India has advanced fairly rapidly in all phases of growth and development but unfortunately this progress also brought along a plethora of (largely) lifestyle related diseases and disorders. The recent report on India: Health of Nation’s States (2017) using GBD methodology attributed 55.4% disability-adjusted life-years (DALY) and 60% deaths to the non-communicable diseases (NCDs). All undesirable forms of malnutrition seem to be ensuing (micronutrient deficiencies, overweight and obesity) or declining very slowly (underweight, stunting, and wasting). Not surprising therefore, poor diets featured as one of the top leading risk factors for morbidity and mortality.
The recent approval to earmark 9000+ crore (60 State: 40 govt. sharing model for 3 years) to push National Nutrition Mission (NNM) off the ground and serve 100 million Indians sounds just about right, a much needed initiative. The NNM, as an apex body, will monitor, supervise, fix targets and guide the nutrition related interventions across the Ministries. The proposal excites the public health and nutrition community with emphasis on features like robust convergence mechanism, improved incentives, enhanced technology use etc. The mission sets a target to reduce stunting (to 25% by 2022), low birth weight by 2% and anaemia by 3% annually. Pretty impressive, though challenging, I thought!
As a public health nutritionist, summarising below few reflections on the NNM’s vision and plan of action to get to proposed outcomes.
a) Convergence across programs and ministries – The Ministry of Women and Child Development(MWCD) has been named as the nodal ministry along with the ministries of Health and Family Welfare, and Drinking Water and Sanitation. The mandate of bringing together several stakeholders will be the make or break feature of the whole
program. We have often seen ambitious programs and policies rolled out but not effective due to inter-ministerial differential priority setting. Thus inviting opinions on how to make this work, strategies to tackle the barriers in bringing together diverse portfolios (even though aimed at welfare of masses) and sturdy robust leadership
providing necessary technical and programmatic responses to potential bottlenecks will be absolutely critical. I am sure experts may have thought this through and I really hope it works out.
b) Leadership – This is related to the above point but needs to be stressed a bit more prominently. We have often seen representations from premier nutrition or health institutes in many committees or task forces designed to provide guidance on specific pieces under the realm of public health nutrition (PHN). However a dedicated
overseeing mechanism with adequate clout, resources (funding, infra-structure) and expertise needs to be constituted. The 29 member multi-disciplinary panel formed fits the bill. However, creating a networking or leveraging mechanism with existing bodies/individuals in the area will be critical. Mapping or identifying key partners and having TORs in public domain will help. Accountability is a key feature. Public opinion,
local contexts, experience sharing, pilot projects, research initiatives, existing evidence from similar settings- all are very important. A system to get this all in from all possible sources to enrich the quality of data collected or interventions planned will be very useful.
c) Scope of work – The NITI Aayog had so rightly pointed out the few guiding principles for nation’s nutrition strategy for next 3 years. This included focusing on life-course approach, integrating the underlying and enabling factors in addition to the basic nutrition feeding programs and policies and creating a strong policy atmosphere. This
also creates a broad base of topics or areas across several ministries under the aegis of NNM’s action plan. Thinking through what is the best we can do in available time and resources for each of the sub-national unit will be required.
d) Leveraging work done by other organisations and researchers – There must be a way to link findings from other institutions to the evidence pool at NNM. This can help reduce the duplication, provide quicker (hopefully more robust) evidence on potential strategies which can mitigate malnutrition. IT tools can help in a big way (use of hashtags, key words, notifying all related bodies to share data/papers as applicable etc.). We know the MWCD had created a nutrition resource platform (NRP) with a similar vision. We can revive that or populate that within the NNM’s frame of work.
e) Data sharing and ownership – Will we be following the IIPS model used for NFHS surveys? Will it be some more advanced form of open access etc.? Again accountability is very crucial here.
f) Monitoring and evaluation (M&E) and feedback hearing mechanism to complete the loop – Who will verify the credibility of data collected or services offered? Central level or state level checks? Frequency and duration of M&E? Where will all the data be synthesised? How will it be integrated within the decision making meetings? Again all this must have been charted out but useful to see. I agree that states should have the flexibility to roll out interventions as per their need, preference etc. But what if they don’t achieve their share? Is there any incentive or penalisation plan?
g) Simplify so that you can amplify– No one likes technical details and complicated stuff. It’s important to have periodic communication across all partners and stakeholders to enhance uptake and impact. So having a well-designed communication strategy is crucial to amplifying the mission’s outreach.
All the above aspects are bound to have emerged during preliminary discussions. I may not have provided anything novel but just wanted to reiterate the issues which appear quite significant in determining NNM’s roadmap for achieving desirable progress and success. Many significant droplets (of action against malnutrition – whether it was NITI Aayog’s work, India’s health of states report, NFHS-4, RSOC, POSHAN and IFPRI work on 640 DNPs, ICMR NIN’s food atlas, FSSAI’s HFSS and trans fat guidelines, FAO’s State of Food insecurity report, Global Nutrition Report, India’s health report with focus on Nutrition and many more) are being increasingly identified. Most of them have overlapping mandates. It’s time we bring them together under NNM and maximise the benefits they can offer. It’s on the NNM to use available evidence and chart out the pathways for improving nutritional status and well-being of one and all.
Dr Shweta Khandelwal
Public Health Foundation of India