In the health and nutrition community, the results of the National Family Health Survey (NFHS) are always eagerly awaited. In mid-December, the government released results from 2019-20 for 10 major states, and in many ways, the picture that emerges is not so encouraging. Why, in spite of healthy economic growth, do we see so little progress on these indicators?
This piece argues that stagnant public spending on women and children lies at the heart of the problem. And the problem is exacerbated by misplaced spending priorities of even those meagre resources (corporate funding might enhance availability of resources, but what is that money spent on?) and hurdles in the flow of funds and paperwork in accessing budgets.
The NFHS is a source of valuable information on a variety of indicators of people’s well being—from health and nutrition indicators to the experience of domestic violence and the reach of essential public services. Between NFHS-2 (1998-99) and NHFS-3 (2005-06), key indicators on children nutrition (proportion who are underweight and stunted) did not show much improvement. Facing flak for those results, the reaction of the then UPA-2 government was to scuttle the next round of the survey. Owing to continuing pressure, NFHS-4 was finally conducted in 2015-16. For 10 years, on key indicators related to people’s well being, India did not have any reliable and nationally representative surveys.
The results of NFHS-4 showed substantial improvement. Using the Multi-dimensional poverty index (MPI), the Oxford Poverty and Human Development Initiative found that poverty had halved between NFHS-3 and NFHS-4. This was likely the result of the grudging commitment, in part due to public pressure, to women and children’s programmes during the UPA years (2004-2014).
Unfortunately, the partial results from the latest round of the NFHS-5 (2019-20) suggest that the steady improvement seen in the previous decade may not have been sustained. As before, while living standards show an improvement, as far as key outcome indicators such as child nutrition, anaemia and mortality are concerned, the results are sobering.
Data for states where undernutrition was concentrated such as Uttar Pradesh, Madhya Pradesh, Rajasthan have not yet been released. An overall assessment will have to wait, but the accompanying graphic, which juxtaposes Bihar with Gujarat, provides a glimpse of where we are.
Out of the 127 indicators where the outcomes can be classified as better or worse, Gujarat fared better than Bihar on 81. For instance, public health services are better in Gujarat: three out of four women received four ante-natal check-ups, near-universal institutional deliveries and lower mortality rates.
Yet, on key outcome indicators—the proportion of stunted or anaemic children, full immunization rates, women with low body mass index and so on—Gujarat and Bihar are indistinguishable. On some indicators of women’s status, Bihar does better: more women in Bihar enjoy property rights, use a mobile phone themselves, etc. Ditto with the proportion of anaemic children under-five children—the next generation—which is an indication of things to come.
Bihar has long had among the worst development indicators. This comparison between Bihar and Gujarat shows that whatever else it might be a model state for, Gujarat is not a model for well-being among women and children.
Heart of the problem
Low public spending is certainly part of the problem. Take two important schemes for women and children: The Integrated Child Development Services (ICDS) Scheme and the Pradhan Mantri Matru Vandana Yojana (PMMVY). Both are part of the National Food Security Act 2013 and have suffered from neglect in different ways in the past six years.
The PMMVY is a cash transfer to pregnant and lactating women. It is supposed to be the equivalent of the Maternity Benefits Act for women in the unorganized sector. Until 2017, a pre-existing scheme, Indira Gandhi Matru Sahayog Yojana, running in 50-odd districts continued as before. PMMVY was instituted in 2017 in diluted form. One, it restricted the cash benefit to the first child and two, instead of ₹6,000, women get only ₹5,000.
Remember, women in the organized sector are entitled to six months wage compensation as maternity benefits, whereas, for women in the unorganized sector, the law provides a fixed amount. It is pegged neither to the minimum wage, nor is it indexed to inflation. The allocations made since 2017 are one-fifth of what is required to achieve universal coverage, as required by the law. Moreover, findings from our survey in six states indicate that the paperwork is so cumbersome that many do not get their benefits.
Similarly, the central government’s allocation for the ICDS scheme has stagnated in the past six years in nominal terms. As a percentage of GDP, it declined marginally (0.15% to 0.10%) in this period. The overall expenditure is higher because the 14th Finance Commission increased the state’s contribution to programmes such as ICDS. We know that the devolution of more funds has gone badly (for example, the current dispute between the Centre and the states over the GST compensation funds). Thus, while states’ obligation has increased, their funds have dried up.
What we spend on
Another worrying development is the potential capture of the meagre social spending by corporates and philanthrocapitalists. This is best illustrated by the central government’s flagship nutrition programme called “Prime Minister’s Overarching Scheme for Holistic Nutrition" (Poshan Abhiyan), which was launched in March 2018.
In theory, the Poshan Abhiyan includes some useful interventions, such as public awareness, education, and behavioural change. There is no doubt that we need to do much more about nutrition education. Poshan Abhiyan could help achieve this. For instance, six months of exclusive breastfeeding is strongly recommended for optimal growth, development, and health. It is something for which the government can only educate and encourage behavioural change.
Yet, between 2015-16 and 2019-20, only one of the ten major states has made significant progress: In Maharashtra, it increased from 57% to 71%, the highest among the 10 major states for which NFHS-5 data is available. In others, between half and two-thirds of children were exclusively breastfed for six months.
On the ground, Poshan Abhiyan is primarily about giving smartphones to anganwadi workers with ICDS-CAS (Common Application Software) installed on them. Have these smartphones helped or hindered their work? Has it facilitated more reliable real-time monitoring?
For instance, on its launch in Gujarat, ICDS-CAS made it to the front page of a Gujarati newspaper: The chief minister tried calling a handful of phone numbers, and none of them answered on the first attempt. Anganwadi workers were projected as being negligent in their duties. No one bothered to find out if they had not answered because they were busy with their duties, or due to phone malfunction, or if they were indeed snoozing, as implied.
Some ground reports suggest that, for months, the app has not been used because of server and internet issues. Centralized software design means that it does not serve the needs of all states. We don’t know much about the usefulness of the intervention.
Since 2011, the Bill and Melinda Gates Foundation (BMGF) has funded an IFPRI project acronymed Poshan: “Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition" (odd coincidence about the shared acronym for the government’s programme and the IFPRI-BMGF project). The project page states that “prominent studies we are undertaking include an evaluation of ICDS-CAS in Madhya Pradesh and Bihar." However, their publications seem to rely, quite sensibly, on NFHS data far more than they do on real-time data from ICDS-CAS. The latter are barely used, if at all.
What is clear is that the nutrition agenda is increasingly driven by international agencies such as BMGF, UNICEF, IFPRI and others. UNICEF now raises funding from corporates and philanthrocapitalists. In India, it partners with Johnson and Johnson, Unilever, Louis Vuitton, CII and Nasscom, among others. While corporates might enhance fund availability, they also use it to further their own agendas.
In fact, Unicef’s Impact4Nutrition platform openly invites private sector participation in the Poshan Abhiyan because “good nutrition is good for business". Among the “direct gains for companies" listed there are recognition as “nutrition champion", “enhanced relations with government" and “economic growth".
What was earlier shunned as conflict of interest has today reinvented itself as a “win-win" formula. There is evidence of this in the Poshan Abhiyan too. More than 70% of its budget was spent on Information and Communication Technology (ICT) enabled real-time monitoring through the ICDS-CAS software developed in collaboration with BMGF.
In December 2017, ₹9,000 crore was allocated for the ICDS-CAS, half from the Indian government and the other half as a World Bank loan. This could have been spent on interventions whose health and nutrition benefits are well established: Giving nutritious food to children, hiring more ICDS staff (vacancies range from 6-8% at the anganwadi to 25% among child development project officers), paying better salaries or providing cash support to pregnant and lactating women.
Instead, it has been spent on interventions whose benefits are unclear: smartphones, software, and organizing large conferences during “Poshan maah" in cities for “behavioural change". ₹9,000 crore could buy 150 eggs a year for the 100 million children enrolled in anganwadis.
How to use funds
Not all government spending is channelled to questionable ends, of course. Cash transfers to women under PMMVY are deeply appreciated by them and can provide relief at a time of immense financial difficulties (e.g., especially for those women who experience complications during their pregnancy or delivery). Similarly, the ICDS budget pays the salaries of anganwadi workers or, in many states, for the provision of eggs and other nutritious food to children.
The flow of funds, however, is not smooth and leads to grievous delays and disruptions in these essential services. Take, for instance, anganwadi workers and helpers. This team of two helps little children get used to sitting, eating by themselves, and being without their mothers for a few hours. In an increasing number of states, they engage them in learning-by-playing activities such as rhymes, art and craft, counting, etc. The salaries of the workers tend to be low, and worse, they are often not paid on time.
Over the past few months, anganwadi workers and helpers, along with ASHAs, have been agitating in different states for better and timely pay. A disruption in the flow of funds also means that cash for buying the food supplies (such as daal, oil, eggs, etc.) may be unavailable. Instances of anganwadi workers advancing money to ensure regular food to children are not unheard of.
Both the Centre and the states are responsible for these issues. The bottom line is that a poorly and irregularly paid workforce can hardly be expected to function effectively.
Need for urgent action
Starting in the mother’s womb, the first 1,000 days of a child’s life provide a window of opportunity to improve their nutrition and health outcomes. Those are closely linked to better education, earnings, and health outcomes in later life. The PMMVY and ICDS are crucial interventions at this stage. On top of the general neglect of these programmes, for most of 2020, anganwadis have remained closed.
The recently released NFHS-5 data pre-dates the disruption caused by the pandemic. This affected a range of time-sensitive services delivered by anganwadis: Registration of pregnancies, immunization, nutrition, cash benefits to pregnant women. Each day of delay in reopening anganwadis means that someone is skipping the registration of her pregnancy or vaccination or a referral.
Getting ICDS services running immediately should be top priority, along with a resumption in school meals. It is a telling comment on our priorities that even as malls and cinema halls have reopened, we barely hear a murmur about reviving anganwadis.
Reetika Khera is an associate professor (economics) at IIT Delhi.
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