11 December 2015

"Make in India" cannot happen if the children 'made in India' are stunted, wasted and underweight

Srinath Reddy, Purnima Menon, me, Min. Gandhi, Min. Nadda, Ramanan Laxminarayan and Soumya Swaminathan 

I just returned from a few days in Delhi.  The first part of the week was teaching on a short course convened by the Public Health Foundation of India for Indian policy and programme professionals: Transforming Nutrition Outcomes, Policy and Action. My fellow course convenors were Purnima Menon (IFPRI), Aryeh Stein (Emory University), Reynaldo Martorell (Emory University), Ramanan Laxminarayan and Shweta Kandelwal (Public Health Foundation of India).  We had 50 participants, all asking very good questions and sharing their pricesless field experiences.  All in all a great few days.

The last day of my visit was to launch the Global Nutrition Report (GNR) in conjunction with the launch of the TransformNutrition/PHFI/IFPRI India Health Report: Nutrition (IHR).  Both reports are supported by DFID and other development partners.  

Things got off to a good start that day -- we saw an op ed in the Times of India from Bill Gates and Ratan Tata about nutrition and its vital role in driving sustainable development and the need for sustained leadership. 

The Times of India front page, Dec 10, 2015

The GNR and IHR both use the latest RSOC data from the Government, 2013-14.  The GNR compares India’s performance against other South Asian countries and the IHR focuses on State level variations.

Between IFPRI, PHFI and the GNR we managed to get a great line up of speakers: Minister Maneka Gandhi of Women and Child Development and Minister PJ Nadda of Health and Family Welfare as well as Dr. Soumya Swaminathan the DG of the Indian Medical Research Council.

Key messages from the 2 reports include:

* At the national level India's rate of stunting decline has increased dramatically: from 1.7% Average Annual Rate of Reduction pre NFHS 2005-6, now to 2.6% post RSOC (a 50% increase). But this is still short of the 3.7% needed to get to the World Health Assembly and SDG target on stunting. GNR

* The benefit cost ratio of investing in the scaling up of essential nutrition programmes in India is 34 to 1. GNR

* Wasting rates have come down by a quarter (from 20 to 15%) but this is still very high. Women's anaemia rates are very high at 48% and are the second highest in the SAARC countries. GNR

2 lead authors of the IHR: Neha Reykar and Moutushi Majumdar
* India is on track for only 2 of 8 global targets for reducing nutrition by 2030 (under 5 overweight and exclusive breastfeeding rates), but it is making good progress on many of the others and may well move to an on track status by the time NFHS 4 is finalised. GNR

* Adult overweight and obesity is relatively low at 26% but is increasing. India needs to resolve issues like stunting, wasting and anemia while slowing down and reversing overweight and obesity rates. GNR

* The 2 big states that had the worst stunting rates in 2005-6 were the ones that made least progress over the 2005-2014 period — Bihar and UP. Efforts need to be redoubled in these two states if the national numbers are to decline faster. GNR and IHR 2015

* Governance and delivery of health and nutrition schemes is highly variable, as seen in the state comparisons of delivery of ANC, ICDS, immunization; need to understand if this is because of capacity, financing, implementation bottlenecks, human resources or community demand-generation. IHR 2015

* Women’s health and status are known drivers of poor nutrition, especially education, health, nutrition and age at marriage; these are issues even in better-off Southern states and need urgent attention. IHR 2015

* Adolescent girls’ nutrition is a particular challenge across the country and has serious implications for transmission of poor nutritional status from young mothers to their children. IHR 2015

* Although exclusive breastfeeding rates have considerably improved, complementary feeding of young children is still a big area of challenge, across the board, almost regardless of which state one looks at. IHR 2015

* Sanitation, another major driver of poor nutrition, remains a major challenge in several states, even in those that perform well on implementation of health and nutrition programs. IHR 2015

* Strengthening full accountability for delivery of certain identifiable set of high impact nutrition interventions is critical to ensuring accelerated improvements in nutrition. IHR 2015

* The need for a comprehensive consistent data collection effort around nutrition is vital. NFHS 4 needs to be published in a timely way and subsequent NFHS surveys should be collected every 3 years. GNR and IHR 2015 Global Nutrition

So, how did the Ministers react?

First of all, it was great to see these 2 Ministers on the stage together—it does not happen often enough. As one of the Ministers noted, this side by side arrangement represented one type of convergence of leadership (the coming together of the 2 major ministries that deliver nutrition specific interventions). 
Ministers Gandhi and Nadda in the middle of the platform

Minister Nadda (Health) said all the right things. He talked about malnutrition in all its forms, the double burden, and the fact that business as usual would not deliver reductions fast enough. 

He quoted the 34:1 benefit-cost ratio for India from the GNR and the fact that that is equivalent to a 12% compound rate of interest over 30 years.  In other words, a fantastic investment. He praised the reports for the signposts to accelerating malnutrition reductions that they delivered.

Minister Gandhi (Women and Child Development) noted the importance of raising the ratio of girls to boys in the country’s poorest 100 districts.  She noted that after just one year the ratio was now much closer to 1000 to 1000  than it had been a year ago (around 750 to 1000). This of course is vital for child survival, but also for nutrition.  She said that the same rapid change would happen for nutrition “once we focus on it”. 

An area of focus for Minister Gandhi was the highly variable quality of food provided for under 5’s in ICDS programmes. She thought that involving businesses more closely to produce food to a specification determined by the Government (and due for a refresh). 

She also mentioned the potential of mobile phones for messaging around nutrition, citing a new initiative with Vodafone that every time the phone is switched on a very short video from the film star Aamir Khan on how to feed your baby plays (and you get 10 rupees if you watch the whole thing).  

She talked about how important it was to train frontline workers and to reduce their burdens.  MPs were also an important set of allies that the Minister thought represented a missed opportunity to engage on nutrition (she recounted her own relative lack of awareness over the role of frontline nutrition workers in her own constituency before taking on her current role).

Earlier that day we had a fantastic meeting with 2 senior bureaucrats in the Prime Minister’s Office.  The 2 officials we met really “got” nutrition—what it was, why it mattered and what to do about it. They confirmed the launch of a National Nutrition Mission in early 2016 and they made us optimistic about its content and influence.  We shall see.

While national level policymakers can enable or hinder state level governments, the state by state variation in implementation, spending and monitoring of national policy shows that the states have a lot of freedom to act for nutrition.  The centre can facilitate or show indifference, but it will not deliver improvements without committed states. 

Purnima Menon, speaking to the Ministers
We called the launch event “Made in India” because this is a play on Make in India, the government’s strap line on reviving indigenous manufacturing to make India the workshop to the world and power its own economic growth (and India is now the fastest growing major economic in the world).  

Based on the data and our gut instinct, we felt India could now be on the verge of driving a very rapid decline in global stunting rates in the SDG period, much as China drove global poverty rates down in the MDG period. 

But my colleague Purnima Menon (who along with PHFI's Ramanan Laxminarayan were the other 2 IHR lead authors) put it best “Make in India cannot happen if the children 'made in India' are stunted, wasted and underweight”.  Absolutely. 

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