Introduction
Every time a "Hunger Index" comes
out, it attracts wide publicity & discussion. Nobody seems to notice, that
the "Hunger index" doesn't measure "Hunger" at all. When
this author found objective survey data on "Hunger" in India, both
the Planning Commission and EPW vetoed its publication. Why? Possibly because it
threatened too many intellectual vested interests.
The author and consultant for the Indian
part of the "hunger index" admitted, that the index is mostly about
Child stunting, wasting etc, which have collectively come to be called
"child malnutrition". If the real problem is Child Malnutrition, then
we need to understand this problem and find solutions to it as we did over last
decade.
India's under 3 year old Child malnutrition
rate(%) was double the poverty rate (%) and 20 times the per cent of hungry in
India (% of households in which any member had less than two (2) full meals, on
any day of the month (i.e. even one day without 2 square meals, counts as
hungry) .
Child Malnutrition
There are three broad aspects of malnutrition that must be
kept in mind when devising strategies for dealing with it. [i]
1)
The ability to
access such food items. This depends on
household income or ability to sustain certain levels of consumption. The rate of Poverty (Head count ratio) is the
standard indicator.
2)
Household/family
knowledge and information about good nutrition.
This includes knowledge about the locally available foods that are good
from the nutrition perspective. This can
be based on, (a) traditional age old knowledge (old wives tales). (b) Ability
to read coupled with availability of appropriate reading material on nutrition.
(c) Access to media such as newspapers, radio and TV, coupled with propagation
of such information on the radio (d) Special programs that directly educate
mothers about child rearing and nutrition such as ICDS.
3)
State of
health. Even if the right kind of food
and nutrition is available a child may not be able to consume and/or absorb it
properly due to ill health or sickness.
For instance a child suffering from diarrhea much of the time is
unlikely to be able to ingest much good and healthy food and absorb the
nutrition, even if it is freely available and provided to the child by the
mother/parents. Historically it has been demonstrated across many countries
that public health measures like clean drinking water, sanitation, sewerage,
control of communicable and epidemic diseases and public health education play
an important role in reducing mortality rates at every age and across
gender. In the Indian environment access
to water and toilets, breast feeding (to impart immunity in an unhealthy
environment), access to sound health advice/treatment, prevalence of
vaccination and availability of vitamin supplements are possible indicators.
Poverty
Poverty affects cross
State differences in Child malnutrition, it has to be addressed through
economic growth, reform of welfare programs etc. Our research confirms that
average per capita GDP is an important determinant of poverty.[ii]
It also showed that higher agriculture growth has an impact on poverty
reduction in addition to its normal contribution to overall GDP growth. A
special focus on agricultural growth in poorer states and in States with
opportunities for productivity improvement can therefore be justified in terms
of poverty removal even though it may not have any impact on overall growth.
The empirical results also justify an added focus on rural roads and telecom
connectivity (in addition to the general effects found earlier) to the extent
that they promote the development of agriculture. Development of rural
connectivity also improves market integration and labor mobility, which in turn
will remove the differential and segmented impact of growth on rural and urban
poverty. The research also showed that the consumption share of bottom 40% of
the population is an important determinant of poverty. Targeted benefit
programs should therefore focus on the bottom 40% of the population. It is
essential to set up a comprehensive data base with unique IDs, photographs and
Bio-metric identification, that will eliminate fraud and help identify the
poorest 30% to 40% of the population.[iii]
Malnutrition Solutions
The research on
cross-State differences in child nutrition outcomes shows, that the greatest
social welfare benefits from direct intervention by government to improve the
lot of the bottom 40% can come if it focuses on two long neglected quasi-public
goods.[iv] First, Public health including communicable
disease and vector control, quality drinking water, drainage, sewerage and
solid waste disposal in every city, town and village in the country. Second
universal primary education and literacy to a global standard that is visible
in outcomes.
Improvement of public
health education and public health facilities clearly has a positive effect on
nutrition outcomes. The ICDS program
seems to have helped in providing public health education to mothers and thus
contributed to the outcome. The policy
implications, however, extend beyond nutrition to other health outcomes. A
comprehensive program for improving civic amenities of a public health nature
to a defined standard is necessary to remove visible symbols of divide between
rich and poor that slums and other neighborhoods with poor drainage and sewage
create.
For every existing town,
States must plan and install a modern drainage, sewerage and water supply
system with water storage and purification, sewage treatment plants and garbage
disposal sites. The impact in terms of
economic activity, health and nutrition can be enormous. Government should help develop consultancy
firms that can Plan and organize such systems and organizations that can
compete with each other to build these systems across the country. Once 100% coverage of towns is attained, we
should extend the planning effort to semi-urban areas and villages in
co-operation with Panchayti Raj institutions and NGOs. We may not be able to match the quality of
public health and civic services
routinely found in the villages of High income country’s, but we must target a
quality level equal to that of middle income countries.
This brings us back to the broader question
of other quasi-public goods that are of critical importance to the poor. Literacy can help in acquiring knowledge
about hygiene, nutrition and sanitation.
Government must ensure that every citizen, has the education that (s)he
is supposed to acquire with the completion of Primary education. But this education must also be made more
relevant by providing information on matters that will improve their lives
(health, hygene, nutrition) and equip them to find useful information.
Cross-country Lessons
Our cross-country results show that
the quality of public health, as measured by variables such as access to better
sanitation and improved water sources, is an important factor in explaining
cross-country variations in the prevalence of malnutrition.[v]
It indicates that improvements in
environmental sanitation could have a significant impact in reducing
malnutrition in India. It also confirms
the importance of primary education, particularly of females, in helping spread
information and knowledge about personal hygiene, sanitation and nutrition. Much more could however be done through
appropriate school curricula and media campaigns to promote public health
education.
Conclusions
Once the current targets of the Swach Bharat
Mission are met it should be raised to a broader and more comprehensive level: A
comprehensive end-to-end water-sewage-sanitation system for the country. One
that starts with clean drinking water and unpolluted irrigation water and ends
in fertilizer and usable water. Similarly Union government health initiative
must be focused on classic public health and public health education in schools
and family health programs (like ICDS).
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A version of this article appeared
in the Indian express OP ed page on October, 2017 under the banner "What
schools have to do with health" http://indianexpress.com/article/opinion/columns/global-hunger-index-india-child-mortality-poverty-what-schools-have-to-do-with-health-4897121/
[i]
Virmani, Arvind, “Causes
of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,
July 2007. MalnutritionChild07July.docx .
[ii] Virmani, Arvind, “The Sudoku of Growth,
Poverty and Malnutrition: Lessons For Lagging States,” Working Paper No.
2/2007-PC, Planning Commission, July 2007. http://planningcommission.nic.in/reports/wrkpapers/wp07StJl12.pdf , http://planningcommission.nic.in/reports/wrkpapers/index.php?repts=wrkpap.
[iii]
Virmani, Arvind, “Poverty
And Hunger In India: What is needed To Eliminate Them,” Working Paper No.
1/2006-PC, Planning Commission, February 2006.
http://planningcommission.nic.in/reports/wrkpapers/wk_pov106.pdf .
[iv]
Virmani, Arvind, “Causes
of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,
July 2007. MalnutritionChild07July.docx .
[v]
Virmani, Arvind, "Undernurishment of Children: Causes of Cross-country
Variation," Working
paper No.WsWp 4/2012, October 2012 [WsWp
4/2012. Nutrition12oct.docx .