BackTackling malnutrition in India
The Comprehensive National Nutrition Survey, being conducted by Unicef and the health ministry, is the first of its kind in terms of sample size and parameters
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Devthala village, in Rajasthan’s Jaipur district, is abuzz with ‘medical’ activity. In one of its dwellings, a six-year-old’s height, weight, arm length, waist size as well as grip strength are being measured by one of half a dozen surveyors. A Unicef delegation is watching over the process. When the child’s grandmother asks know how this will help, someone from the delegation explains the long-term benefits of the exercise. After listening for five minutes, she says, “This is wonderful. This means there will be fewer people sick in our household in the years to come."
Around 65 families out of 600 households in Devthala (as per the 2011 census) allowed city dwellers in white lab coats to collect blood, stool and urine samples and take measurements of their children in December. The surveyors also asked questions regarding education, job status, sanitation facilities, and number of family members, apart from testing the children’s IQ.
The exercise, the first of its kind in terms of sample size and parameters tested, was part of the Comprehensive National Nutrition Survey (CNNS) conducted jointly by Unicef, the ministry of health and family and welfare, the ministry of statistics and program implementation, not-for-profit entity Population Council of India, private sector firm SRL Diagnostics Ltd and ArcelorMittal SA chief financial officer Aditya Mittal and his wife Megha, who have contributed over $10 million for the pan-India survey.
The collection of samples started in March 2016. The survey aims to cover 120,000 children in the 0-19 age group across all Indian states. Unicef says the results will likely be released only in 2018, given the scale and complexity of the survey.
Unicef nutrition specialist Jee Hyun-rah explains the scientific rigour adopted in the methodology and sampling. Each selected village has 500 to 600 houses, which are divided into social and economic segments of 200 to 250 each. Using statistical methodology, 60 to 65 houses are identified for collecting samples.
“CNNS is a multidisciplinary survey that includes biochemical and nutritional samples. It even takes into account cognitive domain, anthropometric, household food security, water sanitation and socioeconomic features," Hyun says.
She believes comprehensive data is key to addressing malnutrition and so far India has been lacking in this field as most of the surveys have been based on cluster samples limited to height and weight indicators. CNNS includes measuring deficiencies in body mass, micronutrients, vitamins, minerals as well as worm infestations among children.
“The survey will help create the right policy interventions to address the root cause of malnourishment," says Hyun.
Citing preliminary findings–from 12 states so far–she points out that worm infestation is very high among children, much higher than expected or recorded till date.
“Due to inadequate data in recent times, we have noticed that a number of state governments have reduced the deworming programs with the belief that worm infestation is down. But this data already suggests that this may not be the case countrywide and policy intervention is still needed to tackle the problem," explains Hyun.
Worm infestation reduces overall absorption of nutrition in the body and is also a cause for anaemia among other health problems.
Vandana Prasad, national convener for Public Health Resource Network, a not-for-profit working on national health issues, says while the study is likely to result in significant insight from the research standpoint, it may not necessarily translate into public action.
Prasad, who has worked in the field of nutrition for over two decades, says a lot of data is already available, even if it is not adequate, but action is not always taken.
She cites the example of National Family Health Surveys (NFHS) 1, 2, 3 and the latest, 4, conducted in 2015-16. All of these highlight severe malnutrition among Indians, especially children. She says there appears to be a lack of political will to address nutritional challenges.
“Surveys like NHFS show that there is rampant malnutrition, it even shows the diversity between different states—some where political action and investments have been geared towards improving the condition on the ground and others where there has been no change. But we are not having the impact needed or making a difference at the rate at which we should."
Prasad says budget cuts for the already minuscule health sector and the state machinery for delivering nutrition have impaired efforts to remove malnutrition.
The Union health budget is just over 1% of the total GDP as compared to the World Health Organization’s recommended 5% and the Bharatiya Janata Party’s manifesto promise of ensuring 2-3% of the GDP for health, she says.
“Disinvestment in the overall health sector and other mechanisms like the Integrated Child Development Scheme (ICDS), which aim to address the root causes of malnutrition, has resulted in a very slow rate of improvement," Prasad says.
The budget for ICDS in the last two years has been cut by almost 50% and the National Food Security Act, 2013, that was finalised in the last leg of the United Progressive Alliance government, is yet to be implemented three years on.
According to Prasad, the determinants for dealing with malnutrition are known and not disputed--poverty reduction, income inequity, dietary diversity and food security--but they are not acted upon with the rigour and investment needed. She added that states such as Kerala, Odisha and even Tamil Nadu have seen some improvement because of focused efforts by the state governments to address them.
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