Context: The National Nutrition Mission or the Poshan Abhiyaan, the world’s largest nutrition programme for children and mothers, must be stepped up to meet the targets set by the Centre to reduce stunting, wasting and anaemia by 2022, says a report by NITI Aayog.
- The review report drafted in March does not factor in worsening poverty and hunger levels over the past seven months due to COVID-19, which is expected to dent strides made since 2018 to achieve nutritional targets.
- More than a third of the children under five face stunting and wasting and 40% aged between one and four are anaemic.
- Over 50% of pregnant and other women were found to be anaemic, said the National Family Health Survey 4 released in 2016.
- The government’s policy thinks tank warns, “We need to now accelerate actions on multiple fronts. We need to quickly graduate to a POSHAN-plus strategy which apart from continued strengthening the four pillars of the Abhiyaan also requires a renewed focus on other social determinants in addition to addressing the governance challenges of NHM/ICDS delivery mechanisms,” notes the NITI Aayog’s third progress report on the Nutrition Mission.
- The report calls for a need to lay as much emphasis on complementary feeding as it does on breastfeeding, which it points out can help avert 60% of the total stunting cases in India.
- On stunting, the review says that India’s targets are conservative as compared to the global target defined by the World Health Assembly (WHA), which is a prevalence rate of 5% of stunting as opposed to India’s goal of reducing stunting levels to 13.3% by 2022.
- The target of reducing prevalence levels of anaemia among pregnant women from 50.3% in 2016 to 34.4% in 2022 and among adolescent girls from 52.9% in 2016 to 39.66%, is also considered conservative.
Child & Adolescent Health
- Two-thirds deaths in children under five years in India are still attributable to malnutrition, according to a report “Child & Adolescent Health” by the India State-Level Disease Burden Initiative and is highest in Rajasthan, Uttar Pradesh, Bihar and Assam, followed by Madhya Pradesh, Chhattisgarh, Odisha, Nagaland and Tripura.
- The report says the overall under-five death rate and the death rate due to malnutrition has decreased substantially from 1990 to 2017, but malnutrition is still the leading risk factor for death in children under five years, and is also the leading risk factor for disease burden for all ages considered together in most States.
- Low birth weight needs particular policy attention in India as it is the biggest contributor to child death among all malnutrition indications and its rate of decline is among the lowest.
- Another important revelation is that overweight among a subset of children is becoming a significant public health problem as it is increasing rapidly across all States.
- The India State-Level Disease Burden Initiative is a joint initiative of the Indian Council of Medical Research (ICMR), Public Health Foundation of India, and Institute for Health Metrics and Evaluation in collaboration with the Ministry of Health and Family Welfare along with experts and stakeholders associated with over 100 Indian institutions, involving many leading health scientists and policy makers from India.
Malnutrition (as per WHO)
- Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.
- The term malnutrition addresses 3 broad groups of conditions:
- Undernutrition, which includes wasting (low weight-for-height), stunting (low height-for-age) and underweight (low weight-for-age);
- Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess; and
- Overweight, obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes and some cancers).
What needs to be done?
- For substantial improvements across the malnutrition indicators, States will need to implement an integrated nutrition policy to effectively address the broader determinants of under-nutrition across the life cycle.
- Focus will be needed on major determinants like provision of clean drinking water, reducing rates of open defecation, improving women’s educational status, and food and nutrition security for the most vulnerable families.
National Nutrition Mission (Poshan Abhiyaan)
- Poshan Abhiyaan, the world’s largest nutrition programme, expected to benefit 10 crore people, aims at improving the nutritional status of Children from 0-6 years, Adolescent Girls, Pregnant Women and Lactating Mothers.
- It was launched on the occasion of the International Women’s Day on 8 March, 2018 from Jhunjhunu in Rajasthan.
- There are a number of schemes directly/indirectly affecting the nutritional status of children (0-6 years age) and pregnant women and lactating mothers.
- Inspite of these, level of malnutrition and related problems in the country is high.
- There is no dearth of schemes but lack of creating synergy and linking the schemes with each other to achieve common goal.
- NNM through robust convergence mechanism and other components would strive to create the synergy.
- NNM targets to reduce stunting, under-nutrition, anaemia (among young children, women and adolescent girls) and reduce low birth weight by 2%, 2%, 3% and 2% per annum respectively.
- Although the target to reduce Stunting is atleast 2% p.a., the Mission would strive to achieve reduction in Stunting from 38.4% (NFHS-4) to 25% by 2022 (Mission 25 by 2022).
- A low weight-for-height is called wasting and a low height-for-age is called stunting.
- The Mission is being implemented by the Ministry of Women and Child Development.
- NITI Aayog has been entrusted with the task of closely monitoring the POSHAN Abhiyaan and undertaking periodic evaluations.
- As a part of its mandate, NITI Aayog is required to submit implementation status reports of POSHAN Abhiyaan every six months to the PMO.
- For implementation of POSHAN Abhiyaan the four-point strategy/pillars of the mission are:
- Inter-sectoral convergence for better service delivery
- Use of technology (ICT) for real time growth monitoring and tracking of women and children
- Intensified health and nutrition services for the first 1000 days
- Jan Andolan
- provides technical support to MWCD for POSHAN Abhiyaan under Country Programme 2018-2022.
- Mapping of various Schemes contributing towards addressing malnutrition.
- Introducing a very robust convergence mechanism.
- ICT based Real Time Monitoring system.
- Incentivizing States/UTs for meeting the targets.
- Incentivizing Anganwadi Workers (AWWs) for using IT based tools.
- Eliminating registers used by AWWs.
- Introducing measurement of height of children at the Anganwadi Centres (AWCs).
- Social Audits.
- Setting-up Nutrition Resource Centres, involving masses through Jan Andolan for their participation on nutrition through various activities, among others.
- All the States and districts will be covered in a phased manner (315 districts in 2017-18, 235 districts in 2018-19 and remaining districts in 2019-20).
- This will be funded by Government Budgetary Support (50%) and 50% by IBRD or other multilateral development bank (MDB).
- A multilateral development bank (MDB) is an international financial institution chartered by two or more countries for the purpose of encouraging economic development.
- In May 2018, it received $200mn loan from the World Bank.
- Government budgetary support would be 60:40 between Centre and States/UTs, 90:10 for NER and Himalayan States and 100% for UTs without legislature.
‘DHATRI’ – Dedicated Health Activist to Replenish the Innutrition
- Recently, a Memorandum of Understanding has been signed between the Ministry of AYUSH and Ministry of Women and Child Development for controlling Malnutrition as a part of POSHAN Abhiyaan.
- The Anganwadi worker who is providing the Ayurveda nutrition message to the community at ground level may be designated as ‘DHATRI’ – Dedicated Health Activist to Replenish the Innutrition.
Rashtriya Poshan Maah
- To give momentum to POSHAN Abhiyan (organised by Ministry of Women and Child Development), ‘National Council on India’s Nutrition Challenges’ decided to celebrate the month of September as Rashtriya Poshan Maah.
- During this month activities related to nutrition awareness will be carried out by all the states/UTs up to the grass root level.
National Nutrition Council on India’s Nutrition Challenges
- As per the mandate of Government of India, Ministry of Women and Child Development (MoWCD) has constituted the National Council on India’s Nutritional Challenges (established under POSHAN Abhiyaan) under the Chairmanship of Vice-Chairman of NITI Aayog with the following objectives:
- To provide policy directions to address India’s Nutrition Challenges through coordinated inter-sectoral action
- To coordinate and review convergence among Ministries
- To review programmes for nutrition on a quarterly basis
- Food Fortification of staple food
National Nutrition Strategy
- NITI Aayog has worked on a National Nutrition Strategy (NNS), isolated the 100 most backward districts for stunting and prioritised those for interventions.
- Vision 2022: “Kuposhan Mukt Bharat”
Objectives and targets:
- 3 point percentage/year reduction in underweight prevalence in children (0-3 years) by 2022 from NFHS-4 levels;
- 1/3rd reduction in anaemia in children, adolescent & Women of Reproductive Age (WRA)
- National Health Mission
- National Nutrition Mission
- Integrated Child Development Scheme
- Swachh Bharat Mission
- Increased provision of 25% flexi funds for States in Centrally sponsored schemes
Government of India is implementing various schemes and programmes to prevent malnutrition.
MoHFW under the umbrella of National Health Mission (NHM) has implemented following schemes and programmes which address the issue of malnutrition:
- Promotion of appropriate Infant and Young Child Feeding (IYCF) practices that include early initiation of breastfeeding and exclusive breastfeeding till 6 months of age through ASHA worker and health care provider at health facilities.
- In order to promote and support breastfeeding, Government has implemented “MAA- Mothers’ Absolute Affection” programme to improve breastfeeding coverage and appropriate breastfeeding practices in the country.
- Vitamin A supplementation (VAS) for children till the age of 5 years.
- ‘National Iron Plus Initiative’ has been launched as an effective strategy for supplementation and treatment of anaemia in children, adolescents, pregnant and lactating women, in programme mode through life cycle approach.
- National Deworming Day is a fixed day strategy to administer Albendazole tablets to all the children in the age group of 1-19 years through the platform of AWCs and Schools.
- In order to increase awareness about the use of ORS and Zinc in diarrhoea, an Intensified Diarrhoea Control Fortnight (IDCF) is being observed during July-August, with the ultimate aim of ‘zero child deaths due to childhood diarrhoea’.
- Incentives are provided to ASHA for tracking of Low birth weight babies.
- Promotion for intake of iodised salt and monitoring salt quality through testing under National Iodine Deficiency Disorders Control Programme.
- Rashtriya Bal Swasthya Karyakram (RBSK), is aimed at early identification and early intervention for children from birth to 18 years to cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays including disability.
- The 0-6 years age group will be specifically managed at District Early Intervention Centre level while for 6-18 years age group, management of conditions will be done through existing public health facilities.
- Mission Indradhanush: The objective is to ensure high coverage of children with all vaccines in identified districts with the goal of reaching the unreached to achieve 90% full immunization coverage in India.
- Village Health and Nutrition Days and Mother and Child Protection Card are the joint initiative of the Ministry of Health & Family welfare and the Ministry of Woman and Child Development for addressing the nutrition concerns in children, pregnant women and lactating mothers.
- Village Health and Nutrition Days (VHNDs) are monthly days held at village level in Anganwadi centre to increase the awareness and bring about desired changes in the dietary practices including the promotion of breastfeeding.
MWCD has implemented the following schemes to address malnutrition:
- Under Umbrella ICDS scheme of MWCD Supplementary Nutrition Programme is being implemented through platform of Anganwadi Centres (AWCs) for addressing under-nutrition in pregnant and lactating women, under-6 children and out-of-school adolescent girls.
- Recently National Nutrition Mission has been approved under MWCD for addressing malnutrition status of the country in a comprehensive manner.
- Micro-nutrient deficiencies are also known as “hidden hunger.”
Global Burden of Disease Study 1990-2017
- India is unlikely to meet targets set under the ambitious Poshan Abhiyaan or National Nutrition Mission (NNM) for reduction in prevalence of stunting, underweight, low birth weight and anaemia in women and children by 2022 if there is no progress achieved in improving the rate of decline observed between 1990 and 2017, according to the Global Burden of Disease Study 1990-2017.
- The report is a joint initiative of Indian Council of Medical Research, Public Health Foundation of India (PHFI) and the Ministry of Health and Family Welfare.
- A new study has also found that though the Government of India’s new initiative National Nutrition Mission (NNM) has led to a progressive decline in child malnutrition, the decline has been slow and the improvements have not been equally distributed across the population.
- The five important malnutrition indicators are: stunting, underweight, wasting, low birth weight, and anaemia.
Understanding Malnutrition among the Children in India
- Deaths due to severe acute malnutrition (SAM) in India could be at least a tenth of what was earlier believed, which implies that instead of taking emergency measures such as providing Ready To Use Therapeutic Food (RUTF), there needs to be a focus on non-food interventions such as sanitation, health, clean drinking water along with an emphasis on nutrition, suggests a new study.
- There are multiple attempts to show that Severe Acute Malnutrition is an acute emergency situation and that afflicted children will either die or never “recover” unless “magical therapeutic food” (RUTF) is provided. The study has busted this myth.
- Mortality in SAM is very low over six months to one-year period and spontaneous recovery occurs in a substantial proportion.
- Preventive measures, apt nutrition counselling, and care for illnesses are vital aspects of SAM management.
- The study also explains that the most vulnerable children probably died before reaching six months, which is before a child begins complementary feeding along and treatment with RUTF becomes relevant.
- These deaths are due to pre-mature birth or low birth weight — factors that account for 46.1% of all deaths of children under five years in 2017.
Ready to Use Therapeutic Food (RUTF)
- According to WHO, RUTF is a high-energy, micronutrient enhanced paste, a thick paste of peanuts, vegetable oil, sugar and milk powder and a complex of vitamins and minerals, used to treat children under age 5 who are affected by severe acute malnutrition.
- As its name implies, RUTF does not need to be cooked or prepared before consumption. This makes it a practical solution where cooking facilities and fuel are limited.
- RUTF has a long shelf life and is safe for use even in the absence of clean drinking water.
Severe Acute Malnutrition
- Severe acute malnutrition is the most extreme and visible form of undernutrition.
- Its face is a child – frail and skeletal – who requires urgent treatment to survive.
- Children with severe acute malnutrition have very low weight for their height and severe muscle wasting.
- They may also have nutritional oedema – characterized by swollen feet, face and limbs.
- About two-thirds of these children live in Asia and almost one third live in Africa.
- Severe acute malnutrition is a major cause of death in children under 5.