Working multisectorally to improve maternal and child nutrition in India: The Karnataka Comprehensive Nutrition Mission
1. 1
Working Multisectorally to
Improve Maternal and Child Nutrition
in India
The Karnataka Comprehensive
Nutrition Mission
Veena S Rao
Advisor, KCNM 28-5-13
2. Some hard truths
• India today, is one of the most nutrition deficient countries in the World.
• More than 42% of the World’s under weight children below five years live in India
(UNICEF 2010).
• The latest NFHS 3 and SRS Bulletins assert that some, but not enough progress has
been achieved in improving the country’s nutritional profile or achieving MDG
goals.
• Poverty is a major, but not the only cause of macro/micro-nutrient deficiency.
• The percentage of population suffering from various forms of undernutrition far
exceeds the percentage below poverty line
• After National Nutrition Policy 1993 and National Plan of Action, 1995 no national
programs or policies for eradicating undernutrition have appeared.
• Today, India has no national programme with a stand alone objective of
combating underlnutrition
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3. Indicators for Assessing Nutritional Status
Direct Indicators
• Low Birth Weight (1/3 babies lbw)
• Infant Mortality Rate (IMR- 47 per
1000 SRS 2011)
• Under 5 Mortality Rate (U5MR- 64
per 1000 SRS 2011 )
• Stunting/ Wasting/ Underweight
• Anaemia (6mts-6 yrs 69.5%)
• Immunization (42%)
• Maternal Mortality Rate (MMR 212
SRS 2011)
• Chronic Energy Deficiency and
Anaemia among adolescents and
adults
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Indirect Indicators
Access to Hygienic
Sanitation and Toilet
Facilities (29% NFHS3)
Access to Safe Drinking
Water (87.9% NFHS3)
Female literacy (65.4%
Census 2011)
Gender equity
4. Stunting/ Wasting/ Under Weight
• In India, 38% of children below 3 years of age are stunted,
19% are wasted and 46% are under weight (NFHS 3 Fact Sheet
2005-06).
• Among children under 5 years of age:
48% are stunted
24% are severely stunted
43% are underweight
16% are severely underweight
20% are wasted
(NFHS 3- 2005-06, Detailed Report)
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5. Nutritional status of adolescents: A matter of Concern
As per the 21st Report of the NNMB (National Nutrition Monitoring
Bureau 2003)
•The percent of underweight adolescent males was 53% and of
females was 39.5%.
•About 39% were stunted. Over all, the prevalence of stunting was
similar in both the sexes (boys: 39.5% and girls: 39.1%)
• The food and nutrient intake of Adolescent Girls was below RDA.
More than two-thirds of them were consuming < 70% RDA for
Vitamin A and Riboflavin
.
•The Indian Adolescent Girl is the most undernourished in the world.
(UNICEF, State of the World Children’s Report 2011)
6. Nutritional Status of adults:
NHFS 3 again paints a gloomy picture:
•36 percent of women and 34 percent of men are undernourished,
with a BMI less than 18.5, indicating a high prevalence of
nutritional deficiency.
•More than half of women (55 percent) and almost one-quarter of
men (24 percent) are anaemic.
8. A Multi Causal Problem
• India’s UnderNutrition is the most multi-
causal in the world
• It is Inter-Generational
• A multi-causal problem demands a multi-
sectoral solution
• Multi-sectoral interventions should attempt to
target all, or at least a majority of the causes
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9. A Multi Causal Problem
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UnderNutrition
Physical
Causes
Socio-
Economic and
Historic
Causes
Governance
Related
Causes
Attitudinal/
Behavioral
Causes
•Hunger
•Calorie/Protein
Micronutrient
Deficit
•Infection and
Disease
•Poverty/Low Income
• Illiteracy/Lack of
Skills
•Gender
Discrimination
embedded in social
custom
•Lack of Information
and Awareness
•Gender Discrimination
•Low Status of Women
•Negative Child/Mother
care practices
•Early marriage of girls
•Early & frequent
pregnancies
•Lack of Information &
Awareness;Superstition
•No national programme
with specific objective of
reducing malnutrition
•Inadequate, health care
services for women and
children;
•Low access to safe
drinking water and
sanitation
•Programmatic gaps
•Poor coverage
• No action based
Nutrition Monitoring
•Lack of accountablity
10. The Two Concentric Cycles:
Inter-generational Cycle of Malnutrition & Cycle of Calorie Protein Micronutrient Deficit (CPMD)
and Poverty
ANC: Antenatal Care
EBF: Exclusive Breast Feeding
Protein calorie
micronutrient deficit
Low working capacity
Low income generation
Poverty
Low Birth
Weight
Stunted Child
Malnourished
Girl
Malnourished
Mother
Inadequate growth
Low weight gain
Poor Diet
Gender discrimination
Early marriage & pregnancy
• Poverty
• Lack of awareness
• Infections
• Gender discrimination
• Inadequate food &
health care
No feeding of colostrum
Lack of EBF* for first 6 months
Delayed & inadequate com food
Frequent Infections & prolonged
diarrhea
Gender discrimination
Inadequate food &
health care
• Inadequate foetal
nutrition
• Multiple pregnancies
• -Gender discrimination
• Poor diet and ANC **
• Female illiteracy
11. Fundamental causes of Malnutrition in India not
yet addressed programmatically:
(1)
Malnutrition in India is deeply rooted in the
intergenerational cycle of low birth weight babies,
underweight children, malnourished, anaemic
adolescent girls and pregnant women.
However, current policies and programmes do not
address the issue inter-generationally.
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12. (2)
More than 30% population of India suffers from a Calorie-
Protein, Micronutrient Deficit, (CMPD) *
This factor not yet acknowledged or addressed specifically in
any programme, (except in general through the TPDS, whose
outreach to the lowest percentile of poverty is poor.)
Besides, TPDS even if working efficiently only provides for
cereals, (and in some cases pulses and sugar,) a subsistence diet
for the poor.
TPDS does not provide adequate calories, protein or
micronutrients for a healthy life.
*(NNMB repeat surveys, 1988-90, 1996-97, NNMB Technical Reports No.
20,21,22, 2000-03)
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13. Proposed Food Security Act:
A laudable beginning to legalize an entitlement to Food
Present provisions
35 KG Rice or Wheat per family per month at Rs 2 per
KG
Family constitutes average 5 members = 7 KG rice or
wheat per month per person = 234 gms per day =
approx 650 calories per person per day as against an
RDA of average 1700 cals
Would amount to prevention of starvation, but not
food or nutritional security.
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14. Until these two root causes are
substantively addressed,
existing scattered interventions
will have negligible impact on
reducing malnutrition.
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15. (3)
There is inadequate awareness and information
regarding proper nutritional practices amongst
the population, especially regarding
child/maternal care, even within existing
purchasing power.
(Population % suffering from malnutrition/ anaemia far exceeds
the BPL%, clearly establishing that at least 10-15% of the
population suffer from malnutrition not because of poverty/lack
of purchasing power but because of lack of awareness and
information)
Every poor person is most likely undernourished,
but every udernourished person may not always be
poor
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16. Economics of Malnutrition
Prof RW Fogel: NBER Working Paper 16- Conquest of High Mortality
and Hunger in Europe and America:Timings and Mechanisms
“The first law of thermodynamics applies as strictly to the
human engine as to mechanical engines. Since the
overwhelming share of calories consumed by the
malnourished populations is required for BMR and
essential maintenance…. the typical individual in the
labour force had relatively small amounts of energy left
for work.”
17. Multi-Sectoral Solutions
•No single intervention can eradicate malnutrition
• The package of interventions must be widely inter-sectoral so as to
address at least a majority of the causes
• They must be simultaneous so that the benefit of one intervention is
not lost on account of the absence of another
• They must cover the entire life cycle of women and children to create
and immediate impact within one generation on the nutritional status
of the three critical links of malnutrition, namely, children, adolescent
girls, and women
•Only then can the benefits be sustainable enough to break the inter-
generational cycle, and be passed on the next generation.
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18. What Are The Sectors and What Are Their Programmes
Programmes Ministries/ Departments
ICDS Women & Child Development Ministry
Sabla – Adolescent Girls Programme Women & Child Development Ministry
Immunization Programme Health & Family Welfare Ministry
Mid Day Meal Programme Ministry of HRD
Vit A Supp Programme Health & Family Welfare Ministry
National Nutritional Anaemia Control
Programme
Health & Family Welfare Ministry
National Iodine Deficiency Disorder Control
Programme
Health & Family Welfare Ministry
National Rural Drinking Water Programme Ministry of Drinking Water & Sanitation
Total Sanitation Campaign Ministry of Rural Development.
These programmes address some causes of Malnutrition but not all of them
and have several programmatic and coverage gaps. In the absence of
seamless and simultaneous interventions, gains accruing from existing,
dispersed and often isolated interventions are lost on account of absence of
other critical interventions.
19. Multi-Sectoral Mega Coordination:
The Inner Core and Outer Circle
Education,
Social Justice,
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Ministry of Information & Broadcasting
Ministry of Women & Child
Development
Ministry of Health & Family
Welfare
Ministry of Food
Ministry of Agriculture
Ministry of Rural Dev
Department of Drinking Water &
Sanitation
Ministry of HRD
STATE GOVTs
Ministry of
Tribal
Affairs
Ministry of Social
Justice
Ministry of
Panchayati
Raj
Ministry of
Labour
20. Essential Interventions to Combat Malnutrition –(Coalition
for Nutrition Security in India – Prof MS Swaminathan)
(A) Direct interventions –
Related to the consumption and absorption of adequate protein calorie/micro-nutrient rich foods
essential to combat malnutrition, namely:
1. Weighment of child within 6 hours of birth and thereafter at monthly intervals.
2. Timely initiation of breastfeeding within one hour of birth, and feeding of colostrum to the infant.
3. Exclusive breastfeeding during the first six months of life.
4. Timely introduction of complementary foods at six months and adequate intake of the same, in terms of
quantity, quality and frequency for children between 6-24 months.
5. Dietary supplements of all children between 6 months – 72 months through energy dense foods made
by SHGs from locally available food material to bridge the protein calorie gap.
6. Safe handling of complementary foods and hygienic complementary feeding practices.
7. Complete immunization and Vit. A supplementation.
8. De-worming of all family members bi-annually.
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21. 9. Frequent, appropriate, and active feeding for children during and after illness, including oral rehydration
with Zinc supplementation during diarrhea.
10. Timely and quality therapeutic feeding and care for all children with severe and acute malnutrition.
11. Dietary supplements of iron – rich, energy dense foods made from locally available food material
prepared by women SHGs for adolescent girls and women, especially during growth periods and
pregnancy to fill the protein calorie gap and ensure optimal weight gain during pregnancy.
12. Anaemia screening for children, adolescent girls and women.
13. Weight monitoring of all adolescent girls and pregnant women.
14. Prevention and management of Micro-Nutrient deficiencies, especially through IFA supplementation to
prevent anaemia in adolescent girls and women.
15. Making available low cost energy foods for the general population.
16. Fortification of common foods.
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22. (B) Indirect Interventions –
Related to issues of health, safe drinking water, hygienic sanitation and socio-cultural factors
such as early marriage and pregnancy of girls, female literacy and poverty reduction, to
eradicate malnutrition on a long term, sustainable basis.
1. Access to safe drinking water (treatment, storage, handling and transport), sanitation and
hygiene.
2. Increased female education and completion of secondary schooling for the girl child,
delayed age of marriage and pregnancy.
3. Increased access to basic health services by women.
4. Expanded and improved nutrition education and involvement at Panchayat and community
level to create demand.
5. Increased gender equity.
6. Linking Agriculture/Horticulture and Nutrition.
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23. The Karnataka Nutrition Mission
• Karnataka the 1st State in the country to
announce a Comprehensive Inter-sectoral
Nutrition Mission
• Demonstrates Political Will & Leadership
• Administrative & Programmatic Priority
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24. The Karnataka Nutrition Mission
Announcement by Chief Minister in 2010
High Powered multi-sectoral Committee chaired by Chief
Secretary set up to draw a roadmap for the Mission Strategy,
and its piloting in 3 Blocks.
Cabinet clearance obtained in March 2011.
Mission being Piloted in 3 Blocks - Gubbi, Shikaripur and
Bellary Rural
Grant of US$ 5 million has been received from JSDF/WB for
piloting in Chincholli and Deodurg Blocks 24
25. Karnataka Comprehensive Nutrition Mission -
Aims
The Karnataka Nutrition Mission (KNM) will specifically aim to
eradicate the problem of malnutrition in the State in the shortest
possible time by introducing innovative strategy changes.
It will be a dedicated, stand alone programme to address the problem
of malnutrition in the State in a targeted and comprehensive manner.
The Programme is implemented in partnership with an NGO
Target Groups: Children between 0-3 years, with priority 0-2 years
children keeping in view the special significance of this period in their
process of development.
Adolescent girls between the ages 11-18
Pregnant and Lactating mothers
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26. The Mission strategy is based on the following over-arching
principles:
• Bridge the protein-calorie-micronutrient deficit which affects at least 50% of the population.
• Cover the entire life-cycle of women and children so as to break the inter-generational cycle of malnutrition
within the shortest possible time.
• Formulate a tightly integrated multi-sectoral strategy to address all or majority of direct and indirect causes
of malnutrition simultaneously, many of which exist in ongoing programmes.
• Interventions include Direct interventions, based on adequate food and micro-nutrients, and Indirect
interventions, addressing issues of health, education, water, sanitation and socio-cultural, factors that are
critical to eradicate malnutrition on a long term, sustainable basis.
• Initiate a sustained general public awareness campaign, through the multi-media and interpersonal
communication mode to reach the general public, especially at the grass-roots, regarding proper nutritional
practices.
• Establish vigorous monitoring mechanisms at the administrative and community levels, using participatory
mechanisms and cast responsibility upon the respective functionaries for achieving results. Build
accountability through intensive monitoring of nutritional indicators in the Mission Blocks by the Mission
Secretariat, Community Monitoring, and by third-party evaluations.
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27. Karnataka Comprehensive Nutrition Mission –
Specific Objectives
(a) Reduce Underweight and under-nutrition among children, low
body mass index among adolescent girls and women in the
project areas in the shortest possible time, through the inter-
generational, life-cycle approach.
(b) Eliminate wasting of children and Grade 3 and 4 malnutrition
among children
(c) Reduce the incidence of low birth babies, infant mortality, child
mortality, maternal mortality, anemia and other micronutrient
deficiencies among children, adolescent girls and women; and
(d) Spread information and awareness to the communities to enable
behavioral change regarding proper child care, care of the girl
child throughout her life cycle, of pregnant and nursing mothers,
and proper dietary practices within existing family budgets
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28. Karnataka Comprehensive Nutrition Mission –
Addressing the Cause-Intervention Disconnect
Innovative Strategy Shifts to address the Causes
• Adopting the inter-generational, life cycle approach by addressing the
nutritional needs of infants, children, adolescent girls and pregnant and
nursing mothers.
• Bridging the calorie-protein micronutrient deficit among the inter-
generational target groups by providing appropriate energy dense
fortified supplementation for consumption.
• Accelerating, integrating and tightly monitoring multi-sectoral ongoing
programmes that have impact on malnutrition, such as Immunization and
Vit A Supplementation, Anemia Control, Water and Sanitation, etc.
• Achieving convergence between the ongoing programmes so that they
operate simultaneously, and
• Covering Programmatic gaps through new initiatives.
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29. Karnataka Comprehensive Nutrition Mission –
Addressing the Cause/Intervention Disconnect
Innovative Strategy Shifts to address the Causes
• Increasing programme coverage by demand creation by
involvement of the community, NGOs, SHGs and VPs.
• Launching a sustained general public awareness campaign,
through the multi-media and interpersonal communication
mode to reach the general public, especially at the grass-roots,
regarding proper nutritional practices within existing family
budgets and proper child and maternal care and create demand
for government programmes.
• Make available low cost energy foods for the general
population through Public Private Partnerships.
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30. Activities Completed/ On Going In Karnataka Nutrition
Mission – Pilot Project
SL. No. Activity
1. Selection and Appointment of Nutrition Volunteers & Other Staff
2. Purchase of Weighing Scale
3. Completion of Base Line Survey
4. Printing of Health & Nutrition Cards
5. Creation of MIS
6. Block Level Workshops
7. Identification of SHGS:
Gubbi Block - 767
Bellary Block -257
Shikaripura - 156
8. Purchase and Installation of Machinery – Weighing Machines
9. Expected Date For Trial Production of EDF
Gubbi Block - May last week, 2013
Shikaripura - May last week, 2013
10. Expected Date For Commencing Production and Distribution of EDF – June 15,
2013
31. Karnataka Comprehensive Nutrition Mission –
Other Initiatives
Feasibility Study sponsored by the Mission to engineer the Agriculture
Nutrition linkage supported by Global Alliance for Improved Nutrition,
(GAIN) Study to be conducted by India Institute of Science, Center for
Rural Technology.
Scope of Study: Though India is one of the largest fruit and vegetable
producers in the world, harvest and post harvest losses amount to about
30%, on account of absence of primary processing facilities and need
based post-harvest technology.
Primary processing of fruit and vegetables at village level. Zero energy
cooling chambers, solar dryers, which have been designed by several
renowned Rural Technology Institutes, and Indian Institute of Science,
must be introduced at rural level, for preservation of fruit and vegetables,
and their consumption by the community.
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32. Addressing UnderNutrition in India-
Do we have an Enabling Environment
• Malnutrition is invisible and silent.
• Malnourished people are not aware of their affliction. Hence, no
demand for relief
• Medical profession is not oriented, as Nutrition is not a faculty
within Medical Education.
• Economists have not yet focused on the national economic loss
caused by malnutrition
• Stronger political will to address malnutrition in a Mission Mode is
required to follow up Finance Ministry’s Budget speech,2012. Need
for multi sectoral paradigm shift and addressing cause-intervention
disconnect
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