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A Nutrition Secure India

India continues to suffer from under-nutrition among large sections of its population. The country is unlikely to realise the first millennium development goal by 2015. How can agriculture be used to improve nutritional status?

COMMENTARY

actions (Haddad 2009). In the mean

A Nutrition Secure India
time, under-nutrition continues to exert

a physical, cognitive and economic toll,

Role of Agriculture

costing India as much as 3% of its gross domestic product (GDP) per year. The Copenhagen Consensus 2008 lists com-Suneetha Kadiyala, P K Joshi, S Mahendra Dev, T Nanda Kumar, Vijay Vyas bating micronutrient under-nutrition as

India continues to suffer from under-nutrition among large sections of its population. The country is unlikely to realise the first millennium development goal by 2015. How can agriculture be used to improve nutritional status?

The authors are grateful to Shenggen Fan, Marie Ruel, Rajul Pandya-Lorch, Stuart Gillespie, Purnima Menon, Liz Drake, Rajani Ved, Sukhadeo Thorat, Harshpal Singh Sachdev, S Parasuraman and Shelly Sundberg for their feedback and suggestions on this article.

Suneetha Kadiyala (s.kadiyala@cgiar.org) is with the Poverty, Health, and Nutrition Division, International Food Policy Research Institute, New Delhi. P K Joshi is with the International Food Policy Research Institute, New Delhi. S Mahendra Dev is with the Indira Gandhi Institute of Development Research, Mumbai. T Nanda Kumar is a member of the National Disaster Management Authority, Government of India. Vijay Vyas is a member of the Economic Advisory Council to the Prime Minister of India.

Economic & Political Weekly

EPW
february 25, 2012

I
ndia’s progress in improving nutrition has been unacceptably slow: given the country’s positive economic trajectory, nutrition has improved at only half the expected pace. Almost one in two Indian children is stunted and 40% are underweight. One-third of all Indian women are underweight. Rates of micronutrient deficiencies are extremely high, with almost 80% of children and 56% of women being anaemic1 (Table 1).

Nutrition Insecurity in India

The data on nutrition indicators reveal significant socio-economic inequalities. Several recent studies show the persistence of economic inequities with respect to nutrition improvements over the last two decades (Sen et al 2011; Subramanyam et al 2011; Pathak and Singh 2011). These findings, in the light of India’s economic growth, suggest that India’s under-nutrition problem has roots in systemic factors affecting virtually the entire population. The prevalence of underweight among children is 14% to 20% higher among the scheduled castes (SCs) and scheduled tribes (STs) than children from other castes. Moreover, the reduction in the prevalence of undernutrition has been far slower among children belonging to SCs and STs than children from other castes (Thorat and Sabharwal 2011).

With sustained political commitment and leadership, countries such as China, Vietnam, Senegal, Thailand and Brazil have taken bold actions to successfully accelerate reductions in under-nutrition and are on track to reach the first millennium development goal (MDG) target by the year 2015. For example, Thailand, Vietnam and Brazil positioned nutrition as an investment and an integral part of socio-economic development making this transformational change possible. But India will meet the first MDG target only in 2043 with its present pace of

vol xlvii no 8

the best development investment, with the rate of return in terms of improved health, reduced deaths and increased income opportunities more than 15 times that of the investment.2

Need for Meaningful Convergence

The multiple causes of under-nutrition, at the individual, household and societal levels, are now well-recognised (Figure 1, p 22). Globally and locally in India, reasonable scientific consensus exists on what direct health and nutrition interventions will work. The central and state governments allocate substantial resources to an array of health and nutrition programmes or schemes, such as the Integrated Child Development Services Scheme, mid-day meals, the reproductive and child health programme and National Rural Health Mission (NRHM) to deliver these direct interventions. The challenge for India now lies in making these interventions truly effective at scale.

While effectively scaling-up direct nutrition and health interventions is essential, it is not enough: India must invest in cross-sectoral efforts to act on the deep-rooted causes of under-nutrition in order to sustainably tackle two-thirds of the under-nutrition burden. As noted above, under-nutrition reductions in countries such as Brazil, China, Senegal and Thailand have shown the need to

Table 1: Under-nutrition in India (%)

Nutrition Indicators NFHS II NFHS II
(1998-99) (2005-06)
Stunting (children <3) 51 45
Wasting (children <3) 20 23
Underweight (children <3) 43 40
Anaemia (<11.0g/dl)
(children 6-35 months) 74 79
Vitamin A deficiency (children <5) NA 57
Women with BMI <18.5 36 33
Men with BMI <18.5 NA 28
Women with anaemia 52 56
Men with anaemia NA 24

Source: National Family Health Survey (NFHS)-3 (2005-06). http://www.nfhsindia.org/pdf/India.pdf

COMMENTARY

Child nutrition status

Direct interventions

Infant feeding

Vitamin A, zinc, iron

supplementation,

hygiene fortification

Indirect interventions

Agriculture, social protection, education, health systems, water and sanitation, women’s empowerment

Economic growth poverty reduction, environment, institutions, governance

Sources: Adapted from UNICEF (1990); Black et al (2008).

complement these interventions with approaches that address under-nutrition’s deep-rooted causes.

This comprehensive approach to solving the under-nutrition crisis is gaining momentum in India. The prime minister’s National Council on India’s Nutrition Challenges, formed in 2008 is multisectoral, with representation from more than one dozen ministries.3 The council’s key recommendations include creation of new institutional arrangements that encourage different sectors to work together. Several states, including Karnataka, Madhya Pradesh, Gujarat and Orissa are experimenting with moving nutrition into “Mission Mode” at the state level to accelerate reductions in under-nutrition.

Any new multisectoral institutional arrangement to promote coherence and convergence of policies, programmes and objectives should have a clear mandate to accelerate reductions in undernutrition, with precise objectives, measurable goals, implementation plans, authority, financial support, monitoring guidelines and accountability. The proposed institutional arrangements should include, inter alia a national-level body to ensure policy convergence and to monitor outcomes. Indeed, accelerating reductions in under-nutrition should become India’s basic organising principle for its faster, sustainable and more inclusive growth strategy.

Immediate causes underlying causes Food/nutrient intake health Access to food Maternal and childcare water, sanitation and health services Institutions Basic causes Political and ideological frameworks Economic structure Environment, technology and people

Nutrition specific interventions

Nutrition sensitive interventions

Why Focus on Agriculture?

The pathways through which agriculture affects nutrition are now widely accepted (World Bank 2007; Gillespie and Kadiyala 2011). Global evidence suggests that many developing countries are exploiting these links, but India seems to lag behind (Headey 2011).

The challenges facing the agriculture sector in India may be significant, but so are the opportunities. First, the agriculture sector employs nearly 58% of the total Indian workforce and generates more than 55% of the rural income, so

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the potential for agriculture to influence nutrition at scale is large. Second, more than 80% of rural women engaged in the labour force work in the agriculture sector. This provides a significant opportunity to unleash the gender dimensions of agriculture-nutrition linkages. Third, the commitment of the Government of India and across the States to invest in agriculture is very strong. A policy space now exists to strengthen agriculture to improve nutrition outcomes.

Some Policy Options

Several entry points exist for the agriculture sector to make agriculture more pro-nutrition (Dev and Kadiyala 2011). Below are some specific policy approaches as a starting point to make the agriculture sector more “pro-poor” and “pro-nutrition”.

Leveraging Existing Platforms: The thrust of Indian agriculture sector is to move forward with key schemes and missions such as Rashtriya Krishi Vikas Yojana (RKVY), National Horticulture Mission (NHM) and National Food Security Mission, initiated in the Tenth and the Eleventh Five-Year Plans. Such largescale platforms should focus on improving Indian citizens’ nutrition security, especially in districts with a substantial overlap between poverty and under-nutrition. RKVY, a bottom-up and demand-driven

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february 25, 2012 vol xlvii no 8

COMMENTARY

platform, gives states the incentive to develop comprehensive plans for the agricultural sector, taking into consideration the available technologies, agroclimatic conditions and natural-resource issues. It encourages effective integration of livestock, poultry and fish farming with the crop sector. RKVY’s flexibility and decentralised planning and implementation make integrating nutrition-security concerns into its agenda a possibility.

NHM paid dividends by increasing production of horticultural commodities. Now is the time to harness NHM’s potential by realigning its goals and strategy from a nutrition perspective. The opportunities to dovetail its implementation, leveraging other platforms such as RKVY, National Rural Livelihoods Mission (NRLM) and statelevel nutrition missions are worth serious exploration.

A minimum of 15% of all RKVY and NHM funds could be channelled to plans that integrate nutrition security concerns into their planning, implementation and monitoring. For example, RKVY, NHM and other platforms could use pronutrition funds for programmes that manage water, prevent agricultureassociated waterborne diseases (such as malaria), develop an ecologically sound small-ruminant sector, and create nutrition-sensitive value chains.

Improving Access

While leveraging the existing platforms, as noted above, has a huge potential to boost production of nutrient-rich foods, India can do more.

Food still constitutes, on average, more than half of the expenditures of Indian households. The overall consumption pattern in the last two decades is one of stable rice and wheat consumption for the poor, a rise in fat consumption, sharp declines in coarse cereal consumption, continued decline in pulses consumption and rising consumption of high-value foods (micronutrientrich fruits, vegetables, livestock and fish). Given these contrasting trends, determining whether the average Indian diet has improved or deteriorated during the last 25 years requires further empirical investigation.

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february 25, 2012

Improve Access to Nutrient-rich Foods:

The agriculture sector is responding to changing demand patterns. In aggregate, the high-value food segment accounts for about 47% of the total value of agricultural output. Because India has a large share of small and marginal holdings, the country should explore providing incentives to small farmers to grow vegetables and fruits for household consumption – a strategy that is successful in Thailand.

Pulse production in the last two decades, with the exception of 2010, has remained stubbornly low. The urgent need for a technological breakthrough to increase the yield potential of pulses is widely acknowledged. India now needs to match this with the required investment in research and development and effective extension services to ensure the poor and vulnerable have access to pulses. A majority of the livestock and small ruminant population is concentrated in marginal smallholdings, and women play a significant role in animal husbandry through direct involvement in major operations like feeding, breeding, management and healthcare. Therefore, progress in this sector will result in a more balanced development of the rural economy, particularly in poverty reduction and improved access to nutrient-rich diets.

Decentralised procurement of foodgrains under the public distribution system must be mandated to ensure revival of agriculture in resource-poor areas. Inclusion of nutritious and diverse foods (such as millets, eggs, soy beans and so on) in the decentralised procurement basket offers an excellent opportunity to provide locally acceptable nutritious food to the people while mitigating the problems of storage of food commodities. It also offers a real potential to fortify food commodities with key micronutrients (for example, fortifying wheat with iron). Food stamps or conditional cash transfers targeted to women for the purchase of perishable nutrient-rich foods such as milk, fruits, and vegetables could be considered. Such reforms offer a win-win solution, improving diet quality as well as stimulating and diversifying local agricultural production.

Biofortification of Staple Crops: India must intensify and accelerate its efforts to realise the potential of biofortified crops

– not necessarily genetically modified organisms (GMOs). Biofortification is a process of breeding higher levels of

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    micronutrients (especially zinc, iron and Vitamin A) directly into key staple foods using conventional breeding methods or biotechnology. Several efforts to conventionally-bred (using non-GMO breeding techniques) beta-carotene-rich sweet potato and iron- and zinc-biofortified pearl millet are underway. India must prioritise public research investment to ramp up the development of technologies and effective supply chains to increase the production and consumption of these nutrient-rich foods.

    Leveraging Agriculture to Empower Women: Accelerating undernutrition reduction in India requires realigning agriculture and rural development policy to empower women in agriculture. Resources targeted to women and women’s groups significantly improve agricultural productivity, women’s control of resources or assets, and health and nutrition outcomes.

    The country should promote women’s cooperatives, producer women’s groups and other forms of group efforts, where they do not already exist. This would enable women to overcome the constraints of small, marginally profitable landholdings, thereby improving the dissemination of agricultural technology and other inputs, as well as marketing of produce.

    The NRLM under the Ministry of Rural Development offers significant potential for convergence with the agricultural sector to empower women to care for themselves and their children. NRLM’s federations of self-help groups (SHGs) could radically alter the balance of power not only in the markets they participate in as both producers and consumers, but also in their communities and households.

    Women’s groups, including SHGs under NRLM, can become instrumental in meaningful convergence of health, nutrition, education and other broad-based schemes addressing the deep-rooted causes of under-nutrition. Examples of such group-centric pro-nutrition approaches include producing and consuming nutrient-rich foods through homestead horticulture and poultry interventions; establishing and maintaining micronutrient food fortification units; producing and marketing low-cost, nutrient-dense supplementary foods; developing primary food processing; enabling women and their children to access essential health and nutrition services; and catalysing critical behaviour change for optimal

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    health and nutrition outcomes in the long run through community mobilisation, including the involvement of panchayati raj institutions, around nutrition-specific issues and actions.

    Empowering women in agriculture, which is essential to India’s nutrition security, requires securing women’s rights to land, providing efficient and effective legal support and enhancing women farmers’ access to inputs. For example, entitling women in land records as cultivators on family farms, where women operate the land registered under the name of the male household members, would make a significant difference in accessing various government programme benefits. The government could accomplish this with a comprehensive, countrywide directive that recognises women’s claims in all government land transfers, including transfers for social protection, income generation (crop cultivation, fish cultivation), or resettlement. While linking women in agriculture to the Mahatma Gandhi National Rural Employment Guarantee Scheme is certainly in the discourse, these linkages are yet to be operationalised.

    Institutions of information, extension, credit, inputs and marketing needs have a profound gender bias that must be corrected urgently by taking into account women’s mobility, domestic responsibilities and social constraints. Improving employment conditions and support systems for women are vital to strengthen their capacity to care for themselves and their children. Easy access to maternity entitlements and optimum quality daycare and healthcare facilities for children within the community or at the workplace are critical to translate higher incomes into health and nutrition benefits.

    Recommendations

    India’s central development strategy should be to systematise structural and sector-specific measures the government can implement immediately to promote nutrition security while not losing sight of the long-term changes needed to create a modern, inclusive and just India. Establishing a vibrant and effective governance mechanism and

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    february 25, 2012

    institutional frameworks with budgets, authority, timelines and accountability to demonstrate progress towards reductions in under-nutrition should be given the top priority.

    Agriculture is fundamental to India’s inclusive and sustainable structural economic transformation. It must therefore play a more significant role in promoting nutrition security. The government can maximise the potential of existing architectures across sectors to make them more pro-nutrition oriented and to promote meaningful coherence and convergence across sectors. This policy note highlighted some practical policy options for such an engagement, within the existing agriculture-related mechanisms, schemes and platforms.

    To incentivise states, 15% of the budget of the existing programmes (for instance, RKVY, NRLM, NHM and others) should go to district-level action plans (particularly in those districts where under-nutrition is high) that can demonstrate progress in relevant nutrition security indicators. Translating these investments into nutrition outcomes will also require India and its states to pursue effective social behaviour change communication and mobilisation strategies to change demand, behaviours and consumption patterns, especially for adolescent girls, vulnerable mothers and young children.

    Critical steps include pilot programmes to pressure-test new pro-nutrition approaches to understand their feasibility, scope and niche; scaling up such innovations; and operations research to improve programme implementation. Commitment to tracking agriculture programmes for relevant nutrition indicators and evaluating the impact of the programmes on nutrition outcomes is central to understanding which approaches reduce the under-nutrition burden, where, and why. India must also scale up its investments in integrated data systems (including health, nutrition, economic, and livelihoods) at regular intervals for diagnostics, problem solving and tracking progress.

    Ignoring the agriculture-nutrition pathways in India will have enormous economic and social costs.

    vol xlvii no 8

    Notes

    1 Although this article focuses on under-nutrition, India’s over-nutrition and chronic disease burden is non-trivial. While more than a third of the Indian men and women are too thin, the prevalence of overweight and obesity, currently at 15%, is on an upward swing, and consequently, chronic diseases pose an imminent public health problem. The International Diabetes Federation estimates that the number of diabetic patients in India more than doubled from 19 million in 1995 to 40.9 million in 2007, the highest in the world. India now needs to manage its economic transformation to ensure that its agri-food sector realises its potential – to reduce poverty and increase access to the optimal quality and quantity of foods to nourish its population and simultaneously address over-nutrition and associated lifelong morbidities on the other.

    2 http://www.copenhagenconsensus.com/The %2010%20challenges/Malnutrition%20and% 20Hunger-1.aspx.

    3 Prime minister’s National Council on India’s Nutrition Challenges. 2010. Record of Discussions Held in First Meeting, 24 November.

    References

    Black, R E, L H Allen, Z A Bhutta, L E Caulfield, M de Onis, M Ezzati, Colin Mathers and Juan Rivera (2008): “Maternal and Child Undernutrition: Global and Regional Exposures and Health Consequences”, Lancet, 371: 243-60.

    Dev, S M and S Kadiyala (2011): “Pro-nutrition Ariculture in India: Entry Points and Policy Options”, India Health Beat, Volume 5(8), World Bank and Population Foundation of India, New Delhi.

    Gillespie, S and S Kadiyala (2011): Exploring the Agriculture-Nutrition Disconnect in India, 2020, Conference Brief 20, prepared for the IFPRI 2020 International Conference, “Leveraging Agriculture for Improving Nutrition and Health”, 10-12 February, New Delhi, India.

    Haddad, L (2009): “Lifting the Curse: Overcoming Persistent Undernutrition in India”, IDS Bulletin, Vol 40, (4), 1-8.

    Headey, D (2011): “Pro-Nutrition Economic Growth: What Is It, and How Do I Achieve It?”, Background Paper for the Conference – Leveraging Agriculture for Improving Nutrition and Health, organised by the International Food Policy Research Institute, New Delhi, 10-12 February.

    Pathak, P K and A Singh (2011): “Trends in Malnutrition among Children in India: Growing Inequalities across Different Economic Groups”, Social Science Medicine, doi:10.1016/j.socscimed.2011.06.024.

    Sen, P, S Bharati, S Som, M Pal and P Bharati (2011): “Growth and Nutritional Status of Preschool Children in India: A Study of Two Recent Time Periods”, Food Nutrition Bulletin, 32, (2) 84-93.

    Subramanyam, M A, I Kawachi, L F Berkman and S V Subramanian (2011): “Is Economic Growth Associated with Reduction in Child Undernutrition in India?”, PLoS Med, 8, (3) e1000424. doi:10.1371/journal.pmed.1000424.

    Thorat, S and N S Sabharwal (2011): “Addressing the Unequal Buden of Malnutrion”, India Health Beat, Vol 5(5), World Bank and Population Foundation of India, New Delhi.

    UNICEF (1990): “Strategy for Improved Nutrition of Women and Children in Developing Countries”, A UNICEF Policy Review (New York: UNICEF).

    World Bank (2007): From Agriculture to Nutrition: Pathways Synergies and Outcomes (Washington DC: World Bank).

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