Malnutrition continues to be a major health burden in the developing countries and India records among the highest rates of malnutrition in the world. Nearly half of India’s children or approximately 60 million are underweight:
- about 45% are stunted (too short for their age),
- 20% are wasted (too thin for their height, indicating acute malnutrition),
- 75% are anemic,
- and 57% are vitamin A deficient (The World Bank, 2013).
Malnutrition not only affects the physical wellbeing of children but if overlooked — especially among 0-3 year olds — it can affect cognitive development too, which is oftentimes irreversible. In addition, malnourished children tend to have lower immunity levels which can increase their susceptibility to diseases; thus malnutrion has been found to be a key reason for high infant mortality rates in India at 56 per 1,000 live births in 2012 (UNICEF 2013).
I have always thought of malnutrition to be the result of inaccessibility of good food due to poverty - for families that earn under $2 a day, feeding their child a balanced diet may not be of great concern. However, participating in a discussion some week ago I began to understand the larger structural and social aspects of malnutrition.
Malnutrition in urban slums
Malnutrition is oftentimes believed to be a just a rural phenomenon with data showing higher incidences of malnutrition in rural areas compared to urban. As a result, authorities are overlooking the magnitude of the problem of malnutrition in cities. In Mumbai — India’s financial and industrial capital — more than 36% of the slum children are malnourished (Divecha Gayatri, 2012) a figure that can't afford to be overlooked.
Urban slums have problems quite unlike rural areas; the health infrastructure in cities is managed by urban local bodies (municipal corporations and development authorities) and they do not take into account the real issues of slum residents. Slums are categorized into declared and undeclared slums, the latter being worse off- declared slums are those that have been recognized by the government as having poor living conditions whereas undeclared slums have conditions just as terrible, but do not receive support under any of the slum rehabilitation programs, which are available to the former. The accessibility and provisions of government facilities and schemes are skewed towards the declared slums. For example, there are no Anganwadi Centres in undeclared slums; Anganwadi Centers started in 1975 as a part of the Integrated Child Development Services (ICDS) to combat child hunger and malnutrition. They provide government-sponsored child and mother care programs in India as part of the public health care system, catering to children 0-6 years old. The Centres supply nutrient supplements and packaged food for children but oftentimes, families do not know how to use the supplementary food packets (usually in a powder form) or the children are unwilling to eat it.
Creating demand for heathy foods within communities
An interesting dimension of purchasing power parity and consumer choices has been included in arguments around creating demand for good health. If an individual has Rs.20 to spend and uses Rs.10 on for mobile credit, his capacity to buy healthy food decreases. How can we influence the choices that individuals are making? This is where the need for marketing health to the public — i.e. social marketing — becomes relevant. Motivating communities to become active participants in the effort to tackle malnutrition, I learned, is the focus of the field practitioners working to improve overall health. There needs to be a greater demand for good health among the communities and if we are able to create this demand, and invoke changes in behaviour, the hope is there would be a trickle- down effect to the children of India.
Tackling malnutrition through the private sector
How are private organizations dealing with the issue of nutrition? Glenmark Foundation, Sneha, Apanalaya, Tarshi and Spandan are some of the organisations that working on malnutrition in different parts of India, using a variety of different approaches such as improving feeding practices, establishing day care centres, early identification and preventive techniques, creating community awareness on improved health and sanitation, and counselling of pregnant women. Child in Need Institute (CINI) and Calcutta Kids, though not present at this discussion, are two programs profiled on Centre for Health Market Innovations (CHMI) also working to address malnutrition. Through its cadre of health workers who focus on child development, CINI promotes low-cost, locally grown nutritious food and operates nutrition clinics at its headquarters south-east of Kolkata. Calcutta Kids' primary focus is to reduce malnutrition and mortality among pregnant mothers and children under the age of three. It provides a family health insurance policy and through a network of providers and community health workers, ensures outpatient, inpatient and community-level follow up for women and young children.
At the close of the discussion, it was clear to me that addressing malnutrition, especially in urban slums, will require the coming together of various organisations – from both the public and private sector – to work on social marketing and behaviour change communication as well as advocacy and policy level change.
Photo: A community health worker in Barwani, India, crouches down to measure the upper arm circumference of a young boy to determine his nutrition status. © 2013 Chelsea Hedquist, Courtesy of Photoshare