The Poshan Abhiyaan was launched on 8 March 2018 by Prime Minister Narendra Modi to affirm the government’s commitment towards eradicating all forms of malnutrition. This ambitious program, architected by Niti Aayog, was woven together using 7 key components: convergence; technology; grievance redressal; training and capacity building; behavioural change and communication (BCC); innovations; incentives.
Last year, the National Nutrition Week (1-7 September) was extended to cover the entire month of September being dedicated to celebrating the Rashtriya Poshan Maah (RPM) or National Nutrition Month by the Ministry of Women and Child Development. This year again the Poshan Maah tries to refresh the focus on nutrition with the tagline of ‘har ghar, poshan tyohar’. The initiative is about spreading BCC messages related to maternal, infant and young childcare and feeding practices along with other related interventions such as growth monitoring, anaemia management, hygiene and sanitation etc.
The past decade has been phenomenal in terms of the attention given to public nutrition, both globally and nationally. However, the impact has been less than optimal. This is disappointing, especially when the public nutrition burden in our country is huge. Even after 70 years of independence, we have around 46.6 million stunted and around 25.5 million wasted children in our country. Childhood obesity is rapidly escalating in India bringing insulin resistance, blood pressure etc. along with it from much earlier ages than in other countries. Additionally, multiple micronutrient deficiencies are widely prevalent across all sections of society. Studies show that poor maternal nutrition, especially during the first 1000 days (conception to a child’s second birthday), predisposes the offspring to earlier onset of many non-communicable diseases.
All these gaps in our public nutrition scenario get exacerbated by lack of a consolidated response to attack malnutrition in all its forms. Problems are plenty, but this piece is focused on what can be done especially at the highest level of leadership. Three main areas have been identified and some examples as pointers for action are provided below.
A. Policy strengthening
a) Adopting and adapting evidence-based success stories in regions that need more support: The government must provide opportunities for innovation where more action is needed. For example, home-based newborn care program; ideas to promote exclusive breastfeeding for 6 months; maximize deworming and immunization; reduce consumption of unhealthy ultra-processed foods high in fats, sugars and salt.
b) Use financial levers for maximum impact: Enable access to healthy and sustainably-produced foods to all sections of society through the alignment of subsidies, taxes and incentives. And reviewing policies targeting food environments, food procurement, public distribution schemes and related infrastructure. For example, Mexico’s increased taxation on sugar-sweetened beverages led to 5.5% drop in consumption in the first year, followed by a 9.7% decline in the second year, averaging 7.6% over the two years. These reductions in consumption are bound to have positive impacts on health outcomes (especially obesity and type 2 diabetes) and reductions in healthcare expenses in Mexico.
c) Restrict advertising and marketing of unhealthy and unsustainable foods targeted towards children, youth and other vulnerable groups: The World Health Organization has advised governments to protect children from targeted junk food advertisements in apps, social media and video blogs. The Global Nutrition Report 2018 reported that globally a third (30%) of school-aged children do not eat any fruit daily, yet, 44% consume soft drinks every day. This effect is increasingly being reported in India too.
d) Applying effective and efficient food labelling laws and regulations: People usually do not have time and specific capacity to process all the confusing information provided on labels. A simplified labelling mechanism must be implemented. Researchers recently analyzed over 23,000 packaged food products and found that about 70% were of relatively poor nutrient quality. Packaged food in India has been ranked lowest in terms of its healthiness in a major global survey of packaged foods and drinks. India’s packaged foods and drinks were found to be the most energy-dense (kilojoule content 1515 kJ/100 g) and number two in added sugar content (7.3 grams per 100 g).
e) Push for agricultural policies emphasizing quality nutritious foods and sustainable food production practices rather than concentrating only on producing greater quantities of food: Lack of dietary diversity, scarce consumption of locally-produced nutritious foods are increasingly seen as risk factors for rising malnutrition and can also be detrimental to the planet. A majority of the tribal populations have switched to wheat and rice that is available via the public distribution system (PDS) and consequently, the rate of non-communicable diseases (like diabetes, hypertension, heart problems) have also gone up in these populations.
f) Urgently invest in public policies and innovations that will reduce food loss and food waste: Food production is responsible for up to 30% of global greenhouse gas emissions and 70% of freshwater use. Land conversion for food production is the single most important driver of biodiversity loss. Reputable international conventions and organizations such as the Convention on Biological Diversity (CBD), the Ramsar Convention on Wetlands and the World Health Organization (WHO) have all endorsed that policy agenda of health promotion, climate change adaptation and biodiversity conservation need to be aligned for effective action.
g) Demonstrate leadership and commitment to ensure coherent food system actions: Engage with multiple stakeholders for policy action – devise accountability mechanisms were absent and strengthen where present. Empower local committees and stakeholders for better action and enable cross-departmental collaboration. All these can come handy in moving ahead against the malnutrition battle.
B. Address logistic challenges
a) Convergence and coordination remain a huge challenge: For Poshan Maah, almost 18 Union Ministries and departments have been listed as participants in the initiative spearheaded by the Ministry of Women and Child Development. However, the role and action plans of the other ministries need to be better articulated.
b) Vacancies and manpower: India’s vast immunization programme, Mission Indradhanush, reaches around 26 million children countrywide with vaccines covering 12 diseases. It is aimed to rapidly increase India’s full immunization coverage to 90% by 2020, targeting the most vulnerable and underserved communities. However, problems in vaccine supplies, cold chain maintenance, manpower, reaching migrant workers, etc. are often reported. Malnourished children may benefit hugely from vaccination and thus efforts to strengthen the immunization drive will also reduce malnutrition.
c) Fund utilization: The irony of the situation is that while many states report under-utilization of funds under designated nutrition activities, there has been a shortage of supplies, poor quality of testing kits etc. reported from others. Better fund management and reviewing periodic progress rather than once in a year may be helpful.
d) Planning better and maximal use of data being collected under national programs and schemes: Proper standard operating procedures on what is being collected, what further needs to be added and why, how will all these data be used, how will it feed into policy-shaping is critical to think through before rolling out ambitious plans using advanced technology etc.
e) Improved monitoring and surveillance with the use of technology must be effectively implemented.
C. Improve education, research and their dissemination
a) Encourage research on the determinants and actions to create an evidence base of systemic drivers and actions, including indigenous and traditional approaches to health and wellbeing.
b) Youth ambassadors and messengers can be India’s strong and influential advocates across the country and globally too.
c) Champion advocacy and education efforts by embedding healthy and sustainable food education into national school curricula.
d) Ensure capacity building mechanisms. All certified nutrition and health professionals working in the field must have a demonstrable level of competence in public nutrition.
e) Harmonize silos of thinking and action to create platforms to work collaboratively on all forms of malnutrition. This can be promoted by multi-disciplinary teams working on common nutrition problems like anaemia, poor breastfeeding rates, sub-optimal infant and young child feeding (IYCF) practices etc.
Let the four Cs that form the bedrock of the massive flagship venture of Poshan Abhiyaan – convergence, collaboration, competition and community involvement – not get marred by the two Cs – conflict of interest and corruption. RPM should help remind all stakeholders to sincerely try their best in a coordinated manner to contribute to the vision of malnutrition free India. A strong similar message should resound through all levels and regions which focuses on these 5 threads – the importance of first thousand days; anaemia prevention; improving personal hygiene and access to safe water; zero diarrheal deaths; enhance diet diversity and mass awareness of nutritious and healthy foods. Social media and high-level forums like ‘chai pe charcha’, ‘mann ki baat’ etc. must be used to bring nutrition centre-stage in all our discussions. Deliberations and focused action not only during this RPM but through the year will ensure we move closer to meeting our nutrition goals.