Schemes to deal with Malnutrition in India

Context: Schemes to deal with Malnutrition in India is an important topic for UPSC Prelims and GS Paper 2.

National Nutrition Mission

National Nutrition Mission (NNM)was set up with a three year budget of Rs.9046.17 crore commencing from 2017-18.

Features:

1. The NNM, as an apex body, will monitor, supervise, fix targets and guide the nutrition related interventions across the Ministries.

2. The proposal consists of :

1. mapping of various Schemes contributing towards addressing malnutrition
2. introducing a very robust convergence mechanism
3. ICT based Real Time Monitoring system
4. incentivizing States/UTs for meeting the targets
5. incentivizing Anganwadi Workers (AWWs) for using IT based tools
6. eliminating registers used by AWWs
7. introducing measurement of height of children at the Anganwadi Centres (AWCs)
8. Social Audits
9. setting-up Nutrition Resource Centres, involving masses through Jan Andolan for their participation on nutrition through various activities, among others.

Major impact:

The programme through the targets will strive to reduce the level of stunting, under-nutrition, anaemia and low birth weight babies. It will create synergy, ensure better monitoring, issue alerts for timely action, and encourage States/UTs to perform, guide and supervise the line Ministries and States/UTs to achieve the targeted goals.

Implementation strategy and targets:

Implementation strategy would be based on intense monitoring and Convergence Action Plan right upto the grass root level. NNM will be rolled out in three phases from 2017-18 to 2019-20. NNM targets to reduce stunting, undernutrition, anemia (among young children, women and adolescent girls) and reduce low birth weight by 2%, 2%, 3% and 2% per annum respectively. Although the target to reduce Stunting is atleast 2% p.a., Mission would strive to achieve reduction in Stunting from 38.4% (NFHS-4) to 25% by 2022 (Mission 25 by 2022).

Background:

There are a number of schemes directly/indirectly affecting the nutritional status of children (0-6 years age) and pregnant women and lactating mothers. In spite of these, level of malnutrition and related problems in the country is high. There is no dearth of schemes but lack of creating synergy and linking the schemes with each other to achieve common goal. NNM through robust convergence mechanism and other components would strive to create the synergy.

ICDS Scheme

The scheme was started in 1975 and aims at the holistic development of children and empowerment of mother. It is a Centrally-Sponsored scheme. The scheme primarily runs through the Anganwadi centre. The scheme is under the Ministry of Women and Child Development.

ICDS Objectives

The chief objectives of the Integrated Child Development Services (ICDS) scheme are as follows:

• To improve the nutritional and health status of children in the age-group 0-6 years;
• To lay the foundation for proper psychological, physical and social development of the child;
• To reduce the incidence of mortality, morbidity, malnutrition and school dropout;
• To achieve effective co-ordination of policy and implementation amongst the various departments to promote child development; and
• To enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education.

ICDS Provisions and Services

Integrated Child Development Services is Centrally-Sponsored and will provide the following six services to the beneficiaries:

1. Supplementary Nutrition (SNP)
2. Health & Nutrition Check-Up
3. Immunization
4. Non-Formal Education for Children in Pre-School
5. Health and Nutrition Education
6. Referral services

These services are provided from Anganwadi centres established mainly in rural areas and staffed with frontline workers.

Supplementary Nutrition Programme (SNP)

Under this segment of the ICDS, children below 6 years and pregnant and lactating mothers are identified within the community and are provided with supplementary feeding and growth monitoring services. The beneficiaries are given 300 days of supplementary feeding. By giving supplementary feeding, the scheme tries to bridge the caloric gap between the national recommended and average intake of children and women in low-income categories.

Health & Nutrition Check-Up

This includes healthcare of children under six years of age, antenatal care of pregnant women and postnatal care of nursing mothers. Services offered include regular health check-ups, treatment of diarrhoea, deworming, weight recording, immunizations and distribution of simple medicines.

Immunization

Children are given vaccinations against the following preventable diseases: diphtheria, polio, pertussis, measles, TB and tetanus. Pregnant women are given vaccinations against tetanus that reduced neonatal and maternal mortality.

Non-Formal Education for Children in Pre-School (PSE)

This segment can be deemed to be the backbone of the ICDS scheme. All the services of the scheme converge at the Anganwadi centres in villages and rural areas, and urban slums. This preschool educational programme mainly for underprivileged children is directed towards providing and ensuring a natural, joyful and stimulating environment, with emphasis on necessary inputs for optimal growth and development. The early learning component of the ICDS is a significant input for providing a sound foundation for cumulative lifelong learning and development. It offers the child the necessary preparation for primary schools and also frees older siblings (particularly girls) from taking care of younger children in the family and thus enabling them to attend schools.

Health and Nutrition Education

Under this component, ladies in the age group of 15 to 45 years are covered for providing Nutrition and Health Education. This forms part of BCC (Behaviour Change Communication) strategy. The long-term goal is to build the capacities of women to enable them to look after their own health, nutrition and development needs as well as that of their children and families.

Referral Services

During the regular health check-ups, any case of conditions or diseases requiring immediate medical attention is referred to the hospital or any primary health centre, etc. The Anganwadi worker is also trained to detect disabilities in children so that early intervention can be done.

Beneficiaries of ICDS Provisions includes pregnant and lactating women and children under 6 years of age

Mid Day Meal Scheme-

Mid Day Meal in schools has had a long history in India. In 1925, a Mid Day Meal Programme was introduced for disadvantaged children in Madras Municipal Corporation. By the mid 1980s three States viz. Gujarat, Kerala and Tamil Nadu and the UT of Pondicherry had universalized a cooked Mid Day Meal Programme with their own resources for children studying at the primary stage by 1990-91. The number of States implementing the mid day meal programme with their own resources on a universal or a large scale had increased to twelve states.

1. With a view to enhancing enrolment, retention and attendance and simultaneously improving nutritional levels among children, the National Programme of Nutritional Support to Primary Education (NP-NSPE) was launched as a Centrally Sponsored Scheme on 15th August 1995, initially in 2408 blocks in the country. By the year 1997-98 the NP-NSPE was introduced in all blocks of the country. It was further extended in 2002 to cover not only children in classes I -V of Government, Government aided and local body schools, but also children studying in EGS and AIE centres. Central Assistance under the scheme consisted of free supply of food grains @ 100 grams per child per school day, and subsidy for transportation of food grains up to a maximum of Rs 50 per quintal.
2. In October 2007, the scheme has been further revised to cover children in upper primary (classes VI to VIII) initially in 3479 Educationally Backwards Blocks (EBBs). Around 1.7 crore upper primary children were included by this expansion of the scheme. From 2008-09 i.e w.e.f 1st April, 2008, the programme covers all children studying in Government, Local Body and Government-aided primary and upper primary schools and the EGS/AIE centres including Madarsa and Maqtabs supported under SSA of all areas across the country.
3. Nutritional Diet provided to children

Primary Level per child

Calories- 480kcal

Foodgrain- 100gm

Pulses-20gm

Vegetables-50gm

Oil/Fat -5gm

Upper Primary Level per child

Calories-720kcal

Foodgrain-150gm

Pulses-30gm

Vegetables-75gm

Oil/Fat-7gm

About the PM POSHAN Scheme

Mid Day Meal changed to PM Poshan Scheme

1. The CCEA cleared the PM POSHAN ( Poshan Shakti Nirman) Scheme for providing one hot cooked meal in Government and Government-aided schools from 2021-22 to 2025-26, earlier known as ‘National Programme for Mid-Day Meal in Schools’ popularly known as Mid-Day Meal Scheme. This is a Centrally-Sponsored Scheme which covers all school children studying in Classes I-VIII in Government, Government-Aided Schools.
2. The Cabinet Committee on Economic Affairs (CCEA), approved the continuation of the national scheme of PM POSHAN in Schools for the five-year period 2021-22 to 2025-26 with the financial outlay of ? 54061.73 crores from the Central Government and ? 31733.17 crore from State Governments & UT administrations. Central Government will also bear additional cost of about ? 45000 crore on food grains. Therefore, the total scheme budget will amount to ? 130794.90 crore.
3. Highlights of the decision that would improve the efficiency and effectiveness of the scheme are as below:
   • The scheme is proposed to be extended to students studying in pre-primary or Balvatikas in Government and Government-aided primary schools in addition to all the 11.80 crore children from elementary classes.
   • The concept of Tithi Bhojan will be encouraged extensively. Tithi Bhojan is a community participation programme in which people provide special food to children on special occasions/festivals.
   • School Nutrition Gardens in schools to give children first-hand experience with nature and gardening. The harvest of these gardens is used in the scheme providing additional micro nutrients. School Nutrition Gardens have already been developed in more than 3 lakh schools.
   • Social Audit of the scheme is made mandatory in all the districts.
   • Special provision is made for providing supplementary nutrition items to children in aspirational districts and districts with high prevalence of Anaemia.
   • Cooking competitions will be encouraged at all levels right from village level to national level to promote ethnic cuisine and innovative menus based on locally available ingredients and vegetables.
   • Vocal for Local for Atmanirbhar Bharat: Involvement of Farmers Producer Organizations (FPO) and Women Self Help Groups in implementation of the scheme will be encouraged. Use of locally grown traditional food items for a fillip to local economic growth will be encouraged.
   • Field visits for progress monitoring and inspections will be facilitated for students of eminent Universities / Institutions and also trainee teachers of Regional Institutes of Educations (RIE) and District Institutes of Education and Training (DIET).

EDITORIAL- A vital cog in Bongaigaon’s response to malnutrition

Project Sampoorna’s success in reducing child malnutrition is a model that can be easily implemented anywhere

‘Let food be thy medicine and medicine be thy food’. This statement is often attributed to Hippocrates, the Father of Medicine, and quite literally sums up Project Sampoorna which was conceptualised and successfully implemented in Bongaigaon district of Assam.

An interlink

• The project has resulted in the reduction of malnutrition in children using near zero economic investment. Sampoorna is in tandem with the United Nations’ Sustainable Development Goals and those set by the UN Secretary General António Guterres in the Food Systems Summit (September 2021) including the need to have food systems and social protection that support resilience and food security.
• Prime Minister Narendra Modi also had identified health and nutrition as priority areas and reiterated the need for a ‘Kuposhan mukt Bharat’ (Malnutrition Free India) while launching the Prime Minister’s Overarching Scheme for Holistic Nourishment (POSHAN Abhiyaan) (National Nutrition Mission) in 2017-18.
• It was during Poshan Maah (Nutrition Month) in September 2020 that 2,416 children were identified to be malnourished in the lush green Brahmaputra valley district of Bongaigaon.
• The National Family Health Survey (NHFS)-5) has documented that the number of children under five who are stunted, wasted, underweight and the number of anaemic women and children in the district are higher than the national average — anaemia being a major determinant of maternal and child health.
• These were corroborated by Project Saubhagya that was designed to reduce the maternal mortality rate and infant mortality rate of the district.
• A real time data sheet is updated by field-level doctors as and when a high risk pregnancy is identified, which is then followed up till safe delivery. The project has yielded encouraging results; maternal deaths for six months (April 1, 2020 to September 30, 2020 compared to April 1, 2021 to September 30, 2021) have fallen from 16 to three and infant deaths from 130 to 63.

Addressing child nutrition

• The highest risk factor for high risk pregnancy is anaemia which is usually nutritional. The vicious cycle of a malnourished child growing into an unhealthy adolescent, and then further into an anaemic pregnant young woman giving birth to an asphyxiated low birth weight baby; this baby then facing possible developmental delays, only to grow into a malnourished child; and this child who struggles further for nutrition and appropriate care while the world around her barely makes ends meet is the one that sucks in all possibilities of a healthy society.
• This portrays the worst-case scenarios, but truth is indeed stranger than fiction. In order to break out of this vicious cycle, the low-hanging fruit had to be targeted — children’s nutrition.

Malnutrition, patriarchy

• Bongaigaon has 1,116 Anganwadis with a total of 63,041 children below five. The massive exercise of plotting their weights and heights in World Health Organization growth charts revealed a total of 2,416 malnourished children; 246 cases of Severe Acute Malnutrition (SAM) and 2,170 instances of Moderate Acute Malnutrition (MAM).
• District Nutritional Rehabilitation Centres, or NRCs, usually have up to 20 beds; and a monthly intake of 200 SAM children is not practical.
• Also, parents of the children who are admitted forgo their daily wages (which to an extent is compensated by the Government) and abandon their farmlands for 10 days.
• Back home, siblings of the SAM child are not taken care of and may become malnourished. The treated child could also slip back to a SAM state after being discharged and if not cared for.
• We needed to innovate now. Based on the success of the community-based COVID-19 management model (Project Mili Juli), we launched Project Sampoorna targeting the mothers of SAM/MAM children, the tagline being ‘Empowered Mothers, Healthy Children’.
• In addition, we identified the mother of a healthy child of the same Anganwadi Centre (AWC) and paired her with the target mother; they would be ‘Buddy Mothers’ (2,416 pairs).
• They were usually neighbours and shared similar socio-economic backgrounds. The pairs were given diet charts to indicate the daily food intake of their children; they would have discussions about this on all Tuesdays at the AWC. Local practices related to nutrition would also be discussed.
• The major hindrance to the project was patriarchy. Mothers had to be empowered financially for sustained results. Therefore, they were enrolled in Self Help Groups (SHGs) under the National Rural Livelihoods Mission (NRLM).
• By the end of three months, 74.3% of mothers were enrolled in SHGs; by the end of six months, enrollment went up to 75.6% and by the end of a year, it was 90%.
• Meanwhile, we arranged for 100 millilitres of milk and an egg on alternate days for all 2,416 children for the first three months, giving time for their mothers to stabilise themselves in the newly found jobs. The large hearted people of Bongaigaon adopted Anganwadis and filled the tiny stomachs with the much needed proteins and their hearts with love.

A sea change

• After three months of Project Sampoorna, out of 246 SAM children, 27 (11%) continued to be SAM, 28 (11.4%) improved to MAM and a whooping 189 (76.8%) became normal.
• Out of 2,170 MAM children, 12 (0.6%) deteriorated to SAM, 132 (6.08%) stayed MAM and an unbelievable 2,015 (92.8%) became normal.
• The best was yet to come. Milk and eggs were stopped after three months but we continued to follow up to see how our Buddy Mothers Model and Women Empowerment Model were working.
• Mothers had done what institutions could not do for years. By March 2021, 84.96% of SAM children and 97.3% MAM children were normal; and by September 2021, 92.3% SAM and 98.9% MAM children were normal. Project Sampoorna had stood the test of time.
• Children who had not improved were checked and treated by doctors under the Rashtriya Bal Swasthya Karyakram (RBSK). UNICEF, IIT Guwahati, Tezpur University and the Social Welfare Department lent their support in periodic course correction.
• Project Sampoorna had prevented at least 1,200 children from becoming malnourished over the last year. The National Nutrition Mission and the State government recognised our project in the ‘Innovation Category’.

Way Forward

The model can easily be implemented anywhere in the world. We believe children everywhere have the right to stay healthy, and hope that the vicious cycle is broken sooner rather than later.