Children are the future and vital human resource of a nation. No society can survive without proper catering to the needs of this dependent segment of the population. The Constitution of India under Fundamental Rights and Directive Principles of State Policy has ensured the holistic development of children through various provisions by providing services to meet the biological, social, emotional and intellectual needs of young children, as the framers of the constitution and policy makers know very well that only healthy children can make positive contribution to the socio-economic development of the nation. The Government of India has launched various programmes for the development/welfare of children, specifically children belonging to the weaker sections of the society. However, modern India still continues to be plagued by social and health ills such as child marriage, early motherhood and domestic violence, infant mortality, physical handicaps and malnutrition. The 2011 Global Hunger Index (GHI) report ranked India in 15th, among the leading countries with hunger situation. It also places India among the three countries where the GHI between 1996 and 2011 went up from 22.9 to 23.7, whereas 78 out of the 81 developing countries studied, including Pakistan, Nepal, Bangladesh, Vietnam, Kenya, Nigeria, Myanmar, Uganda, Zimbabwe and Malawi, succeeded in improving the hunger condition. The World Food Program report noted that India remained home to more than a fourth of the world's hungry, 230 million people in all. It also found anaemia to be on the rise among rural women of childbearing age in eight states across India. Indian women are often the last to eat in their homes and often unlikely to eat well or rest during pregnancy.

India is one of the fastest-growing countries in terms of population and economics, sitting at a population of 1,210.19 million (2011) and growing at 10–14 percent annually. India's gross domestic product (GDP) growth was 6.9 percent in 2011; since independence in 1947, India's economic status has been classified as a low-income country with the majority of the population at or below the poverty line.

Today, child malnutrition is prevalent in 7 percent of children under the age of 5 in China and 28 percent in sub-Saharan African compared with a prevalence of 43 percent in India. The prevalence of stunting among under-5s in India is between 48 percent and 57 percent. Undernutrition is found mostly in rural areas and is concentrated in a relatively small number of districts and villages with 10 percent of villages and districts accounting for 27–28 percent of all underweight children. The lack of access to clean, safe drinking water, the unhygienic living conditions and the lack of proper toilets all make a perfect breeding ground for disease to thrive. China, the other Asian economic powerhouse, sharply reduced child malnutrition, and now just 7 percent of its children under 5 are underweight, a critical gauge of malnutrition. In India, by contrast, despite robust growth and good government intentions, the comparable number is 42.5 percent. Malnutrition makes children more prone to illness and stunts physical and intellectual growth for a lifetime. The need of the hour is to write on this emerging issue as the problem of child malnutrition remains critical, and the reasons it deserves concerted attention of many. Besides the obvious moral obligation to protect the weakest in society, the economic cost to India is – and will be – staggering, and the global food crisis can also be significantly worsening the problem.

Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess (too high an intake), or in the wrong proportions. A number of different nutrition disorders may arise, depending on which nutrients are under or overabundant in the diet. In most of the world, malnutrition is present in the form of undernutrition, which is caused by a diet lacking adequate calories and protein. Although malnutrition is more common in developing countries, it is also present in industrialised countries. In wealthier nations, malnutrition is more likely to be caused by unhealthy diets with excess energy, fats and refined carbohydrates. The World Health Organization cites malnutrition as the greatest single threat to the world's public health.

Malnutrition is estimated to contribute to more than one-third of all child deaths, although it is rarely listed as the direct cause. Lack of access to highly nutritious foods, especially in the present context of rising food prices, is a common cause of malnutrition. Poor feeding practices, such as inadequate breastfeeding, offering the wrong foods and not ensuring that the child gets enough nutritious food, contribute to malnutrition. Infection – particularly frequent or persistent diarrhoea, pneumonia, measles and malaria – also undermines a child's nutritional status. The studies/surveys that have been carried out to determine malnourishment in under-5 children will be discussed in the sections that follow.

Despite India's remarkable economic growth over the last decade, many children still struggle to meet their most basic needs, including access to sufficient food and healthcare. According to the 2005–2006 National Family Health Survey (NFHS-3), 20 percent of Indian children under 5 years were wasted (acutely malnourished) and 48 percent were stunted (chronically malnourished). Importantly, with 43 percent of children underweight (with a weight deficit for their age), rates of child underweight in India are twice as high the average figure in sub-Saharan Africa (22 percent). The consequences of this nutrition crisis are enormous; in addition to being the attributable cause of one-third to one-half of child deaths, malnutrition causes stunted physical growth and cognitive development that last a lifetime; the economic losses associated with malnutrition are estimated at 3 percent of India's GDP annually.

The survey also reveals that 46 percent of children suffer from stunting (height according to age), 43 percent suffer from underweight (weight according to age) and 19 percent suffer from wasting (weight according to height) in Haryana. This was in sharp contrast to Kerala, where only 24 percent children suffer from stunting, 22 percent from underweight and 15 percent from wasting. Hence, it was perplexing to find such problem of malnutrition among the children in the food grains surplus state of Haryana as the NFHS III had revealed a shocking proportion of child malnutrition. The figures were higher in Haryana than the average of sub-Saharan Africa.

Dr Rajeshwari conducted a study on 1,440 households spread over 16 villages in 8 districts of Haryana state to examine the problem of malnutrition among children. Child malnutrition was measured in terms of long-term nutritional intake (i.e., height for age) and a comprehensive indicator of long- and short-term dietary and illness episodes (i.e., weight for age). The findings of that study revealed that child malnutrition was all-pervasive irrespective of spatial and social status. The study showed that whether malnutrition was measured as prevalence of underweight, stunting or wasting, nutritional status of children in Haryana was shockingly poor.

While concern is being raised at the depressing figures of child malnutrition as shown in the Hyderabad-based Naandi Foundation study, HUNGaMA (Hunger and Malnutrition), released recently by the Prime Minister of India, surveys held in the past suggest that it was not only in BIMARU (Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh) states that children were malnourished, but even in a food-affluent state like Haryana, the situation was disturbing.

The HUNGaMA survey conducted across 112 rural districts of India in 2011 provides reliable estimates of child nutrition covering nearly 20 percent of Indian children. Of the 112 districts surveyed, 100 were selected from the bottom of a Child Development District Index developed for UNICEF India in 2009, referred to as the 100 Focus Districts in this report. These 100 districts are located in 6 states: Bihar, Jharkhand, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh. The survey of 1,09,093 under 5-year children revealed that 59 percent children are stunted (height for weight), 42 percent children are underweight (weight for age) and 11.5 percent children are wasted (weight for height).

A major revelation of the study titled “HUNGaMA (Fighting Hunger and Malnutrition)” is that child malnutrition sets in early where the 37-year-old ICDS fails to work. It shows that the prevalence of stunting peaks among children aged 24–35 months. Comparing the 100 most backward districts, alongside the 6 best in the states under study and the 6 best nationwide, the research finds that across all three clusters, children's underweight incidence was the highest at early ages and wasting was the highest for children aged 12–23 months.

The study finds that child stunting among uneducated mothers is 62.9 percent as against 42.6 percent for mothers who have passed class X. Malnutrition also increases for a child born with low birthweight (less than 2.5 kg). In 100 districts (selected from UNICEF's 2010 rankings), the prevalence of underweight children among those with low birthweight is 49.9 percent as against 33.5 percent for children with normal weight. Child wasting, underweight and stunting are higher for children in households with no toilets.

As per the recent report of UNICEF on the state of the world's children, India ranked 46 in the world as far the incidences of under-5 child mortality is concerned. Even our other neighbouring states like China, Bhutan and Bangladesh performed better than us. The UNICEF report reveals that the annual number of deaths under the age of 5 in India in 2010 is 16.96 lakhs. The survey of under 5-year children also revealed that 48 percent children are stunted (height for weight), 43 percent children are underweight (weight for age) and 20 percent children are wasted (weight for height); 28 percent infants have low birthweight.

Based on the review of the above studies, it has been observed that the situation of the children in relation to their health, specifically in terms of nutrition, is very grim. Therefore, it is necessary to have a bird's eye view of the major administrative efforts to improve the nutritional status of children under the age of 5 years.

No doubt, after initiating the planned development, the Government of India has made serious efforts to reduce the infant mortality rate by implementing different welfare and developmental programmes. However, to date, we could not succeed in lowering it down to 48 (2010) as against the target of 37 by 2015. The pace of reducing the IMR rate is 3 percent, which is not sufficient. In this direction, Integrated Child Development Services (ICDS) – launched on 2 October 1975, the world's largest and most unique early childhood development programme –is being satisfactorily operated since three decades of its existence. The rich experience of ICDS has brought about a welcome transition from welfare orientation to a new challenging perspective of social change. The programme provides package of services, comprising supplementary nutrition, immunisation, health checkup and referral services to children below 6 years of age and to expectant and nursing mothers. Non-formal pre-school education is imparted to children of the age group 3–6 years and health and nutrition education to women in the age group 15–45 years. High priority is accorded to the needs of the most vulnerable younger children under 3 years of age in the programme through capacity building of caregivers to provide stimulation and quality early childhood care.

The scheme of ICDS has performed considerably well in our socio-cultural system during the last few years to ensure children's right for survival, growth, protection and development and their active participation in environment where they live, grow and develop. It has attempted to gear up to the popular holistic vision of a comprehensive intervention programme with a child-centred approach respecting all cultural patterns and diversity, and served as an instrument of change to bridge social inequalities in the society. The concept of providing a package of services is based primarily on the consideration that the overall impact would be much larger if the different services are delivered in an integrated manner, as the efficiency of a particular service depends on the support it receives from the related services. The other unique feature of the programme is that it utilises and mobilises all available governmental services at the level of the project. It is multi-sectoral in nature and its successful implementation depends on inter-sectoral functional linkages. It calls for coordination among concerned departments and ensures optimal use of the existing governmental infrastructure at the project level.

Growth monitoring and nutrition surveillance are two important activities that are undertaken. Children below the age of 3 years are weighed once a month and children 3–6 years of age are weighed quarterly. Weight-for-age growth cards are maintained for all children below 6 years. This helps detect growth faltering and helps in assessing nutritional status. Besides, severely malnourished children are given special supplementary feeding and referred to medical services. The financial norms for supplementary nutrition under different categories of beneficiaries are as follows:

The amount allocated above against supplementary nutrition is very meagre, which cannot overcome the acute problem of malnutrition. The above-mentioned rates also include preparation and fuel charges.

The Programme Evaluation Organization of the Planning Commission conducted an evaluation of ICDS through National Council for Applied Economic Research (NCAER) during 2009. Draft report of the said evaluation study was disseminated in August 2010 by the Planning Commission, following which the Ministry of Women and Child Development (MWCD) provided detailed comments on the draft report for its finalisation. Some of the findings contained in the draft report were not agreed to by the MWCD due to their factual incorrectness.

Some of the key findings in the draft report are as follows:

About two-thirds (64 percent) of the children received supplementary nutrition (may not be for all 300 days) out of total children recorded in the delivery register by AWW. Against the norm of 25 days a month, on an average they received food for 16 days in a month.

Overall 42.5 percent of sampled AWCs have their own buildings, 17.4 percent are in rented buildings, 17.3 percent are located in primary schools and the other 22.9 percent are running from AWW/AWH house, Panchayat and community buildings.

Country-wide, a total of about 87 percent AWCs were found to have drinking water supply.

69 percent of sampled AWCs have functional baby weighing scale.

About 94 percent of sampled AWWs reported to have been adequately trained to conduct preschool education.

About 40 percent of AWWs reported getting some help from the Panchayat, with about 36 percent in monitoring and 34 percent in providing infrastructure. About 70 percent of the community leaders felt that the ICDS programme was very useful to the community.

Average attendance of the number of children aged 3–6 years based on three sudden visits by the research team was found to be 14.

Intended behavioural changes of varied intensities have been observed in Kerala, Himachal Pradesh, Andhra Pradesh, Tamil Nadu, Maharashtra, West Bengal and Jharkhand. In general, the practice of breastfeeding within an hour of birth is found to be more widespread among ICDS beneficiaries.

ICDS has also positively influenced formal school enrolment and reduction in early discontinuation among beneficiaries.

Undoubtedly it can be claimed that ICDS has reduced the rate of malnourished children in India. Still the Prime Minister of India considers malnourished children as ‘Shame for India’.

The United Nation Millennium Development Goal (MGD) Report, 2011, reflects that in developing regions, the proportion of children under age 5 years who are underweight declined from 30 percent to 23 percent between 1990 and 2009. Progress in reducing underweight prevalence was made in all regions where comparable trend data are available. Eastern Asia, Latin America and the Caribbean, and the Caucasus and Central Asia have reached or nearly reached the MDG target, and South Eastern Asia and Northern Africa are on track. However, progress in the developing regions overall is insufficient to reach the target by 2015. Children are underweight due to a combination of factors: lack of quality food, sub-optimal feeding practices, repeated attacks of infectious diseases and pervasive undernutrition. In Southern Asia, for example, one finds not only a shortage of quality food and poor feeding practices, but a lack of flush toilets and other forms of improved sanitation. Nearly half the population practise open defecation, resulting in repeated bouts of diarrhoeal disease in children, which contribute to the high prevalence of undernutrition.

Malnutrition is an outcome of various factors resulting from unfavourable socioeconomic circumstances such as difficulties in obtaining food, unemployment, which determines an irregular income for the family's breadwinner, limited access to education and health services, or illness caused by unsanitary conditions. These circumstances are worsened by unequal access to, and distribution of, resources among members of the family. The major factors are detailed below:

• Factors related to child: The major nutritional disorders are deficiencies of iron, vitamin A and iodine. Micronutrient deficiencies influence child survival and the health and development of surviving children, including cognitive development. Although potentially cost-effective and affordable interventions are available, existing food supplementation and micronutrient programmes in India have not achieved significant reductions in nutritional deficiencies at the state or national levels, a factor contributing to the slowing decline of childhood mortality rates. Some of the factors cited as being responsible include poverty, poor hygiene and dirty water, inadequate weaning of young children, frequent illness, family size or level of education and occupation of mother (Ogbeide, 1992; Igbedioh, 1994). Different cultural and religious beliefs or practices, food habits, locality and geographical factors further compound the problem. In effect, no uniform criteria could be assumed to be responsible for malnutrition. The UNICEF report 2012 reveals that only 69 percent children under 5 are being taken to the appropriate healthcare provider under the suspected pneumonia and only 13 percent received antibiotics. Vitamin A supplementary coverage rate among the children under 5 is 34 percent. The data reflects that these factors result in the slow decline in IMR.

• Factors related to mother: Factors contributing to this slowing decline include the lower social, cultural and health status of women in India. Thus, improving female education and nutrition, as well as increasing the use of health services during pregnancy and delivery, would lower child mortality. The UNICEF report 2012 reveals that only 53 percent deliveries took place in the presence of trained attendant. There are only 47 percent institutional deliveries in India. The survey further revealed that only 41 percent mothers initiate breast feeding immediately after birth.

• Factors related to gender discrimination: The level of child morbidity and mortality is higher for girls aged 1 month to 5 years than for boys, and girls receive less healthcare. Malnutrition among Indian children is also very prevalent and contributes to mortality from many causes. NFHS III revealed that child mortality among males were 14 percent, but in females it is 23 percent. The child rearing practices are different with male and female chid in a family. The deprivation of girls – through insufficient breastfeeding and denial of food and healthcare – leads to malnutrition and death

• Factors related to cultural practices: In India, as in most countries, mothers are the chief caretakers of children, feeding them and seeking healthcare when they are sick. Mother's possibilities of undertaking these responsibilities - given their ability - can be constrained by gender-biased cultural values. Based on their traditional beliefs, the mothers did not believe that medical care was an appropriate intervention for childhood illnesses such as malnutrition. The child is not put into breast feeding in the first 3 days after birth in some rural parts of the country (Gwalior region of Madhya Pradesh) due to the misconception that colostrums is harmful. Here instead, the child is put on water. This may prevent the transfer of maternal antibodies and thereby increase the risk for many opportunistic infections in the infant. Adulteration of milk and delay in the start of weaning foods are other misconceptions related to child rearing that may result in protein energy malnutrition and adversely affect the child's health and oral health. There are some beliefs that diarrhoea among children is common during teething and does not need to be taken care of. They also believe that diarrhoea will take off the heat from the body and hence the child should not be fed milk and other liquids and this result in dehydration.

• Factors related to Administration of Services- HUNGaMA survey reveals several chinks in ICDS. It says half of the 74,020 mothers covered never gave their first milk to the child after birth; 58 per cent did not exclusively feed him. “While 96 per cent anganwadi workers knew what malnutrition is, 92 per cent mothers said they had never heard of the term. Anganwadi workers are not counselling mothers. Anganwadi workers are so overburdened regarding maintaining of records that they do not focus on the proper delivery of the services.

The slowing decline in India's child mortality rate calls for new approaches to the problem of child mortality. Future child health policies should build on past lessons from child health programmes in India, sustain the achievements that have already been made, enhance quality and efficiency and address specific gaps in neonatal care. First, a new strategic framework for childhood illness, health and development is needed. The Government of India needs to reassess the country's current child mortality reduction goals and proceed with integrated approaches for child health and nutrition. Existing child health programmes and strategies, including initiatives for the eradication and elimination of vaccine-preventable childhood diseases.

Second, a better understanding of the main determinants of the health and nutrition cycle for mothers and children – the life cycle – is central to developing more effective strategies for child survival, health and development. Socioeconomic, cultural, environmental, behavioural, health and nutritional determinants influence this cycle; the challenges over the next 10 years will be to jointly address the most important determinants and gaps in the cycle with affordable, cost-effective and culturally appropriate interventions. These should take into account both demand and supply factors and involve local communities in identifying needs and priorities.

Third, because of state differences in infant and child mortality levels and performance in India, such child health policies are needed that take into account state-specific epidemiological and demographic patterns and key factors. We should also try to develop and expand community participation in the prevention and treatment of childhood illnesses (e.g., by strengthening care-seeking, compliance and preventive behaviours at the household level). The burden of the anganwadi workers should also be reduced regarding the maintenance of records so that they can concentrate on the women and children's health.

Pool the resources and energies of international, national, municipal and community actors in support of efforts to ensure that marginalised and impoverished children enjoy their full rights. Nutrition must be given higher priority in national development if the MGDs are to be achieved. A number of simple, cost-effective measures delivered at key stages of the life cycle, particularly from conception to 2 years after birth, could greatly reduce under nutrition. These measures include improved maternal nutrition and care, breastfeeding within one hour of birth, exclusive breastfeeding for the first 6 months of life, and timely, adequate, safe, and appropriate complementary feeding and micronutrient intake between 6 and 24 months of age. Urgent, accelerated and concerted actions are needed to deliver and scale-up such interventions to achieve MDGs.

These actions are not goals but means to an end. Eliminating gender differences in mortality rates would significantly reduce infant and child mortality overall and malnutrition among children.

References