Finally, the Government of India has bitten the bullet – by setting a goal of Malnutrition free India by 2022. The Prime Minister himself launched the National Nutrition Mission at Zunzunu on 8th March. He interacted with District Magistrates of the aspirational districts. Earlier, in a National Consultation organized in Vigyan Bhavan on 19th September 2017 to deliberate on the problem of child malnutrition, District Magistrates from over 100 High Burden Districts were invited to deliberate on the issue. Was this focus on districts a consequence of the NFHS – 4 fact sheet and data on child malnutrition available at district level for the first time? One does not know. But there is a clear shift of emphasis from the State level to the District level for planning, coordination monitoring and convergent action.
The sudden emphasis on the importance of the District Administration is unmistakable. It reminds me of the faith displayed by Shashi Kapoor in the film Deewar, when he defiantly tells Amitabh Bachchan “Mere paas maa hai.” The new strategy to tackle child malnutrition makes a similar claim “Mere paas DM hai”!
Am I opposed to the proposition that district is where the action lies? Not at all. In fact, I consider this to be the right approach long overdue. In my own struggle against the issue of child malnutrition, I had placed considerable trust on district administration – and it did bear fruit. It is a different matter that these efforts could not get institutionalized.
But we must ask ourselves if the District Magistrates have a magic wand that will help them win this battle against malnutrition? Obviously not. They need to be provided with wherewithal to wage and win this war. Is it just man management? Better monitoring? Better coordination? What about the more technical nuances of the problem? What would the priorities of the District be? Does one size fit all in taking on this multi-sectoral and multi-factorial problem? It does not, since the pattern of malnutrition as well as the extent of underlying factors differ from state to state, region to region and within a region from a district to district. Even a district may have considerable variation within its blocks. We therefore need a cook-book that can be tailored for tackling the problem in a given district.
Here is an approach which can help a district to ‘customize the algorithm’ – to quote a term used by one of my students, an engineering graduate attending the course on Food and Nutrition, just out of curiosity! “All this algorithm is fine Sir”, he asked, but how do I customize it for, say, Dhule district? “Customizing the algorithm” is not a term a nutritionist would use but software engineers routinely do. This set me thinking and over the course of a year, we did some tentative customization. It followed the known principles, and the comprehensive information provided in the reputed journal Lancet through its 2008 and 2013 series. What we need is customize it based on the context of the district.
The customization proposed can be summed up in four Sutras;
1. Lagaan – the approach
2. Kamjor Kadi Kaun – the analysis
3. Antyodaya – the priority
4. Ernakulum – the Dream
Lagaan the approach: We have dealt with this in some detail earlier. Briefly put, the Lagaan approach emphasizes on the team game, where each player has to play his part. There is a need for convergent action across different department – a task the institution of the District Magistrate is ideally suited for. We also need to focus on prevention rather than cure. Identification of mothers at risk, weight gain during pregnancy, higher birth weight babies, exclusive breastfeeding, full immunization and clean environment and regular deworming go a long way compared to the supplementary nutrition provided under ICDS. But the Lagaan approach by itself is not enough it needs to be supplemented with the following steps.
Kamjor Kadi Kaun – the analysis: Firstly, there is need to find week links in the chain, for, a chain snaps there and not at the strongest links. So, the district must first find out where it stands in terms of the nutritional status of its children and the status of different factors that contribute to it. Fortunately, with the NFHS – 4 data available at the district level we have a good base line for doing this.
So, the first task is to ascertain the nutritional status of children in the 0-3 year age group. In most cases it is adequate to have good weight for age data, for, underweight as an indicator is, in most cases, a good surrogate for stunting and wasting as well. It is useful to have data of all children at least once a year across the district and map it to identify pockets of high and low malnutrition.
Equally important is to know where does the district stand in terms of various factors that affect the nutritional status of children. These factors could be nutrition centric e.g., weight gain during pregnancy, exclusive breast-feeding, immunization, supplementary feeding and the like. These could also be nutrition sensitive e.g., how the PDS works, whether the panchayat is OD free, is there dietary diversity in the food, are the mothers literate and so on.
Having identified the deficient areas, the district must then categorize the interventions in terms of low medium and high impact categories, and the short, medium and long term categories. Quite naturally, the short term and high impact combination must be fast tracked while various other combinations could be moved in parallel.
Convergence provides is one such short term and high impact option, particularly the convergence between ODF, high levels of full immunization and six monthly de-worming. Similarly, identification of households with malnourished children and ensuring that they get full entitlement under MGNREGA is another convergent action. This list can be enlarged but it would depend on the background in the district.
Antyodaya the priority: Incidence of malnutrition is also a mirror to the patterns of disadvantage in a given society. These disadvantages operate across different fault lines. It could be location i.e. urban versus rural. It could be gender. It could be age; children in the 7 to 24 months age being particularly vulnerable. It could be ethnicity; the SC and the tribal children being the worse off. It could be income levels; the lowest two quintiles being worse off. These disadvantages do not just add, they multiply. Chances therefore are, that the rural, tribal girl in the 7-24 months age group from the lowest two income quintiles is likely to be at the bottom of the heap. But this is precisely the reason why we must give priority to the most disadvantaged in each category and improve their lot to an acceptable level.
Ernakulum – the dream: Just as we focus on high burden districts we need to focus on “nearest to the goal post” districts where the number of malnourished children is low. These can be targeted for creating malnutrition free districts; free at least from moderate and severe malnutrition. If these districts also have good track record in terms of the factors that have a bearing on the nutritional status of children, the task of bringing moderate and severe malnutrition to zero will be highly achievable here. The latest strategy of the NITI Aayog does recognize this aspect and talks of incentivizing such “role model” Panchayats, blocks, urban bodies and districts. Readers will recall the electrifying effect Ernakulum district had on the Total Literacy Campaign in the 80s when it became 100% literate district. It fired the imagination of every other district. It is time we once again ignite the fire among all the districts by having at least one district in each state free from malnutrition. The time to do this is NOW!
Satish B Agnihotri
Emeritus Fellow CTARA and PI CoE
IIT Bombay, Powai, Mumbai 400076