Download Launch of “Lifting the Curse”

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
• The Unborn
– stunting at birth is as seasonal as the monsoons
– can be transmitted from one generation to the next
• India’s standing in the world
Growth is not working its magic
Source: growth data, Table 1, Topalova 2008; nutrition data, NFHS
Forget comparisons to China
India is lagging behind Africa in undernutrition
• What percent of infants are stunted in India?
a.
b.
c.
•
0-20
21-40
41-60?
What percent of infants are stunted in Africa below
the Sahara?
a.
b.
c.
0-20
21-40
41-60?
And India has the means…
• Interventions are well known
• Interventions are among the most cost-effective
in development
• The resources are there -- and expanding
• Commitment at the very highest level
…but will only achieve the MDG
in 2043!
The nutrition picture in India
For India, it is about governance, not growth
• Governance is the missing link -- deficits of:
– Capacity
– Accountability
– Responsiveness
• 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 response to
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 electoral 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, at least in terms of outcomes
– Need some top quality impact evaluations
– Need to understand 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
• Location not according to need
• High variability in quality of services
– Focus on inputs not outcomes
– Not adaptive enough
– Understaffed
How strong is the enabling environment for nutrition?
• Need a GoI leader at very senior levels dedicated to lifting the curse
– With vision to develop and sell a nutrition strategy to guide resources (direct and
indirect) towards nutrition improvement
– With authority, political and relational skills to implement this strategy, using all
available institutions and mechanisms, Comptroller and Auditor General Office,
NREGS, Agricultural development, PDS reform
• Need a civil society that has the capacity to:
– inform and advocate
• Regular data on outcomes; Regular data on performance; 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 elsewhere
DFID and EC Public Commitments
Mentions of Nutrition from Jan 2005-Jan 2007
• In Speeches
– DFID: 0/50
– EC: 0/28
• In Press releases
– DFID: 0/197
– EC: 0/239
• In policy documents
– 0 in DFID Social transfers and chronic poverty position paper
– 0 in European Consensus on Development
Source: Sumner, Lindstrom and Haddad 2007. IDS Sussex
Need for different kinds of research
• Governance, e.g.
– Construct new panel data: link state and district CAR 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
Research is Unbalanced
Abstracts submitted to an IDS Bulletin on the Institutional,
Governance and Political Dimensions of the Persistence of
Nutrition in India (Nov 2008)
Topic proposed in abstract
Number of abstracts
received
Socioeconomic determinants of nutrition
10
Intervention impacts
5
Grass roots and local governance, accountability
4
Political economy at State level
3
Exclusion of key groups
2
Training of nutritional professionals
1
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: 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 world-leading 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