Why India Needs a National Nutrition Strategy Lawrence Haddad Institute of Development Studies, UK l.haddad@ids.ac.

uk August 31, 2011 Undernutrition in India remains at high levels despite rapid economic growth. If undernutrition reduction is to be accelerated, the multiple opportunities for--and challenges to--improving nutrition status demand a nutrition strategy backed by strong leadership. Introduction Over the last 15 years India has posted unprecedented economic growth rates. The IMF reports an average real GDP growth rate of nearly 6 percent in the 1990s and of 8 percent in 2000-2010 (1). This progress in economic growth has not driven corresponding reductions in undernutrition reduction (2). Undernutrition in early life is responsible for 35 percent of under 5 child deaths, reduces cognitive attainment, substantially increases the likelihood of being poor and has a close link with illness or death during pregnancy and lactation (3). The nationally representative National Family Health Survey, the Governments most authoritative source of nutrition status statistics, shows that 43 percent of children under 5 were underweight for age in 1998-99. Using a later round of the survey, by 2005-6 that percentage had dropped to 40 percent (4). At that rate of progress India will reach its Millennium Development Goal (MDG) nutrition indicator by 2043 instead of 2015 (5). China has already met its goal, halving its 1990 rate of underweight a few years ago and the MDG will most likely be met for Brazil by 2015 (6). Why are high levels of undernutrition so persistent? There is likely no single answer. The possibilities fall into 4 categories: Indias growth is not pro-poor enough; no matter how pro-poor Indias growth is, the underlying environment for undernutrition reduction is just too challenging; nutrition interventions are not effective; and the governance of undernutrition is not strong enough. What does the evidence say and what are the implications for action? Economic growth is poverty reducing but not nutrition improving The poverty rate has declined at a faster rate post-1991 than pre-1991: 0.5 percentage points per year during 1958-91 compared to 0.8 percentage points per year during 19912006 (7). This compares well against the more lauded performance of China. Over the 1981-2005 period Chinas poverty rates declined from 40 percent to 29 percent while Indias declined from 60 percent to 42 percent (both about a 30 percent proportionate decline). The ability of Indias economic growth to reduce poverty is in line with other countries (8) and has been constant over the past 15 years (7) which is consistent with the evidence that income inequality has remained reasonably stable (it has increased by 12% between 1983 and 2005) (9). So economic growth is reducing poverty at a good rate but it is not reducing undernutrition. Why not? The enabling environment for undernutrition reduction is not strong 1

Might Indias economic growth be preventing from reducing undernutrition because of a weak enabling environment for nutrition improvements? The UNICEF model of undernutrition (10) articulates three levels of determinants: fundamental, underlying and immediate. Economic growth and governance (which will be reviewed later) are key fundamental drivers. Underlying factors include agriculture and food security, womens power in decision making, care to infants and the sanitation and health context. Immediate determinants include diet and infection. This section focuses on underlying determinants and the following focuses on more immediate factors. Agriculture: In most contexts we would expect agricultural growth to have large impacts on the nutrition status of children. Agricultural growth is typically more poverty reducing than other sources of growth (11). Agricultural growth also improves food availability. But agricultural growth in India does not seem to have an impact on infant undernutrition (12). It is vital to unpack this apparent disconnect. There are a number of success stories from the region and elsewhere that can point the way towards making agriculture more nutrition sensitive, ranging from homestead gardening, livestock and dairy interventions, and fruit and vegetable productivity to the biofortification of staple crops with Iron, Zinc and Vitamin A (13). The national agricultural system needs to be supported and incentivised to innovate for improved nutrition. Food Security Programmes: Food security is also promoted by a number of Government programmes: the Targeted Public Distribution System or TPDS, the National Rural Employment Guarantee Act (NREGA) and the Midday Meal Scheme. An evaluation of the TPDS by the Indian Planning Commission in 2005 concluded that the majority of subsidized food does not reach its intended recipients (14). Some have proposed cash transfers programmes (15) to improve transparency and the accountability of efforts to improve nutrition status--a theme we will return to later in the paper. In terms of employment guarantee programmes, the two high quality impact studies show contrasting impacts on household expenditures: one positive and one negative (16). The Midday Meals Scheme covers 139 million children in primary school. The most rigorous evaluation finds it to have a positive and statistically significant impact on stunting and underweight rates of 4-5 year olds (17). This is a positive story but the Scheme does not affect infants in the 2-3 year age group who are most vulnerable to nutrition insults. Womens Status: Discrimination against women in South Asia has long been thought to be one of the key drivers of infant undernutrition in the region (18). Multi-country analysis shows that womens low status relative to men is responsible for a significant, although not a majority, share of the difference in infant undernutrition rates between South Asia and Sub-Saharan Africa (19). Discrimination against women is an important part of the story and efforts to empower womeninside and outside of the nutrition sphere need to be redoubled. Health: Indias health system is ranked significantly below those of Bangladesh and Sri Lanka (20). Spending on the public health system is low (less than 1 percent of GDP) and over 80 percent of health expenditures are out of pocket. There have been recent calls on the Government to increase public sector spending to 6 percent of GDP by 2020 and to adopt a wide range of actions needed to strengthen the system (21).

Water and Sanitation: Rates of access to improved drinking water are low but in line with many other countries at similar levels of economic development. Access to improved sanitation is particularly poor. According to WHO, 640 million Indians still practice open defecation, accounting for 56 percent of the worlds total (22). We know that infection rates are powerfully associated with unsanitary conditions. Community Led Total Sanitation has proven to be a cost-effective way of scaling up latrine use in rural communities in Orissa (23) and its promotion merits consideration. Caste: Social discrimination against certain castes and groups is a powerful exclusionary factor in many Indian states. Cross section data show how low caste is associated with poor access to services and therefore poor nutrition and health outcomes, even when controlling for education and welfare levels (24). Longitudinal analysis from Andhra Pradesh finds being from a scheduled caste or a backward tribe substantially increases the probability of a child being stunted--and persistently so (25). Efforts to reduce such discrimination will greatly enhance the environment for undernutrition reduction. So the underlying context is not strong for economic growth to generate undernutrition reduction: agricultural growth has little effect, womens status is difficult to change quickly, the health system will take time to strengthen, the sanitation environment is extraordinarily undermining of nutrition status and social exclusion is an important and persistent constraint to improved nutrition. Can Indias nutrition interventions overcome these barriers? Nutrition interventions could do more The Integrated Child Development Services (ICDS) programme is the main nutrition related programme. The latest impact evaluation (26) finds that it has a positive and significant impact of six percent on the under three stunting rate, yielding a 3.75 fold net return on investment. This is low compared to community based nutrition promotion efforts elsewhere which attain ratios of 12:1 (27). The evaluation shows the effects of ICDS are weaker for under 2s, for girls, and for those with the most severe stunting and that the centres are not always placed where they are most needed. This suggests scope for ICDS to become more efficient in reducing infant stunting. The consensus on what to do includes: allowing different districts to adapt it to circumstances, employing more nutrition centre workers so that each age group (0-2 and 3-6 year olds) can receive tailored attention, reaching out to excluded castes, improving the quality of physical conditions and the accountability of ICDS centres to the people they serve (28). In terms of other essential nutrition interventions, coverage is low (29). For example, infant and young child feeding interventions cover only 25 percent of vulnerable children and vitamin A supplementation covers 30-40 percent of the vulnerable population, depending on the State. The new Accredited Social Health Activist programme pays community health workers to improve these coverage rates and improve the quality of service delivery to improve young child nutrition. So far no evaluations are available to assess its impact on nutrition status, but other evaluations (30) suggest stronger recruitment and support systems need to be put in place to assist these crucial activists in the fight against undernutrition. The governance of nutrition needs strengthening

Given the multiple opportunities for investing in nutrition and the multiple ways that nutrition status can be undone, it is vital that there is a nutrition strategy backed by strong leadership. Brazil has done this successfully, leading to dramatic declines in hunger and child undernutrition rates (6). The Government is not well supported to do this by available information and is not sufficiently pushed to act strategically. First, nutrition data are collected every 5-6 years. This is too infrequent to track changes and respond to events. Second, because there are so many moving parts in any nutrition strategy the Government needs to use nutrition diagnostic tools to prioritise and sequence action to improve child growth, in the way it does for economic growth. Third, this variation in contexts is also matched by variance in nutrition status. There are many bright spots in the fight against malnutrition (e.g. the recent Karnataka Nutrition Mission) but the incentives to analyse and learn from them are weak. This lack of data and strategic analysis also diminishes the effectiveness of Indian civil society to mobilise around nutrition. For example, the Right to Food Campaigns push for a National Food Security Act makes important demands, but even if some of them are met, they will need transparent monitoring of resource flows to promote accountability of all stakeholders. The research community in India has a vital role to play in helping to meet these needs: to design new ways of monitoring nutrition status more frequently, to develop new ways of diagnosing contexts in terms of priorities for nutrition action, to analyse success and failure in multisectoral coordination, to promote learning within and across states on what works in nutrition and why, and to test and evaluate transparency and accountability mechanisms for nutrition. Conclusion: a nutrition strategy is needed At current rates India will meet its MDG target by 2043 rather than 2015. Economic growth is poverty reducing and this should help undernutrition reduction in the long run. But the current environment is not as supportive to nutrition as it could be. Action is needed to: make agriculture more pro-nutrition by focusing it more on what people living in poverty grow, eat, and need nutritionally experiment with cash-based alternatives to the Targeted Public Distribution System promote community led approaches to sanitation increase coverage of essential nutrition interventions in the context of a stronger public health system focus Integrated Child Development Services resources more on children under 2, on severe undernutrition and locate centres where they are most needed, and continue the fight against gender and social exclusion

But most importantly, India needs a national nutrition strategy with a senior leader within the Government empowered to implement that strategy. Successful implementation needs civil society to play its part, helping to shape and deliver the strategy and promoting greater transparency and accountability in the fight against undernutrition.

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