Describe the national nutrition programmes of India.

Supplementary Nutrition and Micronutrient Programmes

• The integrated child development services (ICDS), launched 1975, is the flagship and among the largest programmes of its kind anywhere
• Its beneficiaries — children under 6, pregnant and lactating women, and adolescent girls
• Its six services must be listed, and the point is that only two are strictly nutritional — 1. Supplementary nutrition; 2. Immunisation; 3. Health check-UP; 4. Referral services; 5. Nutrition and health education; and 6. Non-formal pre-school education
• Three of the six are delivered by the health system and three by the Anganwadi worker, which makes convergence between the two departments essential and is where the programme most often falls short
• It is delivered through the anganwadi centre, one per roughly 1000 population, staffed by an anganwadi worker and helper
• The supplementary nutrition norms — roughly 500 kcal and 12 to 15 g protein for children 6 months to 6 years; 800 kcal and 20 to 25 g for severely malnourished children; and 600 kcal and 18 to 20 g for pregnant and lactating women and adolescent girls
• The intention is to fill the gap between what the child eats at home and what they need, not to replace home food — and substitution, where the family gives less at home because the child is fed at the centre, is the classic failure of supplementary feeding
• Its documented weaknesses — concentration on the 3 to 6 year age group who attend the centre, while the under-3s who need it most are hardest to reach; irregular supply; leakage; emphasis on food delivery over counselling; and an overburdened worker with too many registers
• POSHAN abhiyaan (National Nutrition Mission, 2018), now mission saksham anganwadi and POSHAN 2.0, was designed to address exactly these weaknesses
• Its approach — targets for reducing stunting, anaemia and low birth weight; convergence across health, women and child development, water and sanitation, and education; real-time monitoring through the POSHAN tracker; emphasis on the first 1000 days; behaviour change communication through community-based events; and incentives and capacity building for the frontline worker
• The mid-day meal scheme, now PM POSHAN, provides a cooked meal to children in government and aided schools
• Its objectives are double and both should be stated — improving nutrition, and improving enrolment, attendance and retention, particularly of girls and of children from disadvantaged groups
• Its wider social effect is worth mentioning — children of all castes eating together, and the employment of cooks from disadvantaged communities, has had a measurable effect on social attitudes
• The micronutrient programmes:
• Anaemia MUKT BHARAT, with its 6 x 6 x 6 strategy — six target groups, six interventions and six institutional mechanisms; delivering age-appropriate iron and folic acid supplementation, deworming, behaviour change, testing and treatment, fortification and attention to non-nutritional causes such as malaria and haemoglobinopathy
• The national iodine deficiency disorders control programme, based on universal salt iodisation
• Vitamin A prophylaxis, giving biannual megadoses to children 9 months to 5 years
• Deworming through the national deworming day

Food Security, Fortification and Evaluation

• The public distribution system (PDS), now targeted, supplies subsidised foodgrain through fair price SHOPS
• The national food security act, 2013 converted this into a legal right, covering up to 75% of the rural and 50% of the urban population, and providing subsidised grain, maternity benefit, and meals for children and pregnant women
• It also identifies the eldest woman of the household as the head for the purpose of the ration card, which is a deliberate and effective way of directing the entitlement to the person most likely to use it for the family
• The PDS has been criticised for supplying cereals almost exclusively, which meets energy needs while doing nothing for protein or micronutrient quality, and may even worsen dietary diversity by making cereals artificially cheap relative to pulses and vegetables
• Other issues — leakage and diversion; exclusion of eligible households and inclusion of ineligible ones; and lack of portability for migrants, addressed by one nation one ration card
• Food fortification is the addition of nutrients to commonly eaten foods, and is attractive because it requires NO change in behaviour and reaches people passively
• The Indian standards cover salt with iodine and iron (double fortified salt); wheat flour and rice with iron, folic acid and B12; edible oil with vitamins A and D; and milk with A and D, carrying the +F logo
• Fortified rice has been introduced into the PDS and ICDS, which reaches precisely the households least able to diversify their diet
• The three approaches to micronutrient deficiency should be compared, since this is a favourite question:
• Supplementation — rapid and effective, allows a controlled dose, and suits high-risk groups; but requires contact, has poor adherence over time, and is expensive to sustain indefinitely
• Fortification — reaches the whole population passively, is cheap per head and needs no behaviour change; but requires an industrially processed vehicle, which misses the poorest who eat unprocessed local produce, and needs quality control and regulation
• Dietary diversification — the most sustainable and beneficial in every respect, since it delivers all nutrients together; but the slowest, needing income, availability, education and cultural change
• The correct answer is that all three are needed together, with supplementation for immediate effect, fortification for population coverage, and diversification as the long-term goal
• Other programmes — the mid-day meal; Pradhan Mantri Matru Vandana Yojana, giving maternity cash benefit; the SWACHH BHARAT mission, which is a nutrition programme in effect through its sanitation impact; and the National Nutrition Policy and the Eat Right India campaign
• Why progress has been slower than expected, which any good answer must address:
• Malnutrition is caused largely outside the nutrition sector — by poverty, sanitation, women’s status, education and infection — so food-based programmes alone cannot solve it
• Programmes have concentrated on food delivery, which is measurable and visible, rather than on counselling and behaviour change, which is neither
• The under-3s and pregnant women, who matter most, are the hardest to reach
• Frontline workers are overburdened with multiple schemes and registers
• Weak convergence between departments
• Leakage, irregular supply and poor quality
• The lesson — the programmes that have worked best combine food with health care, sanitation, female education and behaviour change; and the states that have done best on nutrition are those that did best on those other things, not those that distributed the most food
• The three approaches are complements, not alternatives, and the correct answer uses all of them together
• Fortification misses the poorest, who eat unprocessed local produce rather than industrially milled food
• Diversification is best and slowest, needing income, availability, education and cultural change together
• States that improved sanitation improved nutrition, more than those that distributed the most food
• Only two of the six ICDS services are nutritional, which is the point of listing them rather than reciting
• Three services come from the health system, which makes convergence essential and is where the programme fails most
• Supplementary feeding should fill a gap, not replace home food, and substitution is its classic failure
• The under-threes need it most and attend least, which is the central targeting problem in ICDS
• The mid-day meal has two objectives, nutritional and educational, and both should be stated
• Children of all castes eating together has had a measurable social effect beyond nutrition
• Anaemia Mukt Bharat uses a six by six by six strategy, covering groups, interventions and institutional mechanisms
• The Food Security Act made grain a legal right, covering most rural and half of urban households
• The eldest woman heads the ration card, which deliberately directs the entitlement to the likeliest user
• The PDS supplies cereals almost exclusively, meeting energy needs while doing nothing for dietary quality
• Cheap cereals may worsen dietary diversity by making pulses and vegetables relatively more expensive
• One Nation One Ration Card addresses migrants, whose entitlement was previously tied to one location
• Fortified rice reaches those least able to diversify, which is why its introduction into the PDS matters
• Food delivery is measurable and counselling is not, which is why programmes drift toward the former
• Frontline workers are overburdened with registers, and adding schemes without removing tasks reduces all of them
• Poshan Abhiyaan emphasises the first thousand days, with convergence and real-time monitoring as its main instruments
• Swachh Bharat is a nutrition programme in effect, through its impact on enteric infection and absorption
• Malnutrition is caused outside the nutrition sector, which is why food-based programmes alone cannot solve it
• Look for the plus F logo, which identifies fortified food under the Indian standards
• Maternity cash benefit supports nutrition, by allowing rest and reducing the need to work through late pregnancy