In India, malnutrition is not uncommon even in economically well-off sections of the population. It must be understood that malnutrition is not just hunger. It also includes:
- Undernutrition –which includes wasting (low weight for height), stunting (low height for age) and being underweight (low weight for age)
- Micronutrient-related malnutrition –which includes deficiency of important vitamins and minerals or micronutrient excess; and
- Overweight, obesity and diet-related lifestyle diseases
The Global Hunger Index 2021 is basically about undernutrition. It provides us an opportunity to introspect on why India’s performance is not as good as what our economic growth should have ensured. Rather than doing that, the Narendra Modi government has chosen to question the methodology of one particular indicator used in the report to assess the level of undernourishment. It is true that at its core, the Hunger Index is primarily an indicator of child undernutrition and mortality. While it does estimate the prevalence of undernourishment (PoU), its weightage in the index is only one third. The other three components of the index relate to the percentage of children under five years who show wasting, stunting, and child mortality (percentage of children who die before reaching five years of age). Dipa Sinha has explained the methodology of index in this article in The Hindu.
India collects its own data on health and nutrition that is widely considered to be credible and extremely useful. The fifth round of the National Family Health Survey was conducted in 2019-20 and its findings were released in December 2020. However, data for Uttar Pradesh, Punjab, Jharkhand, and Madhya Pradesh was not included in the first phase so the all-India performance is not yet known. The survey found that the progress is worse than expected, and stunting, reflective of chronic malnutrition, has increased in 11 out of the 17 states surveyed. Wasting, indicative of acute malnutrition, has also increased in 13 of these 17 states. Such malnourished children are more vulnerable to illness and disease. The percentage of underweight children has gone up in 11 of the 17 states. In Bihar and Gujarat, 40 per cent of children under the age of five, were underweight.
Undernutrition is one of the leading risk factors for child mortality in India, accounting for 68.2 per cent of total under-five deaths (10.4 lakh) in 2017. Children with severe undernutrition are at high risk of dying from diarrhoea, pneumonia, and malaria.
Our own data is a sign of how worried we should be.
Data gaps in nutrition
Hunger is defined as an uncomfortable or painful physical sensation caused by insufficient consumption of dietary energy. This term is sometimes also used to denote food insecurity. Someone is severely food insecure when they have run out of food and gone a day or more without eating. A person is moderately food insecure if their access to food is uncertain. In this situation, they might have to sacrifice other basic needs just to be able to eat. Such a situation is not uncommon.
It must be noted that the Global Hunger Index 2021 does not present data of impact on hunger and food insecurity as a fall out of the economic impact of the Covid pandemic-induced lockdown from March to June 2020. Several reports have documented the loss of livelihood and income, especially on the 91 per cent of the working population employed in the informal sector. Similarly, the impact of a large number of deaths, largely unaccounted in government records, in the second wave of pandemic in April-May 2021 is not captured by this report. We might get to know the real impact of these events when the household consumption expenditure survey is released.
International Food Policy Research Institute (IFPRI) researchers have published papers on the affordability of Indian diets and a comparison of the Indian diet with the EAT-Lancet reference diet. The latter study found that in the lowest decile of per capita monthly expenditure, only 4 per cent caloric intake is from protein sources against the recommended 29 per cent. These studies are based on consumer expenditure surveys of 2011-12 and the situation may be entirely different now.
When the Modi government decided not to release the consumption expenditure survey conducted by National Statistical Office (NSO) in 2017-18, it was hoped that a fresh survey will be conducted in 2020-21 and 2021-22. But we don’t know yet. In the absence of recent data, it is difficult to assess whether the poorest Indians are eating nutritious diets.
What the government is doing
It is not that the Modi government has been totally oblivious to the challenge of undernutrition of children. In 2017, the Niti Aayog published the National Nutrition Strategy with the vision of Kuposhan Mukt Bharat by 2022. The following sources of funding were identified for this:
- National Health Mission
- National Nutrition Mission (Poshan Abhiyan)
- Integrated Child Development Scheme
- Swachh Bharat Mission
- Provision of 25 per cent flexible funds for states in centrally sponsored schemes
In 2018, Poshan Abhiyan was launched by the government through which it aimed to reduce child stunting, underweight and low birth weight by 2 percentage points per annum and anaemia among children (and young females) by 3 percentage points per annum. Niti Aayog has been evaluating the progress and three reports have been submitted to the government. Anyone concerned about India’s poor standing in the Global Hunger Index should read the latest of these reports to understand the challenges faced by the Union and the state governments in tackling child undernutrition on the ground.
The two most important government interventions to address the challenge of undernutrition are the Integrated Child Development Scheme (ICDS) and National Health Mission (NHM). ICDS has been focused on providing take-home ration to children between 6 to 36 months. It also provides supplementary nutrition to children aged 3-6 years in anganwadi centres with provision for enhanced support to undernourished children. Health-related facilities like immunisation, check-ups and referral services for malnourished children are supposed to be delivered through the state government’s primary and community health centres and hospitals. However, the fragile health infrastructure and severe deficiency of trained health professionals in many states, especially in rural, hilly and tribal areas, is a serious stumbling block in ensuring these. We hope that the PM Ayushman Bharat Health Infrastructure Mission, launched by Prime Minister Narendra Modi, will augment the health infrastructure at the primary and secondary level to address these concerns. Implementation of ICDS also warrants more rigorous coordination and monitoring because, in 2018-19, only 44 per cent of the funds released by the Modi government under the Annual Programme Implementation Plan (APIP) were reported to have been utilised.
India has set a target to end all forms of malnutrition by 2030. To this end, in the Union Budget 2021-22, Mission Poshan 2.0 was announced to improve nutritional outcomes in 112 aspirational districts. Poshan 2.0 is just a new name for existing schemes like ICDS, Anganwadi services, Poshan Abhiyan, Scheme for Adolescent Girls and National Creche Scheme.
Distributing excess grains
Many say that the Union government should distribute excess stock of food grains to those who are not currently covered under the Public Distribution Scheme, in view of rampant undernutrition. In fact, the government has done well to allot an additional 5 kg of wheat or rice per person per month under the Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY). In 2021-22, this allocation is up to November 2021. But only 79.51 crore people with ration cards are eligible for this. There would be many others who would have fallen into poverty as a result of the pandemic and also deserve cheaper food grains.
On 1 October 2021, the central pool stock of rice and wheat was 816.03 lakh tonne against the buffer norm of 307.70 lakh tonnes. Rather than making ethanol from issuable food grains procured at the minimum support price, the government can allow anyone to take 5 kg of wheat or rice per person per month at 50 per cent of MSP. This can address the needs of those who do not have ration cards.
Jharkhand has recently decided to provide eggs at least six days a week to children aged 3-6 years at Anganwadi centres. The Modi government should encourage other state governments to also distribute eggs to children from families where eggs, meat and fish are not taboo. Even if the Union government is reluctant to bear losses incurred in inclusion of nutri-cereals in PDS, the states should consider introducing them at least in aspirational districts that have high incidence of under-nutrition.
Hussain, retired as Union Agriculture Secretary. He is Visiting Senior Fellow, Indian Council for International Economic Relations. Mohapatra was Chief Secretary, Odisha and Union Secretary, Rural Development. Views are personal.
(Edited by Neera Majumdar)