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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