Lifting the Curse

Overcoming Persistent Undernutrition in India
Lawrence Haddad Institute of Development Studies, UK

The “Curse” of Undernutrition
“The problem of malnutrition is a curse that we must remove”
PM Dr. Manmohan Singh August 15, 2008 Independence Day Speech

A Curse for…
• Children
– it kills: 2000-3000 a day in India (compared to 10 for swine flu) – inhibits brain development, irreversibly – increases illness – reduces learning

• The Economy
– reduces income growth

• India’s standing in the world

Growth is not working its magic

Source: growth data, Table 1, Topalova 2008; nutrition data, NFHS

India has the means…
• Interventions are well known • Interventions are among the most costeffective in development • The resources are there -- and expanding • Commitment at the very highest level

…but will only achieve the MDG in 2043

For India, governance is the missing link • Governance really matters because nutrition
– can be undone in many ways  coordination – requires behaviour change  adaptation – is invisible until its too late  vigilance – is no-one’s responsibility  leadership

The standard explanations of undernutrition in India…
• • • • • • Calorie intake is declining Nutrition standards not relevant for India Inequality is growing Women’s status Caste Urbanisation combined with poor sanitation • Weak ICDS

The unasked questions
• Why isn’t growth doing more? • Why is ICDS weak? (not how, but why) • Why do some states do so much better? • Why isn’t there a greater civil society response?

The IDS Bulletin
• • • • 16 papers 41 authors 31 Indian authors Drawn from
– Government of India, NGOs, Academia, Donors

• Co-funded by DFID and IDS

Growth and Nutrition: why are they ships passing in the night?
• Considerable inter-state differences in things linked to undernutrition
– Growth-poverty elasticity (capability) – Electoral balance of power (accountability) – Quality of service delivery (responsiveness)

• Nutrition is a complex public good to deliver and will get off track in a context where
– resource allocation is driven by political needs rather than nutrition needs – there is an input rather than outcome focus

• Caste perpetuates initial undernutrition

Why isn’t ICDS doing better?
• Not terribly clear if it is doing well or badly in terms of outcomes
– Need some top quality impact evaluations – Need to understand intra and inter-state variation

• But plenty of criticisms which seem plausible
– – – – – – – Too many age groups, too many interventions Not enough of a focus on the under 2’s Too much of a focus on food Wide variance in usage rates Focus on inputs not outcomes Not adaptive enough Understaffed

• Is ICDS the right intervention for the 0-2

• Need GoI leadership dedicated solely to lifting the curse – With vision to develop and sell a nutrition strategy – With authority, political and relational skills to implement this strategy, using all available institutions, mechanisms

How strong is the enabling environment for nutrition?

• Comptroller and Auditor General Office, NREGS, Agricultural development, PDS reform

• Need a civil society that has the capacity to: – inform and advocate - collect regular data on nutrition commitments; work with the media – claim rights - work the legal system, RtF; organise – work with local governments - be pragmatic; act, not just talk • Need international partners to support comparisons, benchmarking and sharing of expertise from

• Governance, e.g.

Need for different kinds of research

– Construct new panel data: link state and district governance indicators to nutrition performance – Take advantage of policy experiments: participation of women and excluded groups in village councils – Develop case studies on barriers to cross-Ministry coordination

• Operational issues, e.g.
– Statistical modelling of AWC characteristics such as cleanliness, staffing, outreach, and access  link to changes in behaviours and child nutrition outcomes

• Test innovations, e.g.
– Community monitoring of ICDS quality—when does it work? – Remote but real time monitoring of nutrition status

• Decent impact analyses, e.g.
– 3ie-type evaluations

Recommendations 1
• All : focus on governance—it is the reason that the magic of growth is not working on undernutrition • GoI: appoint a high level focal point on nutrition, develop a nutrition reduction strategy that harnesses existing institutions, resources & implement strategy • ICDS or some other mechanism: focus on under 2’s and empower local providers to tailor to needs of their target groups • ICDS: experiment and evaluate
– audits run by partnerships of civil society and local government – payments for results

Recommendations 2
• GoI: slimmer and more frequent data collection – to empower all those who care about lifting the curse—not just researchers and GoI • Universities and research funders: create a worldleading set of research programmes on reducing undernutrition, focusing on operation and governance issues • Private philanthropists and civil society: exploit world leading ICT/software position to amplify Sen’s spirit—
– sms and georeferenced real time monitoring of undernutrition – create a nutrition reduction commitment index

• Don’t forget the fundamentals: keep working to empower women and reduce caste-based social exclusion

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