India slips in hunger index ranks: Nutrition not just about food but sanitation and access to health care too
The NITI Aayog's National Nutrition Strategy paper points out that a 10% increase in open defecation leads to a 0.7% increase in both stunting and severe stunting. This highlights the importance of sanitation
The fact that India has slipped three places in the 2017 Global Hunger Index (GHI-2017) is going to lead to much finger-pointing and hand-wringing. India was ranked 97 in GHI-2016 but has now slipped to 100th rank. Now, it is possible to slip in rank but improve one’s scores (because some other country could progressed faster), but, unfortunately, India has tripped up here as well. The GHI score in 2016 was 28.5 but is 31.4 in 2017 (a higher score shows poor performance). This score, GHI-2017 says, “is at the high-end of the serious category”.
Now, the GHI measures hunger not as food deprivation (or lack of access to food) but in terms of nutrition. So the index has four parameters: under-nourishment (insufficient calorie intake, which could be a function of food deprivation), child wasting, child stunting and child mortality.
The fourth National Family Health Survey (NFHS-4) shows that while there has been a decline, over NFHS-3, in the percentage of children under five who are stunted, who are underweight and who are anaemic, there has been an increase in the percentage of children who are wasted and severely wasted (wasted means below the appropriate weight for age). Even in the areas where there has been improvement, the levels are still high.
This has happened despite the public distribution system (PDS) being in place (and periodically revamped and now bolstered by the National Food Security Act) from the time of independence and a host of nutrition-related interventions and programmes having been launched over the years. Can poor implementation of all these welfare schemes alone be responsible for such pathetic indicators? No.
Tackling the problem of hunger in the broad definition of the GHI requires an acceptance that there is a problem with the design of the PDS itself.
In this paper, The Bumpy Road From Food to Nutrition Security, Prabhu Pingali, Bhaskar Mittra, Andaleeb Rahman, highlight the skew in India’s food policy towards staple food crops like rice and weight and against traditional micronutrient-rich locally sourced food crops like coarse grains and pulses.
“Where it has been successful, the PDS has helped ensure that the problem of hunger is limited, but its nutritional impacts are unclear.” They make a similar point about the flagship programmes focussed on maternal and child nutrition – the Integrated Child Development Scheme (ICDS) and the Mid-Day Meal scheme – which too, they say, are biased towards staples.
A 2013 study by Neeraj Kaushal of Columbia University on how consumer price subsidies affect nutrition also pointed to the weak link between the PDS and nutrition outcomes. The study, covering six states where the PDS functioned effectively, found that though the food subsidy put more money in people’s hands, it had no effect on nutrition measured by per capita calorie intake, per capita protein intake, and per capita fat intake. It increased the consumption of cereals and sugar but reduced the consumption of cheaper and unsubsidised coarse grains, which are also the source of other essential nutrients.
The Pingali-Mittra-Rahman paper notes that some states have started providing pulses and coarse grains through the PDS – Karnataka and Tamil Nadu provide millets while Chhattisgarh provides iodised salt, black gram and pulses. They suggest that the feasibility of doing this nation-wide needs to be explored seriously.
But providing nutrient-rich food alone is not enough. Nutrition outcomes are certainly influenced primarily by food intake, but equally by whether those nutrients are absorbed by the body. According to the World Health Organisation, 50 percent of malnutrition is the result of repeated diarrhoea or intestinal worms. This clearly has to do with problems like open defecation, lack of access to safe drinking water and sanitation. The prevalence of diarrhoea among children below the age of five increased from 9 percent to 9.2 percent between NFHS-3 and NFHS-4.
The National Nutrition Strategy paper drawn up by the NITI Aayog points out that a 10 percent increase in open defecation leads to a 0.7 percent increase in both stunting and severe stunting. This underlines the crucial need to make the Swachh Bharat Abhiyan a success. The paper also flags the lack of access to health and child care services as determining under-nutrition.
The poor show on the GHI ranking is almost certain to lead to the usual lamentations about the poor implementation of the NFSA, how the use of Aadhaar for welfare benefits is denying the poor access to subsidised food and the cutback in welfare spending by the central government (several welfare schemes have been transferred to the state governments following the implementation of the Fourteenth Finance Commission award). The solution put forth will also be the same – give more money for welfare programmes covering food and nutrition.
But, clearly the war on malnutrition and hunger has to be fought on multiple fronts – the privileging of wheat and rice in the PDS, better governance of nutrition-focussed schemes for children and mothers as well as improving access to safe drinking water and sanitation and access to health services for the poor. Will the GHI-2017 prod everyone involved in this to think on these lines?
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