t the dawn of a new millennium, in September
2000, United Nations Millennium Declaration was the main document of the
Millennium Summit of the United Nations. It contained a statement of
values, principles and objectives for the international agenda for the
twenty-first century. It also set deadlines for many collective actions.
Under the framework of Millennium Development Goals (MDGs) 147 heads of
State and Government, and 189 nations made a promise to free people from
extreme poverty and multiple deprivations [1]. Millennium Declaration is
a historical event because it is not just a written promise by the
member states to achieve eight international development goals by the
year 2015, but it describes achievable goals and ‘realistic’ targets to
accomplish these goals [2].
Whereas the goals and targets are clearly spelled out
in the United Nations Millennium Declaration (UNMD), development of new
strategies and implementation of programs to achieve these targets
remain the responsibility of the countries. Therefore, precise
monitoring mechanisms have been put in place, in form of national
Millennium Goals reports and the Secretary General’s reports to the
General Assembly. Civil society organizations around the world are
creating their own set of reports as well, to ensure that governments
are held responsible to the highest possible standards of performance.
Child Undernutrition and Food Security
Child undernutrition on account of stunting, severe
wasting, and intrauterine growth restriction together are reported to be
responsible for 2.2 million deaths and 21% of disability-adjusted
life-years (DALYs) for children younger than 5 years [3]. Twelve years
after Millennium declaration nearly one in five children under age five
in the developing world is underweight [4]. In India, the national trend
of the proportion of underweight children below 3 years of age
shows that we are going slow in eliminating undernutrition. From
estimated 52% in 1990, the proportion of underweight children below 3
years, required to be reduced to 26% by 2015, is expected to come down
to about 33% [5].
Reduction in proportion of children under age five
who are underweight has found a place in MDGs as one of the indicators
of target 1C ( halve, between 1990 and 2015, the proportion of people
who suffer from hunger) under Goal 1 (eradicate extreme poverty and
hunger) [2]. Assigning child undernutrition to Goal 1 of the declaration
raises a question that child undernutrition is not affected by food
intake alone; it is also influenced by access to health services,
quality of care for the child and pregnant mother as well as good
hygiene practices. Nutrition in children is also influenced by a host of
sociocultural determinants and adversely affected by common childhood
morbidities. Considering the ecology of undernutrition; one wonders
whether reduction of undernutrition in underfive children should have
been prioritized under child health (Goal 4) as well as/ or included
under eradication of extreme poverty and hunger (Goal 1).
World over, lots of efforts have been made during the
last decade to tackle undernutrition using strategies and programs
primarily aimed at reducing extreme poverty and hunger. The road map
towards the implementation of the United Nations Millennium Declaration
(UNMD) outlines potential strategies for action that are designed to
meet the goals and commitments made by the Millennium Declaration.
Strategies, based on "best practices" for moving forwards to achieve
Goal 1 of UNMD, include economic and social initiatives that
focus on poverty reduction, capacity-building for poverty assessment,
monitoring and planning, ensuring that food, agricultural trade and
overall trade policies are conducive to fostering food security for all
through a fair and just world trade system and continuing to give
priority to small farmers [6]. However, one doesn’t find any specific
strategy in the road map which can directly facilitate reduction in
proportion of children under age five who are underweight.
Like many other countries, lot of efforts directed at
eradication of poverty and hunger have been made in India during first
twelve years of the millennium. Several anti poverty programs related to
food security, education, employment opportunities, self employment,
insurance security, low cost housing and all round development of rural
poor have been launched with government of India support. Mahatma Gandhi
National Rural Employment Guarantee Scheme (NREGS) [7] is the latest,
launched in 2006 to provide legal guarantee for 100 days of wage
employment to every household in the rural areas of the country each
year.
Within the ambit of Article 21 of the Constitution of
India, the Supreme Court of India has laid down that the right to food
is a fundamental requirement that falls under the right to life [8].
Since Independence, many programs and initiatives by the Government have
evolved to eliminate hunger in the country. Attempts at ensuring food
security have been made by improving availability of food in the public
distribution system and the market. Mid- day meal Scheme, Integrated
Child Development Services (ICDS) Scheme, Annapurna Scheme and Targeted
Public Distribution Scheme (TPDS) have had success in several states in
India in addressing the needs of poor house- holds [9].
There is no disagreement that a close relationship
exists between child undernutrition and issues of poverty and hunger in
general and a positive impact of hunger and poverty alleviation on
nutritional status of children. Undernourished children across the world
have benefitted by these anti-poverty and food security programs.
Children were among thousands who benefited from Fome Zero ("Zero
Hunger"), a national effort to eliminate hunger in Brazil and there was
a definite reduction in health facility visits for poverty related
health problems due to a national anti-hunger program that gave children
three meals a day [10]. But the question remains whether these
‘secondary gains’ are adequate enough to respond to a challenging
problem like child undernutrition?
Is it logical to look at undernutrition as one of the
common childhood illnesses and include it under MDG 4. If yes, what
would it mean in terms of implementation of programs and specific
interventions. Would it be different than what it is at present?
MDGs - Reduction in Child Undernutrition an Indicator
and not a Target
The framework of MDGs comprises of achievable goals
and ‘realistic’ targets. Indictors significantly reflect the outcome and
contribute to monitoring of inputs towards achieving goals. One can
debate whether undernutrition in under-five children should have been
considered as a ‘target’ instead of an indicator. The target of reducing
extreme poverty by half has been reached five years ahead of the 2015
deadline but hunger remains a global challenge. In the developing
regions, the proportion of children under age five who are underweight
declined from 29 % in 1990 to 18% in 2010. However, progress in
reduction of under-five undernutrition is insufficient to reach the
global target by 2015 [4]. This raises a question whether national
governments would have conceived different strategies and launched more
effective programmes if "halve, between 1990 and 2015, the proportion of
underfive children with undernutrition" was one of the targets of Goal 1
or Goal 4.
An equally important indicator of overall child
health and nutritional status is stunting, which often goes unrecognized
in the developing world. More common than being underweight, stunting
also more accurately reflects nutritional deficiencies and illnesses
that occur during the early-life period, and are likely to hamper growth
and development. Although the prevalence of stunting fell from an
estimated 44 per cent in 1990 to 29 per cent in 2010, millions of
children remain at risk for diminished cognitive and physical
development resulting from long term undernutrition [4]. Stunting did
not find a place in the MDG framework and remains neglected.
Current Status of Child Undernutrition
The most recent MDG report of 2012 indicates that
close to one-third of children in Southern Asia were underweight [4].
Eighty percent of the world’s undernourished children live in just 20
countries including India. Intensified nutrition action in these
countries is believed to lead to achievement of the first Millennium
Development Goal (MDG1) and greatly increase the chances of achieving
goals for child and maternal mortality (MDGs 4 and 5).
Although addressing general deprivation and inequity
would continue to result in substantial reductions in undernutrition and
should be a global priority, major reductions in undernutrition could be
made through programmatic health and nutrition interventions [3].Some of
the known simple cost-effective measures delivered at key stages of the
life cycle, particularly from conception to two years after birth, could
greatly reduce undernutrition. These measures include improved maternal
nutrition and care, breastfeeding within one hour of birth, exclusive
breastfeeding for the first six months of life, and timely, adequate,
safe, and appropriate complementary feeding and micronutrient intake
between 6 and 24 months of age. There is no doubt that evidence based
effective interventions are available for improving child nutrition, but
the question remains as to how these interventions are delivered to the
vulnerable population? To what extent these interventions have been
intensified through various programs after the countdown for MDGs has
begun ?
India has about half the world’s undernourished
children despite modest reduction of poverty in the country. Examination
of recent evidence on nutrition in India suggests that there is a
sustained decline in per-capita calorie consumption during the last
twenty five years or so and the decline is not limited to calories but
also applies to proteins and many other nutrients [11]. According to the
most recent NFHS data, there has been virtually no change in the
proportion of underweight children between 1998-99 and 2005-6 (NFHS-1
and 3). So the question comes up, to what extent target 1C of Goal 1
relates to reduction of undernutrition in children ?
Child Undernutrition - A Multifaceted Public Health
Problem
Child undernutrition is a multifactorial public
health problem which requires focussed attention and coordination across
sectors. Children are underweight due to a combination of factors: lack
of quality food, suboptimal feeding practices, repeated attacks of
infectious diseases and pervasive undernutrition. Lack of flush toilets
and other forms of improved sanitation which might result in repeated
bouts of diarrheal disease and high prevalence of low birthweight babies
are contributory factors. A six state assessment of social determinants
of undernutrition reveals that apart from food security, the critical
social determinants of undernutrition in India are inadequate and
inappropriate feeding practices, limited time for mothers/ care givers
for food preparation and feeding, marketing of commercial ready-to-eat
food, and inadequate responsiveness of government programmes and schemes
to address child nutrition (INCLEN study - personal communication).
Existing programs and schemes specifically focused on
undernutrition in children, like Mid-Day Meal Scheme and Integrated
Child Development Services (ICDS) Scheme, are continuing without
intensification or scaling up. Infant and Young Child Feeding (IYCF)
strategy has a potential to effectively prevent undernutrition.
Integrated Management of Neonatal and Childhood Illness (IMNCI) strategy
includes early detection and management of undernutrition in children
younger than 5 years. However, due to slow pace of implementation and
limited coverage of health programs guided by these strategies, no
visible impact is seen on reduction of number of underfive children with
undernutrition.
Special interventions have been introduced to
identify and manage children with severe acute malnutrition (SAM) in
order to combat death and disability as a consequence of undernutrition.
WHO guidelines are widely used for the identification of 6-60 months old
infants and children for the management of SAM children [12]. Under
National Rural Health Mission, Nutrition Rehabilitation Centers (NRCs)
have been set up at health facilities in many districts in India with
the intention to improve the quality of care being provided to children
with SAM and to reduce child mortality [13]. But limited scope of
performance directed at the tip of iceberg does not help in reducing the
number of under-five children with underweight. All of these programs
have potential, but they do not form a comprehensive nutrition strategy,
and they have not addressed the nutrition problem effectively so far.
Child undernutrition is not just a nutritional
problem. It needs to be seen in the backdrop of child health in general
with specific focus on common childhood illnesses. Despite clear
evidence of the disastrous consequences of childhood nutritional
deprivation in the short and long terms, nutritional health remains a
low priority.The approach ought to be focused on growth and development,
and child survival. Unless concerted efforts are made to reduce child
undernutrition, its importance would be diluted by overarching goals and
targets.
The Way Forward
Child undernutrition continues to be a major child
health problem with barely three years left for achieving MDGs. Since
there is no possibility of further modifications to the indicators,
targets, or goals before the end of the MDG period in 2015, the efforts
need to be channelized towards finding ways to scale-up already known
effective interventions against child undernutrition. It is time for
nutrition to be placed higher on the development agenda. A number of
simple, cost-effective measures to reduce undernutrition in the critical
period from conception to two years after birth are available. Urgent,
accelerated and concerted actions are needed to deliver and scale-up
such interventions so as to extend the gains made thus far.
The period from pregnancy to 24 months of age is a
crucial window of opportunity for reducing undernutrition and its
adverse effects. Program efforts, as well as monitoring and assessment,
should focus on this segment of the continuum of care. It was not long
ago when United Nations Secretary General joined a group of leaders in
pledging to do more to address the global burden of undernutrition. The
group set the ambitious target of substantially reducing undernutrition
during the most vulnerable 1,000-day period of a child’s life, from
pregnancy to the age of two. Nineteen countries have joined the Movement
for Scaling Up Nutrition (SUN). The commitment and leadership of
national stakeholders is the heart of the SUN Movement. Efforts to
scale-up nutrition in SUN countries are driving global progress.
Building on the Sun framework, countries tailor efforts to meet local
needs and capitalize on opportunities to maximize cross-sector
resources, while establishing the foundation for a long-term commitment
to nutrition [14]. So far India is not one of the SUN countries.
There is definitely a need for choosing nutrition
strategies relevant in Indian context. Experiences from other countries,
like multisectoral actions with emphasis on service-oriented nutrition
policies (Indonesia) or mobilization-oriented nutrition policies
(Thailand), should lead India toward innovative nutritional strategies
in order to reduce underfive undernutrition in the country – that too on
a fast track.
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