What Can We Infer from Maharashtra's Nutrition Data?

In last few years, malnutrition has begun to receive relatively more policy attention as several states have taken large scale initiatives to address it. The central government’s decision to launch a National Nutrition Mission reflects the government’s acceptance that malnutrition in India is beyond acceptable and therefore should be prioritised. Maharashtra is often cited as a success story for creating a State Nutrition Mission and managing to reduce stunting by 15 percentage points during 2006-12 (Haddad et al 2014). 

While Maharashtra’s achievement in lowering child stunting has attracted much attention (Nisbett and Barnett 2017, Haddad et al 2014),  less inquired upon is the question of sustainability: will this decline in stunting, brought about in a short period of six years, be maintained? This question is even more pertinent when seen in context of the rise in incidences of wasting—seen as a short term measure of malnutrition which reflects interruptions in access to food and increased risk of death. Wasting and severe wasting in Maharashtra have increased from 16.5% and 5.2% in 2005-06 to 25.6% and 9.4% in 2015-16 respectively (Table 1).

Table 1:  Decline in malnutrition among children below five years of age in Maharashtra (between 2005-06 and 2015-16)

                      Source: Third and fourth rounds of National Family Health Survey

Why Is There a Divergence in the Data?

This contradictory behaviour of various indicators of malnutrition in Maharashtra underscores the rigidity of structural barriers that have been bypassed by ongoing nutrition intervention in the state. My interactions with various officials and staff in the district planning board appear to establish the underlying role of systemic constraints and institutional factors—technical capacity and expertise are often found lacking. Maharashtra has made aggressive interventions to address child malnutrition but the approach is somewhat oriented towards a quick fix and overlooks the need for sustainability. Workers with the non-government organisation (NGO) Apnalaya, which operates in the Mumbai slum areas, have questioned the credibility of data that records 40% decline in child stunting whereas other indicators either remain stagnant or have declined.  According to one of its representatives,

“Stunting as per latest data has declined by 40%. I believe that we might have reached a plateau where any more decrease is strictly dependent on the overall infrastructure development. I do believe that creation of Maharashtra Nutrition Mission might create a difference if it encompasses existing ICDS [Integrated Child Development Services]  and increase in infrastructure and not just on nutrition of children and women”.

The significant reduction of child stunting by around 15 percentage points during 2006-2012 (Haddad et al 2014) has resulted from state interventions that are focused but also highly target oriented: the focus is on meeting numbers rather than improving infrastructure. As a result, the development of nutrition infrastructure has been sidelined, structural requirements have been overlooked and local government institutions have not been involved in the process.  The problem with short-term solutions that achieve measurable results is the sidelining of issues that are deeply embedded and require long-term structural change (Fukuda-Parr and Orr 2014). That is why not all indicators of malnutrition show similar deceleration. This scenario on nutrition intervention in Maharashtra reflects what Nelson (2015) discusses in context of health intervention in Africa: targeting reductions in maternal mortality rates accelerates the trend towards narrow, vertical interventions calculated to move the Millennial Development Goals (MDG) targets without providing sufficient attention to effective systems which could provide healthcare critical for maternal health.

Maharashtra’s nutrition interventions neglect both urban and equity dimensions in incidences of hunger and malnutrition, where equity in urban areas is a greater concern due to a substantial population difference. Evidence from across the globe (IFPRI 2017, FAO 2012, Crush and Frayne 2011, Haddad et al 1999) and from India as well highlights that  malnutrition in urban areas, though still higher than rural counterparts, has been showing greater downward rigidity than the latter (Figure 1). This should be cause for concern for Maharashtra, one of the country’s more urbanised states.

Figure 1: Decline in Child Stunting in Rural and Urban Areas of Selected States of India Between 1998-99 and 2015-16

Source: Based on National Family Health Surveys, 1998-99 and 2015-16

Does Identity Affect Access to Nutrition?

Mumbai has recurrently caught attention due to chronic malnutrition and starvation in its slums (Yadavar 2017, Barnagarwala 2016, Bhavsar et al 2012).  Amidst the prosperity of urban Mumbai, informal settlements along the city’s periphery suffer from rampant malnutrition. These settlements face institutional alienation wherein the local food and nutritional institutions and the municipality are reluctant to claim responsibility over them (Choudhary 2015, 2017). This exclusion is not exogenous, instead it is a product of local sentiments and biases that work against certain communities. For example, a settlement in Govandi is inhabited by allegedly illegal migrants from Bangladesh, and another in Bhandup is inhabited by migrants from Uttar Pradesh and Bihar. Identity mediates the way institutional structures function and contribute to nutrition outcomes. Numerous informal influences based on biases of implementing actors can be observed towards particular groups, which result in an absence of access to various entitlements. These influences have been bypassed by formal institutional design, leading to programme failures vis-à-vis certain groups (Choudhary 2015, 2017). Ostensibly, these settlements represent groups whose boundaries are created or accentuated by others in order to justify discrimination and enrich and empower those who do the classification (Stewart 2004). After reported hunger deaths in last few years, Integrated Child Development Services (ICDS) centres have been created in the vicinity of these groups, but the quality of nutrition remains an issue.

Table 2: Incidence of Stunting in Mumbai and Its Slums

Source: DHS 2005-06 and 2015-16, Apnalaya (2008-09, 2018)

Observations made by a SNEHA (Society for Nutrition, Education and Health Action) representative critique the current state of affairs of Maharashtra’s Nutrition Mission, particularly with respect to the vulnerability of informal settlements and migrants in Mumbai.

‘The nutrition mission set up in Maharashtra has not been much active and its focus is limited to rural areas. Though ICDS centres have been mostly extended to informal settlements also, quality remains a big concern. Also in urban areas, these centers do not measure height of children, as a part of growth monitoring. Thus tracking of child malnutrition, which is an important job of ICDS centers, remains partial’. 

Further, field interactions also reveal that local institutions remain alienated from programme design and other government actions.  It is high time that the states—including Maharashtra—begin to involve local governments in nutrition planning and intervention. While Maharashtra’s nutrition interventions are appreciable, this spirit has not been internalised by ground-level institutions. In the absence of this, the issue of equity, which functions at grass roots level, continues to elude certain groups even though the action plan^[1] of its State Nutrition Mission does recognise these challenges. These are clearly structural issues which have been systematically bypassed under Maharashtra’s nutrition intervention while the creation of the nutrition mission has been followed by much hype.

In Conclusion

The National Nutrition Mission may fall short of meeting its mandate unless structural issues are accommodated in its functioning. Unfortunately, from its inception the government of India’s  intention is to work with a top-down approach. One hundred and fifteen (most backward) aspirational districts have been selected by the government for development in which nutrition is an important component (NITI Aayog 2018). As a part of my ongoing research in Sitamarhi—one of Bihar’s aspirational districts—it came out that the district administration is responsible for meeting nutrition targets while the local government can claim no ownership. Further, since the administration is technically weak, it depends too much upon donor agencies like World Bank and Care India in a way that the state–civil society boundary seems to have been blurred. The question, therefore, is this: can the National Nutrition Mission, with the aforementioned challenges, invoke transformative change and improve India’s nutrition scenario?