A synergistic approach is key to achieve better nutrition outcomes
Nutrition sensitive interventions coupled with community participation can lead to transformational improvement in indicators
Recent discourses on addressing nutritional challenges in the country and elsewhere have unequivocally espoused the need for improving agency of women at the household and community level as well as improved coordination of government and non-governmental programmes. The extent of nutritional challenge in the country is visible from some of the key nutrition indicators across National Family Health Survey (NFHS) 4 & 5, as mentioned in the table below.
It is increasingly being recognised that this is not an either/or situation. For instance, mere awareness generation for a community may not improve the access to food-based schemes. A perceived lack of sensitivity among the service providers on the criticality of food-based interventions and the rights framework quite often may pose as barriers for households and communities to assert their rights and access the programmes. Fear of any political backlash or reprisal can restrain the communities to assert their rights. At a broader level, the outcomes on the nutrition front in India may be typical of a low-level equilibrium trap with budgets and actions lacking a nutrition-sensitive approach.
The search for a missing link warrants an expanded engagement towards addressing hunger and nutrition through demonstrations of coordination of efforts across various ministries and departments engaged with agriculture and food security, water, sanitation and hygiene (WASH), education, finance and social protection than the typical women and child development (WCD) vertical. While the National Nutrition Mission or Poshan Abhiyaan has explicitly mentioned nutrition as everyone’s child, the nutritional outcomes are nothing but manifestations of the limited attempts at harnessing synergies and coordinated planning and execution across various levels of governance.
What needs to be done?
Desired nutritional outcomes at a state level necessarily require a cohesive and comprehensive approach that entail nutrition-specific, nutrition-sensitive and robust governance actions. It is well-understood that nutrition-sensitive programmes in agriculture diversification and food security, women empowerment, social safety nets, access to WASH (water, sanitation, hygiene), and others play a critical role in enhancing the effectiveness of nutrition-specific interventions.
Thus, viewed from a systems lens, effective engagements amongst stakeholders and actors at various nodes of the system are critical for achieving transformational nutritional outcomes. However, despite the highest political commitments, synergistic coordination across stakeholders remains a difficult proposition. The sectoral and department level of thinking and actions at various levels of governance from the federal to the grassroots keeps the desired change in nutritional outcomes at bay. At best, it ends up being incremental.
To address the existing challenges, we consider a systems approach that includes the interplay between different stakeholders, existing good practices, nutrition-sensitive interventions and specific projects to achieve the expected transformational outcomes as given in the framework below:
Role of grassroot organisations: strengthening nutrition-sensitive outcomes
Nutrition, acknowledged under the National Food Security Act (NFSA) 2013 as a right, can be effectively promoted through institution building at the community level that may have a long-term bearing on furthering the agenda of rights and entitlements. A limited engagement of the communities with the local governance institutions or Panchayati Raj Institutions, referred to as PRIs, in village level planning with most of the planning confined to construction of physical infrastructure currently points to lack of adequate sensitivity among PRIs to work with the community for efficient and effective planning and last mile delivery of public services including nutrition-sensitive actions.
There also exists potential for leveraging the social capital of women through community institutions such as Self Help Groups (SHGs) for demand generation as well as last mile delivery of service to the community. A conscious inclusion of the village-level nutrition micro plans in developing the annual plans at the panchayat level is essential and can be accomplished through demand aggregation at the Village Poverty Reduction Plan (VPRP) level through SHGs and incorporation into the Gram Panchayat Development Plan (GPDP) by PRIs.
Moreover, nutrition enhancement interventions such as community kitchens, can be ably managed by SHGs as is done by Kudumbashree in Kerala. A high rate of infant mortality and malnutrition death among tribal communities in the state triggered the need for an intervention and the programme now caters to addressing malnutrition among children, pregnant and lactating women, adolescent girls among others.
Scattered experiments in several states like Uttar Pradesh, Bihar, Madhya Pradesh and Odisha show that keeping a longer-term view of what is now being commonly called as Nutrition-Smart Village (NSV) approach can in the short term at least address the underweight problems among children, with a potential for reducing stunting (height-for-age) and wasting (weight-for-height) in the long term.
Interventions around social behaviour change communication (SBCC), encouraging farmers to cultivate nutrition rich crops, leveraging government platforms and other community institutions, including contributory role of WASH, too, have demonstrated promises for triggering and sustaining improvements in nutrition.
A case in point is the JEEViKa health and nutrition strategy in Bihar that is based upon empowering women to bring about change in health and nutrition practices at the household and community level. Their approach is aimed at building linkages with existing government nutrition and sanitation programmes, income support efforts around promotion of household kitchen gardens or Poshan Vatikas and livestock, coupled with a robust behaviour change communication strategy.
In this context, it may be pertinent to recognized relevance of participatory learning methods in improving nutritional outcomes (as in the often quoted Lancet 2013 series on nutrition). For example, Nutrition Education in Food and Nutrition Security (FaNS) project is building capacity among Anganwadi workers to facilitate nutrition education trainings with women in few districts of Madhya Pradesh. The project has not only strengthened community-based nutrition education but has also contributed to increased dietary diversity among women of reproductive age and young children.
It is also needs to be highlighted that these sessions organised by local institutions at the community level are triggering demand for services under the Integrated Child Development Services (ICDS). The governance under ICDS at all levels has to be steered to deliver other services than the distribution of supplementary nutrition. Unfortunately, in practice, the ICDS has de facto come to be viewed as a scheme essentially aimed at providing supplementary nutrition either through onsite feeding or provision of Take Home Ration (THR).
Complementary interventions for optimal nutritional outcomes
The role of social protection in addressing underlying, basic, and immediate causes of malnutrition is well-established. However, access to social protection benefits is still a challenge for some marginalised groups. The large-scale reverse migration that India witnessed in 2020 in the current pandemic points out to the implementation gaps in reaching out to a vast segment of the informal sector that is devoid of social protection.
While awareness generation has a role in sustained behaviour change, the food safety programmes have to be shock resilient. If pulses as a source of protein could be included as part of the basket of commodities under Pradhan Mantri Garib Kalyan Anna Yojana (PMGKAY) during the pandemic and distributed through the Public Distribution System (PDS), there is a strong rationale for its continuation under the PDS. There is a need to improve the availability of diverse fortified diets in the food safety net programmes like the ICDS, Mid-Day Meal (MDM) and the PDS programmes. This could be done by expanding the basket of food items available within these programs, while also including biofortified and fortified products. It could be useful to target crops and foods that resonate with local diets and are also available in surplus in a given region such as milk in Gujarat and millets in Rajasthan and Karnataka. It is advisable to keep socio-cultural and religious considerations in mind while promoting diverse foods in the safety net programmes.
The effectiveness of multi-sectoral approaches is also crucially dependent on availability of supporting infrastructure such as roads, irrigation and seed supplies. In this context it may be noted that nutrition planning and execution would need participation and representation of various line departments, dealing with women & children, agriculture, public health engineering, animal husbandry, health, education and key schemes like the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS). It is all about translating these at scale.
It is worthwhile to mention the case of the convergence of women’s entrepreneurship with government programmes in Odisha. This is a unique feature where SHG groups have been tied with different departmental initiatives for provisioning of government services and procurement of goods in a structured manner. A prior institutional arrangement for SHGs to run Fair Price Shops (FPS) has helped ensure food security during the pandemic, maintain efficiency in operations and reduced leakages, and resulted in effective coverage of eligible population.
It is also an imperative to focus on making agricultural production more nutrition-sensitive. One of the key policy elements relates to the timely supply of quality seeds for nutritious crops. Given that agriculture is a state subject, state governments will have to be nudged to enhance the seed supplies for creating a more nutritionally-diversified agricultural production. For example, in Bihar, the current system of targets in terms of the number of farmers to whom the seeds of such nutritious crops like of pulses or millets are to be distributed will have to done away by creating adequate supply at the block level. Promotion of certain lead farmers in each block to grow seeds of such crops, coupled with procurement of these seeds by the state level seeds corporations would ensure a northward shift in the supply of seeds at the local level. A diversified food system is possible through institutional interventions for functioning seeds market, capacity building of farmers, and access to credit for improved irrigation facilities.
Fruits and vegetables are a source of essential micro-nutrients and all the more important for women and children at various stages of growth. The Expert Committee of the Indian Council of Medical Research (ICMR), taking into consideration the nutrient requirements, recommends that every individual should daily consume at least 300 gm of vegetables and 100 gm of fresh fruits. Pregnant women should consume 100 gm of green leafy vegetables daily to meet their requirements of iron and folic acid.
However, consumption of fruits and vegetables in rural India fall far below what is recommended by the ICMR, with consumption dropping even further in tribal pockets of Schedule V areas. In many such regions hot-cooked fresh meals served in the Anganwadi Centres are the only source of good nutritious food for pregnant and lactating women and children. In this context, efforts by the Poshan Abhiyaan could consider planting fruit trees around Anganwadi Centres and school premises. This may be achieved through convergence among departments such as agriculture and horticulture and women and child development.
Promotion of livestock, particularly goats and poultry, has major potential to increase the incomes of marginal farmers and landless households and therefore ensure an expanded diet through the income pathway. At an institutional level, improved access to quality veterinary health services, coupled with access to green fodder and livestock breeds can help an accelerated scale up. Efforts towards nutrition-sensitive policies may substantially gain from the robust social and institutional infrastructure of SHGs.
An active partnership between the State Rural Livelihood Missions (SRLMs) with the key line departments such as agriculture, animal husbandry, minor irrigation and skills development is called for providing specific technical support on ways of production diversification and necessary skills development of the women farmers. Strengthening the value chains, leveraging the women SHG platforms for farm aggregation and market will contribute to an accelerated progress of the envisaged replication and impact at scale.
A focus on improved agency for women in decision making on cultivating nutritious crops (on the farm land as well kitchen gardens) coupled with developing the crop-mix based on local tastes and climate can jointly contribute to the Sustainable Development Goals (SDG) of Zero Hunger (SDG 2), Gender Equality (SDG 5) and Clean Water & Sanitation (SDG 6) and Partnerships for the Goals (SDG 17).
And while we consider various interventions, it is equally important to embed strong governance in the framework. The Information Technology (IT) enabled Poshan Tracker app introduced by Ministry of Woman & Child Development, Government of India, has the capacity to do real time tracking and monitoring of all Anganwadi staff and beneficiaries on defined indicators. Analysis of the data gathered could provide useful insights to various stakeholders in strengthening the interventions and addressing any gaps that exist on the ground.
Harnessing the synergies of the range of stakeholders is at the core of a nutrition-sensitive approach. We need to take note of the range of public programmes with committed budgetary allocations and related objectives conforming to the desired actionables indicated in the framework earlier.
Some of these programmes are (i) PDS, (ii) POSHAN-II, (iii) National Rural Livelihoods Mission (NRLM) implemented through SRLMs, (iv) Swachh Bharat Mission (SBM), (v) Jal Jeevan Mission (JJM) to provide Functional Household Tap Connection (FHTC) to every rural household (Har GharNal Se Jal- HGNSJ) and the (vi) agriculture related schemes such as Mission for Integrated Development of Horticulture (MIDH), Pradhan Mantri Krishi Sinchayee Yojana, Pradhan Mantri FasalBima Yojana, Soil Health Card, to name a few.
Of significance here is the need to develop coordination across these programmes when being planned and delivered at the last mile. Taking the village as the unit for convergence and the household as the ‘client’ for each of these programmes would help in drawing out the annual implementation plans for a cohesive nutrition-sensitive approach and monitoring the outcomes through the same lens as well.
(Nikhil Raj is a development economist and former Director of TARINA (Tata-Cornell Institute, Cornell University) and former Deputy Head of Programmes at the UN World Food Programme. Roopashree Shanker is a development professional working at the intersection of nutrition, gender, social protection and governance.)