Currently, around one-fifth of India’s kids less than five years of age fall in the ‘wasted’ low-weight-for-height category. Over the past four decades, there was slow but incremental reduction in the percentage of underweight and stunted kids. But a fortnight ago, when the fifth National Family Health Survey (2020) was released, it unexpectedly showed underweight and wasting rates having increased in the last five years — in states where data is available. Astonishingly, relatively high performing states like Kerala, Gujarat, Maharashtra, Goa and Himachal Pradesh had shown an increase in undernutrition, besides eleven other states, all showing an increase in severely wasted and underweight under-fives. Bihar and Assam, long considered outliers in terms of health indicators, had surprisingly bettered their earlier performance which added another layer to the mystery of how come?
The NFHS is the Indian version of the global demographic and health surveys undertaken every five years for some 90 countries. The survey primarily focuses on women, children and nutrition of under-fives. Identifying underweight, wasted and stunted children and providing the needed interventions is vital because at stake is not just the physical health of millions of children, but their capacity to develop the cognitive ability to stay honed into the school system. If neglected, such children become a burden on the family and society.
India’s supplementary feeding programme — the Integrated Child Development Scheme — has been running in all states for the past 45 years. But the programme was never able to reach the six months to three year age-group which is where the problem of wasting starts and which is also the time the brain cells need maximum sustenance. India has over 14 million Anganwari Centres (AWCs) which are responsible for weighing and measuring children and providing supplementary nutrition. Infants and small kids stay mainly at home where feeding and child-rearing practices are often faulty. Because of over-crowding, lack of domestic hygiene and sanitation, the home itself provides a fertile ground for respiratory illness, diarrhoea and mosquito-related fever in young children. Frequent episodes of these illnesses put the child’s development clock back, sometimes forever.
Ever since the 1970s, the National Sample Survey, the mother of all surveys, collected data on household expenditure on food items asking questions on spending on oil, non-staple food, milk, eggs, fruit and vegetables. This was to measure consumption and calorific intake as a proxy for measuring poverty. The NSSO and NNMB surveys have shown that while the energy intake for adults is nearly adequate, consumption of pulses, vegetables and fruit which affects absorption of nutrition, particularly iron, is low.
The ICDS programme received a shot in the arm when the Poshan programme was launched in 2017. It was to have been completed in three years (which is now, but has had a slow start.) Under Poshan, the BMI measurement of every child was to be recorded to detect those requiring intervention, both underweight and overweight. Although the initiative was essential, it was not designed to address the invisible needs of an infant or toddler because those problems mostly lie inside the home. The challenge is to teach the mother simple recipes to introduce complementary feeding six months after exclusive breast feeding — which isn’t often done. Also, to measure the child’s intake with some understanding of calories, even pointing out unsanitary practices like defecation inside the house, dirty utensils and the presence of flies which are harbingers of disease that need supervision. But who can do all this as part of a supplementary feeding programme?
Once Covid-19 sprang on us last year, all attention was diverted to controlling the pandemic. Even critical health programmes had to take a back seat for reasons which are unexceptionable. But in the totality of things, while critical care for cancer and heart diseases has perforce had to wait, the focus on children has unfortunately diminished. The Poshan programme will take time to get going across the country. Rather than wait for it to gather momentum, what is now needed is to quickly identify the local drivers causing young kids to become underweight and wasted; and then to face the main hurdles head-on and control if not eradicate them.
At the village level, the three trained foot soldiers are the health department’s auxiliary nurse midwives (ANMs), the ASHAs who are the torch-bearers of the State Rural Health Missions and the Anganwari workers from the ICDS. The three women have different responsibilities but meet monthly on Village Health and Nutrition Day to boost convergence. This threesome now needs to extend its outreach beyond its known threshold to visit the homes of identified at-risk children to observe, guide and train young mothers with little education or experience. The task is not difficult as only 15% of the infant population of the villages are wasted and would need this service at a given time.
We need a national programme to manage nutritionally at-risk infants and their mothers at the household level as an add-on to Poshan. That requires not just training but ownership. Only an institutional back-up with skin in the game and having a local presence and the capacity to perceive infant undernutrition as a grave problem can be effective.
Different models are possible. But the Panchayati Raj Institutions (PRIs) exist everywhere and have the biggest stake in the uplift of the village community. The panchayat should be provided with the names of families with babies that appear to be at risk because of continuing low growth indicators. The panchayat members should be trained and incentivised to see that wasting declines. If for every identified child that is saved from falling into the wasting trap, the panchayat and the women volunteers are rewarded proportionate to the success achieved, it could work wonders.
For starters, a postal fixed deposit certificate, encashable once the kid at risk reaches five years of age, without becoming underweight (even overweight) might just succeed!