, government’s main intervention, should be on
components that directly address the most important causes of under-nutrition in India,
specifically improving mothers’ feeding and caring behaviour, improving household water
and sanitation, strengthening referrals to the health system and providing micronutrients.
The basic nature of the programme should be changed from centre-based to outreach-
based, as the child under three cannot walk to the centre and has to be reached at his/her
home. Another advantage of visiting homes is that the entire family, not just the mothers,
are sensitised and counselled.
Discourage ‘ready-to-eat’ food in Supplementary Nutrition Provisioning (SNP)-
Government of India should discourage the distribution of manufactured ‘ready-to-eat’
food, as it leads to grand corruption at the Ministerial level, but unfortunately GOI has
encouraged such tendering by laying down the minimum nutritional norms for ‘take-home
rations’ (a permissible alternative to cooked meals for young children), including
micronutrient fortification, thus providing a dangerous foothold for food manufacturers
and contractors, who are constantly trying to invade child nutrition programmes for profit
making purposes. This may have the unintended consequence of supplementing micro
nutrients without consultation with medical professionals as well as leaving the door open
for large-scale centralised corruption and subversion of the programme through the back-
door entry of private non-descript contractors.
ICDS should learn from the success of hot freshly cooked mid-day meals programme that
runs fairly well even in states not known for efficiency, whereas the supply of packaged
food in ICDS even in efficient states is not popular with the children, besides being
irregular and discouraging local participation. For children below the age of three years,
nutritious and carefully designed locally prepared take-home rations based on locally
procured food should be the recommended option, but there could be centre specific
variations. If fortified milk powder is to be provided, it must be manufactured by a well
known manufacturer. Before inviting financial bids, states must invite technical bids in a
transparent manner so that unscrupulous contractors who get into the racket of supplying
packaged food through bribes are eliminated. Children can eat only small quantities of
food and therefore need fat rich food to obtain necessary calories. In the absence of oil
supplies, there is almost no fat content in the food being given whereas for children below
three, almost 40 per cent of their calorie requirement should come from fats. This aspect
gets totally unfulfilled in the current SNP.
The best solutions to child malnutrition are based on access to diverse local nutritious diets
which will meet calorie, protein and micro nutrient requirements. This can be done
successfully with engagement of local communities in the supply of Supplementary
Nutrition. Evidence is that this has led to increased demand for the programme, better
community monitoring as well as supported livelihoods of thousands of women.
Improve reporting system - Officials at all levels spend a great deal of time in collecting
and submitting information, but these are not used for taking corrective and remedial
action or for analysis, but only for forwarding it to a higher level, or for answering
Assembly/Parliament Questions. Field staff reports only on activities, it is not involved in
impact assessment, or in qualitative monitoring. The concept of stakeholder monitoring is
unknown. No indicators exist for assessing public participation or their awareness.
Reporting system in the state governments needs overhauling, as at present many reports
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are not credible. Malaria deaths (and so are malnutrition deaths) are under-reported, while
immunisation achievements are over-reported.
ICDS too faces substantial operational challenges, such as lack of accountability due to
lack of oversight and an irresponsible reporting system. It appears that state governments
actively encourage reporting of inflated figures from the districts, which renders
monitoring ineffective and accountability meaningless. Each anganwadi centre reports on
the number of malnourished children category wise, but these figures are neither verified
independently by the states nor being used for assessing the effectiveness of the
programme. The practice is so widely prevalent in all the states, presumably with the
connivance of senior officers, that the overall percentage of severely malnourished
children, in case of 0-3 years according to the data reaching GOI from the states is only
two per cent, as against 9.4 per cent reported by Unicef in a recent survey. The field
officials are thus able to escape from any sense of accountability for reducing
malnutrition. Figures from some states show their children to be as healthy as in Denmark
and Sweden!
Table 3: % of severely malnourished children in 2013-14 according to
State Government UNICEF
Andhra Pradesh 0.8 4.7
Gujarat 0.8 10.1
Jharkhand 0.5 16.0
Orissa 1.4 11.0
Uttar Pradesh 0.8 12.9
West Bengal 0.7 8.9
India 2.1 9.4
One district Collector, when confronted with this kind of bogus figures, told the author
that reporting correct data is ‘a high-risk and low-reward activity’! Dr Manmohan Singh as
Prime Minister termed government’s performance as a 'national shame', but he was not
able to persuade the states to accept that the problem exists!
Lack of follow up at the top - After the National Family Health Survey (NFHS) III came
up in 2007 with the startling findings that there has been almost no decline in the
percentage of under-weight children in India during 1998-2006, Prime Minister decided to
establish a high powered Nutrition Council headed by the Prime Minister himself.
Unfortunately it met only once in November 2010 and decided to further strengthen the
programme in selected 200 high burden districts, but formal orders were issued only on
22nd October 2012. Its impact on the field is still to be felt. Moreover, there has been no
all-India survey after 2006. Rather than reduce the gap between the periodicity of NFH
Surveys, government has unfortunately delayed the next survey, thus diluting
accountability and escaping from responsibility for poor progress.
Staff vacancies - There are massive vacancies due to which their effectiveness is limited.
As per the Ministry’s website, the sanctioned strength of CDPOs and Supervisors in
March 2013 is 9034 and 54103 in the country, but only 5985 and 34639 respectively were
in position. Thus more than one-third of these positions are vacant. In Bihar, for instance,
90 per cent of the Supervisors’ posts were vacant. Only 64 percent of AWWs received
their salary either regularly or with a delay of one month, the rest reported delay of two to
six months in getting their meagre salaries (Planning Commission 2011).
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Unresponsive bureaucracy - Absenteeism of field staff is rampant though seldom
measured. Many ICDS centres are often closed or function irregularly. Referral services
for severely malnourished children are very weak as primary health care system does not
function satisfactorily.
Lack of decentralization – Very few state governments involve local bodies in
implementation of programmes relating to health, nutrition, and hygiene. Empowering
local panchayats to deal with the problems relating to hunger and malnutrition will
certainly help achieve convergence and meet the challenges of poor delivery in many parts
of the country.
Improve mobility - The supervisory officials in ICDS do not visit villages and give the
excuse that they have no access to a government vehicle. State governments should
introduce a scheme for giving interest free loans to CDPOs and Supervisors to buy motor-
bikes, provided they possess a driving license.
Focus on behaviour change is missing - The child-rearing practices in India
unfortunately are highly unscientific, as giving colostrum to the newborn, exclusive
breastfeeding for first six months of a child’s life, and complementary feeding several
times a day after six months are not commonly practised. Similarly the scheme for
distribution of iron folic acid tablets for pregnant and lactating women, and adolescent
girls does not function well for weaknesses on both fronts - supply as well as demand.
Corruption - There are large-scale irregularities in the supply of Supplementary Nutrition
Provisioning (SNP) in violation of the orders of the Supreme Court by the engagement of
contractors in ICDS in many states such as, Maharashtra, Karnataka, Uttar Pradesh and
Gujarat.
There is grand corruption afflicting the programme both at the GOI level and the states.
Instructions from the GOI officials that supplementary nutrition must conform to certain
nutrition standards are motivated, to ensure that only 'ready to eat food' manufactured in
the factories is distributed. These manufacturers bribe at various levels, including
ministers, but packaged food that is distributed in many states is not palatable, nor does it
contain the claimed amount of calories and micro-nutrients. Ultimately it ends up in the
market or as cattle feed.
Non-functional child care system in urban India- ICDS runs very poorly in urban slum
areas because of lack of space for setting up of Centres. In urban slums, the problems of
appallingly low rent allocations (Rs 1000 per month for Delhi, for instance) for hiring
spaces and non-availability of government buildings need to be addressed urgently to fill
the gap in universalising services for slum populations. In the short term, temporary
structures can be put up to provide toilets in those slums where either due to legal issues or
space constraints, it is not possible to put up permanent structures.
Weak links with sanitation Only 35% households in rural India have toilets. Besides,
due to bad quality of water and lack of toilets children are exposed to stomach infections,
develop diarrhoea, and start losing weight. Evidence is now sufficient to conclude that
open defecation is an important cause of child stunting. Children’s height matters because
the same early life health and net nutrition that help children grow tall also help them grow
into healthy, productive, smart adults. Open defecation is particularly harmful where
population density is high – so children are more likely to encounter germs from faeces –
which means that India’s widespread open defecation and high population density
constitute a double threat. Lack of medical attention further aggravates malnutrition, as
discussed below.
11
Political economy of ICDS reforms
Many of the suggestions listed above have been made by professionals and even World
Bank over the past several years. Why is then nothing happening? Is it just turf battle or
bureaucratic inefficiency or are there some deeper issues?
There are several factors that explain lethargy on the policy front. The Ministry of Women
& Child Development, as also the Departments incharge of ICDS at the state level are
weak organisations with little clout over other sections of government or over the field
staff. IAS officers take it as a punishment posting, and are keen to move on to more
attractive economic Ministries. During their short stay they find it convenient to be in a
‘denial mode’ about under-nutrition, and collude with the field staff who under-report the
extent of malnutrition. Fudging of weighment registers can be checked if the children are
weighed in an open meeting with village participation (as is done in Thailand, described
below), but unfortunately of all the important flagship programmes ICDS has the least
degree of peoples’ participation.
The Ministry of Women & Child Development has never been keen to make the ICDS
field machinery responsible for nutrition outcomes. They would like this difficult task to
be passed on to the Health Ministry and gladly keep the Anganwadi centres responsible
only for pre-school education, as it was before 2004. However, Health Ministry has not
been keen on taking the added responsibility. Lack of ownership leads to indifference on
the part of the Ministry officials, and they do not suggest radical reforms so badly needed
to correct the design flaws.
In the last ten years a lot of vested interest has developed, especially at the states’ level, in
favour of centralised contracts for ‘ready-to-eat’ food. Concerns about high malnutrition
are then used to justify even higher budgets for nutrition, discouraging at the same time
independent studies that would show alarming leakages.
Learn from International experience: Thailand has been one of the most outstanding
success stories of reducing child malnutrition in the period 1980-1988 during which child
malnutrition (underweight) rate was effectively reduced from 50 per cent to 25 per cent.
This was achieved through a mix of interventions including intensive growth monitoring
and nutrition education, strong supplementary feeding provision, high rates of coverage
ensured by having high human resource intensity, Iron and Vitamin supplementation and
salt iodization along with primary health care. The programme used community volunteers
(with no honorarium) on a huge scale (one per 20 children), and involved local people, so
as to instil self-reliance and communicate effectively with target groups. Communities
were involved in needs assessment, planning, programme implementation, beneficiary
selection, and seeking local financial contributions. Inter-village competition in reducing
the number of under-nourished children was encouraged, and villages were rewarded for
their success.
This has significance for nutrition programmes in India as the levels of per capita GDP,
proportion of women in agricultural workforce and child malnutrition rates around 1980 in
Thailand were similar to what we have in India now.
Linkages with Health Programmes
Although bringing strong nutrition focus in Health programmes is one of the objectives of
ICDS, the health sector itself suffers from several deficiencies. India is likely to miss
achieving the Millennium Development Goals in respect of health indicators. For instance,
Infant mortality rate (IMR) is to be reduced to 28 by 2015, but the decline has been from
60 in 2002 to only 42 in 2012. Wide differences exist between the attainments of health
12
goals in the better performing States as compared to the low performing States. The Infant
Mortality Rate in the poorest 20% of the population is 2.5 times higher than that in the
richest 20% of the population. It is clear that national averages of health indices hide wide
disparities in public health facilities and health standards in different parts of the country.
Given a situation in which national averages in respect of most indices are themselves at
unacceptably low levels, the wide inter-State disparity implies that, for vulnerable sections
of society in several States, access to public health services is nominal and health
standards are grossly inadequate.
Rural health care in most states is marked by unfilled staff vacancies, absenteeism of
doctors/health providers, low levels of skills, shortage of medicines, poor management,
inadequate supervision/monitoring, and callous attitudes. There are neither rewards for
service providers nor punishments for defaulters. In addition, the behaviour of public
services in terms of interactive quality is of serious concern and is an important factor that
influences health seeking behaviour. As a result, despite instructions that a severely
malnourished child should receive medical attention, this rarely happens because of non-
existent and uncaring curative health care close to the village.
Doctors and nurses need to be present at the primary health centres and effective at their
jobs, and provide the care that children need. But they are often mired in a system where
the incentives for effective service delivery are weak, and political patronage is a way of
life. Highly trained doctors seldom wish to serve in remote rural areas. Since those who do
serve are rarely monitored, the penalties for not being at work are low (World Bank 2003).
Even when present, they treat poor people badly. The declining quality of public health
and education threatens past achievements and future prospects, and imposes additional
costs on women and children.
Indian public spending on health is grossly insufficient – amongst the lowest in the world;
and the consequent high proportion of private out-of-pocket expenses (69 per cent)
imposes a heavy financial burden on most people. The private sector health care is
unregulated pushing over-medication and the cost of health care up, thus making it
unaffordable for the poor. From the meagre public spending its share on preventive health
services has a low priority over curative health in the country as a whole.
India has tried to meet public health challenges with antibiotics, unlike the west, where the
battle was won with clean water and sanitation, and focus on primary health care.
Therefore complementary investments in nutrition, drinking water and sanitation, and
schooling are essential for achieving better synergies to guarantee nutrition and health
outcomes.
There should be better coordination between the Anganwadi and ASHA health workers.
GoI should expand the role of ASHAs and include nutrition education, and treatment of
some common illnesses such as diarrhoea in their duties. While we need incentives, both
monetary and non-monetary, to get resident doctors and nurses in remote areas, we also
need to accept the principle of locally resident health workers and systems to train them.
To facilitate the treatment of children requiring hospitalization, the State Government
should set up Nutrition Rehabilitation Centres, linked to the Community Health Centres at
the sub-district level.
Re-examine the role of the Ministry
When the new Ministry of Women & Child Development was set up it was expected that it
would take a holistic view of the problems of women and children, and keep a watchful
eye on the activities of all other Ministries, such as health, education, labour, drinking
13
water and sanitation that deal with the subjects impinging on children’s welfare. It would
develop systems that inform GoI, for instance, how and why children are malnourished.
On the other hand, it has been observed that the new Ministry took a minimalist view of its
responsibility, and reduced itself to dealing with the ICDS only without critically
monitoring the lack of other inputs needed for reducing malnutrition. Such ostrich like
attitude defeats the purpose for which the Ministry is created. It was expected that the
MWCD would generate field reports that look at the access of children to health, water
and sanitation, and how it affects malnutrition. Continuous measurement of the critical
inputs alone will put pressure on other Ministries and their field administration to improve
all services holistically. However, in the present circumstances, advocacy is not a popular
agenda with the MWCD officials.
Summing up
Higher public investment in nutrition based programmes needs to be accompanied by
systemic reforms that will improve the quality of public expenditures and overhaul the
present system of service delivery, including issues of control and oversight. At the same
time, ICDS should correct the design flaws, focus more on the younger age group, on
community participation, and strengthening of convergence with related health and
sanitation programmes.
Problems of lack of coordination between the Ministries (Women & Child, Health, Water
& Sanitation) cannot be resolved by passing laws or by incorporating goals of minimising
stunting and under-nutrition in the Food Security Act. The experience of both Right to
Education and Right to Employment shows that problems of bad design, inadequate
funding, and poor implementation require administrative and not legal action.
In the ultimate analysis, the constraints to overcoming malnutrition and hunger are rooted
in bad policies, faulty design, lack of appropriate monitoring and evaluation, poor
governance and lack of political will. Action is needed on all the fronts. Economic growth
alone is insufficient to bring about significant reductions in the prevalence of
malnourishment among children, or improvement in health of the poor. Without a major
shake up in policy and an improvement in design of the ICDS as well as in the
effectiveness of its implementation, the attainment of the goal of fast reduction in hunger
and malnutrition looks unlikely.
References
Chambers, Robert and Gregor von Medeazza. 2013. ‘Sanitation and Stunting in India:
Undernutrition’s Blind Spot’ Economic & Political Weekly, June 22, vol XLVIII no 25.
Chand, Ramesh and Jaya Jumrani. 2013. ‘Food Security and Undernourishment in India:
Assessment of Alternative Norms and the Income Effect’, Indian Journal. of Agricultural
Economics, Vol.68, No.1, Jan.-March.
Chandrasekhar, C. P. 2012. ‘Chronic famishment’, The Hindu, February 19
Economic Survey. 2013. Finance Ministry, GOI. New Delhi
Gupta, Shalini. 2012. ‘Food Expenditure and Intake in the NSS 66th Round’. Economic &
Political Weekly, January 14, vol XLVII no 2
14
Haddad, L. 2009. ‘Lifting the Curse: Overcoming Persistent Undernutrition in India’ IDS
Bulletin, 40 (4):1-8
Hungama 2012: ‘Fighting Hunger & Malnutrition’, at
http://www.naandi.org/CP/HungamaBKDec11LR.pdf (accessed on 7 July 2014)
IAMR 2011. India Human Development Report, New Delhi, p. 140
IFPRI 2012. Global Hunger Index Report: The Challenge of Hunger. International Food
Policy Research Institute, Bonn
NSSO 2014. Level and Pattern of Consumer Expenditure, 2011-12 Report No. 555, NSS
68th ROUND Ministry of Statistics & Programmme Implementation, February
Planning Commission 2011. Evaluation of the ICDS, New Delhi, at
http://planningcommission.nic.in/reports/peoreport/peo/peo_icds_vol1.pdf (accessed on 7
July 2014)
Planning Commission 2012. Report of the Working Group on Nutrition for the 12th Five
Year Plan (2012-17), New Delhi
Rozario, Adv. Clifton D’ 2013. Deaths of unnamed children: Malnutrition and Destitution
among Adivasis in Kerala, May, at sccommissioners.org.in, (accessed on 7 July 2014)
Saxena, N.C. 2011. ‘Hunger, Under-Nutrition and Food Security in India’, Working Paper
44, Chronic Poverty Research Centre, UK, at
http://r4d.dfid.gov.uk/PDF/Outputs/ChronicPoverty_RC/CPRC-IIPA44.pdf (accessed on 7
July 2014)
Sen, P. 2005. 'Of calories and things: reflections on nutritional norms, poverty lines and
consumption behaviour in India', Economic and Political Weekly, 22 October
Viswanathan, Brinda 2012. Counting Undernourished Children, Economic & Political
Weekly May 19, vol xlvii no 20 20
World Bank 2003. WDR 2004: Making Services Work for Poor People, World Bank and
Oxford University Press
World Bank 2006. India’s Undernourished Children: A Call for Reform and Action,
Health, Nutrition and Population (HNP) Discussion Paper, New Delhi
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malnutrition.pdf (accessed on 7 July 2014)
UNICEF 2009. Tracking Progress on Child and Maternal Nutrition, A survival and
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July 2014)
15
List of Abbreviations
ASHA Accredited Social Health Assistants
AWCs Anganwadi Centres
CAG Comptroller and Auditor General of India
CDPOs Child Development Project Officers
FYP Five Year Plan
gm gram
GOI Government of India
HUNGaM
A Hunger and malnutrition
ICDS Integrated Child Development Services
IMR Infant mortality rate
kcal kilo calories
kg kilogram
MPCE Monthly per capita expenditure
MWCD Ministry of Women & Child
Development
NFHS National Family Health Survey
NSSO national Sample Survey Organisation
Rs Rupees
SC Scheduled Caste
SN supplementary nutrition
SNP Supplementary Nutrition Provisioning
ST Scheduled Tribe
UTs Union Territories
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