Hunger and malnutrition in India

This is a discussion regarding  hunger and nutrition situation prevailing in India and suggests policy measures for ensuring adequate food security at the household level, particularly for marginalised groups, destitute people, women and children.

Despite rapid economic growth in the past two decades, India is unlikely to meet the first Millennium Development Goal (MDG) of cutting the proportion of hungry people by half. Per capita availability, as well as consumption of food grains, in India has declined since 1996; the percentage of underweight children has remained stagnant between 1998 and 2006; and the calorie consumption of the bottom half of the population has been consistently declining since 1987. In short, all indicators point to the hard fact that endemic hunger continues to afflict a large proportion of the Indian population.

Hunger in simple terms is the desire to consume food. However, as a result of an inadequate diet over time the human body gets used to having less food than is necessary for healthy development, and after a while the body does not even demand more food. In such cases hunger is not expressed, although a lower intake of essential calories, proteins, fats, and micronutrients would result in under-development of the human mind and body. Thus objective indicators such as calorie consumption, body mass index (BMI), the proportion of malnourished children, and child mortality capture hunger more scientifically than the subjective articulation by individuals.  Surveys on self-reported hunger depend on the responses of the head of the household, often a man, who may not admit that he cannot provide even two square meals to his dependants. Pride, self-image and dignity are issues here, which lead to a deep sense of shame and reluctance on the part of heads of households to publicly admit their incapacity to provide for their families. This may result in under-reporting on the number of meals family members are able to afford. Despite this limitation, a recent United Nations Development Programme (UNDP) survey (2008) of 16 districts in the seven poorest states of India showed that for 7.5 percent of respondents access to food is highly inadequate, and for another 29 percent of the households it is somewhat inadequate. A West Bengal government survey also reported that 15 percent of families were facing difficulties in arranging two square meals a day year round. These figures are gloomier than those in the National Sample Survey Organisation (NSSO) survey of the Ministry of Statistics and Programme Implementation, which claim a drastic decline in self-reported hunger in India from 16.1 to 1.9 percent in the past 20 years.

However, NSSO‟s calorie intake data show that at any given point in time the calorie intake of the poorest quartile continues to be 30 to 50 percent less than the calorie intake of the top quartile of the population, despite the poor needing more calories because of harder manual work. The data also show higher reliance of the poor on cereal-based calories because of a lack of access to fruits, vegetables and meat products. Second, daily calorie consumption of the bottom 25 percent of the population has decreased from 1,683 kcalories in 1987–88 to 1,624 kcalories in 2004–05. These figures should be judged against a national norm of 2,400 and 2,100 kcalories/day for rural and urban areas fixed by the Government of India (GOI) in 1979. Similar downward trend is observed for cereal consumption too. As the relative price of food items has remained stable over the past 20 years, declining consumption can be attributed to the lack of purchasing power and contraction of effective demand by poor people, who are forced to spend a greater part of their limited incomes on 3

non-food items like transport, fuel and light, health and education, which have become as essential as food.

Calorie intake refers to the most proximate aspect of hunger, but it neglects other effects of hunger, such as being underweight, and mortality. These are captured by the Global Hunger Index (GHI) which was designed by the International Food Policy Research Institute (IFPRI) based on three dimensions of hunger: lack of economic access to food, shortfalls in the nutritional status of children, and child mortality, which is to a large extent attributable to malnutrition. IFPRI estimated the hunger index for India as 23 percent in 2008, which placed it in the category of nations where hunger was „alarming‟, with Madhya Pradesh being categorised as „extremely alarming‟. Worse, India's score was poorer than that of many sub-Saharan African counties with a lower GDP than India‟s.

This is primarily because anthropometric indicators of the nutritional status of children in India are among the worst in the world. According to the National Family Health Survey, the proportion of underweight children remained virtually unchanged between 1998–99 and 2005–06 (from 47 to 46 percent for the age group of 0–3 years). These are appalling figures, which place India among the most „undernourished‟ countries in the world.

The higher child malnutrition rate in India (and for that matter in the whole of South Asia) is caused by many factors. First, Indian women‟s nutrition, feeding and caring practices for young children are inadequate. This is related to their status in society, to early marriage, low weight at pregnancy and their lower level of education. The proportion of infants with a low birth weight in 2006 was as high as 30 percent. Underweight women produce low birth-weight babies which become further vulnerable to malnutrition because of low dietary intake, lack of appropriate care, poor hygiene, poor access to medical facilities, and inequitable distribution of food within the household.

Second, many unscientific traditional practices still continue, such as delaying breast feeding after birth, no exclusive breastfeeding for the first five months, irregular and insufficient complementary feeding in the period six months to two years of age, and lack of disposal of children's excreta because of the practice of open defecation in or close to the house itself. Clearly the government‟s efforts to change these age old practices are not working well.

Third, poor supply of government services, such as immunisation and access to medical care, and lack of priority to assigned primary health care in government programmes also contribute to morbidity. These factors, combined with poor food availability in the family, unsafe drinking water and lack of sanitation, lead to high child under-nutrition and mortality. About 2.1 million deaths occur annually in under-five-year-old children in India. Seven out of ten of these are caused by diarrhoea, pneumonia, measles, or malnutrition and often a combination of these conditions.

Policy recommendations

First, revamp small-holder agriculture. Because of stagnating growth in agriculture after the mid-1990s there has been employment decline, income decline and hence a fall in aggregate demand by the rural poor. The most important intervention that is needed is greater investment in irrigation, power and roads in poorer regions. It is essential to realise the potential for production surpluses in central and eastern India, where the concentration of poverty is increasing.

Second, launch watershed development programmes in the uplands, where most tribes live. In a successful watershed programme the poor benefit in three ways. First, as the net sown area and crop intensity increases, more opportunities for wage employment are created, which may also increase the wage rate besides the number of days of employment. Second, greater water availability and reduced soil erosion increase production on small and marginal farmers‟ lands. And, last, the higher productivity of common property resources (CPRs) improves access of the poor to more fodder, fuelwood, water and non-timber forest products (NTFPs).

Third, start a drive to plant fruit trees on degraded forest and homestead lands that belong to or have been allotted to the poor. This will not only make poor people‟s diet more nutritious, but will also diversify their livelihoods and reduce seasonal vulnerability.

Fourth, create more job opportunities by undertaking massive public works in districts with low agricultural productivity. The legal guarantee of 100 days wages available under the National Rural Employment Guarantee Act (NREGA), according to the Comptroller and Auditor General of India (Comptroller and Auditor General 2007), has been fulfilled in only 3 percent of cases. In addition to increased outlays, the scheme should have a food component, now that the GOI has a comfortable stock of food grains. Monitor the inclusion of old people, especially widows, among the wage workers, who are often illegally turned away from worksites. Their work guarantees should be extended to 150 days through an amendment in the Act.

Fifth, provide separate ration cards as well as NREGA job cards to all „single‟ women, regardless of whether they live alone, with dependants, or in their natal or husband‟s home. Likewise for aged, infirm and disabled people who may or may not live with „able-bodied‟ caregivers.

Sixth, improve the skills of the poor for market oriented jobs, so that they are absorbed in the sunrise industries such as hospitality, security, health and construction.

Seventh, improve the distribution of subsidised food grains to the poor through the Public Distribution System (PDS). This would require a correct listing of below-poverty-line (BPL) families, as errors mean many BPL families are excluded while above-poverty-line (APL) families are included. Launch a drive in collaboration with civil society to cover the poorest, as a large number of homeless and poor people living in unauthorised colonies in urban areas have been denied ration cards, and are thus not able to access the PDS, on the grounds that they do not have an address!

Eighth, restructure the Integrated Child Development Services (ICDS). Despite a three-fold increase in its budget by the GOI in the past five years and the contention of the Ministry of Women and Child Development that there are 1.5 early child-care centres (ICDS centres) per village now, ICDS is reaching only 12.5 percent children in the age group six months to six years. As each centre is likely to be located in the richer part of the village, it may not reach the vulnerable children of poorer households and lower castes and those living in remote areas. The programme targets children mostly after the age of three, when malnutrition has already set in. It does not focus on the critical age group of children under three years, the age window during which health and nutrition interventions can have the most effect.

The focus of ICDS should be health and nutrition education, encouraging women to breastfeed exclusively for six months and after that to add semi-solid family food four

to six times a day in appropriate quantities for the infant, which alone can improve the infant‟s nutrition levels. For nutrition to improve, we have to strengthen proper breastfeeding and complementary feeding, together with complete immunisation and prompt management of any illness.

Ninth, cover all adolescent girls under ICDS. They need to be graded according to age, such as 10–15 group, 16–19 group and pregnant girls. Then they should be weighed regularly, and given appropriate nutritious food containing all the desired micro-nutrients and iron. Similar initiatives are needed for all women.

Tenth, establish ICDS centres as a priority within one year in all primitive tribal group (PTG) settlements and the most marginalised scheduled caste (SC) – previously the untouchable people - settlements, without any ceiling on minimum children; do this for all other hamlets with more than 50 percent SC, ST, or minority populations within two years. In all these centres ICDS staff should be locals from the affected communities, two hot meals should be served instead of one to children aged three to six years; and weaning foods given at least twice daily to children below three years of age.

Eleventh, prepare a comprehensive list every two years of all destitutes needing free or subsidised cooked food. Open kitchens that serve mid day meals to the old, the destitute and the hungry in the village. This is already being done in Tamil Nadu, and its replication in other states should be funded by the GOI. Establish community kitchens across cities and urban settlements to provide inexpensive, subsidised, nutritious cooked meals near urban homeless and migrant labour settlements.

Last, India requires a significant increase in targeted investments in nutrition programmes, clinics, disease control, irrigation, rural electrification, rural roads, and other basic investments, especially in rural areas, where the current budgetary allocations are inadequate. Higher public investments in these areas need to be accompanied by systemic reforms that will overhaul the present system of service delivery, including issues of control and oversight .