India has to be better prepared to take on the twin challenge of malnutrition and obesity.
PM Narendra Modi launched the ambitious National Nutrition Mission covering all 640 districts of the country on International Women’s Day in 2018. The goal was to attain “Kuposhan Mukt Bharat (malnutrition-free India)” by 2022.
The purpose of this article is to outline some of the potential areas which may need further thought/strengthening so that it can take on the twin challenges – of undernutrition on the one hand, and rising prevalence of overweight and obesity on the other. While undernutrition is slowly and unevenly declining, not even a single state in our country reported a decrease in overweight/obesity in the past few years.
Critically discussing the S-A-A-R-E-G-A-M-A of the National Nutrition Mission (NNM) may provide useful insights, so that the health of our future citizens is not compromised:
1. Sustainability (especially financial): The first question that comes to mind is how will NNM operate and continue to do so for several years in a sustainable fashion.
The Centre has committed funds for NNM but also requests states to match investments flexibly. The modes of sharing, funding and costing for each state will depend on their socio-demographic profile, current level of health and nutrition indicators, motivation levels, incentive schema etc.
The commitment for sustained funding needs to be a given, around which regular expected expenses and scale-up activities can be planned. It will also be useful to have diversified financing for nutrition from several developmental programmes.
2. Accountability: Who is going to be the lead body at the Centre and subnational levels responsible for steering this through? If it is the NITI Aayog, how will it ensure state participation and who will be the contact points in different states? Prior experience of multi-sectoral panels/council of experts showed limited success (for example, Prime Minister’s Council on Nutrition). How will previous experience guide next steps in the accountability issue? It may be useful to have mutually pre-agreed timeline-based allocation of responsibilities – both individually to the key ministry and also jointly with other ministries etc. Periodic progress reports from each party should be peer-reviewed and put out in public domain to allow transparent tracking of anticipated deliverables.
3. Alignment with other stakeholders: Nutrition sector requires nourishment from several domains, which directly or indirectly determine its outputs. Nutrition in India has largely been oscillating between ministry of health and ministry of women and child development for past several decades. However there are other key players from sectors including but not limited to agriculture, environment, transport, social development etc which need to be on the nutrition and health discussion table for holistic sustainable progress.
Efforts should be made to break down silos and develop a comprehensive programme, which will propel the mission towards attaining its envisioned goals.
4. Research and operational capacity strengthening: The mission requires a huge human resource input including from the research community. But it’s important to think through some basic requirements, such as, who and how many people will be required to contribute to the mission? What will be the mechanism of recruitment? How often will they be trained?
Since this programme entails a variety of tasks – both technical and non-technical – numerous levels/types of personnel may be required. Who will be responsible for data collection and quality check, and how will they liaise with the research team reviewing the data? All efforts should be made to prioritise and invest in the data needed and strengthen capacity to utilise the collected information.
5. Education: How can we rope in early education system in preschools or schools to colleges to better sensitise students to the issue of investing in health and nutrition? Children can be the change agents for their families and vice versa. What about workplace education? This component needs to run in parallel with other capacity building and strengthening activities.
6. Grievance redressal and conflict of interest: This is an important piece in a programme of huge size and role, operational at multiple (national and subnational) levels. A centralised call center is unlikely to suffice for the massive programme with diverse features.
Processes should be fair and transparent so as to avoid errors of inclusion and exclusion. The mechanism of vigilance committees at various levels should be strengthened and effective grievance redressal mechanism should be developed. Such reforms measures are crucial to ensure a leakage- and diversion-free PDS (public distribution system) and that no needy person is denied benefits.
7. Awareness or Jan Andolan: Participatory programmes (especially those with local accountability and ownership) usually have a better rate of success and longevity than top-driven initiatives. There is a flip side too – people may demand too much, too fast, with too little understanding of participatory development and its implications. How will the process of empowering masses be rolled out?
8. Monitoring: This seems to be the biggest challenge for any programme’s optimal delivery and long-term efficiency. For NNM, advanced technology including real-time monitoring and follow-ups, has been envisaged. In a low-and-middle-income-country with challenges around power supply, literacy, handling technology sensitively and sensibly may require a long period of hand-holding and capacity building. Motivating people to report and collect data ethically will also need to be emphasised.
9. Evidence to policy to improved Action: Overall our focus should be to make healthy diets accessible and affordable to drive better nutrition across the life-course with special consideration for the vulnerable stages like pregnancy, childhood, adolescence etc. This should resonate strongly with NNM’s mission and planned activities at all stages. Just desiring longevity may not suffice. Trying to get our children to live and attain their full neurocognitive potential needs a paradigm shift. In this regard, how will the collected data be collated and processed by researchers to be used by policymakers to inform and improve action in a continued manner?
In all its spirit, National Nutrition Mission is set out to be one of the seminal steps in the history of any nation’s efforts to improve public health and nutrition, but it needs better preparation and surveillance mechanism to bear the desired fruits.
Shweta Khandelwal is the Head of Nutrition Research and Associate Professor at the Public Health Foundation of India (PHFI). Opinions are personal.
This is an edited excerpt from ‘National Nutrition Mission: Will it harmonise with India’s health and nutrition agenda?’ published by Ideas for India.