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Flaws in Child Nutrition and Health Governance

Decades of misguided policies and untrained or weak leadership have left the children of India defenceless, threatening the future of the country. What are the solutions?

COMMENTARY

Flaws in Child Nutrition and Health Governance

Arun Gupta, Navdeep Singh Khaira

has a number of causes. Many experts and scientists have given their views on what should be done and how [Bhutta et al 2008]. We, however wish to highlight some fundamental flaws in the governance of child health and nutrition after briefly describing the need to

Decades of misguided policies and untrained or weak leadership have left the children of India defenceless, threatening the future of the country. What are the solutions?

Arun Gupta (arun@ibfanasia.org) is a paediatrician working with the Breastfeeding Promotion Network of India and the regional coordinator for International Baby Food Action Network, Asia. Navdeep Singh Khaira (nskhaira@yahoo.com) is a nephrologist working in the department of nephrology Dayanand Medical College, Ludhiana, Punjab.

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april 26, 2008

I
ndia is said to be standing on the threshold of an economic resurgence. We expect to achieve a growth rate better than that of many economic super powers. The huge reservoir of a relatively younger population is thought to be a major contributor to this success story. It is obvious that the relatively poorer population will form a bulk of this workforce. Today’s children are tomorrow’s contri butors to this success. Therefore, one must pause and ponder what efforts successive gov ernments have made to improve the health of children and strengthen this reservoir of the proposed economic miracle.

About 40 million children under three years of age are undernourished. It is all the more unfortunate that these figures have barely changed in the last two to three decades. India has the dubious distinction of having the highest rates for infant and under-five deaths and undernourished children. This shameful indictment of our national programmes dealing with child health and nutrition focus our attention on the first 24 months of life. We also seek to offer some solutions to these flaws because they are in direct conflict with the interests of children of India, and threaten the country’s vision of becoming a super economy and power. We believe that without having solved fundamental problems it would be futile to expect any dramatic change.

Importance of Inputs

Recently, based on solid scientific evidence the Lancet has shown us what works to improve malnutrition in young children. The comment [Horton 2008] by the editor on its five article series says,

…As this series shows so clearly, there are proven effective interventions to reduce stunting and micronutrient deficiencies. According to strict criteria around admissible evidence, breastfeeding counselling, vitamin A supplementation, and zinc fortification have the greatest benefits...

Poor nutrition inputs during early infancy, like suboptimal breastfeeding during zero to six months and inadequate

17

COMMENTARY

complementary feeding after six months, remain the major reason for childhood malnutrition. One of the main conclusions of the Lancet is to focus on the window of opportunity – from conception to the first 24 months of life. This issue has been raised at national and international levels by a number of experts who have offered solutions for India [Working Group for Children under Six 2007; Nair 2007; Ghosh 2004]. It is agreed that early infancy should be the main focus of attention of any programme aimed at improving the nutritional status of children and hence, the young adults of India. This is not just a health issue but an economic one also. As already alluded to, today’s children are the workforce of tomorrow. Therefore, improving the nutritional status and health and decreasing mortality of today’s infants is the key to India’s emergence as an economic power.

Why is it that we have failed to recognise the importance of child health in nation building? Many a time the issue is not of lack of evidence but of poor understanding and implementation.

Take the example of suboptimal breastfeeding; issues around it are not yet fully understood by our planners and policymakers. Twenty million out of about 26 million babies born in India do not get optimal nutrition – exclusive breastfeeding – by the time they are six months old. This speaks loud enough but is not given the kind of importance needed because most of those entrusted with implementing nutrition programmes are under the impression that India is a “breastfeeding nation”. This continues despite the fact the prime minister of India gave a call on August 15 from the Red Fort to eliminate child malnutrition in India. He pelt out three additional needs apart from the ongoing Integrated Child Development Scheme (ICDS) and mid-day meals. These were: safe water, breastfeeding of infants and good healthcare support. While the other two are anyway required for the general health of any country and require lot of infrastructure and inputs, breastfeeding is something that can be promoted by merely increasing awareness and providing support to women and mothers. Moreover, the expense involved is much less than what the government already proposes to spend on other programmes. What we need is a more intense focus on this very important area. How do we do that?

For example, allocation of a separate budget to promote breastfeeding and initiate a national programme is one method by which we can pay more attention to breastfeeding. After all, it is well known that only that work gets going, which has a budget attached.

Why is it that those who matter do not understand basics of undernutrition? It is their capacity, both operational and strategic as well as a lack of adequate and appropriate technical knowledge, which is to blame? The National Rural Health Mission (NRHM), a flagship programme of the ministry of health and family welfare (MoHFW), and the ICDS of ministry of women and child development (MWCD) are the two key programmes of the government of India that deal with undernutrition. These have to respond to the prime minister’s call if we wish to make any dent into the problem of undernutrition. Unfortunately, they seem to be themselves stricken by some serious disorder of malnutrition!

It is not without reason that the media have raised serious concerns about the NRHM and ICDS. Media reports speak for themselves: “Unhealthy India”; “public healthcare in India is in a shambles”; “an abysmal state of public health in India”; “all that is wrong is with its management”; “the National Rural Health Mission’s report is a damning indictment of the rural healthcare system”, another news report says it all about MWCD, “nothing wrong with that except that the women and child development ministry seems to be batting for the industry to take over supply of food under the scheme”. It is obvious that both ICDS and NRHM, if they are serious about eliminating undernutrition in children, will need to do something different. It is this management arena that we enter in next section.

Flaws in Governance

There are some fundamental flaws in the governance of child health and nutrition in India. Joseph Stiglitz (2007), the Nobel laureate economist defines governance as “how decisions are made in whose interest”. The health and nutrition of India’s

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children would thus, largely depend upon the governance of both these programmes. Of the many flaws in management, four fundamental flaws need urgent attention.

Convergence

Convergence, or rather, the lack of it is a fundamental problem with these two key ministries. It is listed as a major issue in almost every national, regional or local debate or forum where problems of child health and nutrition are taken up. The government of India’s Eleventh Plan document mentions in no uncertain terms how to deal with convergence [Government of India 2007]. Our experience of more than 30 years of working in the health sector has shown how the two programmes continue to struggle to make convergence a possibility. Most agencies working in this area have faced problems because of lack of convergence. Whenever faced with a problem, both the ministries are smart enough in passing the buck to each other. A state secretary of the MWCD was once heard saying to a journalist in Bhopal (she had published a story on high infant mortality in Madhya Pradesh) “How come you people write like that? This is not our job, we are responsible after the baby is six months old… this is the job of ministry of health”.

It is quite common for the MOHFw to put the ball in the MWCD’s court while dealing with nutrition and vice versa. A Ramadoss, minister of health and family welfare answered a question in the Lok Sabha on December 7, 2007, listing an eightpoint intervention being implemented by the MOHFW.1 However, when one Subrata Dutta asked the MoHPW through the right to information (RTI), the details of activities and specifics, referring to above response given in the Parliament, the answer was, “... I am directed to refer to your application dated January 2, 2008 on the above subject and to say that the subject matter of IYCF national guidelines have been issued by the ministry of women and child development, you are requested to kindly approach and seek nece ssary and relevant information from them please.…” This RTI answer exposes the system and shows how responsible the caretakers of child health and nutrition are.

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The issue of convergence also came up for discussion on February 7, 2008 during a panel discussion on child malnutrition in the public forum on the Lok Sabha television channel. The former head of the Food and Nutrition Board (FNB) of the MWCD said, “FNB is a small entity, and being downsized”. And who listens. MoHFW is a “big brother”. Most experts were of the opinion that convergence at all levels was essential for any meaningful outcome of the various child health and nutrition projects. Therefore, if “convergence” continues to remain an issue, it would be rather difficult, if not impossible, to see any change in the undernutrition situation. We need to spend sufficient time and energy in making convergence a reality and make this issue history. Even though coordination would still be required with several other sectors, MWCD and MoHFW, both of which deal with child health and nutrition, just have to stay together and work synergistically, rather than in the current fashion where they either pass the buck or blame each other. One solution may be bringing both ministries under the prime minister’s direct care or a merger of child health and nutrition. This will not only make the programme more effective but also reflect the degree and sincerity of our concern. Making a “single window” would mean ending the fundamental flaw of convergence. It is heartening to know that some states have already made progress in this direction or are considering doing so. Many countries deal these under one window.

Untrained Leadership

The next fundamental flaw is weak or untrained nutrition leadership. In a study of 20 countries with the highest levels of undernutrition, only few had adequate strategic capacity and only one had the capacity to oversee nutrition [Bryce et al 2008]. In the same study, operational capacities to design, implement and manage nutrition programmes were weaker than the strategic capacities. The weakest was the capacity for training. Let us have a look at these capacities in India. We have a very weak or may we call it “malnourished leadership” in both the ministries. There is no nutrition-related post in the child health section of MoHFW. There is, however, a post of “adviser nutrition” under the director general of health services, MoHFW. Currently, the person who holds this job is not a nutritionist. Being in solely an advisory capacity, he is unable to exercise any decision-making power nor he has any power in the ladder to reach the decision-makers whose number is at least six times. In the organogram of the ministry, it is hard to locate him.

Given the inextricable link between illhealth and malnutrition, the lack of a department of public nutrition in the MOHFW is itself inexplicable. When one realises that over 50 per cent of infant and young child mortality is linked directly to malnutrition, the lack of child nutrition expertise and leadership in the child health division of the MOHFW exposes the system as all rhetoric with no actual commitment to the lives of India’s future and ensuring their full and optimal growth and development. Rather, the child health and nutrition wings in MOHFW do not even seem to work in synergy. Sometimes they are found to be competing towards the same ends. The same is true about nutrition leadership in the MWCD. Anything related to child nutrition is passed on to the FNB, which does not have the capacity or capability to deal with infant and young child nutrition. Nor does it have the potential to deal with nutrition, as the recruitment rules for technical officers do not have nutrition literacy as a prerequisite. There is no other nutrition leadership in MWCD. Thus, its role and effectiveness to tackle child malnutrition or undernutrition is severely undermined. The FNB was originally a subsidiary of the ministry of agriculture and was shifted en block to the MWCD many years ago but the government of India has failed to build its strategic capacity to deal with nutrition and operational capacity to manage nutrition programmes. Even the former chief of the FNB was of the opinion that the involvement of the board was no more than a token gesture. How can we expect them to deliver? Why are we happy with ad hoc responses to the problems of undernutrition?

The weakness of lack of nutritional expertise and leadership exposes the two ministries to the influence of lobbying, which is becoming the way to have any

COMMENTARY

impact on the programmes. We need peo and by the time they learn and reach a governments recommended the adoption
ple qualified for the job at key positions in level of understanding (which cannot be of these new WHO child growth standards
departments dealing with nutrition and said to be satisfactory) they get trans as a policy for the country in February
we need to give them the authority ferred. The understanding and commit 2007. Even though the government of
required to implement the programmes. ment to a policy gets diluted much more India called the meeting, the recommen-
Even the current creation of leadership in than one expects. Technical officers or dations have not been implemented so far.
child health, which is closely related, is advisers are empowered to only brief the The fate of recommendations brought out
flawed. There are currently two posts of officers. If the decisions are to be made by by consensus on the government of India’s
assistant commissioners in child health “poorly knowledgeable” and “weakly own initiative is sufficient proof, if one
and one of deputy commissioner of child informed” officers, it would be foolish to was required, of the failure of governance.
health. They are doing a reasonably good expect good nutrition and health out- It is common knowledge that the
job but they have limitations because they comes for India’s children. Here is one administrative officers only have the time
are not child health specialists. Is it the glaring example of the poor understanding for the inaugural or closing ceremonies at
recruitment rules that leads to this situation or of scientific evidence and failure to the technical consultation meetings held
are good pediatricians not available? implement the same for the good of our for the implementation of such pro-
Weak capacity was also highlighted in children: the World Health Organisation grammes. It is not surprising that one sec
one study of the reproductive and child (WHO) has recently provided well retary of science and biotechnology said
health (RCH) programme, where the authors researched new child growth standards, in a conference of state secretaries, “You
concluded, “The pace of annual progress which clearly prove that the growth of should devote time and sit in the technical
after 1998 in many RCH indicators is slower children was remar kably similar for all meetings”. This is the kind of ad hoc mech
than before and a few indicators (e g, child ethnic groups across the world if they anism or “temporary advice” on which the
immunisation) have worsened, despite the were give the basic environment of “opti entire programme of child nutrition and
expenditure on the programme being mal breastfeeding” and “no smoking”. The health rests. Why can’t we remove this
doubled. Decentralisation and integration WHO standards set aside the theory that fundamental flaw? Do we lack the exper
of basic healthcare services may not be ethnicity is responsible for poor growth.2 A tise or are we resistant to change? The
effec tive unless monitored centrally and national consultation of experts and state usual argument against putting qualified
backed by full-time health (medical/
paramedical) professionals at the delivery
level” [Srinivasan et al 2007]. Experts
have called for strengthening inter
national and national nutrition leadership
[Morris et al 2008]. AD – 11.5 x 2
New child health resource networks
and centres are being set up, there are the
national nutrition institutes but how do
we remove fundamental flaws in nutri
tion management? Strategic capacity,
which is urgently needed, should include
knowledge, skills, leadership, and human
resources for envisioning, shaping and
guiding the national and state agendas.
Having said that, even if we had all that is
being dreamt of here, not much will be
achieved unless the nutrition leadership is
vested with the power to make decisions.
Making Poor Decisions
This brings us to the next “fundamental”
flaw, which is how decisions are made, and
in whose interest. Currently, the power to
make decisions is with administrative
officers who are not expected to provide
more than what we have cited as “weak
leadership” in the earlier section. The fault
is not with the officers but with the system.
The officers come for a variable tenure

april 26, 2008

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COMMENTARY

professionals in key positions and empowering them with decision-making of programmes is that they do not know much about management. However, the same would apply to the administrative officers who have no training in child health, public health and application of malnutrition alleviation programmes.

Conflicting Interests

The next “fundamental” flaw relates to conflict of interest. It seems that the government of India does not have a clear policy on conflict of interest while implementing child health and nutrition programmes. There are, of course, several interested parties, which include business and trade interests as well international organisations who come in with their own agendas. A national debate on whether children should be offered ready to eat foods under ICDS or hot cooked ones is going on. A lot was heard about biscuits versus hot cooked foods for mid-day meals and seems to have been settled for the moment. Who should decide or who should influence the decision-making? As we mentioned earlier, lobbying for one’s interests has become the order of the day. There are many organisations that are pushing for micronutrients (which are of course necessary) without even ensuring basic nutrition for babies. Some people talk about fortified foods, other talk of supplements. There are a few parallel bodies or task forces floated by people to make their impact on childrens’ nutrition, which even call for corporate sector involvement. There is no mention anywhere of “conflict of interests”. Why can we not have an Indian policy guidance, which can be used for applying these standards considering our people and their needs? Needless to say that conflict of interests have to be completely avoided if we follow Stiglitz’s definition of governance. This issue has been amply highlighted by Muhammad Yunus (2007), the winner of the 2006 Nobel Peace prize, on how international agencies even bribe the government officials to win over the projects they want to implement.

Conclusions

In conclusion, the problem of malnutrition among children is not merely a health issue but a question of India’s economic

Economic & Political Weekly

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april 26, 2008

resurgence. We have to accept that more energy and resources need to be spent on the window of opportunity of the first 24 months of life. Promotion of good breastfeeding practices requires more attention because investment in this area has long lasting health benefits. Ensuring that adequate and appropriate complementary feeding is given to children after six months of age requires both supplementation of food as well as measures that will ensure that each family has the ability to access enough of the right foods to ensure proper development and growth. However, mere acceptance of reality and starting special programmes towards this end will remain an exercise in futility unless we remove the fundamental flaws in running these programmes. There is an urgent need to have an honest debate on this issue and we would like scientists, planners, politicians, industrialists, and educationists to boldly come forward with suggestions.

The prime minister of India needs to take serious steps to remove the fundamental flaws so that convergence becomes history. Setting up a public nutrition department and the concept of “single window” can go a long way in solving some of the problems. We understand that MWCD is planning something in this direction. Expanding the FNB a little would not help. We strongly feel that the leadership for any such endeavour should rest with the technical experts with required skill sets. For example, the director or chief executive officer of the nutrition department should report directly to the minister and should also be held accountable for inaction. Defining the roles of administrative officers is required. As a second option, if we cannot merge child nutrition with health, then an “authority” having a technical oversight arm could govern both of these. The government of India should also define the role of national and international organisations working on nutrition to make nutrition advice consistent with national needs. A policy of application of conflict of interest in child health programmes consistent with the World Health Assembly resolutions should be framed.

India needs to act fast. The prime minister, having given the call to wipe out child malnutrition, has an obligation to initiate the change. We call upon him to make eradication of child malnutrition as important a priority as climate change, and create that kind of interest required to deal with it. Otherwise, what Irwin Corey said, “If we don’t change the direction soon, we’ll end up where we’re going”, will be the unfortunate future for India.

Notes

1 http://164.100.47.4/rsquestion/ShowQn.aspx? qno=132026. 2 http://www.who.int/childgrowth/en/accessed February 16, 2007.

References

Bhutta, Zulfiqar A et al (2008): ‘What Works? Interventions for Maternal Child Undernutrition and Survival’, Lancet’s Series, Maternal and Child Undernutrition, available at http:// www. thelancet. com/ journals/lancet/ article/ PIIS 0140673 607616936/fulltext.

Bryce, J, D Coitinho, I Darnton-Hill, D Pelletier, P Pinstrup-Andersen (2008): ‘Maternal and Child Undernutrition Study Group* Maternal and Child Undernutrition Effective Action at National Level’, Lancet’s, Maternal and Child Undernutrition 4.

Ghosh, Shanti (2004): ‘Child Malnutrition’, Economic & Political Weekly, Vol 39, No 40, pp 4412-13.

Government of India Planning Commission (2007-12): Eleventh Five-Year Plan, Draft, 54th NDC Meeting, New Delhi.

Horton, R (2008): ‘Comment’, Lancet’s Series, Maternal and Child Undernutrition, available at http://www. thelancet.com/online/focus/undernutrition.

Joseph, E Stiglitz (2007): Making Globalisation Work, W W Nortan and Company Inc, New York.

Morris, Saul S, Bruce Cogill and Ricardo Uauy (2008): ‘Effective International Action against Undernutrition: Why Has It Proven So Difficult and What Can Be Done to Accelerate Progress’? Lancet’s Series, Maternal and Child Undernutrition, available http://www. thelancet.com/journals/ lancet /article /PIIS014067360761695X/fulltext

Nair, K R G (2007): ‘Malnourishment among Children in India: A Regional Analysis’, Economic & Political Weekly, September 15, pp 3797-3803.

Srinivasan K, C Shekhar, P Arokiasamy (2007): ‘Reviewing Reproductive and Child Health Programmes in India’, Economic & Political Weekly, July 14, Vol 42, No 27, pp 2931-39.

Working Group for Children under Six (2007): ‘Strategies for Children under Six’, Economic & Political Weekly, Vol 42, No 52, pp 87-101.

Yunus, Muhammad and Alan Jolis (eds) (2007):

Banker to the Poor, The Story of Grameen Bank,

Penguin Books India.

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