NUTRITIONAL STATUS
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- Title
- NUTRITIONAL STATUS
- extracted text
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RF_NUT_14_SUDHA
Nutritional Status and Gender Differeces in the Children of less
than 5 Years of age Attending ICDS Anganwadis in Vadodara
City
Author(s): KD Bhalani, PV Kotecha
Vol. 27, No. 3 (2002-07 - 2002-09)
Deptt. of P.S.M., Government Medical College, Vadodara, Gujarat
Abstract:
Research questions: 1. What is the prevalence of malnutrition in the children of ICDS
anganwadies of Vadodara city? 2. In there a gender difference in malnutrition prevalence
among the children attending anganwadis? 3. What is the impact of ICDS programme on the
nutritional status of children of anganwadis?
Objectives: 1. To measure the prevalence of malnutrition with the gender difference and age
trend in the children of less than 5 years of age. 2. To compare the level of malnutrition in the
children in the years of 1996 to 1998. 3. To study the pattern of change in the nutritional
status of the children from the year 1996 to 1998.
Study design: Cross-sectional study with a cohort data analysis.
Settings: 30 randomly selected anganwadis of Vadodara city.
Participants: 3157 children aged less than 5 years attending ICDS anganwadis of Vadodara
city.
Statistical analysis: Simple proportions, Chi square test.
Results: From the total 3157 children 62.9% were found malnourished. The prevalence of
moderate to severe malnutrition among girls was 28.4% as against 16.9% in boys (p<0.0001).
Nutritional status of the children started worsening in the 2nd year of their life. More than
60% of infants were fond normal as against 37.6% of children of age group of 1 to 2 years,
29.3% of children of 2 to 3 years and 23.5% of children of 3 years and above (pO.OOOl).
From the children who were normal in 1996, only 44.4% remained normal after attending
ICDS anganwadis for two years, while from the children who were malnourished in 1996,
17.8% children deteriorated further, 58.0% remained as malnourished as they were and only
24.2% of them improved.
Conclusion: ICDS programme failed to bring the expected results in the slum children of
Vadodara city.
Keywords: Pre-school children, Nutritional status, Gender differences, ICDS
Introduction:
Nutrition is the cornerstone of socio-economic development. The nutritional problems are
multifactorial with roots in the sectors of education, demography, agriculture and
development. During 1995, more than 28% of the world's children under the age of 5 years
were underweight for their age ranging from 2.9% in the developed countries to 31% in
developing countries1. Because of the size of the population, almost half of the world's
malnourished children are to be found in just 3 countries - India, Pakistan and Bangladesh2.
Integrated Child Development Services (ICDS) scheme is running for the last 25 years all
over India with the main objective of improving the nutritional status of the children under 5
years of age. The network of ICDS consists of 3,907 projects and reaches out to 17.8 million
children of disadvantaged group3
However, there are studies, which have shown the decline in 'severe' and 'moderate'
malnutrition in the pre-school children, the present study measured the prevalence of
malnutrition and also the impact of ICDS on the nutritional status of children with special
reference to gender among urban anganwadis.
Vadodara is a city with total population of 1.03 million according to 1991 census4. There are
336 slum areas scattered in the 10 different administrative wards of Vadodara Municipal
Corporation, in these slums 160 anganwadis (AWs) function, 120 of which are managed by
the Vadodara Municipal Corporation, while remaining 40 are managed by Kashiba Children's
Hospital.
Material and Methods:
This is a cross-sectional study that was carried out between July 1, 1998 and August 31, 1998.
Initially, a complete list of AWs of urban slums of Vadodara city was obtained from the ICDS
office of the Vadodara Municipal Corporation. The permissions of the Chief Medical Officer,
Municipal Corporation, Vadodara and ICDS officer, Kashiba Children's Hospital, Vadodara
were obtained to conduct a study and field survey.
The schedule was prepared in the computer package Epi-info 6.04b and was pre-tested by
visiting one of the selected AW and modified accordingly.
The sample for the study was selected by systematic random sampling method. Out of 160
AWs 30 were selected.
All the selected AWs were visited and list of the children of less than 5 years of age with their
age (in months) and sex records were obtained from the register maintained by the anganwadi
workers (AWWs). Weight records (in Kgms.) of the children for the months of June 98, June
97 and June 96 were also obtained from the AWs. For classification of malnutrition, Indian
Academy of Paediatrics (IAP) classification was used.
Results and Discussion:
From the total of 3157 children studied in 30 AWs, 705(22.4%) were moderate to severely
malnourished according to IAP classification (in grade II and III) and 1280(40.5%) were
mildly malnourished (in grade I), while only 1172(37.1%) children were not malnourished.
There was no child in grade IV in the study population.
Table I: Sex-wise prevalence of malnutrition in the children of less than 5 years of age in 1998.
Malnutrition
Total (n=3157)
Female (n=1498)
Male (n=1659)
IAP grades
95% CI No. (%) 95% CI No. (%) 95% CI
696 (42.0) 39.6-44.4 476 (31.8) 29.4-34.2 1172 (37.1) 35.4-38.8
No. (%)
0
II
683 (41.2) 38.8-43.6 597 (39.8) 37.4-42.4 1280 (40.5) 38.8-42.3
264 (15-9) 14.2-17.8 370 (24.7) 22.5-27.0 634 (20.1) 18.7-21.5
IV
16
I
55
0.6-1.6
(1-0)
(3.7)
71
2.8-4.8
(2.3)
1.8-2.8
x2 = 78.2;p<0.0001.
More girls (68.2%) were malnourished than boys (58%) and the difference was statistically
significant. Even in severity of malnutrition this difference persisted (Tablel).
There are number of possible explanations for the gender difference like, negligence of girls,
poor nutrition, more morbidities and less health care facilities and overall lower social status
of the girl child. However, it could also be because the same yardsticks (reference curves)
were used in IAP classification for assessing nutritional status in male and female children.
Table II: Age-wise prevalence of malnutrition in the children of less than 5 years of age in 1998.
Malnutrition
No.
No.
(%)
(%)
24-35
months
(n=777)
12-23 months
(n=731)
6-11 months
(n=417)
<6 months
(n=293)
IAP
grades
No.
>35
months
(n=939)
No.
(%)
No.
(%)
228
(29.3)
221 (23.5)
344
(44.3)
441 (47.0)
(%)
0
191
(65.2)
257
(61.6)
275
I
84
(28.7)
109
(26.1)
302
((4^
17*6)
II
14
(4.8)
46
(11-0)
133
(18.2)
187
(24.1)
254 (27.1)
III
4
(1-4)
5
(1.2)
21
(2.9)
18
(2.3)
23
x2 = 318.73; pO.OOOl.
(2.4)
5.2% of the children under 6 months of age were normal. As the age advanced, the proportion
of normal children in the age group decreased. Among the children aged 3 years and above
only 23.5% were normal. The shape fall in the proportion was observed in the second year of
life. The rise in level of malnutrition continued with increasing age but the rate of rise was
much lower after second year. The prevalence of moderate to severe malnutrition were from
6.2% to 29.5% in different age groups (Table II). There was an increased level of malnutrition
with increasing age (pO.OOOl).
Breastfeeding meets all nutritional needs of the child for the first 6 months of life. Because of
the conventionally adopted good practice of breastfeeding, the level of malnutrition in this age
group is minimal and often it is similar to the children in Europe and North America as the
food the children receive is the best2.
The National Family Health Survey (NFHS) 1992-93 has also shown similar trend. The
results of the survey underline the critical period of infancy in the strategies for reducing
malnutrition rates. The pooled data from 18 states showed that the malnutrition rate increased
sharply in the end of the first year of life. There was a little change in the rates in children of
24 months and above. If fewer children were malnourished at 12 to 23 months of age, it is less
likely that the rates will increase further in older age groups5.
Around 6 months of age, all children need other foods, besides breast milk, as it alone is no
longer adequate for child's nutritional progress2. After the age of 4 to 6 months,
supplementary feeding (weaning) should be started. Late start of weaning or inadequate
supplementary food can lead a child to malnourishment. During the weaning process, children
are particularly exposed to the deleterious synergistic action of malnutrition and infection.
Once the child becomes malnourished, due to weakened immune system, child becomes prone
to infections and may fall in the vicious circle of malnutrition to illness and illness to
malnutrition.
Sudden rise of malnutrition level in second half of infancy and in the second year of life seen
in our study could be because of the poor weaning practices prevalent in the society. In India,
Bangladesh and Pakistan, the proportion of breastfed children aged six to nine months
receiving complementary foods is less than one third2.
Malnutrition in 1996,1997 and 1998:
Table III: Prevalence of malnutrition in the years of 1996,1997 and 1998.
Malnutrition
IAP grades 1996 (n=786) 1997 (n=1615) 1998 (n=3157>
no.
%
no.
%
no.
%
250 (sTsF 542 (33.6) 1172 (37.1)
0
I
343
(43.7)
706
(43.7)
1280
(40.5)
II
176
(22.4)
323
(20.0)
634
(20.1)
III
16
(|¥ 42
(Z6T
71
(237
IV
1
(0.1)
2
(0.1)
0
(0) ’
Overall there was not much change in the level of moderate to severe malnutrition in the
children from 1996 to 1998. 22.4%, 22.7% and 24.5% were the respective figures of the
prevalence of moderate to severe malnutrition in the years of 1996, 1997 and 1998. 37.1% of
the children were normal in 1998 against 33.6% and 31.8% children in the year of 1997 and
1996 respectively.
It was observed that in many slums, large number of people influxed from the other states are
living. Their children had not attended the anganwadis for the whole year, as they didn’t live
there for the whole year. In some areas because of different reasons (as shown by the people
during informal talk e.g. helper was not calling children, snack was not given etc.), some
people were not sending their children regularly to take the advantage of ICDS services. Such
reasons could neutralize the gain in reduction in level of malnutrition in the children, if any.
Child to child shift (96-98) in nutritional status:
Malnutrition status of children for 3 years was compared where data were available with
ICDS anganwadis to see their progress with age and attending anganwadis. The shift
(difference of grades) of malnutrition in children from their grades in the year 1996 to their
grades in 1998 was studied in those 786 children, whose weight records of the year of 1998
and 1996 were available.
Table IV: Child to child shift of nutritional status in the children (96 to 98).
Child to child shift of nutritional status (96-98)
Sex
3
Male (n=413)
0
■
(%) -2 (%)
-1
(%)
0
(%)
+1
(%)
+2 (%) +3 (%) +4 (%)
14 (3.4) 108 (26.1) 224 (54.2) 62
(15.0) 4
0
1
(23.0) 198 (53.1) 56
(15.0) 6
Female (n=373)
1 (0.3) 25 (6.7) 86
(1?6) 1
(0.3) 0
Female (n-37-3)
[This should
actually be
TOTALLakshmi]
1 (0.1) 39 (5-0) 194 (24.7) 422 (53.7) 118 (15.0) 10 (1.3) 1
(0.1) 1
x2 = 8.89, shift = change in the IAP grade; p=0.261.
422(53.7%) of the total 786 children remained in the same grade of malnutrition and
234(29.8%) worsened (negative shift of malnutrition), while only 130(16.5%) of them
(0-2)
(0.1)
improved from their malnutrition status of 1996. There was not much difference in the shift of
malnutrition status between male and female children (p=0.261).
But 'no shift' is making confusion here. The child who was malnourished in the year of 96 and
remains malnourished in the year of 98 and the child who was normal in the year of 96 and
remains normal in the year of 98, both represent entirely different picture of shift in
malnutrition. Because the children who are normal i.e. in grade 0 cannot improve further
according to IAP grading, which is not the case for the children who were malnourished.
So the children who were Normal (in grade 0) in the year of 96 and who were Not Normal (in
grade >0) or Undernourished in the year of 96 represent two different cohorts which should be
studied separately.
Table V: Shift of nutritional status in the ’Normal1 children.
Child to child shift of
nutritional status (96-98)
Sex
-3 (%) -2
Male (n=160) J
E
(%) J -1
(8-7) j 70
(%)
0
(43.8) 76
(35.6)| 35
(%)
(47.5)
(38.9)
Female (n=90) 1 | (1.1) 22 (24.4) ! 32
Total (n=250) 1 (0.4)' 36 (14.4) j 102 (40.8) 111 (44.4)
x2= 13.54; p=0.0036.
250(31.8%) of the total 786 children were normal in 96. Only 44.4% of them could maintain
their normal nutritional status in the year 98, while 40.8% shifted down by one grade and
14.4% shifted down by two grades of malnutrition. The removal of confounding effect of
'nutritional status of the children in 1996' brought the difference in the shift between two sex
(p=0.0036) to surface in this cohort. 47.5% of the boys remained normal, while only 38.9% of
the girls remained normal. Moreover, 24.4% of the girls shifted down by two grades of
malnutrition as against only 8.7% of boys.
Thus the large proportion of healthy children in 1996 had shifted to different levels of
malnutrition in 1998, showing the retrograde trend. It is important to note that here this shift
from healthy to malnourished status is proportionately more in girls than in boys. Possible
explanations have been discussed earlier.
Table VI: Shift of nutritional status in the ’Malnourished’ children in 1996.
Sex
Male (n=253)
Child to child shift of nutritional status (96-98)
-2 (%) -1 (%) 0 (%) +1 (%) +2 (%) +3 (%) |+4 |(%)
38 (15.0) 148 (58.5) 62 (24.5) 4 (L6)]0~[(^~[r~|(0.4)
Female (n=283) 3 (1.1) 54 (19.1) 163 (57.6) 56 (19.8) 6 (2.1) 1
Total (n=536) 3” (0.6) 92 (17.2) 311 | (58.0)118 (22.0) 10 (1.8) 1
(0.3) 0
(0)
(0-2) 1
(0-2)
As an expected cell value is less than 5, x2 is not valid.
536(68.2%) of the total children, were malnourished in 1996, only 24.2% of them showed
improvement in their nutritional status, while 75.8% of them remained either unchanged (0
shift) or shifted in higher grades of malnutrition. This means that 3/4th of the children, who
were malnourished in the year 1996, either didn't improve at all or worsened further in two
years. This is in contradiction to what ICDS anganwadis result, we would expect.
20.2% of the malnourished girls worsened further as against only 15% of the boys, while
26.5% of the boys improved from their nutritional status of 96 as against 22.2% of the girls,
showing privileged position of male gender.
Table VII: Age trend in the shift (96-98) in the children.
Sex
Child to child shift of nutritional status (96-98)
> +1
■ +3
+4
+2
0■
-3 j - x : «
Mean age (months) 29.0 32.8 [36.7 42.4 42.2 39.7 42.0 37.0
Children between the age of 2 and 3 years (as in 1998) worsened more than their elder
colleagues. This may be because these children were of around 6 months of age in 1996 and
because of the good breastfeeding practices, they were well nourished in 1996. But in 1998,
because of the poor weaning practices, they shifted to higher grades of malnutrition.
Conclusions:
From the study, it is concluded that,
1. According to IAP classification, 22.4% of the children of under 5 years of age,
registered in the anganwadis of Vadodara city were moderate to severely malnourished
(Gr II, III and IV) with a significant difference in its prevalence between male (16.9%)
and female (28.4%) children.
2. The level of moderate to severe malnutrition in the elder children was higher than that
in younger children ranging from 6.1% in the age group of under 6 months to 29.5% in
the age group of 36 to 59 months, with a steep rise in the level in the second year of
life.
3. There was almost no change in prevalence of malnutrition in the children of under 5
years, registered in the ICDS anganwadis during these two years i.e. from June, 96 to
June 98.
4. A study of child to child shift of malnutrition (according to IAP classification) by
cohort analysis from the record data in the children showed that, only 44.4% of the
children, who were Normal in the year of 1996 remained Normal, while from the
Malnourished (in 1996) children, only 24.2% improved and all others either remained
in the same grade of malnutrition or worsened further.
5. Gender-wise analysis of the shift study revealed a significant difference in the shift
between male and female children, who were Normal in 1996 favoring the male
children.
Recommendations:
ICDS has been by far the best comprehensive nutritional programme and a detailed qualitative
study is required to understand the reasons of failure of this programme to improve nutritional
status of children attending AWs.
Acknowledgements:
We heartly thank Medical Officers of Vadodara Municipal Corporation and staff members of
AWs besides little children attending AWs.
References:
1. Park K. Park's textbook of Preventive and Social medicine; M/s Banarsidas Bhanot;
1997; 344: 358-369,416-429
2. Vulimiri R et al. The Asian enigma; The progress of nations, UNICEF. 1996; 10-17.
3. Government of India (1995) Integrated child development services.
4. Government of India (1991) Census 1991, Vadodara district.
5. International Institute for Population Science (1995) National family health survey 9293, India.
2005-06 National Family Health Survey
(NFHS-3)
Adult
Nutrition
Adult Nutrition
The poor nutrition conditions of
young children in India have
received much attention recently,
but adults are also experiencing a
variety of nutritional problems that
will be examined in this
presentation.
NFHS-3, India, 2005-06
Contents
• Malnutrition
•Anaemia
• Micronutrient
intake
NFHS-3, India, 2005-06
Body Mass Index (BMI)
• The BMI is defined as weight in kilograms divided by
height in metres squared (kg/m2).
• A cut-off point of 18.5 is used to define thinness or acute
undernutrition and a BMI of 25 or above indicates
overweight or obesity. BMI Of 17.0-18.4 refers to mildly
thin and <17.0 refers to moderately/severely thin. BMI of
over 30.0 refers to obesity.
• This index excludes women who were pregnant at the
time of the survey and women who gave birth during the
two months preceding the survey.
NFHS-3, India, 2005-06
Dual Nutritional Burden
1
■.■■:
- Rwiyitj
ion
nea wno
ci ....... ;iai c
I?
Ware msAmwlv dr sevi
t...
-
'
.
- '
.-V-l y
>.
'
'
- - .
■
.‘j
LliS-Kle
... -
• The percentage of ever-married women age 15-49 who are
overweight or obese increased from 11 percent in NFHS-2 to
15 percent in NFHS-3
• This is a growing problem in India. Women suffer from a dual
burden of malnutrition with nearly half of them being either
too thin or overweight
• As undernutrition decreases, overnutrition increases by
about the same amount
NFHS-3, India, 2005-06
Prevalence of Undernutrition and
Overweight/Obesity among Adults by
Resi
Undernutrition is
41
Wo
38
more prevalent in
rural areas.
Men
36 34
25 27
24
16
13
7 6
!
Urban
J|—
i
!
Rural
Total
Undernutrition
(°/o abnormally thin)
III
Urban
Rural
Total
% Overweight/
obese
Overweight and
obesity are more
than three times
higher in urban
than rural areas.
Both
undernutrition and
overweight and
obesity are higher
among women
6
Undernutrtion and
Overweight/Obese Women by Age
Malnutrition
levels are higher
among young
girls. Almost half
of the girls in
age 15-19 are
undernourished.
38
31
26
lliilf
s»
«®ss
illli
Undemutrition
i declines and
oyernutntion *
increases with
age of women y
■ Underweight ■ Overweight/Obese
47
17
-
8
2
_~ 1
15-19
24
r
i
i
20-29
30-39
40-49
Age in years
NFHS-3, India, 2005-06
Underweight and Overweight/Obese
Women by Education
The prevalence of
under-nutrition is
nearly twice higher
among women with no
education than those
with 12 and more years
of schooling.
The prevalence of over
weight and obesity is
three times higher
among women with 12
and more years of
schooling than those
with no education.
a Underweight ■ Overweight/Obese
No education
■■■I
42
SHI 7
37
<5 years complete
11
34
5-7 years complete
14
35
8-9 years complete
14
29
10-11 years complete
12 or more years complete
18
22
24
NFHS-3, India, 2005-06
Underweight and Overweight/
Obesity among Women by Wealth
■ Underweight I Overweight/Obese
52
I
46
38
VI
■I iv
-
15
Incontntst, _
J0ii o.
31
29
-
Lowest
I i iI
4
2
Second
18
I i
Middle
Fourth
Highest
NFHS-3, India, 2005-06
State Variations in Malnutrition
The percentage of
women who are too thin
is particularly high in
Bihar (45%),
Chhattisgarh and
Jharkhand (43% each).
Malnutrition levels are
lowest in Delhi, Punjab,
and several of the small
northeastern states.
The percentage of
women who are
overweight or obese is
highest in Punjab (30%),
followed by Kerala (28%)
and Delhi (26%)
Underweight Women in India
NFHS-3, 2005-06
“--•i
r
INDIA
S00 Ijux.
+00
fix
J'' <
A;
I
Percentage
(NFHS-3, 2005-06)
□ Below 20
□ 20 to 29.99
□ 30 to 39.99
(9)
(6)
(9)
[3 40 and above (5)
st
4
«
&
'is
)6
Underweight and
Overweight/Obese Men
Similar variations are seen by state in the
percentage of men who are thin and the
percentage of men who are overweight and
obese.
The prevalence of underweight and overweight
among men shows similar variations by age,
education and wealth index.
----- -'
'
NFHS-3, India, 2005-06
Contents
• Malnutrition
•Anaemia
• Micronutrient
intake
NFHS-3, India, 2005-06
Trends in Anaemia Prevalence
among Women
56
52
The anaemia
situation has
worsened over time
Tor wome
ilOftiis®
lilil
WfSA.yy
lills
illli
16
15
Illi
'Si
Sii'i/S/
2
2
_____________________
i—
r
Mild
Moderate
Severe
10.0-10.9g/dl
7.0-9.9g/dl
<7.0g/dl
I
1—
Any anaemia
NFHS-3, India, 2005-06
Anaemia Prevalence among
Women and Men by Residence
■ Urban S Rural B Total
Women
57 56
Men
51
Up
40 39
36
Hi
■
B I
1
H <■
■
S
i
I
Mild
iiii
28 24
18
1R 16
14 16
11
11 14 13
2
M - B ■ [IB
Moderate
|
2
2
_ __
Severe
i
I
1
Any
.
I
Mi
Mild
B
12 10
«
p!
’■J
J
Moderate
■
2
1
1
/.
1
''11—
Severe
Any
The anaemia prevalence levels are more than two times higher among women than men i1
with almost half of them with mode rate, to severe anaemia. This indicates^the worse
rihaemicconditionambngVvonlen.
anaemic*condition among wromen.
The prevalence of aneaemB is marginally higher in rural than urban areas but anaemia
is a eommoh problem in bbtlf urban arid rural areas.
<
More than 50 percent of women in urban areas are anaemic with almost a thin! of them
with moderate to severe anemia.
■■ ’S'x
Nmb-3, inaia, zuuo-uo
Anaemia Prevalence among
Pregnant Women
-
The prevalence of
anaemia among
pregnant women is
higher.
59
e
The prevalence of
moderate to severe
anaemia is greater
among pregnant
^rhehJ^riieffi
Sj
R"
' R ' ^RbRbR R - PR I R
If
26
liilll
Ill p
T------------------------- 1
I
1
Mild
M
2
.
Moderate
Severe
Any anaemia
NFHS-3, 2005-06
NFHS-3, India, 2005-06
Prevalence of Anaemia among Women
in India, NFHS-3, 2005-06
Prevalence of Anaemia among Women
.
in India, NFHS-2,1998-99
INDIA
INDIA
SOO Km.
f 00
//
0
/
SOO Em.
+00
A
H
N
N
^2-
7
'bajksaiejh
J£f
4*
BAY OF BENGAL
BAY OF BENGxU
ARABIAN SLA.
Percentage
(NFHS-2,1998-99)
0
1
%
%
Percentage
(NFHS-3,2005-06)
ARABLAN SEA
[J Below 40
(3)
□ 40 to 59.99 (16)
H 60 to 75
(9)
(Note: Data not available tor Nagaland
due to non-eoHsctten of blood lamplei)
h
si
D
1
A
□ Below 40
(5)
□ 40 to 59.99 (16)
H 60 to 75
(7)
1 <":;<•' L
%
*
HiSt
\ 1
(Hots: Data not available tor Nagaland
due to non-collectlon of blood lample»)
it
•■3
* $
NFHS-3, India, 2005-06
Contents
• Malnutrition
• Anaemia
Micronutrient
intake
NFHS-3, India, 2005-06
Percentage of Household Using
Iodized Salt By Residence
Only about half of
the households in
India use cooking
salt with
adequately content
51
41
More than two
29 30 ■
24 25
thirds of uiban
households used
adequately idolized
cooking salt
T
compared to just 41r
Urban
Rural
Total
percent in rural
areas.
■ Not iodized ■ Inadequately iodized ■ Adequately iodized
I
NFHS-3, India, 2005-06
Food Consumption
• NFHS-3 asked women and men about the frequency of
consuming food from different food groups:
Milk or curd, pulses, fruits, dark green leafy
vegetables, eggs, chicken or meat and fish
• 33 percent of women and 24 percent of men are
vegetarians
• Consumption of fruits at least once a week is less
common. Sixty percent of women do not consume
fruits even once a week
• The pattern of food consumption by men is similar to
that of women, but men are more likely than women to
consume milk or curd regularly
NFHS-3, India, 2005-06
Cont
• Food consumption shows variation by residence,
education, religion and cast and the wealth index
• The frequent consumption of milk and curd is most
common in the Northern and Southern regions, as
well as in Sikkim and Gujarat
• Egg, fish and meat consumption is more common in
the south except for Karnataka, Northeastern states,
Goa, West Bengal and Jammu and Kashmir
NFHS-3, India, 2005-06
Key Findings
• Indian women suffer a very high burden of
nutritional deficiency but the prevalence of
overweight and obesity are also on the rise
• This is a dual burden of malnutrition, with
nearly half being either too thin or overweight
• The prevalence of overweight or obesity
among women is highest in Punjab followed
by Kerala and Delhi (the low fertility states)
NFHS-3, India, 2005-06
• The prevelence of overweight and obesity
are on the rise among women in urban areas,
women who are well educated, women in
households in the highest wealth quintile,
and Sikh women
• The anaemia situation has worsened over
time for women
• Anaemia increases with the number of
children ever born and decreases with
education and the household’s wealth
NFHS-3, India, 2005-06
6.2 DIETARY INTAKES AND NUTRITIONAL STATUS
NNMB surveys provide data on time trends in dietary intake (by 24 hours dietary recall)
and nutritional status of the population in eight states from 1975 to 2005. The NNMB
and INP surveys provide information on dietary intake and nutritional status of all major
states in India in mid nineties.
Time Trends in dietary intake
Data on time trends in dietary intake in rural areas (Annexure 6.2.1) and urban slums in
nine states was available from surveys conducted by the NNMB (Table 6.2.1). Data
from NNMB surveys shows that over the last three decades there has been some
decline in cereal intake both in urban and rural areas. Over this period there has been a
substantial decline in the cost of cereals and improvement in availability of and access
Table 6.2.1: Dietary Intake in Rural and Urban areas (g/intake unit /day)
_____
NNMB
_____________
Urban Slums
Rural
93-94
75-79
04-05
96-97
00-01
88-90
75-79
380
416
396
457
450
490
505
Cereals & Millets_____
75
42
116.6
85
85
92
116
Dairy products_______
27
33
28
34
29
32
34
Pulses & Legumes
Vegetables
Green leafy
Others( includes tubers)
8
54
9
49
15
47
16
109
18
57
11
40
16
47
INP (1995-96)
RDA
Rural
Urban
488
126
33
420
143
55
460
150
40
32
70
23
75
40
60
"SQ37
~26~
15
26
~24
27
25
23
13
Fruits_______________
20
21
14
17
13
14
14
12
13
14
Fats & oil____________
30
_______
20 22
22
20
14
23 _______________________________
21
29
23
Sugar & jaggery
Source: National Nutrition Monitoring Bureau (NNMB), India Nutrition profile (INP). Survey Population: Rural & urban. Sample Size:
NNMB, Rural, 33048 (1975-79), 14391 (1996-97), 30968 (2000-01),
(2000-01), 32500 (1975-80), 5447 (1993-94); INP (46457)
to cereals. The decline is therefore not due to economic constraints. Over the same
period there has been a decline in the dietary intake of pulses, which are a major source
of protein in Indian diets. This is partly attributable to the soaring cost of pulses and
inability of the poor to purchase adequate quantity inspite of higher expenditure on
pulses. In spite of massive increase in milk out put in the country, improvement in per
capita intake of milk over years has been small. Intake of vegetables and fruits also
continues to be very low. In rural areas there has not been any significant increase in
per-capita intake of fats/oils and sugar/jaggery. Data from NNMB rural surveys suggest
that dietary intake has not undergone any major shift towards increase in intake of
fat/oils, sugar and processed food in rural population. However in urban slum dwellers
there has been an increase in oil intake and some increase in sugar intake.
Intake of cereals and leafy vegetables are lower in urban areas; however intake of
pulses, milk and milk products, fruits and fat and oils are higher in urban areas (Table
6.2.1). There are no urban rural differences in sugar and other vegetable intake. Data
from NNMB and INP surveys (using 24 hour dietary recall method) show that in the mid
nineties average intake of cereals were near RDA; intake of pulses, vegetables and
fruits were low (Table 6.2.1, Annexure 6.2.1, 6.2.2, 6.2.4).
124
Interstate differences in dietary intake
NNMB
Cereals and millets formed the bulk of dietaries in all states. The intake of cereals was
adequate to meet the RDA in most of the states. Cereal intake was lowest in Kerala and
intake of cereal and millets was highest in Orissa. Cereal and millet intake was lower in
the 1996-97 surveys than that in the previous two surveys in almost all the States, with
Karnataka showing the steepest fall. Intake of pulses was less than the RDA in all
states, with intake in Kerala being less than 50% of the RDA. With the exception of
Kerala and Gujarat, in all other states the intake of pulses has gone down between
1975-79 and 1996-97. The intake of green leafy vegetables (GLV’s) is considerably
lower than the RDA in all states with the exception of Orissa. Although there was an
increase intake of GLV’s (except in the state of Maharashtra) between 1975-79 and
1996-97, the increase was marginal. Dietary intake of GLV’s is still way below the RDA
in all states except Orissa where the intake met the RDA in 1996-97. The intake of other
vegetables is below the RDA in almost all the states (except Kerala and Orissa), with
intake in Karnataka and Andhra Pradesh being less than half the RDA. In 1996-97, a
steep fall in vegetable intake was observed in Kerala and Tamil Nadu, as compared to
the intake in 1975-79. Intake of roots and tubers was lowest in Andhra. Roots and tuber
intake was highest in Kerala and Orissa. The intake of milk was less than the
recommended level of 150 ml in all states except Gujarat. Intake of milk and milk
products were highest in Gujarat and lowest in Orissa. In none of the States, the intakes
of fats and oils were adequate. A marginal increase was however observed in the intake
of fats and oils in 1996-97 as compared to 1975-79 (Annexure 6.2.1).
INP
The state wise data on average intake of foodstuff under INP survey is given in
Annexure 6.2.2. Intake of cereals and roots and tubers, which constitute the major bulk
of Indian diet, was adequate in most states and UTs. The exceptions were Chandigarh,
Delhi, Arunachal Pradesh, Meghalaya, Mizoram, Goa, Maharashtra, Daman and Diu
and Dadra and Nagar Haveli for cereals and Goa for roots and tubers. Average intake
of pulses was inadequate in most of the states except Chandigarh, Delhi, Mizoram,
Tripura, Dadra and Nagar Haveli. Average intake of green leafy vegetables was
markedly below their RDAs in most of the states except in those in hill states of
northeastern region (except Meghalaya) Himachal Pradesh, Sikkim and Daman and
Diu The intake of other vegetables was adequate in most of the states except in
Haryana Himachal Pradesh, Punjab, Rajasthan and Nagaland. Intake of milk and its
products’ and fats and oils was inadequate in almost all the districts of India excepting
those belonging to northern region, Haryana, Himachal Pradesh, Punjab, Rajasthan,
Chandigarh and Delhi. Intake of fats and oils was adequate in Mizoram and Daman and
Diu.
There were significant differences in dietary intake between NNMB states and states
covered under INP surveys (Annexure 6.2.1, 6.2.2). The dietary intake of all foodstuffs
125
is lower in all age groups NNMB states (Annexure 6.2.3) as compared to INP states
(Annexure 6.2.4); this is attributable to higher dietary intake especially cereals and
pulses in the non-NNMB states, which were covered in the INP. Dietary intake was
higher in some states with high per capita income (Punjab) but not in others
(Maharashtra) suggesting that greater per-capita income is not always associated with
higher dietary intake. Both NNMB and INP data showed that cereal intake was higher in
some of the poor states (Orissa in NNMB, Uttar Pradesh in INP survey); this is perhaps
because majority of the population are working as manual labourers and require high
cereal intake to meet their energy requirements. NNMB surveys in 2004 indicated that
as compared to 1975-80 there has been a reduction in cereal intake; pulse intake,
vegetable and fruit intake remained unchanged (Annexure 6.2.3) in all age groups.
Time trends in of nutrient intake
Table 6.2.2: Nutrient Intake in Rural and Urban (CU/day)
“
Energy (Kcal)
Protein (g)
Calcium (mg)
Iron (mg)
Vitamin A
Thiamin
Riboflavin
Niacin______
Vitamin C
1975-79
2340
62.9
590
30.2
257
1.6
0.9
15.7
37
INP (1995-96)
NNMB
Urban Slums
1993-94
1975-79
1896
2008
1988-90
2283
Rural
1996-97
2108
2000-01
2255
2004-05
61.8
53.7
58.7
49.4
53.4
556
521
523
439
492
18.96
352.5
1834
28.4
24.9
17.5@
14.8
24.9
294
300
242
257
248
1.5
1.2
1.4
1.2
1.27
0.9
0.9
0.8
0.6
0.81
15.5
12.7
17.1
14.7
14.6
37
40
51
44
40
46.75
0.79
42
Rural
Urban
2321
70
2259
70
673.4
22.3
356.0
1.9
1.0
18.8
62.4
631
23.2
355
1.9
1.0
19.7
55.2
52.3
____________________________
62
153
Folic acid
_________ ___________________________
©method
of
estimation different *data not available
Source: National Nutrition Monitoring Bureau, India Nutrition Profile
Survey Population: Rural & urban
Sampleliz^
14391 (1996-97), 30968 (2000-01), 32500 (1975-80), 5447 (1993-94), INP (46457)
Data on time trends in nutrient intake is available from surveys conducted by the NNMB
(Table 6.2.2 & Annexure 6.2.5). Data from NNMB surveys show that over the last three
decades there has been a small decline in energy intake (Figure 6.2.1). There has been
some decline in intake of most of the nutrients both in urban and rural areas over the
last three decades. Over the past three decades there have been a reduction in percent
of total energy intake from carbohydrates and some increase in percent dietary energy
from fats (Figure 6.2.2). In spite of this, the proportion of dietary energy from fat remains
lower than 15 %. However, these aggregate measures mask large disparities between
intakes of urban and rural populations, different states and different socio-economic
groups. Dietary intake of iron from Indian dietaries has always been low. The steep
decline reported in iron intake in the last two NNMB surveys can be attributed to
different estimation methods; newer methods showed that absorbable iron was only
50% of earlier values.
126
Figure 6.2.2: Nutrient intake as percent
of energy
100
10.6!
Figure 6.2.1: Time trends in energy intake
2500 -i
>, 2300
E5
5 2100 -
1900
£ 1700 1500 -
1975- 1988- 1996- 2000- 200405
01
97
90
79
Rural
1975- 199394
79
Urban slum
80 -
c
0)
60 -
8
40
(D
Q.
80.3
20 -
M
0
1979
Source: NNMB reports E Protein
Source: NNMB reports
78.6
2004
Carbohydrate BFat
Energy intake is lower in urban areas in spite of higher intake of fats and oils because of
lower cereal intake (Table 6.2.2). Data from NNMB suggests that the intake of all
nutrients is lower in urban slums as compared to rural areas.
INP survey, which covered most of the major states not covered by NNMB surveys, did
not show any significant difference in nutrient intake between urban and rural areas
(Annexure 6.2.6). Interstate differences in nutrient intake and the fact that NNMB survey
data was available only from urban slums are some of the factors that might account for
the apparent differences between NNMB and the INP survey data.
Interstate Differences in nutrient intake
NNMB
Time trends in nutrient intake in different NNMB states are given in Annexure 6.2.5. The
trends in nutrient intakes in states are similar to overall trends even though there are
substantial inter state differences. There was a reduction in energy, protein, iron and
calcium intakes, between 1975-79 and 1996-97. Although intake of vitamin A was
higher 1988-90 and 1996-97 as compared to 1975-79, but was still way below RDA.
There has been a gradual increase in the intake of riboflavin between 1975-79 and
1996-97. Thiamin intake showed a decline over the same period. Intake of protein,
energy, vitamin A and riboflavin were less than the RDA in almost all States. Calcium
intakes’were above the RDA (400 mg) in all the States except in Orissa. Iron intake (as
per the revised nutritive values for Indian foods) is low. Bioavailability of iron from Indian
diets is very low. Low dietary intake coupled with poor absorption is the major reason for
widespread prevalence of anaemia. For the first time, NNMB computed folate content
of the diets in 1997-97, the intake of which was less than RDA of 200 pg in all the
States, except Gujarat. Inspite of low nutrient intake, Kerala, has lowest prevalence of
under-nutrition and nutritional deficiency signs. This can be attributed to a relatively
more egalitarian society with equitable distribution of food based on needs and ready
access to health services; high literacy rate and consequent awareness about
importance of health, hygiene and sanitation and ability to access services may also
have played an important role. Orissa has the highest dietary intakes of nutrients but
this high intake does not lead to a better nutritional status perhaps due to inequitable
127
distribution of food within the state, districts, different income groups and within the
family. Poor access to health care might be another factor that aggravates under
nutrition.
INP
India Nutrition Profile (INP) provides data on nutrient intake in all non-NNMB states of
the country in urban and rural areas. The reported nutrient intake in most of the states is
higher in INP as compared to National Nutrition Monitoring Bureau (NNMB). At the
aggregate national level, total energy intake was less than 2,300 kcal/ cu/ day, even in
the mid-nineties (Annexure 6.2.6).
Average intake of nutrients (cu/day) for all the states covered in INP is shown in
Annexure 6.2.6. The total energy intake did not meet requirements in the states except
in Chandigarh, Bihar, Manipur and Daman and Diu. Intake of protein was marginally
higher than NNMB states in almost all INP states. Iron intake met around or more than
70% of the recommended level, though, it was inadequate in Assam, Mizoram and Goa.
However, the NIN has revised iron content of foodstuffs in the Nutritive Value of Indian;
if this correction is applied to INP states iron intake is low in all the states. The poor
dietary intake and low bioavailability of iron mostly from vegetable based diet are the
major factors responsible for high prevalence of anaemia. Average calcium, thiamin,
niacin and vitamin C intake were adequate in almost all the states surveyed; vitamin A
intake was inadequate in most of the states except Arunachal Pradesh, Mizoram and
Nagaland.
Data on energy consumption per consumption unit in different states computed from
NSSO consumer expenditure survey in 1993-94 were compared with energy intake per
consumption unit per day computed from NNMB surveyl996-97 and INP 1995-96 using
24 hour dietary recall method ( Figure 6.2.3, 6.2.4, and 6.2.5). In all the states energy
intake computed from NSSO was higher than energy intakecomputed from NNMB/INP
Figure 6.2.3: Interstate difference in Calorie intake in rural areas CU/diem
3500 -I
3000 2500 -
S 2000 1500 -
1000 500 -
mini
I
1
s
a
i
I _J
zz
I
Source: NSSO (93-94) ; INP (95-96) ; NNMB 96-97
128
■ NSSO
EJ INP
|
survey. The magnitude of difference is relatively low in Goa, Sikkim, Kerala, Andhra,
Bihar, Chandigarh, and Manipur. The difference in energy intake between NSSO urban
and INP urban survey were relatively small. The higher energy consumption in NSSO
Figure 6.2.4: Interstate differences in calorie intake in urban areas CU/diem
3500
3000 -J
2500
w
o 2000
1500
r
1000 -
500
I
co
<8
>.
E
co
£
Q.
'c
co
o
CD
1
3
cn
£
co
.S’
£
</>
co
<2
6
m NSSO
Source: NSSO (93-94) & INP (95-96)
□ INP
rural surveys might be attributable to the fact that NSSO surveys take into account the
total household expenditure on food for computing consumption; food sharing between
2800 -i
2500 2200
To
o
1900
1600
1300 -
1000
22
co
1E
£
co
E
•u
c
-C CD
-O TJ
C CO
co
x:
< (fc
£
ro
co
'S'
0
m NNMB
® NSSO I
Source: NSSO & NNMB (04-05)
family, guests or servants will therefore not be taken into account in NSSO surveys, but
will be taken into account while computing household dietary intake in NNMB/INP
surveys.
129
Source of dietary energy
Data on time trends in total energy intake, % of energy intake from fat, carbohydrate
and protein from NNMB (9 states) and data on in total energy intake, % of energy intake
from fat, carbohydrate and protein from all the major states from INP in different age
groups is given in Annexure 6.2.7. Carbohydrates remain the major source of energy in
Indian dietaries. There has been no major change in % of total energy intake from
carbohydrates and protein and some increase in % dietary energy from fats over the
past three decades at the aggregate level. Even now the proportion of dietary energy
from fat is far lower than 15% (Figure 6.2.2)
Data from diet surveys suggest that dietary intake has not under gone any major shift
towards increase in intake of fat/oils, sugar and processed food. There has not been
any increase in energy intake in any age group (Annexure 6.2.8 and 6.2.9). The
undernutrition appears to be mainly due to improved access to health care. The
reported improvement in child problem of over-nutrition in adults and health hazards
associated with it appears to be attributable mainly to reduction in physical activity.
Effect of family income on dietary and nutrient intake
Table 6.2.3:lntake of foodstuffs according to per capita monthly income (g/Cu/Day) NNMB 1996-97
Intake of foods (CU/day) based on Per Capita Monthly Income (Rs.)
__________ ________
RDA
>300
155-300
|60-150
30-60
<30
460
381
407
443
484
505
Cereals and Millets
40
39
32
33
”
36
30
Pulses and Legumes
40"“
6“
10
11
19“
13
Green leafy veg.
150
284
184
103
51”
69
Milk and milk products
Fats and oils
Sugar and Jaggery
9“
iF
18
30
14
29
12
21
20““
24
36
40““
Source: NNMB Pooled data 96-97
Data on dietary and nutrient intake from the pooled data of NNMB survey 1996-97 was
anlaysed with respect to per capita monthly income to assess the effect of income on
these parameters (Table 6.2.3 and 6.3.4). The intake of cereals and millets was highest
in the lowest socioeconomic group; however, their diet lacked diversity. With increasing
Table 6.2.4:lntake of nutrients according to per capita monthly income (g/Cu/Day) NNMB 1996-97
Intake of nutrients (CU/day) as per Per Capita Monthly Income (Rs.)
Nutrients
60-150
30-60
<30
RDA
>300
155-300
Proteins
53
54
57
59'
65
60
Energy
2134'
2145'
2210
2283'
2428
2425
Total fat
20
25
35
51'
66
“46
Iron
2^6
25?8
25?6
24?9'
252
28
Vitamin A
330
257
290
306 ‘
327
“600
Riboflavin
07
(Ts
0?8
01
VI
T4
Source: NNMB Pooled data 96-97
130
incomes, the intake of cereals decreased but dietary diversification increased
It is noteworthy that the intake of protein, energy, total fat and riboflavin increased with
increase in income but iron and vitamin A intakes remained lower than the RDA in all
income groups. It is therefore not surprising that over 85 % of Indians are anemic and
anemia remains the most common micronutrient deficiency in the country.
Dietary diversity
National Family Health Survey-2 (NFHS-2, UPS, 1998-99) collected data on frequency
of intake of various types of foods (other than cereals which are consumed everyday by
everyone) from women (daily, weekly or occasionally) to assess dietary diversity among
90,000 ever-married women in the age group 15-49 living in 26 states; however details
regarding quantity of intake were not obtained from these women. Data from the survey
are presented in Annexure 6.2.10 and 6.2.11. All adult women in India consume cereals
every day; their diets tend to be monotonous and there is very little dietary diversity.
Fruits are eaten daily by only 8 % of women and only one-third of women eat fruits at
least once a week. Almost one-third of women in India never eat chicken, meat, or fish
and very few women (only 6 %) eat chicken, meat, or fish every day. Eggs are
consumed less often than chicken, meat, or fish.
There were substantial differentials in food intake patterns by selected background
characteristics. Poverty has a strong negative effect on dietary diversity. Women in
households belonging to low socio-economic group are less likely than other women to
eat items from each type of food group listed, and their diet is particularly deficient in
fruits and milk or curd. Age does not play an important role in women’s intake patterns.
Women in urban areas are more likely than women in rural areas to include every type
of food in their diet, particularly fruits and milk or curd. Illiterate women have less varied
diets than literate women, and seldom eat fruits. There are substantial inter state
differences in intake of different types of food.
Time trends in nutritional status
Figure 6.2.6: Time trends in Mean Heights in Males and Females (Rural)
««--- «
160
... "“iX
^140
E
— 120 -
110080 60 -
o
t
oj
t
in
co
it
&
i
o
io
Age (Years)
Source: NNMB Surteyjs
—♦— Females 1975-79
MaleS 1975-79
— Females 1988-90
— Males 1988-90
CD
+
r-
XT
cn
00
XT"
-A— Females 1996-97
H— Males 1996-97
•e-
xt
xt
ub
xj-
O
O
uS
co
co
aS
xr
io
m
X
cm
CO
CD
Females 2004-05
—-— Males 2004-05
Data NNMB rural surveys on time trends in weight, mid-arm circumference and triceps
fat fold thickness in all age groups is shown in Figures 6.2.6, 6.2.7, 6.2.8 and 6.2.9
respectively. Even in rural population there is an increase of about four cms in adult
131
height; the increase in body weight over the period is greater. This is mainly due to fat
deposition as shown by progressive increase in the fat fold thickness over this period.
Figure 6.2.7: Time trends in Mean Weights in Males and Females (Rural)
65 n
55 J
U)
45 -
2 35 O)
25
15 5
o
+
co
<t
t
i A
•M-
co
r-
uS
CXJ
5
t S
LT)
in
■m-
co
o
io
m
ftA
—-— Females 2004-05
x Males 2004-05
—i— Females 1996-97
—A— Males 1996-97
—•— Females 1988-90
-b—Males 1988-90
—*— Females 1975-79
—♦—Males 1975-79
S 3
it
co
Source:NNMB surveys
Figure 6.2.8: Time trends in Arm circumferences of Males and Females (Rural)
30
8c
25
8
i §o. 20
o
15
E
<
10
o
CM
+
o
xT
O
00
CD
■M-
<?
CD
CM
00
LO
LO
m
co
Age (Years)
T"
_Females 1975-79 -®— Females 1988-90 —^—Females 1996-97
. -K— Males 1975-79
—♦— Males 1988-90
—i— Males 1996-97
Females 2004-05
Males 2004-05
Source: NNMB surveys
The increase in fat fold thickness begins in childhood and increases with age in both
males and females. The increase is more in women.
Figure 6.2.9: Time trends in Mean Fatfold thickness in males and Females (Rural)
15 -i
E
E
2 10 o
S3
iE
5
+
o
+
T-
+
CXJ
+
CO
+
XT
it
<t
—*— Females 1975-79
—*— Males 1975-79
it
4
<•
(t
o
t
CXI
co
t
V-
X—
X—
T—
Females 1988-90
Males 1988-90
it
co
+
r-
—A— Females 1996-97
—I—Males 1996-97
xT
cxj
oo
3
5
in in
cxj
co
it S_ o
7?A
in
uS
uS
■'t
m
Females 2004-05
—— Males 2004-05
J
Source: NNMB surveys
_____
Data from NNMB surveys in urban slums on time trends in weight; mid-upper arm
132
circumference and fat fold thickness at triceps are shown in Figure 6.2.10, 6.2.11, and
Figure 6.2.10: Time trends in weights of males and females (Urban)
65 n
55
oi 45
♦
£ 35 .S’
’S
5 25 J
15 5
£
CD
CM
O
A
O
co
co
ID
CM
CD
X—
O
CM___
—4—Females 1975-80
•—A—Males 1975-80
Source: NNMB reports
S
ID
ID
CO
7
n
O
o
o
ID_________
co
941
—s— Females 1993-94
Males 1993-94
I
6.2.12. Mean body weight, mid upper arm circumference and fat fold thickness at
triceps are higher in all age groups in 93 - 94. The increase in body weight is mainly due
to increase fat as shown by rising fat fold thickness. Data from NNMB reports shows
Figure 6.2.11: Time trends in Mean Height of Males and Females (Urban)
170 H
-A-
A-----&----- A-----
---- ♦---- >----
— 145
E
120
O)
s
95
70 -
45
or
txx
<bx
z
❖
&
❖
<bx
Age (years)
—b— Height Females 1993-94
Height Males 1993-94
—♦— Height Females 1975-80
—a— Height Males 1975-80
I Source: NNMB surveys
that both in men and women over years, there have been an increase in body weight
Figure 6.2.12: Time Trends in Mean Arm Circumference of Males and Females (Urban
slum)
30
o
c
a>
25 -
£ 5 ? 20 < E
3
O
15
10
o
CXI
co
4
■M’
CM
CD
Age (years)
co
ID
CM
O
CXI
—*—Females 1975-80
—A— Males 1975-80
Source NNMB surveys
133
ID
in
ID
ID
6
co
o
O
to
co
—»— Females 1993-94
Males 1993-94
o
A
J
and fat fold thickness. The increase in body weight and fat fold is greater in urban slum
dwellers.
E 18 1
E 16-
Zo 14
-I
12
I 10
V)
Q.
o
8
6
4
2
0
o
O
CM
LO
CO
A
Age (years)
Source: NNMB Reports
Figure 6.2.14: Time Trends in mean triceps skinfold thickness in Urban Females
20
T3
O
15 -
£ ~
E
M E 10
.—»—_____gj—jg.
Q- 3,
o
5
0
o
cti
co
imitooOToiisiiniincoitSnTSSS
Age (yearsf
Source: NNMB Reports
—•— NCHS
1975-80
1993-94
To sum up data from NNMB surveys indicate that during the past three decades diets
continue to be cereal based and monotonous; among poorer segments fruit, vegetable
and animal food intake continues to be low. There has been
> a progressive reduction in already low pulse intake
> small increase in fats and oil intake in urban slums
> increase in dietary diversity among rural high income group
There has been reduction in energy and protein intake except among the poor; over all
there has been a small decrease in total energy and protein intake in both urban and
rural areas.
> some increase in dietary energy derived from fat and a reciprocal reduction in %age
of dietary energy derived from carbohydrate.
134
Intakes of most micronutrients continue to be low. Iron intake is low; this coupled with
poor bio-availability of iron from Indian diets is responsible for high prevalence of
anaemia. There has been:
> small 2-4 cm increase in height over 3 decades both in urban and rural areas
> there has been a greater increase in weight, more in the urban than in rural areas
The weight gain appears to be mainly due to increase in body fat-the increase in fat fold
thickness is more in urban areas
References:
6.1.1 Department of Women and Child Development. 1995-96. Indian Nutrition Profile. Government of
India, New Delhi
6.1.2 National Family Health Survey (NFHS-2): http://www.nfhsindia.org/india2.html; last accessed on
24/09/07
6.1.3 National Family Health Survey (NFHS-3): http://mohfw.nic.in/nfhsfactsheet.htm; last accessed on
24/09/07
6.1.4 NNMB National Nutrition Monitoring Bureau. 1979-2002. NNMB Reports: National Institute Of
Nutrition, Hyderabad
6.1.5 NSSO National Sample Survey Organization. 1975-2000.;
http://mospi.nic.in/mospi nsso rept pubn.htm; last accessed on 24/09/07
135
(i) “Nutritional trend in Kancheepuram Block”, (ii) “Self reported hunger and
surveillance for measuring acute hunger through community surveys - A note on
potential use and limitations”, and (iii) “A note on indicators used by current early
warning systems for assessing acute food insecurity in India and their increasing
irrelevance” have been made available in hard copy format in the folders. However, since
these have been prepared by PhD scholars of CSMCH as part of their ongoing PhD
research, they cannot be shared more widely at this stage.
Rama Baru “Epidemics as Markers of Socio-Economic Inequalities” is awaiting author’s
approval before wider circulation.
Only hard copy available with us 1. Sheila Zurbrigg’s “The Hungry Rarely Write History, and Historians are Rarely
Hungry”
2. Lalita Chakravarty “Biological Stress and History From Below: The Millet Zone
of India 1970-92”
3. Ritu Priya “Health and Nutrition: People, Policies and Politics'
4. Ritu Priya “Preventing Chronic Hunger, Acute Malnutrition and Starvation:
Action 2010”
FACT SHEET
Percentage of children under age 3 yrs, who are wasted, stunted and under weight
Under
Report
Wasting
Stunting
NFHS-I
NA
NA
52
NFHS-II
16
19
46
38
47
46
NFHS-III
weight
State-wise Percentage of Children under age 3 years as
Undernourished on Anthropometric Indices (Stunted, Wasted or
Underweight) of Nutritional Status (as per NFHS-III) in India
(2005-2006)
Nutritional Status of children as per NFHS
III in India
Stunted (too
short for
age)
Wasted
(too thin
for
height)
Underweight
(too thin for
age)
Andhra pradesh
34
13
36.5
Arunachal Pradesh
34
17
36.9
40.4
States/UTs
Assam
35
13
Bihar
42
28
58
Chhatisgarh
45
18
52.1
33.1
Delhi
35
16
Goa
21
12
29
Gujarat
42
17
47.4
Haryana
36
17
41.9
Himachal Pradesh
27
19
36.2
Jammu & kshmir
28
15
29.4
Jharkhand
41
31
59
Karnataka
38
18
41.1
28.8
Kerala
21
16
Madhya Pradesh
40
33
60
Maharashtra
38
35
39.7
Manipur
25
8
24
Meghalaya
42
28
46.3
Mizoram
30
9
22
Nagaland
30
15
30
Orissa
38
19
44
Punjab
28
9
27
Rajasthan
34
20
44
Sikkim
29
13
23
Tamil Nadu
25
22
33
Tripura
30
20
39
Uttar Pradesh
46
14
47.3
Uttaranchal
32
16
38
West Bengal
33
19
43.5
38 |
| India
19 |
46 |
Table 12: Trends in Child Nutrition: NFHS Data
Proportion (per cent) of children under the age of three years
who are undernourished
NCHS1 Standards
New WHO Standards
1992-3
1998-9
2005-6
1998-9
2005-6
Below 2 SD
52
47.0
45.9
42.7
40.4
Below 3 SD
20
18.0
n/a
—
17.6
15.8
Below 2 SD
n/a
45.5
38.4
51.0
44.9
Below 3 SD
n/a
23.0
n/a
27.7
22.0
Below 2 SD
n/a
15.5
19.1
19.7
22.9
Below 3 SD
n/a
2.8
n/a
6.7
7.9
Weight-for-age
Height-for-age
Weight-for-height
The data for children under five in 2005-2006 is similar to the above.
per cent of under-fives suffering from: underweight, moderate & severe
43
per cent of under-fives suffering from: underweight, severe
16
per cent of under-fives suffering from: wasting, moderate & severe
20
per cent of under-fives (suffering from: stunting, moderate & severe
48
50urce: http://www.unicef.org/infobycountry/india statistics.html
Gomez Classification
Weight for age (% of NCHS Standard)
Nutritional Grade__________
>90
Normal____________________
75 - 89.9
Grade I (Mild under nutrition)
60 - 74.9
Grade II (Moderate under
nutrition)__________________
<60
Grade III (Severe under
nutrition)
1 Until 2006, the World Health Organization (WHO) recommended the US National Center for Health Statistics
(NCHS) standard, and this was used inter alia in the first and second rounds of the National Family Health
Survey. In April 2006, the WHO released new standards "based on children around the world (Brazil, Ghana,
India, Norway, Oman, and the United States) who are raised in healthy environments, whose mothers do not
smoke, and who are fed with recommended feeding practices" (International Institute for Population Sciences,
2007, p. 268). These new standards were used in the third National Family Health Survey.
NNMB 2002
45
40
35
30
25
20
O
O)
S
c
S
o
Fig.12 Distribution (%) of children (1-5 Years) according
to Gomez classification and Sex
43.3
6.4 F 6.4
8.r
Normal
c
Q
O
O
CL
41.1
<• W
15
10
5
0
0.
OS Boys
B Girls
41.51
43.4
Mild
Moderate
Severe
Fig.13 Distribution of Children (1-5 Years) according to
Gomez Classification and Age___________
50
43.4 43.4
42.5
45
1-3 Years
40.1
40
3-5 Years
■r~i
35
30
25
p-
■
20
15
10
5
0
9.9
8.0
I
Normal
I□
n'n- bi
Mild
6.6 6.1
i H H i vU
j H || W
Moderate
Gomez Grades
, th
Severe
Distribution (%) of 1-5 years Children by Nutritional Status (Weight for Age) Gomez Classification
State
Kerala
Tamilnadu
Karnataka
Andhra Pradesh
Maharashtra
Gujarat
Madhya Pradesh
Orissa
West Bengal
Sex
Sex
N
Boys
Nutrition Grades*
Normal
Mild
Moderate
Severe
191
17.3
55.0
26.2
1.6
Girls
184
24.5
45.7
27.7
2.2
Pooled
375
20.8
50.4
26.9
1.9
Boys
540
10.4
51.3
34.8
3.5
Girls
501
10.6
49.9
35.7
3.8
Pooled
1041
10.5
50.6
35.3
3.7
Boys
411
7.1
44.5
46.2
2.2
Girls
339
7.4
46.0
44.0
2.7
Pooled
750
7.2
45.2
45.2
2.4
Boys
439
11.8
49.0
36.0
3.2
Girls
398
11.1
48.2
35.7
5.0
Pooled
837
11.5
48.6
35.8
4.1
Boys
406
6.2
40.6
45.3
7.9
Girls
341
10.6
38.4
44.6
6.5
Pooled
747
8.2
39.6
45.0
7.2
Boys
390
6.7
40.8
42.6
10.0
Girls
328
8.2
47.3
36.9
7.6
Pooled
718
7.4
43.7
40.0
8.9
Boys
381
5.5
29.7
49.6
15.2
Girls
363
6.1
31.1
48.8
14.0
Pooled
744
5.8
30.4
49.2
14.7
Boys
382
9.2
39.0
44.2
7.6
Girls
392
4.3
38.8
50.0
6.9
Pooled
774
6.7
38.9
47.2
7.2
Boys
319
7.8
42.9
43.9
5.3
Girls
341
7.0
43.1
41.9
7.9
Pooled
660
7.4
43.0
42.9
6.7
n
Nutrition Grades*
Normal
Mild
Moderate
Severe
8.7
9.2
43.5
43.3
41.5
41.1
6.4
6.4
9.0
Pooled
6646
*. NCHS Standards
43.3
41.3
6.4
Boys
Girls
3459
3187
Distribution (%) of 1-5 years Children by Nutritional Status (Weight for Age) Gomez Classification according to age
State
Kerala
Tamilnadu
Karnataka
Andhra Pradesh
Maharashtra
Gujarat
Madhya Pradesh
Orissa
West Bengal
Age
(Years)
N
1-3
Nutrition Grades*
Normal
Mild
Moderate
Severe
211
24.2
46.4
27.5
1.9
3-5
164
16.5
55.5
26.2
1.8
Pooled
375
20.8
50.4
26.9
1.9
1-3
571
10.7
51.8
33.6
3.9
3-5
470
10.2
49.1
37.2
3.4
Pooled
1041
10.5
50.6
35.3
3.7
1-3
392
9.9
43.4
44.1
2.6
3-5
358
4.2
47.2
46.4
2.2
Pooled
750
7.2
45.2
45.2
2.4
1-3
441
12.2
48.8
4.5
3-5
396
10.6
48.5
34.5
37.4
Pooled
837
11.5
48.6
35.8
4.1
1-3
381
9.4
41.5
42.3
6.8
3-5
366
6.8
37.7
47.8
7.7
Pooled
747
8.2
39.6
45.0
7.2
1-3
375
7.2
42.7
39.5
10.7
3-5
343
7.6
44.9
40.5
7.0
Pooled
718
7.4
43.7
40.0
8.9
1-3
360
4.2
30.6
51.9
13.3
3-5
384
7.3
30.2
46.6
15.9
Pooled
744
5.8
30.4
49.2
14.7
1-3
367
6.8
36.2
47.7
9.3
3-5
407
6.6
41.3
46.7
5.4
Pooled
774
6.7
38.9
47.2
1-3
9.4
44.5
39.0
3-5
310
350
7.2
7.1
5.7
41.7
46.3
6.3
Pooled
660
7.4
43.0
42.9
6.7
Age (Years)
n
1-3
3408
3.5
Nutrition Grades*
Normal
Mild
Moderate
Severe
9.9
43.4
40.1
6.6
3238
8.0
6646
9.0
Pooled
*. NCHS Standards
43.4
43.4
42.5
41.3
6.1
6.4
3-5
Malnutrition Among Children Under Five Years Based on the WHO Child Growth
Standards and the NCHS/WHO International Growth Reference
Percent
M WHO Child Growth Standards
S NCHS/WHO International Growth Reference
48
48
n ■I
43
42
il-il/
»ia
S!
17
■I
ll»u.
Stunted
Wasted
11
SO
IP
II
20
I
I
... c
Underweight
Global Nutrition Scenario
Acute malnutrition - Recent and severe weight loss ;as a result of acute food shortage and/or
illness. Measured by weight for height or MUAC
Chronic malnutrition - Inadequate diet persistently, over a longer period. Child is stunted (height
for age) and/ or underweight (weight for age)
Global Acute Malnutrition (GAM): Weight for height <-2SD, or weight for height <80% or
MUAC <125mm
Severe Acute Malnutrition (SAM): Weight for height OSD, or weight for height <70%, or
MUAC <1 lOmm and/or bilateral edema
Under Nutrition among children under 5 years in selected countries
Percent underweight, based on the NCHS/WHO Growth Reference
India 2005-06
Bangladesh 2007
Nepal 2006
45
Niger 2006
44
Madagascar 2003-04
Ethiopia 2005
Cambodia 2005-06
Mali 2006
29
Nigeria 2003
26
Guinea 2005
................
Malawi 2004
22
20
Kenya 2003
■ 19
Cameroon 2004
______
Zimbabwe 2005-06
16
Swaziland 2006-07
Dominican Republic 2007
4
Analysis of the worldwide burden of acute malnutrition
Under-5
Und®r-5 population Wasting prevalence
2000 (x 1000)
(%)
Regions!
*
.
Wasting numbers
(xlOOO)
Annual mortality numbers
■
_______________
Moderate
and severe
Severe
st2Z scores
below WFH
*3 Z scores
below WFH
2-3 Z scores
below WFH*
>3Z scores
Total
“ __________________
WFHt
10639
3192
565768
Sub-Saharan Africa
106394
10
3
421767
987535
Middle East and north Africa
44 478
7
2
3114
890
168942
117547
286489
SouthAsia
166566
15
2
24985
3331
2085151
159 454
4
-
6378
1644950
484528
440201
East Asia and Pacific
Latin America and Caribbean
54 809
2
0
1096
832/3
-
CEE-CISand Baltic states
30020
4
1
1201
300
68416
39668
108084
99
10
2
49182
10 929
2905951
1444214
4350164
2
IIO46
2209
671290
291918
963209
60 228
13139
3 577 241
1736132
5 313373
Industrialised countries
50655
Developing countries
546 471
Least developedcountries
110458
Total
707 5 84
.
•
|
484 528
83273
■■
Population and prevalence ofwasting from UNICEF global database on child malnutrition 2001.* CEE-CIS-Central and Eastern Europe and Commonwealth of Independent
States. WFH=weight-for-height index. 'Moderate mortality rate=76/1000/year (average of nine studies range 30-148 for children with <80% weight for height or2 Z scores).” tSevere mortality rate=132/1000/year (average offive studies,, range 73-187 children with mid-uppei-ai m circumference <110 mm)?
Table: Worldwide burden ofacute malnutrition in children aged less than Syears
Adapted from Collins et al. Lancet 2006 (42)
From "Nutrition in India: Facts and Interpretations" Angus Deaton & Jean Dreze April 2008
Adult Weights and Heights
Table 12 presents the proportion of men and women with BMI below 18.5 (a standard cut-off
conventionally associated with “chronic energy deficiency”) in the nine NNMB states. The
proportion of individuals with low BMI, like that of underweight children, declined steadily
during the last 30 years or so. In spite of this, Indian adults today (like Indian children) have
some of the highest levels of undemutrition in the world, with 36 per cent of adult women
suffering from low BMI (rising to well over 40 per cent in several states).[fii 7 - International
Institute for Population Sciences (2007), page 304. This is consistent with the NNMB-based figures presented in
Table 12 for 9 states. The international figures are available at http:Z/www.measuredhs,com/aboutsurveys.]
Among 23 countries of sub-Saharan Africa for which comparable data are available from the
Demographic and Health Surveys, only one (Eritrea) is doing worse than India in this respect
(Table 13). In fact, the proportion of adult women with low BMI is above 20 per cent in only
four of these 23 countries (Burkina Faso, Chad, Eritrea and Ethiopia), and the populationweighed average for all these countries together is 16 per cent, much less than half of the
Indian figure.
Table 12: Nutrition Status of Indian Adults, 1975-9 to 2004-5 (Body Mass Index)
Proportion (%) of adults with Body Mass Index below 18.5
% decline
(1975-9 to
1975-79
1988-90
1996-97
2000-01
2004-05
2004-5)
Men
56
49
46
37
33
41
women
52
49
48
39
36
31
Sources'. National Nutrition Monitoring Bureau (1999, 2002, 2006). These figures apply to the nine “NNMB
states”: Andhra Pradesh, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, West
Bengal. Data for 1975-79 and 1988-90 exclude West Bengal; data for 1996-7 exclude Madhya Pradesh. See text
for further discussion.
Table 13: International BMI Data (Women Aged 15-49 Years)
Mean BMI
Proportion (%) of women
with BMI < 18.5
South Asia
India
20.5
35.6
Bangladesh
20.2
34.3
Nepal
20.6
24.4
Sub-Saharan Africa
Eritrea__________
Ethiopia_________
Burkina Faso
20.0
20.2
20.9
37.3
26.5
20.8
20.3
20.8
Chad_________________
19.2
20.8
Madagascar___________
19.2
21.4
Niger________________
18.2
22.3
Senegal______________
15.2
22.3
Nigeria_______________
15.0
21.6
Zambia_______________
13.2
22.9
Congo 2005___________
13.2
21.8
Guinea_______________
13.0
24.3
Mauritania____________
12.3
22.7
Kenya_______________
12.1
22.2
Uganda______________
10.7
22.4
Benin________________
10.4
22.3
Tanzania_____________
9.8
21.8
Rwanda______________
9.3
23.1
Ghana ______________
9.2
22.0
Malawi______________
9.2
23.1
Zimbabwe____________
8.6
22.1
Mozambique__________
6.6
23.5
Gabon___________ _
5.7
25.1
Lesotho______________
15.8
21.9
Population-weighted
average for sub-Saharan
Africa (23 countries)
____________________ __________________ _____
Source'. “Demographic and Health Surveys” (DHS) data available at www.measuredhs.com. The reference years
vary between 2000-1 and 2005-6. India’s National Family Health Surveys (NFHS) are part of the DHS series.
f
SPECIAL ARTICLE
Strategies for Children under Six
WORKING GROUP ON CHILDREN UNDER SIX
Development indices show that India neglects the early
care and development of children, especially those
under the age of six. The recently released report of the
third National Family Health Survey shows that progress
in the improvement of their condition is very slow.
These children receive very little attention in the media,
political debates or Parliament. This paper prepares
a framework for the Eleventh Plan that urges the
government to prioritise policies towards children under
tU ° age of six to protect their rights and ensure a better
1 v^ure forthem.
This paper, prepared at the request of the Planning Commission, builds
on a presentation made at the Commission on June i, 2007. An earlier
version, published as a discussion paper (Gupta et al 2007), includes
more detailed recommendations.
The Working Group on Children Under Six was constituted for writ
ing this paper, at the request of the Planning Commission. The group
consists of Arun Gupta, Biraj Patnaik, Devika Singh, Dipa Sinha,
Jean Drdze, Radha Holla, Samir Garg, T Sundararaman, Vandana Prasad
and Veena Shatrugna.
Economic & Political weekly
December 29, 2007
I I arly childhood care and development (eccd) has correctly
|^ been understood to be the critical foundation for overall
1 1 1 growth and development, not only of children but of
society on the whole. That it has been seriously neglected in India
is amply demonstrated by the poor developmental indices that
relate to the situation of children under the age of six, whether
they be infant or under-five mortality rates or the prevalence of
malnutrition. It is also a fact that most interventions in this issue
have so far changed the situation minimally and far too slowly.
The recently released results of the third (2005-06) National
Family Health Survey (nfhs-s) show not only the poor state of
children under six years of age but also that the progress is very
slow. Almost half (46 per cent) of all children under three are
underweight (an improvement of only 1 percentage point com
pared to nfhs-2 which was carried out seven years earlier) and
almost 80 per cent of children in the age group of 6-35 months
are anaemic. Only 24 per cent of babies are breastfed within one
hour of birth, and just about 46 per cent are exclusively breastfed
during the first six months. Only 44 per cent of all children in the
12-23 months age group have received all recommended vaccines
and only half the pregnant women had at least three ante-natal
check-ups. As many as 57 of every 1,000 children die before they
reach the age of one year.
On the other hand, only about 1 per cent of the total union
budget is spent on children under six years of age (hereafter
“children under six”) [haq, Centre for Child Rights 2007]? These
children also receive little attention in the newspapers, political
debates or the Parliament. For instance, according to a recent
analysis of parliamentary proceedings by haq: Centre for Child
Rights, only 3 per cent of the questions raised in Parliament dur
ing the last four years related to children. Further, among the
child-related questions, less than 5 per cent were concerned with
childcare and development in the age group of zero to six years.
There is, therefore, an urgent need to prioritise policies towards
children under six, not only to protect their rights but also to en
sure that the future generations are healthy and well.
The Supreme Court case - People’s Union of Civil Liberties
(pucl) vs Union of India and Others, Writ Petition (civil) 196 of
2001 - on schemes related to the right to food covers the
Integrated Child Development Services (icds) scheme, a
significant state intervention for children under six. An early
interim order issued by the Supreme Court in the context of this
case converts the benefits of these schemes, including the icds,
into legal entitlements. This, and subsequent interim orders, have
provided a fresh impetus to advocacy efforts on strategies to
redress the gross neglect of this issue. A group of people related
to the right to food campaign and the Peoples’ Health Movement
87
- India (Jan Swasthya Abhiyan) have been engaged with this in
various ways, whether it be through grassroots action, research
or interventions in policy. Some of these efforts are detailed in
the 'Focus on Children Under Six' (focus Report), released in
December 2006 [Citizens’ Initiative for the Rights of Children
Under Six 2006].
Simultaneously, a more positive environment has been
building up in favour of children under six amongst policymakers
who are beginning to acknowledge the problem and look for
solutions. In several states, there have been interesting initiatives
in this field (for example, related to icds) during the last few years,
and much more can be done in this direction. This is further
enhanced by the advent of complementary policy frameworks
such as the National Rural Health Mission (nrhm) and Sarva
Shiksha Abhiyan (ssa), which have the potential to provide much
support to eccd even though its primary responsibility lies with
the ministry of women and child development.
The Eleventh Plan is a critical process of policy determination
for the next phase that could put into motion fresh strategies
while positively reinforcing those that have worked before. These
could include interventions in the icds with a better focus on
nt and young child feeding (iycf) and outreach to children
under the age of three years, as well as complementing strategies
of creches and maternity entitlements to women working in the
informal sector. The Planning Commission also has the potential
to provide the convergence and oversight that is critical to seriously
addressing the intersectoral issue of malnutrition and eccd. It is
in this context that individuals associated with the campaigns re
ferred to previously initiated a process of dialogue with the Plan
ning Commission, which resulted in the preparation of this paper.2
The interventions that are being recommended can only gain
ground with continuing debate and advocacy, and it is with that in
tent that this publication is being placed in the public domain.
1 General Principles
The care of young children cannot be left to the family alone - it
is also a social responsibility. Social intervention is required, both
in the form of enabling parents to take better care of their chil
dren at home, and in the form of direct provision of health, nutri
tion, pre-school education (pse) and related services. Interven> for children under six years or eccd must broadly address
at least three dimensions: child health, child development/
education and child nutrition. These must necessarily be provided
simultaneously in the same system of care. Further, while
planning for provision of eccd, it must be kept in mind that
different age groups require different strategies. The three cru
cial age groups are generally considered to be: (1) children zero
to six months of age - the period of recommended exclusive
breastfeeding; (2) children six months to three years - until entry
into pre-school; and (3) children three years to six years - the
pre-school years, until entry into school.
This paper argues for comprehensive strategies for these
understanding that the icds was conceived as a comprehensive pro
gramme addressing all these needs of children under six.
It is well understood that the health and nutrition of a young
child is also determined by the status of the mother’s health.
A malnourished mother often gives birth to an underweight
child who in turn grows up to be a malnourished adolescent,
and in the case of girls, perpetuates the cycle of malnutrition by
giving birth to a low birth weight baby. It is also important that,
simultaneously, there are interventions to ensure nutrition of
adolescent girls and women, and for women’s access to care
during pregnancy, and this has been the rationale of the “life
cycle approach”. Therefore, the two aspects to addressing
malnutrition, i e, prevention of malnutrition and management
of malnutrition, are both linked and complementary. Care of the
malnourished child thus, also contributes to prevention through its
impact on future generations.
The poor status of women has a direct correlation with malnu
trition not only through its effect on birth weight but also on
childcare. The “care-giver” role of women is so steeped in invisi
bility, so poorly understood and so much taken for granted,
that interventions to provide support are largely missing even
as huge bodies of work now exist to show the relationships of
women’s work, time, energy and power to the health of children.
It is this factor that gives rise to the so-called “south Asian
enigma”, where populations of non-south Asian countries show a
better status of child nutrition than south Asian countries even
when the former are substantially poorer. This difference has
been attributed to relatively high levels of gender inequity in the
south Asian context [Sundararaman and Prasad 2006].
It is recognised that the overarching determinants of malnutri
tion include not only gender inequality, but also poverty. Poverty
has an impact on malnutrition in multifarious ways - by reducing
purchasing power for good quality calorie dense foods, by reduc
ing access to healthcare, by giving rise to physical environments
lacking in safe water and sanitation and by its impact on educa
tion. If this is accepted as one of the main determinants of malnu
trition, there must be strategies built in to create livelihoods, re
duce poverty and empower the poor. Conversely, no strategy for
better nutrition should have the opposite effect.
In this paper, we restrict ourselves to looking at the strategies
needed to meet the comprehensive needs of children under six,
with special emphasis on nutrition. In particular, we examine the
extent to which existing programmes such as the icds, with ex
panded coverage and quality improvements, can be utilised.
Complementary interventions such as maternity entitlements,
creches and support to iycf are also discussed.
1.1 Essential Components of Early Childhood Care
Strategies for children under six require three essential
components:
(a) A system of food entitlements, ensuring that every child re
ceives adequate food, not only in terms of quantity but also in
groups of children, with a special focus on their nutritional
terms of quality, diversity and acceptability.
needs, even though there is a close relationship between health,
growth, nutrition and development in this age group and these
dimensions need to be considered holistically. In fact, it is with this
(b) A system of childcare that supplements care by the family and
empowers women. Such care needs to be provided by informed,
interested adult carers, with appropriate infrastructure.
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(c) A system of healthcare that provides prompt locally available
care for common but life threatening illnesses. Such a system
needs to address both prevention and management of malnutri
tion and disease.
1.2 Age 0-6 Months
According to most recent guidelines (World Health Organisation
(who) - guidelines and national guidelines for iycf), breastfeed
ing must be initiated within one hour of birth and exclusive
breastfeeding should continue until six months of age. Studies
have shown that exclusive breastfeeding alone provides all the
nutritional requirements in this age group. It has also been shown
that this is the best prevention and treatment for the major killers
during the neonatal period (for example diarrhoea, pneumonia
and sepsis). Recent studies have shown that starting breastfeed
ing within one hour of birth can help reduce the risk of neonatal
mortality by almost a third. Universal coverage of exclusive
breastfeeding up to six months of age can save 13 to 15 per cent of
all under five deaths, i e, about more than 3.5 lakh children each
year for India [bpni 2006]. Continued breastfeeding for two years
of age and beyond, along with the introduction of adequate and
. opriate complementary feeding from the seventh month on
wards, can further reduce the risk of death by 6 per cent or so.
Even though breastfeeding is such a vital means of reducing
deaths of young children, and ensuring their best growth and
development, little emphasis is paid at the policy level to promot
ing and supporting mothers to breastfeed their babies adequately.
India is committed to protecting, promoting and supporting
breastfeeding through the ims act.3 However, there is no budget
head for this in the existing child health and development pro
grammes of the country.4 The National Maternity Benefit
Scheme (nmbs), which provides for a one-time payment of
Rs 500 to pregnant women below the poverty line, partially
addresses maternity entitlements and the nutritional require
ments of pregnant women and breastfeeding children. However,
this scheme is currently languishing in most of the country
[Saxena and Mander 2007]. The huge gap in maternity entitle
ments for the majority of women who work in the informal sector
needs much more public attention as an important element of
social security for the well-being of women and children, and
.ifically for the food security of very young children.
The following are some of the interventions required to ensure
exclusive breastfeeding:
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SPECIAL ARTICLE
adequately skilled and trained person at the family level, and
supported by a “specialist counsellor in iycf” at the cluster level
to help solve the difficult problems that a mother may face.
Creches: Ensuring exclusive breastfeeding requires that
mothers stay close to their infants during this period. However,
many breastfeeding women, especially poor women, often need
to work outside the home, where they cannot take their infants
with them. Creches at/near workplaces to support frequent
breastfeeding, flexible hours and breastfeeding breaks must
be provided.
Maternity Entitlements: Women must be enabled to stay home
to breastfeed the very young child and compensated for the
loss of wages. This is not a controversial concept, since it has
broadly been accepted for the “formal sector”. Many women are
extremely undernourished themselves. While they can still pro
duce adequate milk to feed their infants, exclusive breastfeeding
for such long periods can further jeopardise these mothers’
health. Women must have access to adequate nutrition and other
forms of support to enable them to exclusively breastfeed their
infants without endangering either their own health or their eco
nomic status. All these, as well as entitlements to healthcare, are
included in the term “maternity entitlements”.
Creches and maternity entitlements are not part of current
strategy at all. Provisions need to be made for this by expanding
and improving existing programmes such as the nmbs, Rajiv
Gandhi Creche Scheme and icds. In the current strategy breast
feeding counselling and support is expected to depend mostly
upon the skills, training and time of the accredited social health
activist (asha), who has many other tasks. Significantly, while
many of her other tasks are incentivised, there are no incentives
for achieving early and exclusive breastfeeding or optimal iycf
targets. It is only through adequate training and motivation of
the auxilliary nurse midwife (anm), ‘anganwadi’ worker and
asha together that effective breastfeeding counselling and
support can be provided.
Children in this age group also require growth monitoring, im
munisation, newborn care and referral services to the health sys
tem. Details of what needs to be done, including employing a sec
ond worker at the anganwadi to work specifically on children
under three years of age, are presented in the Section 2.
1.3 Age 6 Months to 3 Years
Breastfeeding Counselling and Support: Initiating breastfeed
ing within the first hour and ensuring colostrum feeding requires
that the mother be provided support and counselling for this
immediately after the delivery. Many myths that exist, especially
regarding colostrum feeding, must be countered through coun
selling women and their families. Awareness campaigns must be
directed towards increasing society’s support to mothers for
exclusive breastfeeding for six months. Mothers need to be given
constant support to continue breastfeeding. There should be a
support system that allows a home visit twice a week during
the first two weeks and once a week later, after birth, to assist
and maintain exclusive breastfeeding. It should be done by an
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December 29, 2007
From six months onwards, complementary foods are to be intro
duced to children along with continued breastfeeding for two
years or beyond. Children can eat “normal home food” (in
mashed or semi-solid form), however children at this age can eat
only small quantities at a time and therefore, need to be fed many
(about five) times a day and need to be given food that has ade
quate calories, proteins and micronutrients.
Some of the interventions required for this age group are, first,
ensuring that frequent meals in adequate quantity are given to
the children. This food has to have adequate nutrients in the form
of animal proteins (milk, eggs, meat, fish), adequate in fats, fruit
and vegetables. Nutrition counselling and nutrition and health
89
education sessions for mothers and family members are also
required. Second, nutritious and carefully designed take-home
rations (thr) based on locally procured food should be provided
as “supplementary nutrition” for children in this age group.
Currently thrs are in the form of just grain - this is inadequate.
Also, thrs must be combined with nutrition counselling to
ensure that they are used for the child rather than distributed
amongst the family.
Third, creches must be provided, with trained workers, to
ensure that these children are provided with adequate care
and development opportunities, especially if there are no adult
carers at home. Finally, further services children in this age group
require include regular immunisation and growth monitoring,
treatment for anaemia and worms, prompt care for fever,
diarrhoea, coughs and colds and referral services for the sick
and severely malnourished child.
Most of the above can be provided by the asha and the anganwadi worker, provided that a second anganwadi worker is avail
able (the need for a second anganwadi worker is discussed in
more detail below). However, current strategy provides neither
for a second anganwadi worker nor for day care/creches. This is
i spite of the widely accepted case for increased focus on chil
dren under three for prevention and management of malnutri
tion. Thus, the currently-proposed new strategies for desired
focus on nutrition of under threes are limited to nutrition coun
selling and healthcare by asha, that too not incentivised.
to this activity while a second anganwadi worker looks after chil
dren under three in the community, as well as for anganwadi
cum creche as and where required. Many children in the three to
six age group will also continue to need day care services.
From the above discussion it is clear that different strategies
are required for addressing the health, nutrition, care and devel
opment needs of children under six, depending on their age. The
components of the services required by the three age groups
Table 1: Essential Components of Early Childhood Care
Food
Childcare and
development
Healthcare
Zero to Six Months
Six Months to Three Years
(until joining pre-school)
Three Years to Six Years
(until joining school)
Counselling and support
for exclusive breastfeeding;
supplementary nutrition
and maternity entitlements
for lactating mother.
Creches at worksites and
maternity entitlements to
ensure proximity of mother
and child.
Supplementary
nutrition in the form of
nutritiousTHRs, nutrition
counselling, nutrition
and health education.
Creches; expanding
existing creche schemes
and creating anganwadi
cum caches.
Nutritious hot cooked
Immunisation, growth
monitoring, home-based
neonatal care, prompt
referral when required.
Immunisation, growth
monitoring, prompt
care for childhood
illnesses, referral care
for sick and malnourished
children, de-worming,
iron supplementation.
meal at the centre.
Pre-school at the
anganwadi centre;
cr^ches/day care
facilities forthose
who might need it.
Immunisation,
growth monitoring,
prompt care for
childhood illnesses,
referral care for sick
and malnourished
children, de-worming,
iron supplementation.
among children under six are summarised in Table i.
1.4 Age 3 to 6 Years: Focus on Pre-school
2 Strategic Interventions
It is well established that pse is very significant in helping chil
dren prepare for formal schooling, pse assists children both to
enter school and to remain in the system. A child cannot fully re
alise her right to education unless she has access to quality early
childhood care and education. The interventions required for
children in the age-group of three to six years (until joining
school) are one, a centre-based play-school facility with a teacher
trained in conducting pre-school activities. Again, this can be
provided by the anganwadi worker only if a second anganwadi
worker is appointed for the community-based interventions for
children under three, pregnant and lactating mothers.
Two, hot cooked meals, serving the same broad purposes as
nid-day meals in primary schools. These include not only nu
tritional support but also enhance child attendance, promote so
cial equity, provide income support to poor households, and act
as a form of nutrition education. Three, health interventions such
as growth monitoring, de-worming, immunisation, care of com
mon illnesses, referral services etc.
The focus should therefore shift to quality pse as the main
task, with nutrition and health services playing roles similar to
the Mid-Day Meal Scheme and the School Health Scheme in pri
mary schools. Currently hot cooked balanced meals with ade
quate (animal) proteins, fats, fruits and vegetables are not part of
the strategy for this group of children. (The “supplementary nu
trition programme” under icds is further discussed below.)
If it is accepted that the icds centre (anganwadi) is to function
as a proper pre-school facility then a provision has to be made for
a teacher-equivalent anganwadi worker who is fully committed
It is therefore seen that the following systems would be required
to provide comprehensive early childhood care and development:
(a) Maternity entitlements to ensure proximity of mother and
child during the first six months as well as adequate care to
both mother and child; (b) breastfeeding, iycf and nutrition
counselling and support services to families; (c) community-based
day care services/creches; (d) pre-school centres; (e) supplemen
tary nutrition; and (f) healthcare services-predominantly
community-based with institutional backup.
The icds, which is currently the only national programme to
address the health, nutrition and pre-school needs of children
under six years has the potential and mandate to fulfil many of
these requirements. It requires expansion to reach to all children
and improvements in quality. However, icds alone cannot pro
vide all the required facilities and services. It should be seen as
one component, among others, of a comprehensive strategy for
children under six.
Specifically, such a strategy must have the following
components:5
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2.1 ICDS: Universalisation with Quality
Given the central role of icds in this context, and the fact that
about half the child population and over 70 per cent of all poor
children are malnourished, an effective strategy for children
under six must include the universalisation of icds or more
precisely, “universalisation with quality”.6 The universalisation
of icds is one of the core commitments of the National Common
Minimum Programme, and is also required for compliance with
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Economic & Political weekly
SPECIAL ARTICLE
recent Supreme Court orders. In concrete terms, “universalisation with quality” would mean that (1) every settlement has an
anganwadi centre,7 (2) all icds services are extended to all chil
dren under the age of six years and all eligible women and girls,
(3) the quality of services is radically improved, and (4) priority
should be given to disadvantaged groups, especially residents of
scheduled caste/scheduled tribe (sc/st) hamlets and urban
slums, in this whole process.
As discussed earlier adequate attention must be paid to the
needs of children within the different age categories. The
anganwadi worker must be trained to provide quality pse to
children in the three to six year age group. Her tasks would
also include providing a hot cooked nutritious meal that is
sufficient in fats and proteins, including animal proteins where
culturally acceptable.
A second anganwadi worker must be provided in all anganwadi
centres (other than the existing Anganwadi worker and helper),
who will focus on children under three years of age, pregnant
and lactating mothers. The tasks of this second anganwadi
worker would include breastfeeding counselling, nutrition and
health education and counselling, growth monitoring, provision
ipplementary nutrition to children in the six months to three
years age group and pregnant and lactating mothers, motivation
for ante-natal care, immunisation and related matters. On
some of these tasks, she would work in coordination with the
asha. She would also be required to help in anganwadi cum
creche centres.
Universalisation with quality also requires a range of other
steps including adequate and quality training, improved infra
structure, appropriate cost norms to provide nutritious supple
mentary nutrition, increased community participation, convergence
with the health department and so on. iycf counselling and sup
port should be recognised as one of the core “services” of icds.
2.2 National Rural Health Mission
There should be greater convergence between icds and the
nrhm for prevention and management of malnutrition. At the
village level the asha and the second anganwadi worker can
work together towards promotion of breastfeeding, nutrition
counselling, etc.8 For this, nutrition-related tasks performed by
asha (such as ensuring early initiation of breastfeeding)
should also be incentivised. The asha would further be required
to provide essential home based newborn care by making three
to seven visits in the first week of birth as well as prompt care on
first day of fever, diarrhoea, coughs and colds. Where required,
she would have to refer children to the anm or primary health
centre (phc).
Treatment of severely malnourished children must be the joint
responsibility of the health department and the icds. While it
would be the responsibility of the icds to identify severely mal
nourished children, the health department must make arrange
ments at the sub-centre and phc levels for treatment of such
children. This requires setting up nutrition rehabilitation
centres in phcs in areas with high malnutrition, training of anms
on nutrition related issues, and authorising the anganwadi
worker to refer malnourished children to the health department.
Economic & Political weekly
December 29, 2007
Financial provision should be made to support these children’s
families during the period of rehabilitation.
iycf counselling and support, while included under icds,
should also be a mainstream intervention in reproductive and
child health (rch) and nrhm, and listed as a child survival inter
vention along with “immunisation”. The creation of “iycf coun
selling and support centres”, run by skilled women in a cluster of
5-30 villages, should also be considered. This “service” should be
made available as an entitlement.
Further, the health department must also ensure that the na
tional programmes of immunisation, iron and vitamin-A supple
mentation are carried out and de-worming takes place. While the
anganwadi worker would play a role in motivating children for
this, the health department must ensure adequate and appropri
ate supplies (such as paediatric formulations of iron). A drug kit
with essential drugs must be provided at the village level with
either the asha or the second anganwadi worker.
2.3 Maternity Entitlements
Maternity entitlements are virtually non-existent in the country
today, especially for poor women working in the informal sector.
It is time that a beginning is made to correct this. Tripartite
boards and funds must be set up to implement such entitlements
for all sectors of informal work, so that employers contribute. An
expanded and improved National Maternity Benefits Scheme
must be put in place for all women left out of other schemes/
provisions for maternity benefits.
A task force should be set up to look at the existing provisions
for maternity entitlements in the country and make recommen
dations such that programmes are in place that protect the rights
of the mothers and children to nutrition, rest and exclusive
breastfeeding for six months. The existing laws (Maternity Ben
efits Act, Employees’ State Insurance Act, proposed Unorganised
Workers Social Security Act, etc) must be brought in line with the
recommended principles.
2.4 Creches
As mentioned earlier, provision of creches is an important inter
vention in addressing malnutrition, as they also provide proper
care and attention to children while allowing their mothers to go
for work. Existing schemes such as the Rajiv Gandhi Scheme
must be expanded, icds cum creches must be provided as identi
fied by need. It must be ensured that the provision under the
National Rural Employment Guarantee Act (nrega) for a creche
at the work site is implemented. Labour welfare boards as under
the Building and Construction Workers Act 1996, need to be
brought in for the provision of creches.
3 ICDS: Specific Issues
In this section, we discuss some specific, major steps that are
critical for quality improvement and better impact of icds.
3.1 Supplementary Nutrition Programme
The “supplementary nutrition programme” (snp) under the
icds has a crucial role to play in combating child malnutrition.
Nutrition education alone is unlikely to have a major impact, in a
91
country unable to provide literacy to half its women, especially in
the context of food shortages at the household level. Even in the
us, one of the richest countries in the world, there is a substantial
school breakfast and lunch programme for the country’s poor
(which provides bread, cheese, fruit, juices, vegetables, etc) be
cause it is recognised that nutrition education cannot be a
substitute for food.
However, in its current form the snp under the icds cannot be
expected to have a significant impact. For children in the age
group of three to six years, the snp consists of poor, cereal-based
items that have little nutritional value. A transition needs to be
made towards hot, nutritious cooked meals. The feasibility of
providing nutritious cooked meals has been well demonstrated in
the context of the mid-day meal programme in primary schools,
and this approach needs to be extended to children in the age
group of three to six years under the icds. As for children below
the age of three years, they are virtually excluded from the snp
component of the icds in most states. For these children, care
fully devised thr programmes, combined with nutrition coun
selling, are recommended.
1 Nutrition Aspects of SNP
As we move towards the universalisation of icds, it is important
to learn from past mistakes relating to the snp.
The magic figure of 300 calorie deficit for the snp component
of icds needs to be re-examined. The latest National Nutrition
Monitoring Bureau (nnmb) data (2006-07) show that even today
there is a deficit of about 500 calories in the intakes of one to three
years old and about 700 calories among the three to six years old
(Table 2). There are bound to be additional multiple vitamin and
mineral deficiencies when there is a 40 per cent deficit in calories.
It is, therefore, not surprising that
Table 2: Nutrient Intakes
the current nutrition supplements of
of Pre-schoolers
Age (years)
Intake
RDA
300 calories, consisting mainly of cere
(Calories) (Calories)
als, often fail to result in better weights
1-3
791
1240
and heights of children (though their
3-6________ 1020
1690
RDA - recommended daily allowance.
nutrition status might have been even
Source: National Nutrition Bureau (2006).
worse in the absence of these limited
supplements). The icds programme must incorporate the above
information on actually existing food deficits in the country and inse the snp amounts to 400-500 calories in two sittings.
The snps under the icds have tended to concentrate on provid
ing a “least cost” source of proteins and calories for children.
Pulses were chosen as a source of cheap protein but well known
foods like milk, eggs and meat have been ignored. It is known
that even small quantities of meat help iron absorption from the
diet. In addition, the quality of meat protein is many times supe
rior to cereals and pulses. Milk contains protein, calcium and
other nutrients like vitamin a, etc, and egg yolk contains many
other nutrients in the right proportion. Over the years even the
cereal-pulse recommendation was corrupted to 300 cals from
cereals alone, resulting in massive deficiencies of all nutrients,
bulky foods and do not have high concentration of calories. The
who advises that 30-40 per cent of calories should be derived
from fats, thus cutting down volumes and assuring energy densi
ties. Currently, the snp has no component of fats and oils.
Another important point to consider is that foods like vegeta
bles and fruits are an important source of vitamins and other nu
trients. They also contain newly identified protective compounds
such as anti-oxidants and phytonutrients, which are protective
against cancers and chronic diseases.
Providing a hot, cooked, nutritious meal consisting of cereal,
pulse, eggs and vegetables is essential for the snp to have an impact.
The provision of good quality balanced meals also has a demon
stration value from the point of view of nutrition education.
Table 3: Possible Components of SNP
Source
Quantity/Frequency
Calories
_______ Nutrients____________
^9____
1 on alternate days
Vitamins A, N3, fats, proteins
Oil______
Rice/wheat
Vegetables
10 ml
60gm_______________
Carrots, greens, tomatoes,
120
90
240
Groundnut
Sugar
beans, others_________
20g m_______________
10-15 gm
25gm on alternate days
Pulse
Dairy product
140
“60
100
Fats, vitamin E_______________
Calories, proteins
Vitamins, minerals,
protective compounds, etc______
Calories, proteins, calcium______
Calories___________________
Protein, calories, vitamins, minerals
Protein, calcium, vitamin A
As an example of improved snp menus, the food items in Table 3
may be used in different combinations over the week to provide a
varied, tasty and energy-dense meal every day. For example:
Day-1: egg, rice, oil and vegetables
Day-2: pulse, rice, vegetable and oil
Day-3: wheat, groundnut, sugar and oil
Day-4: egg, rice, oil and milk
Day-5: groundnut, sugar and pulse
3.1.2 On Take Home Rations
Available experience suggests that thrs are the best option
for providing food supplements to pregnant and lactating
women as well as to children under the age of three years. This
is because a pregnant woman or a very young child, may not be
able to come all the way to the icds centre every day just to re
ceive food supplements. Further, centre-based nutrition pro
grammes such as cooked meals are often not well suited to the
needs of young children, who need frequent feeding throughout
the day.
thrs are often distributed on fixed days that may correspond
to the anm’s visit or to health and nutrition activities such as
ante-natal care or immunisation. This is a useful arrangement,
which helps to ensure regular and transparent distribution of
thrs and facilitates these complementary activities.
Though the concern has been articulated that thrs find
their way into the family pot rather than the stomachs of
the children they are intended for, it is considered (and sub
stantiated by collective experience) that thrs can be effective
when combined with nutrition counselling and support at the
including micronutrients.
family level (this, again, requires the involvement of a second
It is known that children have small stomach capacities and
are only able to eat small volumes at a time. This they would be
unable to get all the calories they require from cereals, which are
anganwadi worker).
As with nutrition supplements provided at the anganwadi,
current thrs have also tended to be cereal-based only. It is
92
December 29, 2007
Economic & Political weekly
-
-
recommended that thrs comprise of fats/oils and proteins in ad
dition to cereals and pulses at Rs 3 per child per day (plus food
grains) to be most effective.
Of course, pregnant or lactating women and children under
three who prefer to come to the centre on a daily basis should re
ceive hot cooked meals as discussed above.
3.1.3 Food Fortification and Micronutrients
Fortified foods and micronutrient supplements, mixed in differ
ent vehicles such as ‘atta’, rice, biscuits, candies, etc, are rapidly
spreading in the snp under icds, even when they have question
able nutrition value.9 Often this happens under pressure from
various lobbies and commercial interests. These processes and
technologies promote centralised production and procurement of
food stuff and detract from local control and autonomy over di
ets. Sometimes they even displace local livelihoods such as mill
ing. They certainly promote the notion that special, “medicalised” and expensive food is required to deal with micronutrient
deficiencies. Where there is, on the one hand, a decision not to
spend on more expensive “natural foods” like milk or eggs, there
is no hesitation to spend much more on micronutrient supple.ts of this variety.
To illustrate, consider the case of atta fortification. When this
form of fortification is adopted for our local atta the phytates tend
to precipitate the iron making the fortification ineffective. This is
even more likely to happen when a long shelflife is required as in
the case of programmes like icds and the public distribution
system (pds). Large-scale micronutrient and fortified distribu
tion to populations with malnutrition may not only be ineffective
but also have hazardous effects.
However, all these concerns have not compelled the creation
of a government policy on micronutrients and food fortification.
Thus, it is critical to constitute a regulatory framework for fortifi
cation and micronutrients in India. Such a framework must ad
dress the following issues: first, any large-scale micronutrients
fortified food distribution should be preceded by a process of
documenting and researching its implications.10 Second, any re
quest for a trial of micronutrients and food fortification with
undernourished populations should be placed before an appro
priate authority, constituted by the government of India. The trial
ild be continuously monitored and recorded by an independ
ent monitoring group, so as to record any adverse effects.
It is the responsibility of the state to provide wholesome
balanced food to children rather than a package of chemical
nutrients. Micronutrient deficiencies in India exist because of
massive macronutrient deficiencies, and if adequate food is
supplied, most micronutrient deficiencies will disappear. There
are already three national programmes pertaining to micro
nutrient deficiencies of vitamin a, iodine and iron. These should
be carried out effectively. Thus, the icds programme must focus
on a meal-based strategy rather than a pill-based strategy for
micronutrient deficiencies.
There is an urgent need therefore to constitute a regulatory
body which approves all usage of micronutrients only after
proper scientific scrutiny and after the efficacy of the micro
nutrients has been established over and above the many
Economic & Political weekly
December 29, 2007
7
SPECIAL ARTICLE
benefits of providing hot cooked good quality meals as detailed
in the section above.
3.1.4 Diverse Roles of SNP
Before concluding on the snp, it is worth pointing out that the
provision of nutritious food to young children under icds’ snp
serves a range of important purposes, including - but not
restricted to - nutritional goals. Indeed, this programme can
serve at least seven important purposes:
(1) It provides quantitative supplementation by increasing
children’s food intake, and in particular their calorie intake.11
Children aged three to five years who are attending the anganwadi
for pre-school activities for a period of three hours most certainly
require to be fed at least once in that duration to prevent
“classroom hunger”.
(2) It enhances the quality of children’s diets by giving them
nutritious and diverse food items they may not get at home, such
as vegetables, eggs, fruit, etc.
(3) The provision of nutritious, cooked meals at the anganwadi
is a form of “nutrition education” - it helps to convey what a nu
tritious meal looks like, and to spread the notion that children
require a regular and balanced intake of various nutrients.
(4) The provision of nutritious food at the anganwadi helps to
ensure regular attendance.12 This provides an entry point to all
the other comprehensive health and development services that
the icds offers.
(5) The snp is a form of implicit income support and an interven
tion in poverty, since it saves feeding costs to the parents.
(6) The sharing of cooked meals at the anganwadi, irrespective
of caste and class, helps to break traditional social prejudices,
and to impart egalitarian values to children at a young age. This
is an important start to the kind of socialisation required to bring
about social change.
(7) Finally, aside from these instrumental roles, nutritious meals
at the anganwadi have intrinsic “enjoyment value”. They can
bring a touch of colour and well-being in the fives of poor children,
especially when they are shared in a welcoming environment.
The snp needs to be seen in the light of these diverse roles of
nutritious meals. A narrow focus on “quantitative supplement
ation” (important as it may be) tends to miss the rich opportu
nities presented by this programme. This is, indeed, an important
lesson from India’s recent experience with mid-day meals in
primary schools.
3.2 Priority without Targeting
The suggestion is often made that nutrition programmes (or
other components of icds) should be “targeted” at specific
groups of children. For instance, an early draft of the Sarva Bal
Vikas Abhiyan proposal13 suggested that the snp under icds
should be “operationalised as follows for the management
of underweight”:
- “Children with mild underweight: Caregivers/mothers
would be advised to take care of the children with available
foods at home.
- Children with moderate underweight: Single ration would be
provided along with appropriate nutrition and health advice.
93
children in the age group of three to six years) should have
universal coverage.
- Children with severe underweight: Double ration would be
provided along with appropriate nutrition and health advice and
referral service.”
This targeted approach, however, is problematic for several
reasons. First, this issue has to be seen in the light of the massive
reach of undernutrition among Indian children. As mentioned
earlier, nearly half of all Indian children are undernourished
based on standard “weight-for-age” criteria, and nearly 80 per
cent are anaemic (nfhs-s). Thus, only a small proportion of
children could be “safely” excluded from nutrition programmes.
The financial savings involved in excluding this small minority
are unlikely to justify the efforts, costs and risks associated with
targeting - especially the risk of inadvertent “exclusion” of many
undernourished children.14
Second, this approach focuses exclusively on the “manage
ment” of undernutrition, at the cost of “prevention”. Providing
nutritious food to all children (through take-home rations at an
early age, and nutritious cooked meals from the age of three)
helps to ensure that most of them do not fall in the category of
“moderate or severe underweight” in the first place. This is much
better than trying to extricate them from this predicament after
have lost weight - repairing that damage can be quite diffi
cult, increasingly so as the child gets older. (The notion that chil
dren with mild underweight could be effectively protected by
advising their mothers to “take care of the children with available
foods at home” is wishful thinking.)
Third, targeting is a slippery slope. It paves the way for grad
ually narrower eligibility restrictions, possibly leading to the
“dismantling” of the programme (recent experience with the
public distribution system is quite sobering in this regard). Tar
geting is also divisive and undermines social solidarity. As it is,
political commitment to icds is quite weak. Targeting would
further undermine this fragile support for the programme, as
the better off sections of the population would no longer have a
stake in it.
Finally, the targeting issue has to be assessed bearing in mind
the diverse roles of the supplementary nutrition programme, dis
cussed in the preceding section. For instance, a universal snp has
much greater “socialisation” value than a targeted programme.
Similarly, a universal programme is likely to have stronger inceneffects, in terms of promoting regular attendance.
Thus, in many different ways, the targeting of nutrition
programmes is fundamentally at variance with the “rights
approach” advocated in this paper. Having said this, it should
be clarified that we are not arguing for identical treatment of
all children. Universalisation does not mean “uniformity”. For
instance, intensive rehabilitation of severely undernourished
children is essential, and this involves a limited form of target
ing. We have also argued, elsewhere in this paper, for giving
priority to disadvantaged groups (for example, residents of
scheduled caste/scheduled tribe hamlets and urban slums) in
the process of universalisation. Special financial allocations
The icds programme through the anganwadi centre aims to pro
vide a package of comprehensive services addressing the health,
nutrition, growth and development needs of children under six.
For this to be done effectively, each anganwadi centre must have
two anganwadi workers and a helper. The second worker is re
quired because the number of women and children to be covered
by an anganwadi is too large to be handled by a single anganwadi
worker. The number of children being covered by a typical an
ganwadi would be around 100.15 Added to this, the anganwadi
centre would also have to reach out to pregnant and lactating
mothers and adolescent girls. It is impossible for a single angan
wadi worker to provide effective services to such a large number
of women and children.
Secondly, as discussed earlier, the services required by the
different age groups (namely, zero to six months, six months to
three years, and three to six years) entail diverse strategies.
While children under three mainly require community-based
services,16 children in the three to six-year age group require
centre-based services. In the present scenario of having one
anganwadi worker, neither of these two groups is being effec
tively reached. While many have pointed out the neglect of chil
dren under three by the icds, studies have also shown that the
iCDshas failed in providing quality pre-school education to chil
dren in the age group of three to six years. Therefore, having two
workers and a helper at each anganwadi is essential to ensure
that all icds services are provided effectively to the different age
groups. The three of them could work as a team with one angan
wadi worker focusing on children under three and the other on
providing pre-school education. Both the workers would have to
be given basic training on the entire range of issues.
One anganwadi worker would focus on providing community
based services for children under three, pregnant and lactating
mothers. Her tasks would include the provision of supplementary
nutrition to pregnant and lactating mothers, breastfeeding coun
selling and support for families of zero to six month old children,
growth monitoring of children under three, distribution of takehome rations, and nutrition education and counselling for families
with children under three. Further, she would have to identify se
verely malnourished children and sick children and refer them to
the health system. She would motivate families for immunisation,
update the “mother and child card” and work along with the asha.
This worker would be key to convergence between nrhm and icds.
The second anganwadi worker would run the anganwadi centre
for children in the three to six years age group. She would be a
teacher-equivalent worker who provides quality pre-school edu
cation to the children attending the anganwadi centre. Further,
she would have to ensure that pre-school children are provided
with a nutritious hot cooked meal everyday and health check ups
for deprived areas may also be advisable in some circumstances.
as with the school health programme.
Thus, we are not ruling out some differentiation of entitle
ments between different groups. But the basic entitlements
(for example, to a nutritious cooked meal, in the case of
The anganwadi helper would be responsible for fetching the
children, cooking and serving the food in the anganwadi centre,
keeping the centre clean and helping children and anganwadi
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3.3 Need for Second Anganwadi Worker
December 29, 2007
Economic & Political weekly
worker in play activities. In anganwadi-cum-creches, the team
would be responsible for running the creche services for
young children.
Other than these three workers of the icds programme, the
asha under the nrhm would also have a role. The asha is re
sponsible for the promotion of an early initiation of breastfeeding
within one hour of birth, colostrum feeding and follow up sup
port for the first two weeks. She would also be responsible for
home-based neonatal care by making home visits during the first
month after birth. These tasks of the asha must be incentivised.
The asha cannot however replace the need for a second anganwadi
worker as she has many other responsibilities such as mobilising
the community towards local health planning, help in developing
a village health plan, escort women and children requiring medical
treatment, provide primary medical care, promote construction
of household toilets and so on?7
Table 4 summarises the main tasks of different workers in the
proposed approach.
Another benefit of the two-worker model is that it would enhance
the accountability of anganwadi workers and improve their
work environment. The disempowering work environment of
anwadi workers is one reason for the poor quality of icds
services in many states. The fact that the anganwadi worker has
to cope on her own with all the challenges of looking after up to
100 children, with little support (if any) from her supervisor, is
one aspect of this disempowering environment. The two-worker
model, on the other hand, makes room for mutual support as well
as peer monitoring.
The “two-worker” model is often resisted on the grounds
that it is too expensive. This view fails to appreciate how
“cost-effective” this model actually is. To illustrate, under the
current salary norms (Rs 1,000 per month), posting an additional
worker in each of the country’s 8.5 lakh anganwadis would
only cost about Rs 1,000 crore per year. This is a very small
price to pay for a measure that could make a big difference.
Of course, both the number of anganwadis and the salary
norms are likely to increase during the Eleventh Plan. But even
posting a second worker in 14 lakh anganwadis, at twice the
current salaries, would cost just Rs 3,360 crores per year. This
is not much more than what India spends every year to defend
the Siachen glacier.
Further, these figures refer to financial costs, and the “real”
economic costs are likely to be much lower. Indeed, to a large extent,
the labour of an anganwadi worker is an efficient substitute for much
greater expenses of labour on the part of the children’s mothers.
For instance, when the anganwadi worker and helper provide a
mid-day meal to the children, their work “saves” a lot of work to
the mothers, who don’t have to cook for the children at home. While
the anganwadi worker’s work is paid, the mothers’ work is unpaid,
and this creates the impression that a “cost” is involved but in
fact, resources are being saved! This would be reflected in the
financial costs if mothers’ work were paid, and it is the absence
Table 4: Role of Anganwadi Workers, ASHA and ANM (in Relation to Children under Six, Pregnant and Lactating Mothers)
Focus Group
Zero-six months
AWW1
Focus on under-3s
Supporting exclusive breastfeeding.
Motivating for immunisation.
Growth monitoring and encouraging
early initiation of breastfeeding.
AWW 2
Pre-school Teacher
_________
ASHA
Community-based
Providing new born care, supporting management
of low birth weight and sick babies.
Weighing at birth and recording birth weight,
assist in beginning breastfeeding within one hour,
and establishing exclusive breastfeeding as an
accepted community norm, establishing complete
immunisation as a community norm.
Six-36 months
Growth monitoring, providing
supplementary nutrition in the form
Positively influencing complementary feeding
ofTHR.
Motivating for complete immunisation,
encouraging adoption of hygienic practices
regarding water and sanitation, early detection
and management of childhood illness especially
management of diarrhoea.
Counselling and follow up of families with severely
practices of families and at the community level,
vitamin supplementation. Nutrition
rehabilitation of severely
undernourished children and referral
Pre-school education, growth
monitoring, organising cooked
mid-day meal, nutrition rehabilitation
of severaly undernourished
Inree-six years
ANM
Sub-Centre Based with Field Visits
Providing immunisation services and
timely curative & referral services for sick
new borns.
Assists in beginning breastfeeding within
an hour (if she is conducting delivery)
Management of severely undernourished
children
Providing timely curative and referral
services. Management and referral of
severely undernourished children
undernourished children
Identification and referral of sick children.
Counselling and follow up of families with severely
undernourished children
Health check ups and curative services,
management and referral of severely
undernourished children
Pregnant
Growth monitoring and supplementary
Working with women, families and the community
Antenatal care, promoting delivery by
women
nutrition
to ensure adequate weight gain through appropriate
nutrition, reduction in workload, rest and accessing
trained birth attendant, promoting and
supporting institutional delivery
timely health services especially supporting clean
and institutional delivery
Postnatal care, encouraging early initiation of
Postnatal care, immunisation
Nursing mothers Supplementary nutrition, breastfeeding
AWW-cum-
support_________________________________________________
Both the anganwadi workers to be full-time workers where they continue to
breastfeeding
perform their regular duties and also share the responsibility of running the
crfcche
(0-6 years)
creche.
(10%
ofallAWWs)___________________________________________________________________
Anganwadi helper (full-time in
• Cook and serves food in the creche
case of AWW-cum-creche)________________________ • Help children and AWW in play activities
Source: This table is adapted from Sundararaman and Prasad (2006).
Economic & Political weekly
December 29, 2007
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SPECIAL ARTICLE
of any payment for domestic work that creates the illusion that
anganwadi workers are “expensive”. Further, reduction in house
hold work would contribute to better health and nutrition for
women, which is closely linked to the status of health and malnu
trition of children. Taking all this into account, the economic cost of
the two-worker model is likely to be much lower than the financial
cost, and good economics requires us to focus on the former.
This conclusion would be reinforced by a proper accounting of
the benefits of having additional anganwadi workers. It is not just
that the children will be healthier, better nourished and better
prepared for school. Anganwadi workers are also useful role
models and agents of change in a fairly conservative and patri
archal rural society. In many villages, the anganwadi worker is
the only woman who has a paid and dignified job, with opportuni
ties to develop her creativity and talent. Her presence can greatly
help, in many different ways, to give younger girls a sense of pos
sibility and to secure a better deal for women in society (in
some states, for instance, anganwadi workers have played an
active role in recent campaigns against domestic violence and sexselective abortion). All this adds to the social value of anganwadi
workers. As the largest employment programme for women in
il India, with a potential to employ as many as four million
women everyday, icds also has a very significant contribution to
make to women’s empowerment.
In short, the two-worker model is not just enlightened social
policy but also sound economics. India has a “comparative ad
vantage” in labour-intensive provision of social services; largescale mobilisation of educated women as anganwadi workers
would be an excellent use of this comparative advantage.
Poor capacities to manage such a large public programme, poor
governance, high leakages, lack of local accountability, low moti
vation levels and poor community ownership are some of the
problems that have plagued icds.
An understanding of poor icds performance as stemming
mainly from operational problems often leads to a search for
“contracting out” solutions, where commercial and not-for-profit
non-governmental institutions are asked to organise the services.
But since the central problem behind the inefficiency of state-run
icds is mis-governance and not merely lack of capacities, any
attempt at contracting out part or all the functions usually
leads to even greater problems of governance - but now without
the built-in checks and balances that public service delivery has.
Thus, the operational issues of managing such a large and ex
panding programme as a public service need to be faced. Some of
the key operational issues are discussed below.
3.4.1 Decentralisation and Community Participation
Decentralisation and the involvement of communities is the first
key aspect that must be considered. For instance, the selection of
anganwadi workers must be done by the gram panchayat but
through a supervised process that involves the community. It
should not be left to the whims of the local elite who often control
the panchayat but nor should it disregard the central authority of
the panchayat, for the alternative is usually an unacceptable
process where selection is left to the bureaucracy or the local leg
islative member. What is said for selection is also applicable to
the process of accountability and of monitoring and support primarily by the panchayat but not passively left to it.
There is very little community involvement in
Learning from Thailand's Experience___________________________________
How to Close the Gap
the current programme. Except for rare instanc
India (2007)_______________
Thailand (1980s)__________
Strengthening ICDS
Child malnutrition rate stagnant
Able to halve child malnutrition
es like the Mitanin programme in Chhattisgarh
for last five years___________________________________________
levels in 1980s__________
or the work of the Rajmata Jijau Mission in
Coverage - low, two-thirds children Increase no of AW centres
Coverage - universal, very high
left out
Increase no ofworkers in each AWC to
Aurangabad, the involvement of communities
coverage ensured
two to enhance outreach_____________
and panchayats has rarely gone beyond sub
Raise SNP norm in ICDS to Rs 3 per child/day
SNP - 300 kcal, mainly cereal
SNP- Strong universal SNP provision,
contracting tasks (like the cooking of the meals)
plus 80 gram grain. Provide oil, pulses in take
provided 450 kcal in 100 grams by
home rations for under 3s, Provide hot cooked
with very little real financial or other powers.
providing pulses and fats
meals with eggs/milk for three-six year olds
Yet there are large areas of untapped potential for
Having two AW workers each in 14 lakh centres
High manpower intensity: 1 nutrition Worker: child ratio at 1:100, single
community contribution.
worker per 20 children, helps to ensure part-time worker per centre unable will enable a ratio of 1 worker per 25-30
children and effective nutrition education and
Informed and involved communities can have
very high coverage of under-6s and
to devote time to home visits
coverage
*ive nutrition education on
a major impact on nutrition practices and out
(feeding, complementary feeding______________________________________________________
comes. For instance, one of the barriers in the
Universal iron, vitamin supplementation Supplementation part of strategy and Ensure regular supplies of iron supplements to
policy but huge gaps in providing it - women and children
fight against undernutrition is the gross social
- successful in reducing anaemia
absence of pediatric iron tablets
under-recognition of this issue. Community mo
Irregular IFA supply for pregnant
bilisation can play a critical role in influencing
women_______________
ICDS-heaIth convergence at all levels from
Weak linkage with health so far,
the way society perceives undernutrition and
Strong linkage with health
ASHA onwards
malnutrition not seen as any
create a social will to fight it.19
Regular drug kits to AW centres
department's responsibility,
Community mobilisation can also play a ma
but NRHM present as an opportunity Clinical support for Grade 3 and 4 children
needing institutional check-up or care
jor role in supporting behaviour change in long
Source: Garg and Nandi (2007).
standing childcare practices, and in achieving
improvements in the utilisation of icds services.
3.4 Making ICDS Work
For instance, there may be a variety of genuine reasons for a
In moving towards universalisation with quality, one major chal mother not sending her child to the anganwadi (for example, dis
lenge is the management of a large public service delivery pro tance from the centre, irregular opening hours, low-quality food,
gramme.18 Much of the hesitation to sanction such an expanded lack of trust in the anganwadi worker). In such a situation, a
scheme stems from the past experience with implementing icds. stand-alone behaviour change communication (see) message to
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December 29, 2007
Economic & Political weekly
................
the mother, asking her to send her child to the anganwadi may
not work but the community may be able to tackle some of the
underlying issues. Community mobilisation is needed to create
an enabling atmosphere for more appropriate childcare practices
and empowerment of the local community, especially families
facing marginalisation or social exclusion. Community monitor
ing of icds can also help in ensuring greater regularity and qual
ity, and in building a more functional relationship between the
anganwadi worker and the community.
The asha is one of the key agents in achieving active commu
nity participation and in promoting equity of access at the village
level. Some of her roles have been discussed earlier but it is im
portant to recognise that the asha is also a significant link be
tween the community and the government (particularly the
health system). Other important tools of community mobilisation
arising from the nrhm include the monthly “health and nutrition
day” and the village health committee (vhc). These committees
are initiated by the ashas with the help of the anganwadi worker,
and they are also intended to link with existing community insti
tutions such as mahila mandals, youth clubs, self-help groups
(shgs) and panchayati raj institutions, vhcs can be an important
it of community mobilisation, by motivating parents to send
tneir children to the anganwadi, monitoring undernutrition lev
els in the village, drawing out an action plan, spreading aware
ness of health-related issues, helping anganwadi workers in eccd
and bcc tasks, helping remote hamlets to access icds services,
and monitoring anganwadis, among many other possible activi
ties. They can also act as forums through which women become
more aware of their rights and fight gender discrimination in
health, nutrition and other fields. Other community-based groups
and forums (such as mahila mandals, shgs, gram sabhas and
youth clubs) can play similar roles, in collaboration with ashas
and anganwadi workers. Adequate budgetary provision should
be made for supporting such community mobilisation processes.
Another useful aspect of decentralisation would be district
specific planning. Different districts have different technical
and administrative requirements. They need to tailor commu
nication materials, training programmes and nutrition schemes
to suit their specificities. District planning designs (and then
fund allocations based on such plans) is an operational chal;e but the effort can be quite rewarding, and requires little
additional resources. However, district level planning needs to
proceed “bottom up”, based on village-level and panchayatlevel planning. Panchayat-level planning can be used as a
mechanism for bringing the various aspects of icds together, as
well as for achieving local convergence between icds, the asha
programme and Sarva Shiksha Abhiyan. The plans should
clearly outline the roles of different sectors in contributing to
wards the elimination of undernutrition and the provision of
comprehensive child care.
3.4.2 Developing Human Resources
Human resource issues are critical to the success of the icds.
An effective human resource policy must be created for the
same. To start with, anganwadi workers should be recognised
as regular, skilled workers and their concerns should be
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December 29, 2007
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SPECIAL ARTICLE
addressed, particularly those relating to work overload, inade
quate remuneration, delayed salary payments and poor working
conditions. Avenues must be made available for promotion, skill
enhancement and accreditation. Anganwadi workers should not
be recruited for non-icos duties and their official job descrip
tion should be adhered to.
Urgent action is needed to address the shortage of icds staff at
all levels. Women should be better represented among supervi
sors, child development project officers (cdpos) and other icds
staff above the anganwadi level. Programme management struc
tures should also be strengthened by inducting subject-matter
specialists, especially women (example for pre-school education,
health and nutrition) at the district, state and central levels. This
could be facilitated by building linkages between local colleges of
home science and social work and training institutions.
An essential element for securing better operational results is
better capacity-building. About 5 to 10 per cent of expenses must
be earmarked for capacity-building of the anganwadi workers
and other staff on a regular basis. Continued capacity-building
also requires the creation of adequate institutions for this purpose.
This involves re-examining the existing modes, means and
sites of training and development of training content and materi
al. The inadequacy of present arrangements is reflected in the
fact that the government of India allocated a sum of just Rs 87
crore in the last financial year for training activities, in a pro
gramme that has more than a million workers and helpers.
Nearly a fourth of this money apparently remained unutilised.
Training, both initial (“pre-service”) as well as ongoing (“in
service”), is usually recognised as an important component of
programme implementation. Unfortunately, the current training
system appears to be quite divorced from field reality and practi
tioner experience. Most training institutions have neither any
field sites nor directly run anganwadi centres, which could en
able them to make the training more practice oriented. Ongo
ing field-based training is almost absent as most supervisors
focus mainly on registers, attendance, salaries and numbers
rather than processes.
One reason for the disjunct between training and field reality
is that training curriculum, syllabus and material are usually
centrally determined. This information is then transmitted down
the chain to the anganwadi worker who is expected to convert it
into practice and improve child development indicators for the
entire programme. Building more lively and effective training
programmes, linked with ground realities, would require:
(i) building crucial linkages between training, programme imple
mentation and review, and child development knowledge and
practice; and (ii) building technical and institutional capacity in
the icds programme to develop into a learning system.
The following steps would be useful in this regard: first, decen
tralised development of training curriculum, approaches and
material (say, at the state or district level) based on national
guidelines. Second, convergence of icds and nrhm training, not
simply by training the respective staff together but also through
joint development of the training modules. Third, allocating
anganwadi training centres (awtcs) for capacity-building at the
district or sub-district level. Fourth, recognition of pre-school
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education and nutrition counselling as essential components of
training programmes. Fifth, developing a system for continuous
field level support (for instance, identifying a relatively acces
sible anganwadi and developing it as a local resource centre,
where the supervisor/trainer can facilitate peer learning
through monthly cluster-level meetings). Sixth, upgrading
mid-level training centres (mltcs) and awtcs, not only as
training centres but also as local resource and research centres.
Seventh, enabling mltcs and awtcs to directly run anganwadis
in their campus/vicinity.
3.4.3 Governance Reforms
The icds suffers from high levels of corruption and mis-manage
ment. It is essential to define standards and norms for access and
quality of services and to monitor and support the programme to
ensure that these standards are attained and sustained. Output
and outcome indicators, and a reliable monitoring system, also
need to be put in place so that the progress of icds in each district
is known.
In addition, wide-ranging action is required to restore trans
parency and combat corruption in the entire system. All icdsted information should be in the public domain. The provibxoiis of the Right to Information Act, including proactive disclo
sure of essential information, should be implemented in letter
and spirit in the context of icds. All agreements with private
contractors (if any) and ngos should be proactively disclosed
and made available in convenient form for public scrutiny. All
awcs should be sign-posted and the details of icds entitlements
and services should be painted on the walls of each anganwadi.
Social audits of icds should be conducted at regular intervals in
gram sabhas and/or on “health and nutrition day”.
Effective indicators of good governance need to be developed
for icds for the adequate evaluation of the scheme at every levels.
Decentralisation, adequate space for public participation, greater
attention to human resources and transparency are important
steps towards building a responsive and accountable administra
tion and these need to proceed apace with the greater devolution
of funds for the programme.
4 Financial Requirements
f budgetary allocations have been one of the key factors reo^unsible for the limited impact of the icds and related pro
grammes so far. For instance, the current allocation for icds is
only around one rupee per child per day (on average, for all chil
dren under six). This level of expenditure is utterly inadequate to
ensure effective and universal programmes. Much higher alloca
tions are needed for actually making a real dent on malnutrition,
ill-health and gaps in psycho-social development.
Table 5 (p 99) presents estimates of what is required for fair
implementation of the framework proposed in this paper during
the Eleventh Plan. The reference year for these estimates is the
“terminal year” of an expansion phase, by the end of which (1)
icds would reach universal coverage, and (2) substantial progress
would have been made towards providing other support struc
tures such as maternity entitlements, creches and supplemen
tary nutrition for adolescent girls. The terminal year of this
98
expansion phase is not specified, but it would have to be, at any
rate, within the Eleventh Plan.20
The estimates in Table 5 are based on the following assump
tions:
(1) The number of awcs: This has been fixed at 14 lakh, in line
with Supreme Court orders as well as with independent estimates
of the number of awcs required to implement improved norms
for the creation and placement of anganwadis. Of these, we as
sume that 10 per cent (1.4 lakh) will have the status of “anganwadi-cum-creche” in the reference year (as a step towards wider
outreach of creche facilities).
(2) The number of children: It is estimated that there are cur
rently about 14 crore children under six in the country, of which
10 crore live in rural areas and 4 crore reside in urban areas. It is
further estimated that about 1 crore children live in urban
slums [Government of India 2007: 1]. Allowance has to be
made for the fact that not all parents may wish to enrol their
children at the local anganwadi. Assuming that about 75 per cent
of children in rural areas and urban slums are enrolled, the budg
et estimates are for 8 crore children under six. Of these 8 crore
children, 10 per cent (0.8 crore) would be enrolled in anganwadicum-creche centres.
(3) snp: The snp allocation here is similar to the enhanced
norms that have been proposed to the Planning Commission for
the mid-day meal scheme [Sundaram 2007] i e, Rs 3 per child per
day (in addition to 80 grams of grain).
(4) Second anganwadi worker: As explained earlier, a second
anganwadi worker is essential to provide adequate care to children
below the age of three years along with food supplements and
quality pre-school education for those in the age group of three to
six years. Thus, a provision has been made for implementation of
the two-worker model in all awcs.
(5) Remuneration of anganwadi workers and helpers: Our esti
mates assume that central government’s contribution to the re
muneration of anganwadi workers is raised from Rs 1,000 per
month to Rs 2,000 per month (for four hours of skilled work per
day for around 25 days a month). For anganwadi helpers the cor
responding contribution would be Rs 1,000 per month.
(6) Anganwadi-cum-creche centres: These centres would re
quire higher allocations, for both staff and food. The two an
ganwadi workers and helper would have to be paid for fulltime work, and children attending the creche will have to be
given adequate food. Thus, we have made an allowance for
higher remuneration of anganwadi workers and helpers at an
ganwadi-cum-creche centres (Rs 3,000 and Rs 1,500 per
month, respectively), and doubled the provision for supple
mentary nutrition.
(7) Maternity entitlements: For maternity entitlements, we propose
a national scheme on the lines of the Dr Muthulakshmi Reddy
Maternity Benefit Scheme in Tamil Nadu. This involves cash
support of Rs 1,000 per month for six months for care during
pregnancy and after delivery. We recommend that, as a first step
towards eventual universal coverage of maternity entitlements,
25 per cent coverage should be achieved in the reference year.
Other schemes would also need to be developed to cover the
range of circumstances of women working in the informal sector.
December 29, 200?
Economic & Political weekly
SPECIAL ARTICLE
Under these assumptions, the proposed plan of action would
cost around Rs 33,000 crore (at 2006-07 prices) in the reference
year, including “recurrent costs” of Rs 30,000 crore per year. If
Table 5: Financial Requirements
ICDS: Universalisation with Quality
1
i.r
L2_
1.3
1.4
2
2J_
22
23_
3_
4_
4.1
5.1
5.2
5.3
5.4
6_
6.1
Assumptions
Total under six children covered
Number
8 crore
Children covered by AWC-cum-creches
Pregnant, lactating women covered__________________________
Total anganwadi centres (AWCs)____________________________
Anganwadi centres also working as creches (10 percent of total centres)
Anganwadi buildings to be built and equipped per year
Budget Required (Rs crore)
80 lakh
1 crore
14 lakh
1.4 lakh
2 lakh
No
Recurring Costs
Supplementary nutrition
7,20,00,000
SNP children (@ Rs 3/day for 300 days/yr)
1,00,00,000
SNP pregnant/lactating women (@ Rs 3/day for 300 days/yr)
80,00,000
SNP for children in AWC cum caches (@ Rs 6/day for 300 days/yr)
Rice/wheat (80 gram per child per day)_______________________________ 8,00,00,000
Education/healthkits___________________________________________
Pre-school education kits for AW centres (Rs 1,000 per AWC per year)______ ____ 14,00,000
14,00,000
Medicine kits for AW centres (Rs 1,000 per AWC per year)
AWW 2 honorarium (at Rs 2,000 per month)____________________________
AW helper/cook (at Rs 1,000 per month)______________________________
Workers in AW cum crfeches (3 full-time workers at Rs 3,000, Rs 3,000 and Rs 1,500)
Training_____________________________________________________
Existing anganwadi workers (six days of training @ Rs 150/day)______________
NewAWWI (IQdays oftraining @Rs 150/day)__________________________
AWW2(10daysoftraining@Rs 150/day)______________________________
CDPOs (eight days oftraining per year at Rs 300 per day)___________________
6.2
63^
63_
6.4
District POs (eight days oftraining at Rs 300 per day)______________________
6.5 State officials (three officials per state, eight days oftraining at Rs 600 per day)
7_
Z1_
Z2_
Z3_
8
8.1
82
83
9
9.1
9.2
9.3
10
11
Salaries and office expenses____________________________________
State office________________________________________________
District office_______________________________________________
Project/block office__________________________________________
Contingencies______________________________________________
Project___________________________________________________
District___________________________________________________
State_____________________________________________________
Fuel_____________________________________________________
Project___________________________________________________
District___________________________________________________
State____________________________________________________
A Sub-total (recurring)________________________________________
Non-recurring costs (capital expenditure)__________________________
Equipment and furniture for AWCs_______________________________
Anganwadi buildings (@ Rs 1.30 lakh materials cost per building with
unskilled labour component of Rs 40,000 from NREGA) and assuming 2,00,000
centre buildings will be constructed per year________________________
B Sub-total (Non-recurring)____________________________________
C Total (ICDS)______________________________________________
Maternity benefits
(Rs 1,000 per month for six months, for 65 lakh women [25 per cent of all
pregnant women] to begin with - see text)_________________________
SNP for adolescent girls
Covering five crore adolescent girls (at Rs 3 per day for 300 days)__________
5 Summary of Key
Recommendations
Rate (Rs)
Frequency of
Cost per Year
300
3
6
0.8
300
300
300
6,480
900
1440
1920
1,000
1
1
140
140
7
Ts'
1
700
12
12
144
1,000
2,000
2,000
12
12
3,024
3,024\
1,000
7,500
12
12
1,512
1,260
150
150
150
300
300
600
6
10
10
8
8
8
67.5
97.5
210
1.44
0.14
0.04
600
6,000
12,00,000
10,00,000
7,00,000
1
1
i
3.6
60
420
6,000
600
30
30,000
60,000
1,00,000
1
1
i
18
3.6
0.3
6,000
600
30
1,00,000
1
1,00,000
1,00,000
1
1
60
6
0.3
2,1887
12,60,000
12,60,000
12,60,000
1,40,000
7,50,000
6,50,000
1,400,000
6,000
600
90
__ 30_
Economic & Political weekly
December 29, 2007
In this paper we have tried to present
a broad framework of action for “chil
dren under six” in the Eleventh Plan.
Before concluding it may be useful to
summarise some of the key elements
of this framework.
5.1 General Principles
1,000
25,000
5,000
200
240
2,00,000
5,000
1
100
2,00,000
1,30,000
1
2,600
2,700
24,587
65,00,000
1,000
6
50,000,000
3
300
3,900
4,500
32,987
D Grand total_______________________________________________
Components from other programmes
NRHM
ASHA incentives (Rs 100 per family counselled (four neonatal visits) assuming
1 crore families will get counselling per year
NREGA
Labour component of AW building construction (assuming 2 lakh buildings
will deconstructed per year)
Amount
(Rs crore)
3
6,000
IEC materials (Rs 25,000 per project per year)___________________________
Untied grant to AWCs (Rs 5,000 per AWC per year)________________________ 14,00,000
AWC rent (till such time that centres don't have their own buildings)
6,00,000
Rural_______________________________________________________
Urban_______________________________________________________ 2,00,000
Honorarium for AWWs/helper_____________________________________
AWW 1 honorarium (at Rs 2,000 per month)____________________________
the Indian economy grows at 8 per cent per year on average during
the Eleventh Plan, this financial requirement will represent about
one half of 1 per cent of India’s gdp five years from now. This is a
very reasonable price to pay to pro____________________
tect 14 crore children from hunger,
____________________ ill-health and related deprivations.
1,00,00,000
100
1
100
2,00,000
40,000
1
800
The general principles are the
following:
Rights Approach: This framework
recognises that childcare, health
care, nutrition and development are
basic rights of all Indian children.
Age-specific Interventions: Atten
tion has to be paid to the varying re
quirements of different age groups
(specifically, zero to six months, six
months to three years, and three to
six years), and to the need for corre
sponding interventions.
Three Core Interventions: These
interventions involve the integra
tion of three related systems, focus
ing respectively on: (i) food and
nutrition; (ii) health services; and
(iii) childcare.
Role of ICDS: Many of these inter
ventions can be taken care of through
the icds, provided its initial vision is
revived.
Complementary Strategies: How
ever, other institutional arrangements
are also required, including (i) mater
nity entitlements; (ii) creches and
childcare arrangements; and (iii) in
stitutionalised support for “infant
and young child feeding” (especially
breastfeeding).
Convergence: Effective strategies
for children under six also require
99
SPECIAL ARTICLE
active “convergence” between core programmes, especially icds,
the nrhm and Sarva Shiksha Abhiyan.
Decentralisation: A decentralised approach is required, foster
ing participatory planning, community ownership, responsive
ness to local circumstances, and the involvement of panchayati
raj institutions.
Community Action: Various forms of community action need to
be promoted. These include monitoring and supporting the local
anganwadi, selection and evaluation of anganwadi workers,
participatory planning, use of untied grants, etc. This process should
be adequately planned, budgeted for and institutionalised. The asha
needs to be empowered to play the critical facilitation role between
the communities, panchayati raj institutions and the programme.
Capacity-Building: Major investments in capacity-building and
training are required at all levels, all the more so as eccd is
poorly understood. Programmes of such scale and complexity as
icds cannot succeed without extensive investments in improving
management skills and practices.
niiman Resources: Anganwadi workers should be adequately
remunerated and they should be recognised as regular skilled
workers. A human resource policy needs to be put in place for
anganwadi workers.
Administrative Reforms: Capacity-building and decentralisa
tion are essential but not sufficient conditions of improved gov
ernance. There needs to be a central mechanism that sets stand
ards, maintains quality, safeguards equity concerns, redresses
uneven development and allocates (and accounts for) resources
in a transparent and equitable manner. This would require im
proved institutional frameworks, improved workforce manage
ment policies and professionalisation of management. Account
ability at senior levels of administration and governance needs
to be measured through appropriate mechanisms, subjected to
public scrutiny.
Overseeing Mechanism: A high-level overseeing mechanism
■ example, empowered steering committee along the lines of
uie nrhm) should be created to ensure convergence and account
ability in the range of interventions concerned with child nutrition.
5.2 ICDS: Key Recommendations
The following are the key recommendations regarding the icds:
Universalisation with Quality: “Universalisation with quality”
should be the overarching goal for icds in the Eleventh Plan. This
would include raising the number of anganwadis to a minimum
of 14 lakhs (with priority to disadvantaged groups), extending all
icds services to all children under six and all eligible women,
and improving the quality of services.
Focus on Children under Three: icds should give much greater
priority to children under the age of three years. This would
100
include providing adequate incentives to ashas for the relevant
services (including home-based neonatal care, breastfeeding and
nutrition support), provision of nutritious thrs, better training
on issues related to children under three, and the adoption of the
“two-worker” model.
Two-Worker Model: Adequate care of children under three com
bined with effective pre-school education for children aged three
to six years cannot be achieved without the involvement of two
anganwadi workers (along with the anganwadi helper).
Anganwadi-Cum-Creches: Creches ensure that adequate care
and development opportunities are available to children whose
mothers go for work outside the home (especially if there are
no adult carers at home). Creches are required for children, in
both the zero to three and the three to six age groups, for the
entire day. To begin with, we recommend that 10 per cent of all
anganwadis be converted to anganwadi-cum-creches. This
would mean that these centres are open full time, both the
workers are present all day and are given additional training
on running a creche.
Pre-School Education: For children aged three to six years,
pre-school education should be the primary focus of icds activi
ties. Aside from adoption of the two-worker model, this requires
appropriate training, infrastructure, equipment, supervision
and support.
Nutrition Programmes: For children in the age group of three to
six years, the snp should be based on hot, cooked, nutritious
meals, along the same lines (and with the same financial norms)
as the “mid-day meal” scheme in primary schools (with a mini
mum financial norm of Rs 3 per child per day in addition to
grains). For younger children, it should be based on carefullydesigned thrs, combined with nutrition counselling.
5.3 Other Recommendations
The other recommendations are:
Maternity Entitlements: A national scheme for maternity entitle
ments in the informal sector, on the lines of the Dr Muthulakshmi
Reddy Maternity Benefit Scheme in Tamil Nadu (including cash
support of Rs 1,000 per month for six months for care during
pregnancy and after delivery), should be introduced. A national
task force should be created to further investigate the modalities
of universalising maternity entitlements to all working women.
All existing laws - mba, esi Act, all labour laws, proposed unor
ganised workers social security act, etc, should be brought in line
with recommended principles.
Creches: Apart from the creation of anganwadi-cum-creches on
a pilot basis (in io per cent of all anganwadis), there should also
be a major expansion and improvement of creche facilities under
the Rajiv Gandhi National Creche Scheme. The provision for a
creche at all nrega worksites, as provided for under the act
must be implemented so that women can avail of employment
December 29, 2007
Economic & Political weekly
opportunities as well as have a safe place to leave infants where
their basic needs are addressed.
Infant and Young Child Feeding: Infant and young child feed
ing counselling and support should be recognised as one of the
core “services” both in icds and nrhm, with a clear budget head.
This should include skilled counselling and support (incentive
based) for initiating breastfeeding within the first hour of birth,
continued counselling and support in the form of home visits for
maintaining exclusive breastfeeding for six months, and counsel
ling and support for continuing breastfeeding for two years or more,
along with adequate and appropriate complementary feeding.
Financial Commitments: Fair implementation of the above
recommendations would require a recurrent budget of around
NOTES
1 The share of child development (which includes ICDS
and the creche scheme) and child health in the total
union budget is 1.3 per cent.
2 Since we had been specifically requested to analyse
the experience of countries like Thailand during the
levelopmental phase when they were most akin to
.ndia, a companion paper on Thailand's experience
has also been prepared [Garg and Nandi 2007] and is
summarised in a table in this paper.
The
full name of this act is the Infant Milk Substi
3
tutes, Feeding Bottles and Infant Foods (Regulation
of Production, Supply and Distribution) Act, 1992, as
amended in 2003 (IMS act).
4 The Supreme Court directive of Rs 2 per day per child
for supplementary nutrition covers all children, in
cluding infants zero to six months old. However,
these infants do not need any supplementary nutri
tion, they only need breastmilk. The money meant
for this group of children (Rs 2 per child born for
180 days) can be used for protecting, promoting
and supporting breastfeeding through a separate
budget head created for this purpose.
5 Detailed recommendations consistent with what fol
lows are presented in the FOCUS Report (2006) and
Gupta et al (2007).
6 For further discussion see the collection of articles on
ICDS published in Economic & Political Weekly on
August 26,2006.
7 Specific directions on this are included in the
Supreme Court’s judgment of December 13, 2006
which also establishes a right to “anganwadi on
demand”: “...rural communities and slum dwellers
should be entitled to an ‘anganwadi on demand’ (not
later than three months) from the date of demand in
cases where a settlement has at least 40 children un
der six but no anganwadi”.
See Sinha (2007) on convergence with NRHM on
malnutrition, need for a second anganwadi worker to
reach out to the households and role of the anganwa
di worker and ASHA in behaviour change communi
cation.
9 In a recent unpublished meta-analysis by
H P S Sachdeva (presented at the National Institute of
Nutrition, April 2006), the impact of iron fortified
foods on anaemic populations was studied. Only an
increase of 0.4 g in existing haemoglobin levels was
found.
10 In fact, the Prevention of Food Adulteration Act cur
rently does not allow fortification of foods with any
thing else besides iron and iodine.
11 Though the concern is sometimes raised that the SNP
may displace food provided by the family, there is
evidence that this rarely happens [Jacoby 2002]. If
any substitution does happen, it is typically less than
one-to-one, so that there is some “net” quantitative
supplementation. Qualitative supplementation through
the programme can only add to the net gains to the
child. There is thus the real potential of augmenting a
largely cereal-based home meal with good quality
more expensive foods as part of an SNP.
12 The fact that the provision of cooked food has consid
erable effects on child attendance is well-documented
Economic & Political weekly
DECEMBER 29, 2007
13
14
15
16
17
18
19
20
Rs 30,000 crore at 2006-07 prices, to be reached in a phased
manner within the Eleventh Plan. By the end of the Eleventh
Plan, this is likely to represent just over one half of 1 per cent of
India’s gross domestic product (assuming a growth rate of 8 per cent
per year). This is quite reasonable, considering that children un
der six account for 15 per cent of the population, and represent
the future of the country.
Children under six have been grossly neglected for a long time
in Indian planning, and the country is paying a heavy price for
this today. The Eleventh Plan presents an opportunity to correct
this bias and give children their due. However, this cannot be
done through marginal expansion or superficial “reform” of
existing child development programmes. It requires bold
initiative, new strategies and - not least - a massive increase in
financial allocations for children under six.
in the context of mid-day meals in primary schools
[see e g, Dr^ze and Goyal 2003 and Khera 2006]. If
anything, the attraction of nutritious food is likely to
be even higher for younger children. The FOCUS sur
vey found that the provision of cooked food at the lo
cal Anganwadi raised the probability of regular at
tendance of an average child by nearly 50 percentage
points (FOCUS Report 2006: 61).
Government of India (2007). More recent versions of
this document, however, do not include this approach.
There is much evidence of poor reporting of weightfor-age data under ICDS as things stand. Anganwadi
workers are often under pressure to “hide” undernu
trition (especially severe undernutrition), and the of
ficial figures often underestimate the number of mal
nourished children [see for example Garg 2006].
This would be the case when the new norms of one
anganwadi centre per 800 population comes into
force assuming about 80 per cent of children use
ICDS services.
As mentioned in previous sections many of these chil
dren also require that cr&che/day care services are
provided at the anganwadi centre.
For ASHA’s roles and responsibilities, see the web site
of the ministry of health and family welfare (www.
mohfw.nic.in).
This section draws on an earlier discussion note for
the Planning Commission prepared by Patnaik, Desh
pande, Zaidi and others (2007).
On this issue, see for example Garg (2006) and Sinha
(2006).
In this connection, it is also important to remember
that the Supreme Court judgment of December 13,
2006 on ICDS directs the government to expand the
number of anganwadi centres to 14 lakhs by Decem
ber 2008.
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1R;eso
Government of Maharashtra
Child Deaths Evaluation Committee
Second and the final report
(24th March 2005)
Recommended Measures
On Child Mortality and Malnutrition
(Executive Summary)
Executive Summary
A)
The Child Mortality Evaluation Committee
As announced in the legislative house, the government of Maharashtra
established the 'Child Deaths Evaluation Committee' on the 12th of December 2003
(GR No BMS / 2003 / P K 281/2003, K K 3, dated 12/12/2003).
Dr. Abhay Bang is the chairman of the committee which started off with 13
members and with new members joining in January 2005, its final strength was 17
members.
The Scope of Work of the committee includes
1. Assessing infant and child deaths in the state.
2. Reviewing malnutrition amongst children in the tribal areas.
3. Reviewing all schemes that have been designed for reducing child
mortality, infant mortality, maternal mortality, malnutrition etc and
recommending measures to remove the lacunae within these.
B)
Focus of the two reports of the Committee
The first report, submitted on the 24th of August 2004, focused on the
magnitude and causes of child mortality and malnutrition in Maharashtra. It also
looked into the implementation of various orders earlier issued by the government.
The second and final report, (submitted on the 24th of March 2005)
concentrates on recommending measures to the government to reduce malnutrition
and child mortality.
C)
The Challenge of Child Mortality and Malnutrition
•
Government of India's estimates (Sample Registration System, SRS) place
the infant mortality rate (IMR) in Maharashtra at 45, (2002) with very little
improvement in the last seven years.
2
•
According to these estimates, nearly 120,000 children under the age of 5
years die each year in Maharashtra. The voluntary organizations put this
estimate at 175,000.
•
5.4% of all children in Maharashtra, i.e. nearly 800,000 are severely (grade
3+4) malnourished (NNMB). An additional 21%, nearly 3.2 million children
are moderately (Grade 2) malnourished.
D)
Goal
Maharashtra has adopted a population policy with a goal of reducing the Infant
Mortality Rate, from the present rate of 45, to 15 by the year 2010.
Most child deaths occur due to a combination of malnutrition and diseases
caused by infections. Neonatal deaths, pneumonia and diarrhoea cause 80% of all
child deaths in the state. These three causes can be addressed by simple measures. It
is therefore reasonable to expect that the goal of reducing child deaths can be
achieved.
E)
Boundaries and the Focus
The committee is aware that social and economic conditions are important
determinants of child deaths. However, since the committee has been formed to
primarily
look
into
health
and
nutrition
related
issues,
it
has
focused
on
recommending immediate measures in these two areas so that child deaths and
malnutrition can be rapidly reduced in the next five years.
F)
Measures and Recommendations
The main directions of these recommendations are
A)
The government must accord a high priority to the problems of child
deaths and malnutrition and allocate necessary funds to solve the
problems along with introducing an accountability system at the all levels
of administration.
The committee has suggested the deprived groups
and high priority geographic areas.
B)
Each village, habitat, hamlet or slum should have an Anganwadi for
nutrition program and a local community health worker.
3
These two
workers should reach out to every household with the recommended
health and nutrition measures.
An essential package of technical interventions to reduce child mortality
C)
and malnutrition has been recommended.
The need to regularly monitor and evaluate government activities has
D)
been emphasized and measures have been suggested for people's
participation in this war against child mortality and malnutrition.
1.
State Policy
i.
Reducing child deaths and malnutrition must be a matter of immediate
priority for government. A time-bound campaign lead by the highest
leadership in government should be launched.
ii.
Children constitute 14% of the population of the state. Which means
nearly 15 million children are at risk. Government needs to allocate on
priority
basis
separate
funds
in
the
budget
for
alleviation
of
malnutrition and child deaths.
iii.
The government should identify deprived districts in the state based on
the infant mortality rate and proportion of malnutrition. These districts
along with the tribal blocks and vulnerable communities should get
proportionally additional financial and human resource support for
alleviation of child deaths and malnutrition.
The committee recommends that the following areas / community groups in
Maharashtra be treated as the deprived and vulnerable groups. These areas / groups
should receive the top priority for any intervention that is planned.
(1) All tribal talukas in the state.
(2) All rural areas in the districts in which the infant mortality rate is higher
than the state average.
(3) Remote talukas and villages in the remaining districts.
(4) Urban slums and pavement dwellers.
(5) Population groups who temporarily migrate for the livelihood.
4
iv.
Designed and planned on the lines of the very successful 'Sant
Gadgebaba Gramswachchata Abhiyaan', Government should launch a
state wide competition with prizes for 'Child Death Free Village' and
'Malnutrition Free Village'. The competition should be widely publicized
with attendant public education on the issue. Gram panchayats and
women's savings groups should be given the opportunity and finances
for the activities to reduce malnutrition and child deaths.
v.
The various government programmes to reduce maternal and child
mortality and malnutrition should be implemented primarily though the
state government's 'Rajmata Jijau
Mother and
Child
Health and
Nutrition Mission' and the Health and Family Welfare department. The
objectives of the proposed mission should include reducing child
mortality on priority basis.
2.
Administrative Measures
Preventing child deaths must be the highest priority of the health
department. This must reflect prominently in the performance review
and appraisals of health department personnel across all levels.
ii.
Incidence of child mortality must be an integral part of the reviews
periodically conducted by the Chief Executive Officer of the Zilla
Parishad and the Divisional Commissioner. It should also be part of
their own performance appraisal.
iii.
A system of performance accountability on the issue of child deaths and
malnutrition must be introduced
across all
levels of the health
department and Integrated Child Development Scheme (ICDS).
iv.
For such monitoring and evaluation, 100% and accurate recording of
births and deaths is necessary. This will mean that the Management
Information System (MIS) of the health department will have to be
immediately improved to record and report all child deaths. This can be
done by implementing the recommendations made by this committee
in the first report.
5
It is recommended that a transparent policy and clear guidelines
V.
should govern appointments and transfers of health system personnel
including doctors and nurses. These have been delineated in the report.
vi.
Government
implements
various
schemes
maternal
addressing
mortality, malnutrition and child deaths. It is necessary to develop a
mechanism by which the implementation of these schemes will be
evaluated and the impact assessed against the financial cost incurred.
This evaluation should be done every two years by a capable and
reputed agency outside the government system. To begin with, the
following activities need such immediate evaluation
(1) Iron-folic acid tablets that are distributed to pregnant women.
(2) The monetary incentive scheme for safe delivery.
(3) Supplementary nutrition provided to children in the 3-6 year age
group through the anganwadi.
(4) The Management Information System (MIS) of the health department.
(5) The current and future interventions to reduce child mortality.
vii.
Monitoring mechanisms of the health system should be decentralized.
People's participation should be elicited and obtained in the monitoring
committees that can be set up from the village to the state level. These
committees
can
be
given
the
responsibility
of
monitoring
implementation of health schemes.
3.
Improving the ICDS to address malnutrition
The coverage of the ICDS must be increased to cover all children in the
state. (The Union government has already doubled the budgetary
provision for the same in the 2005 budget)
ii.
The focus of the ICDS must be altered from the current near exclusive
focus on feeding children of 3-6 years age to :
•
Neonates, children in the 0-2 year group, pregnant and lactating
mothers and adolescent girls must form the target group for the ICDS.
6
•
Health education, neonatal care, diagnosis and treatment of sick
children and supplementary nutrition education must be the important
interventions.
•
Instead of the anganwadi centre merely becoming a distribution point
for food, it should take these services to each doorstep.
iii.
The figures and data on malnutrition reported by the ICDS does not
seem to be reliable. These data must be verified and the methods of
measurement corrected and validated regularly with the help of the
National Nutrition Monitoring Bureau (NNMB) of the central government.
iv.
Rather than initiating treatment after a child is severely malnourished,
the earlier manifestation of growth faltering should be detected and
immediate remedial action started.
v.
Along with supplementary nutrition, health education and treatment of
select diseases of children should be available at the anganwadi center.
vi.
There should be special emphasis on improving health of adolescent
girls and preventing child marriages.
4.
Addressing malnutrition in tribal areas
The gramsabhas in tribal villages must be involved in the planning and
implementation of development schemes.
ii.
To ensure integrated development and co-ordination amongst various
departments, senior officers from the administrative services must be
appointed as the project officer.
iii.
Effective implementation of the employment guarantee scheme and
better access of the tribals to forests will result in poverty alleviation.
iv.
Extensive public education campaigns should be initiated to educate the
tribals on health issues and eradicate superstitions.
v.
One health worker should be trained in every village / hamlet. She will
then be the conduit for taking health services to everyone in the village.
7
vi.
Providing supplementary nutrition twice a day to the children should be
tried on experimental basis.
vii.
Effective and rigorous implementation of various other measures
suggested in this report.
5.
Health interventions for reducing child deaths
Simple public health interventions can prevent two third of the current
child deaths. These interventions should therefore be incorporated into the
state health programmes.
i.
Effective health education to improve knowledge and practices of both
parents.
ii.
The highly effective and proven 'Home Based Neonatal Care' method to
be taken to scale.
iii.
Treating children's illnesses such as pneumonia, diarrhoea, malaria,
measles and worms in the village itself by a trained health worker.
iv.
6.
Hospitalization wherever needed.
Interventions to reduce maternal mortality
Normal deliveries should take place at the PHC and high risk deliveries
at the rural / district hospitals. At both these places the necessary
emergency services must be made available round the clock.
ii.
No economic incentives should be offered to women for delivering in
the government health facilities.
Instead, the quality of care and the
behaviour of the staff should become better and humane.
iii.
In order to ensure safety in home deliveries, the traditional birth
attendants should be trained and provided with kits.
iv.
To enable quick transfer of a case of difficult delivery to the hospital, a
'vehicle and delivery fund' should be made available at the village level.
This fund should be entrusted to a 'mothers support group' in the village.
v.
Private obstetrics services should be monitored and regulated in order
to ensure good quality.
8
7.
Interventions to make health services effective
be responsible to make available various
The health services should
measures suggested to reduce child mortality in the state. For that purpose :
A community health worker (CHW) should be present in every village /
hamlet / slum.
She should
be selected
properly,
trained
well,
motivated, provided with adequate supplies, supervised and monitored
well.
Help can be sought for the same from non governmental
organizations in the state.
ii.
This CHW should not be made a government servant,
Her control
should be in hands of a village health committee.
iii.
Such a CHW is a part of the 'National Rural Health Mission' that has
been announced by the Central Government. Efforts should be made to
include Maharashtra in this mission.
iv.
The health interventions suggested above (under 6) to address child
deaths should be implemented in two phases (details in the report) in a
time bound manner in the entire state.
Action on the recommendations and the follow-up
G)
i.
Regular monitoring of the actions on the recommendations made by the
committee in the first and second report is essential. A high powered group
should be established for this purpose.
ii. Information on the implementation of the recommendations and the impact on
child deaths and malnutrition should be published each year.
xxxxx-
9
Ml
ii
Comment
German Cochrane Centre, Department of Medical Biometry and
Statistics, University Medical Centre Freiburg, D-79104 Freiburg,
Germany (EvE); Swiss Paraplegic Research, Nottwil, Switzerland
(EvE); Clinical Epidemiology Program, Methods Centre, Ottawa
Hospital Research Institute, Ottawa, ON, Canada (DM); and
Department of Epidemiology and Community Medicine,
University of Ottawa, Ottawa, ON, Canada (DM, JL)
vonelm@cochrane.de
Wethank France Gagnon, Julian Higgins, John loannidis, and Muin Khoury for
helpful comments. We are co-authors of the STREGA statement and are
involved in other reporting guideline initiatives, including CONSORT, STROBE,
and the EQUATOR Network. Maja Zecevic, North American Senior Editor at
The Lancet, was part of the STREGA group.
1
McCarthy Ml, Abecasis GR, Cardon LR, et al. Genome-wide association
studies for complex traits: consensus, uncertainty and challenges.
Nat Rev Genet 2008; 9:356-69-
2
loannidis JP. Personalized genetic prediction: too limited, too expensive, or
too soon? Ann Intern Med 2009; 150:139-41-
3
Clark MF, Baudouin SV. A systematic review of the quality of genetic
association studies in human sepsis. Intensive Care Med 2006; 32:1706-12.
4
Altman DG, Simera I, Hoey J, Moher D, Schulz K. EQUATOR: reporting
guidelines for health research. Lancet 2008; 371:1149-50.
5
von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP.
The Strengthening the Reporting of Observational Studies in Epidemiology
(STROBE) statement: guidelines for reporting observational studies.
Lancet 2007; 370:1453-57-
6
loannidis JP, Gwinn M, Little J, et al. A road map for efficient and reliable
human genome epidemiology. Nat Genet 2006; 38:3-5-
7
Little J, Higgins JP, loannidis JP, et al. STrengthening the REporting of
Genetic Association studies (STREGA): an extension of the STROBE
statement. Hum Genet 2009; 125:131-51- http://www.medicine.uottawa.
ca/public-health-genomics/web/assets/documents/FinalSTREGA%20manuscript-Feb2%202009-pdf (accessed June 22,2009).
8
Moher D, Simera I, Schulz KF, Hoey J, Altman DG. Helping editors, peer
reviewers and authors improve the clarity, completeness and transparency
of reporting health research. BMC Med 2008; 6:13-
9
Plint AC, Moher D, Morrison A, et al. Does the CONSORT checklist improve
the quality of reports of randomised controlled trials? A systematic review.
MedJ Aust 2006; 185: 263-67-
New WHO growth standards: roll-out needs more resources
See Comment page 94
On May 22, WHO and UNICEF issued a statement
endorsing new case definitions of severe acute
malnutrition based on the 2006 WHO growth
standards.1 Before the global food crisis, a 2006
review estimated that 13 million children had such
low weight-for-age.5 This definition was changed to
weight-for-height6 to better identify children who
would benefit most from treatment. Weight-forheight expressed as Z scores is useful for surveys, yet
many treatment programmes admit children with
malnutrition.2 By January, 2009, aid agencies reported
about 19 million affected.3 Calls were made for the
disease-burden demand to be met with increased supply
conceptually simpler %-of-median measures. (Minus
1 Z score=l standard deviation below a normally
distributed population median. Nutritional oedema
is also part of the case definition for severe acute
malnutrition.) More recently, focus has been on
of treatment services.3 Increases in the prevalence of
severe acute malnutrition associated with adoption of
the new case definitions have been noted,4 but balances
in treatment-service supply and demand are also crucial
and need to be urgently addressed.
Numbers of children diagnosed as malnourished vary
greatly depending on which case definition is used.
Each has advantages and disadvantages, and is useful
for particular purposes. Malnutrition for admission
to feeding programmes was originally defined by
Number of cases
<70% of median weight-for-height (NCHS)
<70% of median weight-for-height (NCHS), or:
<-3 weight-for-height Z scores (NCHS)
7
<-3 weight-for-height Z scores (WHO)
i
Asia. 4: Eastern Africa. 8; Middle Africa, 1; Northern Africa, 2: Western Africa. 6:
Southern Africa,! Guidelines include versions marked as final ordraft All protocols
classify oedematous malnutrition as severe acute malnutrition, and all accept
. mid-upper-arm circumference <110 mm as defining such malnutrition.
i Table: Case definitions
ins ofsevere acute malnutrition in 22 na^onal
' guidelines
100
mid-upper-arm circumference?
WHO growth standards are an international gold
standard describing how children should grow when
measured by weight and height.8 Previously, severe
acute malnutrition was defined as weight-for-height
<70% or <-3 Z scores below the National Centre for
Health Statistics (NCHS) median. The new case definition
is weight-for-height <-3 Z scores below the WHO
growth standards median. The diagnostic threshold of
mid-upper-arm circumference has also been changed
from 110 mm to 115 mm. Increases in the diagnoses of
severe acute malnutrition with the new WHO weightfor-height criteria have been noted.9-11 However, until
now there has been no documentation of which case
definition countries are using, and therefore the size of
the expected change in prevalence estimates for severe
acute malnutrition.
In the table, we present treatment admission criteria
in 22 countries where severe acute malnutrition is
www.thelancet.com Vol 374 July 11,2009
Comment
prevalent. Most countries currently use %-of-median.
Changing from <70% median (NCHS) to <-3 Z scores
(WHO) results in particularly dramatic increases in the
prevalence of severe acute malnutrition (times eight
in one study10). This finding contrasts with 1-5-3-fold
increases when switching from <-3 Z scores (NCHS)
to <-3 Z scores (WHO).9,11 The widespread use of
%-of-median has not previously been appreciated.12
If treatment capacity were unlimited, increased
diagnosis would represent major opportunities: more
children treated, at an earlier stage of severe acute
malnutrition, with better outcomes likely. However,
supply/demand considerations reveal important chal
lenges. First, treatment supply is insufficient for even
rent demand. Action Centre la Faim and Medecins
Sans Frontieres estimate only 9% of children with
severe acute malnutrition currently receive treatment.3
Demand increases exacerbate this mismatch.
Second, substantial financial investments are needed
to create and sustain programme expansion. Availability
of specially formulated ready-to-use therapeutic
food—increasingly central to treatment for severe acute
malnutrition—is often the largest cost component for
care in feeding programmes. Resources are also needed
to maintain logistics and supply chains for such food,
and to research and develop local stand-by alternatives
for periods when there are failures in the supply chain.
Even more is needed to support the health systems and
staff directly delivering treatment.
Third, demand can change overnight with new
case definitions for severe acute malnutrition. By
trast, increasing treatment supply takes time, even
if financial resources were unlimited. Community
based management of acute malnutrition is simple,
effective, and the current internationally favoured
treatment strategy.13,14 Yet even such community-based
management takes time to build up to full capacity in
often fragile, local health systems.
Shortterm, ifadmissions for severe acute malnutrition
increase too rapidly due to the combined effects of
food shortages and new case definitions, treatment
capacity risks being overwhelmed. In this situation,
limited resources might not necessarily go to the most
vulnerable children. It is important to anticipate and
address such possible adverse scenarios.
Strategic roll-out planning is essential for both
community-based management of acute malnutrition
www.thelancet.com Vol 374 July 11,2009
■H
and the WHO growth standards. The new growth
standards represent great opportunities for national
and international nutrition programmes: indicators
can be harmonised and their purpose more clearly
articulated (eg, identification of children at highest
risk of mortality who benefit most from treatment).
Ultimately, more children can be treated at an earlier
stage of the disease and greater public health impact
achieved. However, for this to happen, policy makers
must be fully aware of the varied effects, and possible
side-effects of change. They must ensure adequate
resources to increase supply of treatment for severe
acute malnutrition. Strategies and practicalities
for feeding programmes and roll-out of the WHO
growth standards must be harmonised. Immediate
efforts should prioritise roll-out of effective evidence
based community programmes.14 Horizontal health
systems approaches, with extensive local buy-in and
integration with existing services, take extra time
initially but often pay off longer term. Once treatment
supply increases, coping with extra demand will be
easier. Even when focusing on the short-term needs
from the food crisis, long-term vision is vital.
*Marko Kerac, Rebecca Egan, Sam Mayer, Anne Walsh,
Andrew Seal
UCL Centre for International Health & Development,
London WC1N 1EH, UK (MK, AS); Clinton Foundation HIV/AIDS
Initiative, Boston, NY, USA (RE, SM); and Valid International,
Oxford, UK (AW)
marko.kerac@gmail.com
Our views and do not necessarily reflect the positions of our organisations.
AW works for and MK's PhD research was funded by Valid International, which
provides technical consultancies for CMAM nutrition programme roll-out and
from which arose Valid Nutrition, a registered charity which manufactures
RUTF.
1
2
3
4
WHO, UNICEF. WHO child growth standards and the identification of
severe acute malnutrition in infants and children. 2009- http://www.who.
int/nutrition/publications/severemalnutrition/9789241598163/en/index.
html (accessed May 23,2009).
Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A.
Management of severe acute malnutrition in children. Lancet 2006;
368:1992-2000.
Action Centre la Faim (ACF-IN), M^decins Sans Frontteres (MSF). Briefing
paper: one crisis may hide another: food price crisis masked deadly child
malnutrition. Time for Refocus at Madrid Food Summit, Madrid, Spain;
Jan 26-27, 2009= http://www.reliefweb.int/rw/lib.nsf/db900SID/YSAR7NKRVC?OpenDocument (accessed May 23,2009).
IASC Global Nutrition Cluster, Standing Committee on Nutrition (SCN)
Task Force on Assessment, Monitoring and Evaluation. Fact sheet on the
implementation of 2006 WHO child growth standards for emergency
nutrition programmes for children aged 6-59 months. March, 2009.
http://www.humanitarianref0rm.0rg/humanitarianref0rm/P0rtals/l/clu
ster%20approach%20page/dusters%20pages/Nutrition/Factsheet%20WHO%20Growth%20Standards%20in%20emergencies%202009.pdf
(accessed May 23, 2009)-
101
I
Comment
5
WaterlowJC. Protein-Energy malnutrition (reprint of original 1992 version,
with new supplementary material). New Barnet, UK: Smith-Gordon, 2006.
6
WHO. Management of severe malnutrition: a manual for physicians and
other senior health workers. 1999- http://www.who.int/nutrition/
publications/en/manage_severe_malnutrition_eng.pdf (accessed
May 23,2009).
Myatt M, KharaT, Collins S. A review of methods to detect cases of
severely malnourished children in the community fortheir admission
into community-based therapeutic care programs. Food Nutr Bull 2006;
27 (suppl): S7-23.
7
8
WHO. The WHO child growth standards. 2006. http://www.who.int/
childgrowth/standards/en (accessed May 23,2009)-
9
Seal A, Kerac M. Operational implications of using 2006 World Health
Organization growth standards in nutrition programmes: secondary data
analysis. BMJ 2007; 334:733Isanaka S, Villamor E, Shepherd S, Grais RF. Assessing the impact of the
introduction of the World Health Organization growth standards and
weight-for-height z-score criterion on the response to treatment of severe
acute malnutrition in children: secondary data analysis. Pediatrics 2009;
123:e54-59-
10
11
12
de Onis M, Onyango AW, Borghi E, Garza C, Yang H. Comparison of the
World Health Organization (WHO) child growth standards and the
National Center for Health Statistics/WHO international growth
reference: implications for child health programmes. Public Health Nutr
2006; 9:942-47de Onis M, Onyango AW. On the WHO child growth standards.
BMJ March 15, 2007. Rapid response: http://www.bmj.com/cgi/
eletters/334/7596/733 (accessed May 23,2009).
13
WHO, World Food Programme, UN System Standing Committee on
Nutrition, UNICEF. Community-based management of severe acute
malnutrition. May, 2007- http://www.who.int/nutrition/topics/statement_
commbased_malnutrition/en/index.html (accessed May 23,2009).
14
Collins S, Sadler K, Dent N, et al. Key issues in the success of
community-based management of severe malnutrition. Food Nutr Bull
2006; 27 (suppl 3): 549-82.
Highlights 2009
A photograph fixes a moment of time in a way that few
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To submit a Lancet Photograph
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taken by our readers during 2009 that capture the
reality of international health in any of its manifold
contexts—from global health to clinical medicine, from
the individual person to populations, from Bangladesh
to Barcelona.
We welcome submissions of photographs that have
not been published previously from anyone with
experience of, or training in, a health-related field.
Lancet editors will pick a selection of images to publish
that reflect a range of subjects in global medicine from
different geographical locations; submissions from
professional photographers will not be selected.
102
For photographs of people or patients, the person's
written consent to publication, or that of the next of kin,
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or black and white photographs and text should be
submitted through the journal's electronic submission
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Photographs will need to be high-resolution images. If
using a digital camera, set your camera to the highest
quality setting and supply JPEG files. If using a film
camera, supply an 8x11 inch glossy print, which can be
posted to The Lancet. The deadline is Oct 5Joanna Palmer
The Lancet, London NW17BY, UK
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