Persistent malnutrition causes the biggest good governance challenges to India and many other developing countries.Malnutrition is directly or indirectly associated with 56% of all child mortality and is the main contributor to the burden of disease in poorer communities.
Malnutrition is a silent killer. Often parents, community leaders, the media, and government at all levels do not recognize the extent of the problem. It is so widespread in some places that adults have lost perspective on the dimensions of a well-nourished child.
Unlike many other health issues, it is difficult to cite clear numbers of deaths resulting from malnutrition that can be used to mobilize action.
Good Governance Challenge 1 Malnutrition weakens Education
Malnutrition is not only a matter of death. Early child malnutrition is often irreversible and intergenerational, with consequences for chronic disease later in life. Many of the children who survive will suffer from poorer cognitive development and lower productivity.
Malnourished children are less likely to enrol in school.
If they do at all, they enrol later than other children. Hungry children are also more likely to drop out. Malnutrition also reduces school performance.
Iodine and iron micronutrients are critical for cognitive development. As adults, their ability to assure good nutrition for their children could be compromised, perpetuating a vicious cycle. Micronutrient and/or vitamin deficiencies found in vast numbers of people are referred to as hidden hunger.
Good Governance Challenge 2 Tackle Gender and Other Biases
The life cycle of malnutrition to a degree reflects the extent to which gender bias is prevalent. Many low-income women have been malnourished from childhood, and as malnourished adults, they are married early and have their first child in adolescence. Early and frequent births increase the risk of low birth weight, and the risk of infant and maternal mortality and morbidity.
Childhood malnutrition is, in part, the outcome of low birth weight. Infant and maternal underweight is the leading risk factor in terms of its contribution to the burden of disease. A combination of factors affects the nutrition status .
These include • general food insecurity (quantity and quality) • intra-household resource food and care allocation skewed away from women, • feeding behaviours during pregnancy (eating less, either due to cultural factors or in response to lack of adequate birthing facilities—smaller babies are easier to deliver without complications), and • a lack of knowledge about the importance of promoting the nutrition status of adolescent girls Exclusive breastfeeding is inhibited due to lack of knowledge of its importance, poor nutrition status of the mother, and a lack of time or opportunity.
Good Governance Challenge 3 Subsistence Based Households
Foods that are rich in protein and micronutrients (meat, milk, vegetables and fruits) are often scarce in subsistence-based households afflicted by chronic hunger. Fortified infant foods are neither available nor affordable. Malnutrition is a solvable problem Malnutrition erodes human capital and reduces productivity by diminishing physical and mental capacity. Malnutrition is a cause and consequence of poverty. Freedom from malnutrition also provides a sound platform for economic growth.
We can drastically bring down malnutrition if we choose to do so. Such a choice is political. Unfortunately there is no targeted and sustained advocacy to influence such a political choice. Malnutrition is a solvable problem that requires public action and commitment. Unfortunately the high prevalence of malnutrition in the population is not seen as anomalous or indicative of the inability of the government to fulfil its duties to its citizens. As a result the state has not effectively prioritized malnutrition in the objectives and resource allocation patterns of government.
Good Governance Challenge 4 Invoke a Sense of Crisis
Such high levels of malnutrition do not invoke a sense of crisis. When addressing malnutrition, the government tends to focus on bureaucratic arrangements and programming that involves mid-level managers rather than political leaders, with little attention to the issue in any fundamental policy reforms in which they may engage.
As a result the State and Central governments consistently under invest in efforts to reduce malnutrition. No one is in Command Political commitment and a policy environment that will create the context for technical actions that deliver the calories, nutrients, knowledge, and income to the vulnerable is missing. Policymakers have no access to necessary nutrition analyses and technical inputs to guide the formulation of policy and the allocation of resources.
In fact there are no policy champions. Malnutrition is not understood or communicated in compelling moral terms. The illegality and foolishness of malnutrition are never discussed. There is a limited understanding among political leaders and policymakers of both the costs of aggregate malnutrition in the country for national development and the determinants of nutritional status.
Yet in all the sectors concerned, whether health, education, agriculture, water and sanitation, or others, nutrition activities tend to be viewed as secondary priorities and improved nutrition outcomes as secondary sectoral objectives.
Authority, responsibility, accountability, and management of the state commitment to malnutrition reduction goals unfortunately are not operationally and for accountability with a single, stable, and high-level minister/Department. There is no charisma or will behind the state’s fight against malnutrition.
Good Governance Challenge: 5 Engage Civil Society Groups
There is little engagement by civil society groups in nutrition advocacy. This failure likely reflects a lack of public awareness of the costs of malnutrition and how to address the problem. There is a need for increasing understanding of the importance of good nutrition and what constitutes good nutritional continuum of care, leading to a political dialogue cantered on the problem of malnutrition at more local levels. Over time, such efforts should increase expectations on government that it has a responsibility for ensuring that all citizens are properly nourished.
The current perception is that malnutrition is part of the normal order of things. Hardly anyone sees malnutrition as a solvable problem that, in part, requires public action. Nobody seems to realize that governments can be held accountable for the persistence of undernourished women and children in the population.
Some of the problem questions are
1. How do we increase the dietary intake and health of a child?
2. How do we advocate for the food security of families
3. How do we advocate a continuum of care for mothers and children?
4. How do we advocate for a proper health environment?
5. How do we advocate for the increase of potential resources available to a community?
6. How do we influence the political, cultural and social factors that influence the optimal utilization of these resources?
7. How do people get a voice in how government resources (panchayats/ district / state/ resources) are allocated?
What combinations of actions will lead to the greatest reductions in child malnutrition? Given resource constraints and knowledge of the costs of alternative interventions, how should policymakers prioritize investments to reduce child malnutrition most quickly in coming decades? Very little futuristic thinking is done on the subject.
Good Governance Challenge 6 Think of the Future
What would a county look like ten years, 20 years, 50 years from now if it 1. Does nothing different for nutrition? 2. Does something different for nutrition? 3. Does everything possible for nutrition?
Those who are most vulnerable Malnutrition is also silent, because those who are most vulnerable to it in a biological sense—infants, girls and women–are also those most vulnerable to deprivation from social processes. These individuals have the least voice within society to press their claims to be free from malnutrition.
Good Governance Challenge 7 Put the Vulnerable First
Vulnerability is such a prominent characteristic of the environments in which food insecure households live. Guidance and tools to assist in measuring access indicators are limited or are not readily available.
The individuals whose nutritional status is of most concern are children younger than two years and pregnant and lactating women. Faltering growth begins in the first 6 months of life—age specific prevalence rates for malnutrition generally increase with age until about two years of age and then level off In formulating priorities for addressing malnutrition, these two nutritionally vulnerable demographic groups do not receive timely help.
[wc_highlight color=”yellow”]To a child you cannot say tomorrow. Her name is today.[/wc_highlight].
Rarely does a child who is stunted at age two fully recover his or her growth deficit in later years—to a large degree, the stunting is permanent. Thus, the window of opportunity to prevent malnutrition is relatively narrow.
This vulnerable age bracket is also the time of peak child mortality, as well as the time that a child’s brain is growing most rapidly. Pregnancy is also a period of relatively high risk and, correspondingly, a time that preventative measures can be most effective. Folate or iodine deficiency in early pregnancy can cause irreversible defects in the child.
Similarly, iron deficiency anaemia increases the risk of maternal mortality and of low birth weight babies. Women’s low social status, lack of decision-making power, and lack of control over income have a significant adverse effect on health-seeking behaviours and child health and nutrition outcomes.