Being home to 31% of the world’s children who are stunted and 42% of those who are underweight, and with many children and adults affected by micronutrient deficiencies, India is facing huge challenges in the field of nutrition. Even though the Indian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the Integrated Child Development Services program alone costs 3 billion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons for this reduction are not unambiguous and appear to include state government commitment, focus on the ‘window of opportunity’, improved status and education of women, a lowered fertility rate, and combinations of nutrition-specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked with a range of partners to improve access to nutritious foods for large parts of the population, through public and private delivery channels. This supplement presents a selection of these activities, ranging from a capacity assessment of frontline workers in the ICDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.
The burden of micronutrient malnutrition is very high in India. Food fortification is one of the most cost-effective and sustainable strategies to deliver micronutrients to large population groups. Global Alliance for Improved Nutrition (GAIN) is supporting large-scale, voluntary, staple food fortification in Rajasthan and Madhya Pradesh because of the high burden of malnutrition, availability of industries capable of and willing to introduce fortified staples, consumption patterns of target foods and a conducive and enabling environment. High extraction wheat flour from roller flour mills, edible soybean oil and milk from dairy cooperatives were chosen as the vehicles for fortification. Micronutrients and levels of fortification were selected based on vehicle characteristics and consumption levels. Industry recruitment was done after a careful assessment of capability and willingness. Production units were equipped with necessary equipment for fortification. Staffs were trained in fortification and quality control. Social marketing and communication activities were carried out as per the strategy developed. A state food fortification alliance was formed in Madhya Pradesh with all relevant stakeholders. Over 260,000 MT of edible oil, 300,000 MT of wheat flour and 500,000 MT of milk are being fortified annually and marketed. Rajasthan is also distributing 840,000 MT of fortified wheat flour annually through its Public Distribution System and 1.1 million fortified Mid-day meals daily through the centralised kitchens. Concurrent monitoring in Rajasthan and Madhya has demonstrated high compliance with all quality standards in fortified foods.
Micronutrient malnutrition is widely prevalent in school children in India. India’s national school feeding program, the Mid-Day Meal (MDM) scheme, is the largest in the world and caters to 120 million children in primary schools. Complementary strategies such as deworming or fortifying meals provided through the MDM scheme could increase the nutritional impact of this program. India’s Supreme Court has directed that only hot, cooked meals be provided in MDM, through a decentralised model. However, in urban areas, big centralised kitchens cook and serve a large number of schools, with some kitchens serving up to 150,000 children daily. The objective of this project was to test the operational feasibility of fortifying the school meal in centralised kitchens, as well as the acceptability of fortified meals by recipients. A pilot was conducted in 19 central kitchens run by the Naandi Foundation in four different States. Several food vehicles were used for fortification: wheat flour, soyadal-analogue and biscuits. More than 750, 000 children were reached with fortified food on all school days for a period of one year. Fortified food was found to be acceptable to all stakeholders. The government is in favour of continuing fortification. The Naandi Foundation has adopted fortification as their norm and continues to fortify all meals provided from their central kitchens. In conclusion: fortification of school meals with micronutrients can be integrated in the normal cooking process and is well accepted by all stakeholders. This pilot could hold lessons for other states in adopting fortification in MDM.
Integrated Child Development Services in India through its supplementary nutrition programme covers over 100 million children, pregnant and lactating women across the country. Providing a hot cooked meal each day to children aged between 3-6 years and a take-home ration to children aged between 6-36 months, pregnant and lactating women, the Integrated Child Development Services faces a monumental task to deliver this component of services of desired quality and regularity at scale. From intermediaries or contractors who acted as agents for procuring and distributing food to procurement directly from large food manufacturers to using women groups as food producers, different State Governments have adopted a variety of strategies to procure and distribute food, especially the take-home ration. India’s Supreme Court, through its directive of 2004, encouraged the Government to engage women’s groups for the production of the supplementary food. This study was conducted to determine the operational performance, economic sustainability and social impact of a decentralised production model for India’s Supplementary Nutrition Program, in which women groups run small scale industrialised units. Data were collected through observation, interviews and group discussions with key stakeholders. Operational performance was analysed through standard performance indicators that measured consistency in production, compliance with quality standards and distribution regularity. Assessment of the economic viability included cost structure analysis, five-year projections, and financial ratios. Social impact was assessed using a qualitative approach. The pilot unit has demonstrated its operational performance and cost-efficiency. More data is needed to evaluate the scalability and sustainability of this decentralised model.
Improved infant and young child feeding practices have the potential to improve child growth and development outcomes in India. Anganwadi Workers, the frontline government functionaries of the national nutrition supplementation programme in India, play a vital role in promoting infant and young child feeding practices in the community. The present study assessed the Anganwadi Workers’ knowledge of infant and young child feeding practices, and their ability to counsel and influence caregivers regarding these practices. Eighty Anganwadi Workers from four districts of Gujarat participated in assessment centres designed to evaluate a range of competencies considered necessary for the successful promotion of infant and young child feeding practices. The results of the evaluation showed the Anganwadi Workers possessing more knowledge about infant and young child feeding practices like initiation of breastfeeding, pre-lacteal feeding and colostrum, age of introduction of complementary foods, portion size and feeding frequency than about domains which appear to have a direct bearing on practices. A huge contrast existed between the Anganwadi Workers’ knowledge and their ability to apply this in formal counselling sessions with caregivers. Inability to empathetically engage with caregivers, disregard for taking the feeding history of children, poor active listening skills and inability to provide need-based advice were pervasive during counselling. In conclusion, to ensure enhanced interaction between the Anganwadi Workers and caregivers on infant and young child feeding practices, a paradigm shift in training is required, making communication processes and counselling skills central to the training.
Iodine deficiency disorders (IDD) constitute the single most important preventable cause of mental handicap at global level. Recognizing the importance of coordination and synergy of the activities of wide range of universal salt iodisation (USI) stakeholders, WHO/ Unicef/ ICCIDD has prescribed a national multi-sectoral coalition as one of the ten indicators essential for attaining sustainable elimination of IDD at national level. Challenge for coordination among different stakeholders of IDD/USI is even greater in democratic and diverse country like India. In the present article we present successful experience from India regarding formation of a national coalition and contributions made by the coalition towards promoting USI in India. The activities of the national coalition in India are classified into three phases; 1) Phase 1- year 2006 to 2009- the inception; 2) Phase 2- year 2009 to 2012-consolidation; 3) Phase 3- year 2013 and ongoing- expansion. The National coalition for Sustained Optimal Iodine Intake (NSOI) has been instrumental in ensuring greater coordination and synergy amongst IDD and USI stakeholders in India and partially responsible for the current 71 percentage household level coverage of adequately iodised salt. The most significant contribution of the national coalition has been to act as a high level advocacy channel and provide a platform for regular dialogue for all partners of the coalition. With “mission” approach and allocation of optimal resource, India can achieve and should achieve USI by 2015, an apt culmination of a decade of existence of the national coalition.