The first results of the fifth National Family Health Survey or NFHS-5 released earlier this month have somersaulted on past gains. They show a widening gap in 15 out of 22 states in levels of anaemia and stunting and wasting among those aged under five. Surprisingly, even Kerala and Himachal Pradesh, both of which are shining examples of better health indicators in India, have shown an increase in underweight, stunted and wasted under-fives plus overweight kids.
The question quite simply is — why?
There could be several reasons. First, the testing methods used were not accurate. Second, the quality of nutrition given to young children at home and through the government supplementary feeding programmes has fallen short of their needs. Third, other determinants like sanitation and hygiene are responsible for repeated illnesses, which start a cycle of undernutrition and recurrent infections. Fourth, family income went down and affected the capacity to buy pulses, green vegetables and fruit — all essential items for a balanced diet. No single answer can be given with certitude. Which is why the opinion of both experts and grassroots workers can provide food for thought.
Nutrition is not an impossible task
Dr V. Subramaniam of the Harvard School of Public Health has studied the data and advises decluttering the present approaches to child nutrition by keeping it simple. He advises against a disproportionate focus on anthropometry (body measurements) and suggests instead to have “a direct engagement with diet and food intake.”
Prema Ramachandran, director of the National Nutrition, said in a conversation with me that the gold standard for testing anaemia is the cyanmethemoglobin method, which has not shown deterioration in anaemia levels in much larger surveys like the Annual Health Survey, the District Level Health Surveys, and UNICEF’s Comprehensive National Nutrition Survey — all of which use the cyanmethemoglobin test, which is almost 100 per cent reliable. The HemoCue test used by the NFHS is, according to her, not accurate enough to assess small changes over time in the prevalence of anaemia.
NGOs like Chetna in Ahmedabad (with which I am associated), have underscored the need to pay attention to poorer families with young kids because they often need counselling on hygiene, sanitation, feeding practices and child-rearing.
But when India can get bigger things right, why do nutritional deficiencies remain insurmountable?
Success with maternal/infant mortality
From the 1970s until 15 years ago, reducing maternal and infant mortality seemed impossible. Internationally, a country’s progress is principally judged by these two indicators (MMR and IMR). But for decades, India’s progress was too slow to give hope. Except for Kerala and Tamil Nadu, these indicators in most states were appalling, particularly compared with our poorer neighbours. High levels of MMR and IMR in Odisha, Uttar Pradesh, Bihar, and Rajasthan seemed irreversible.
But during the early years of the new millennia, various committees like the Commission on Macroeconomics and Health gave primacy to correcting this. The National Rural Health Mission was launched in 2005, which was later expanded and renamed as the National Health Mission (NHM). The programme has been a watershed in health management as both infant and maternal mortality rate began to decline with each passing year. Data from some of the erstwhile ‘BIMARU’ states showed the biggest decline took place there, largely attributed to the Janani Suraksha Yojana (JSY) — the safe motherhood intervention of the NHM.
Every pregnant woman began to be identified and tracked through the next nine months with three-monthly antenatal check-ups, fortified with medical interventions as per need, and escorted to a fixed facility for delivery. With everything provided free, the woman was nonetheless paid both in cash and kind when she finally went home with the baby. An intrauterine device (IUD) was inserted with her consent to protect her from unwanted pregnancy and promote spacing between children.
These strategies have not only had a dramatic effect on both maternal and infant mortality but also on the fertility rate. Today, practically all states have achieved or even gone below the ideal fertility rate of 2.1. Except for Bihar and Uttar Pradesh, which no doubt are home to the largest chunks of the population, the remaining states have reached European levels of fertility.
Without question, the success can be attributed to the NHM, which received sustained support from all governments, central and state. Tracking and checking every pregnancy, using ASHAs, Anganwadi workers and Auxiliary Nurse Midwives (ANMs) to follow the pregnant woman until delivery, measuring and documenting the progress strengthened all links in the chain.
Kids got left behind
Now compare that with the supervision of the growth and development of infants and young children. The structure and primacy given to the JSY programme is not available to Integrated Child Development Services (ICDS) — despite being a 45-year-old programme.
Experience has shown that children attending the Anganwari centres are usually older than 0-3 years — the age at which undernutrition sets in. Once the condition has got a foothold, the symptoms persist. The ICDS does not reach the under-three age group as assiduously, which is where nutrition interventions would be most effective. Studies have also shown that the food provided at the ICDS centres far from being a supplement becomes a substitute for home food. The Poshan Abhiyaan does envisage measuring the height and weight of all children to identify kids with low body mass index (BMI). Only some 15-20 per cent of the under-fives are thin. If they are given focussed attention with food supplements, care during convalescence, improvement can be accelerated.
NGO Chetna has been working in villages in Gujarat, Madhya Pradesh, and Rajasthan for decades. The field workers found that many small interventions worked. Simply by teaching families not to let a child run around while being fed and having a fixed time and place for feeding, nutrition levels improved. It was found that practices like discarding the colostrum — the first milk — took away the very antibodies that the infant needed the most to ward off infections.
Reaching poorer villages and slum homes with neonates and children below age three is called for. When it could be done for pregnant women under the JSY programme, it needs to percolate to include newly born children at least to when they are three years of age. Fewer illnesses, better cognitive ability and better capacity to stay rooted in the school system will be the outcomes.
India’s next generation deserves that much.
Shailaja Chandra is a retired civil servant and former secretary in the health ministry. Views are personal.