Written by Vijay Avinandan, Alok Mishra, Subham Awasthi
The findings of the National Family Health Survey (NFHS-5) have come as a reality check, and even experts are trying to make sense of it. The survey shows that food security and nutrition in India have worsened since the last NFHS round (2015-16). Among the 22 states and Union Territories (UTs) for which the data was released, 18 show either stagnation or worsening of stunting (height-for-age) levels among children less than five years. Since the data presents the pre-COVID-19 picture, the current nutritional status could be more worrying, especially for the poor and the marginalised sections. The final figures and the trend for the country will, however, be only known after the data becomes available for the remaining states/UTs.
Several studies have shown that childhood stunting, reflecting long-term chronic malnutrition, is associated with poor school achievement and diminished income-earning capacity in adulthood. Nutrition also serves as an effective entry point for human development with high economic returns – studies show that for every rupee spent, more than 16 will be returned.
Globally, India accounts for roughly one-third of the total population of stunted children under the age of five. The country, thus, has a tough road ahead for achieving the Sustainable Development Goal of 2030 for childhood stunting.
The implementation of the National Food Security Act was expected to make a dent in the nutritional challenges. The Act made access to food a legal entitlement for a large part of the society — 75 per cent of the rural and 50 per cent of the country’s urban population. Today, NFSA is the key pillar supporting India’s food-safety-net schemes, especially the Targeted Public Distribution System (TPDS), Mid-Day-Meal (MDM) and Integrated Child Development Services (ICDS-Anganwadi-Supplementary Nutrition Programme). TPDS alone provides subsidised food grains to roughly 76 crore ration cardholders.
National figures for food grain procurement, off-take, and budget allocations under the NFSA are staggering. Procurement of rice and wheat increased by nearly 35 per cent between 2009-10 and 2018-19. Annual off take of food grains increased by roughly 30 per cent during the same period. Overall, the annual consumer food subsidy — or the difference between economic cost of procurement and sales realisation at central issue prices — has nearly tripled, from Rs 42,489.7 crore in 2009-10 to Rs 1,15,570 crore in 2020-21. In fact, the actual budget figures could be higher due to dues pending to the Food Corporation of India.
NFSA, however, seems to have missed its mark in achieving nutritional outcomes for a number of reasons.
First, the provision under the Act to diversify commodities distributed under TPDS has not been met due to procurement-related issues. The current food basket (rice, wheat, coarse grains) under the Act does not substantially improve the dietary diversity of beneficiaries. Both government and independent studies have highlighted that the Indian diet, across states and income groups, is imbalanced. The calorie share of whole grains is much higher than the recommended benchmark, while that of fruits, vegetables, and meat is significantly lower. The lack of dietary diversity is associated with malnutrition, micro-nutrient deficiencies, and non-communicable diseases, a pattern evident in the NFHS-5 findings.
Second, the review and appraisal mechanism of the NFSA continues to be output-oriented. For instance, the last data on actual calorie intake derived from consumption expenditure among households is available only for 2011-12. Moreover, the NFHS reports do not provide results disaggregated by ration card ownership. Not surprisingly, the space for evidence, for the last seven years, is populated with less-rigorous evaluations and food bulletins that do not provide any insight into nutritional outcomes. These studies and bulletins focus primarily on administrative aspects like ownership of ration cards, supply of food grains, end-user satisfaction, food grain allocation and off-take ratios, financial spending etc. As a result, key issues such as dietary diversity get neglected consistently, which weakens the capacity of policymakers to undertake evidence-based course corrections.
The Act provides for greater oversight by states through State Food Commissions (SFCs). An SFC, comprising relevant experts, is expected to monitor and evaluate the NFSA and bring out state-specific challenges and mitigation measures. However, less than half the states have functional SFCs and there is little information on their actual role. In a recent national review meeting, key challenges voiced by 13 SFCs included, financial constraints, infrastructural challenges, staff shortage, and lack of autonomy.
Lastly, the provision to experiment with tools like direct benefit transfers (DBT) or food coupons have not been put into practice. A commodity-heavy system like TPDS is not only expensive but also suffers from leakages, diversions and inefficiencies. The alternative, recognised in the Act, is to enable cash transfers to the end-users at a fair rate and allow them to procure food grains directly from the market.
The DBT modality under NFSA has only been implemented in UTs of Chandigarh, Puducherry, and Dadra & Nagar Haveli (now Dadra and Nagar Haveli and Daman and Diu). Even in these UTs, studies indicate that end-users may not prefer cash transfers due to the insufficient amount of subsidy amount, low awareness, transaction expenses, and subsidy diversion by male members of the household.
So, what can be done to improve the food-safety-net?
First, the DBT experiment for NFSA requires a more careful piloting and expansion across willing states. A dynamic nutrition-line, similar to the poverty line, can be reinforced to act as the target for NFSA to achieve. Stronger “conditionalities” like linking the cash transfer to school attendance, immunisation etc, can be introduced. Moreover, behaviour change communication can be introduced to reduce possible diversion of cash by households in non-food related expenditure. Investment in high-quality monitoring and evaluation (M&E) for DBT is a must since such programmes are prone to inclusion or exclusion errors.
Countries like Mexico and Brazil present good examples of successful Conditional Cash Transfer (CCT) programmes. Mexico and Brazil subjected their CCT programmes to impact evaluations over several years and introduced course corrections based on the findings. This led to a significant improvement in health, education, and nutritional outcomes. These successful models certainly merit a closer study and comparison with the Indian DBT.
Second, in the meanwhile, the food basket under NFSA also needs to be diversified to include more food groups. Some promising steps have been taken like the inclusion of pulses under the NFSA during the COVID-19 pandemic lockdown, and the expansion of the pilot scheme for distribution of fortified rice to aspirational districts. Several states have also taken the initiative to introduce millets under the TPDS. But more concerted efforts and investments will be required to mitigate the current imbalance in dietary habits and the resulting nutritional outcomes. The diversification of food groups is bound to increase the already significant public expenditure. Therefore, the current system of beneficiary targeting would be required to nudge-out ineligible beneficiaries — estimated to be roughly around 25 per cent to 37 per cent of total TPDS beneficiaries till 2011-12.
In 2017, the NITI Aayog, through the National Nutrition Strategy, had suggested several measures including, greater convergence between existing nutrition-focussed schemes, dietary diversification to include food groups rich in Vitamin A, C, and iron, strengthening of the existing monitoring and early warning systems, and greater ownership and monitoring by the local community. Some states have undertaken innovative measures in this regard, such as the MAMTA, a conditional cash transfer scheme by Odisha, in which pregnant women and lactating mothers receive monetary support contingent on conditionalities such as registration of pregnancy, undergoing antenatal check-ups, vaccinations, etc. Chhattisgarh and Jharkhand, among others, have implemented strategies to track and counsel pregnant women and lactating mothers through community-led models like Nava Jatan and Dular strategy. An evaluation of Dular in 2007 noted that the programme resulted in increased knowledge about child feeding, nutrition, and care, and other improved health and nutritional results. Based on the findings, the government of Jharkhand expanded this strategy to cover all Anganwadi centres.
Last but not the least, the NFHS-5 has helped fill some evidence gap in absence of the NSS Household Consumer Expenditure Survey of 2017-18 (PIB, 2019). Going forward, the most immediate step should be to transform from output to an outcome-focussed performance management of NFSA by capturing more information on end-user well-being. Currently, the evaluation mechanism for NFSA covers 27 states and UTs in India, reported quarterly, and undertaken by research institutions and third-party evaluators. The last quarter of evaluation for each state can include questions on dietary diversity and calorie intake for households. Also, the quality of survey can be strengthened by including new and robust indicators — these could include dietary diversity, overall household food security, increasing the sample size of respondents, stronger oversight. Some efforts have already been made in this respect, such as indicators in the SDG India dashboard. But there is a need to logically adopt such indicators and surveys under the NFSA. Expert organisations like the Development Monitoring and Evaluation Office NITI Aayog, and its partners, can be engaged to provide technical assistance and oversight to the entire process. The investment in M&E, costing only a fraction of the total NFSA budget, can provide much-needed insights on outcomes more frequently, as compared to longer national-level surveys.
The verticalised approach of delivering schemes to improve nutritional outcomes seems to have run its course. Given the diverse local dietary habits, which have often been distorted by over-supply of cheap food grains, the solution to India’s nutritional problem requires a system-based approach based on greater convergence between stakeholders, decentralisation in its true spirit, and better data systems to drive quicker learning and course-corrections.
(Avinandan is Monitoring & Evaluation Officer United Nations World Food Programme, Mishra is Deputy Director General, Development Monitoring and Evaluation Office (DMEO), NITI Aayog and Awasthi is Monitoring & Evaluation Lead, DMEO, NITI Aayog)