The findings of the National Family Health Survey (NFHS-5) (IIPS, 2019-20) have come as a reality check, and even experts are trying to make sense of it.
Food security and nutrition in India have worsened since the last NFHS round with 18 states showing worsened stunting levels among children under five.
The findings of the National Family Health Survey (NFHS-5) (IIPS, 2019-20) have come as a reality check, and even experts are trying to make sense of it.
The survey shows that food security and nutrition in India have worsened since the last NFHS round (2015-16). Among the 22 states and Union Territories (UTs) for whom the data was released, 18 show either stagnation or worsening of stunting (height-for-age) levels among children less than five years.
Since the data presents the pre-Covid-19 picture, the present nutritional status could be more worrying, especially for the poor and the marginalized sections. The final figures and the trend for the country, however, will only be known after the data becomes available for the remaining states/UTs.
Studies show that childhood stunting, reflecting long-term chronic malnutrition, is associated with poor school achievement and diminished income-earning capacity in adulthood. Nutrition also serves as an effective entry point for human development with high economic returns of 16:1 (for every rupee spent, more than 16 will be returned). Globally, India accounts for roughly one-third of the total population of stunted children under the age of five years. Thus, the country has a tough road ahead for achieving the Sustainable Development Goal of 2030 for childhood stunting.
NFSA – Leaving no poor person behind.
The implementation of National Food Security Act (NFSA) 2013 onwards, was expected to make a dent into the nutritional challenges. The Act made access to food a legal right and entitlement for a large portion of the society (75% of rural and 50% of urban population). Today, NFSA is the key pillar supporting India’s food-safety-net schemes namely, Targeted Public Distribution System (TPDS), Mid-Day-Meal (MDM) and Integrated Child Development Services (ICDS-Anganwadi-Supplementary Nutrition Programme). The TPDS alone accounts for serving subsidized food grains to roughly 76 crore ration cardholders (GoI, n.d.) (as of December 2020) through a network of more than 5 lakh fair price shops, and a large number of state and national warehouses.
National figures for food grain procurement, off-take, and budget allocations under the NFSA are staggering. Procurement (PRS, 2020) of rice and wheat increased by nearly 35% between 2009-10 and 2018-19 (57.4 to nearly 77.7 million tonnes/year). Annual off take of food grains increased roughly by 30% during the same period (49.7 to 65.9 million (DFPD, 2018-19) tonnes/year). Overall, the annual consumer food subsidy (i.e. difference between economic
cost of procurement and sales realization at central issue prices) has nearly tripled, from Rs. 42,489.7 crores in 2009-10 (GoI, 2009-10) to Rs. 1,15,570 crores in 2020-21 (GoI, 2020-21).
The actual budget figures may be more due to pending dues (PRS, 2020) to the Food Corporation of India.
Issues and challenges in NFSA
Despite building a comprehensive system of food grain procurement and distribution, NFSA seems to have missed its mark in achieving nutritional outcomes for a number of reasons, and we explore a few.
First, the provision under the Act to diversify commodities distributed under TPDS has not been met due to procurement-related issues, and the current food basket (rice, wheat, coarse grains) under NFSA does not substantially improve the dietary diversity of beneficiaries. Both government (NIN & ICMR, 2020) and independent (Sharma, Kishore, Roy, & Joshi, 2020) studies have highlighted that the Indian diet, across states and income groups, is imbalanced.
The calorie share of whole grains is much higher than the recommended benchmark, while that of fruits, vegetables, and meat is significantly lower. The lack of dietary diversity is associated with malnutrition, micro-nutrient deficiencies, and non-communicable diseases, a pattern evident in the NFHS-5 findings.
Second, the review and appraisal mechanism for NFSA continues to be output-oriented. For instance, the last data of actual calorie intake derived from consumption expenditure among households is available only for 2011-12. Further, the NFHS reports do not provide results disaggregated by ration card ownership. Not surprisingly, the space for evidence, for the last seven years, is populated with less-rigorous evaluations (DFPD, n.d.) and food bulletins that
do not provide any insights into nutritional outcomes. These studies and bulletins focus primarily on administrative aspects like ownership of ration cards, supply of food grains, enduser satisfaction, food grain allocation and off-take ratios, financial spending etc. As a result, key issues such as dietary diversity get neglected consistently, which weakens the capacity of policymakers to undertake evidence-based course corrections.
The Act provides for greater oversight by states through State Food Commissions (SFCs). An SFC, comprising of relevant experts, is expected to monitor and evaluate NFSA and bring out state-specific challenges and mitigation measures. However, less than half the states have functional SFCs and there is little information available on the actual role they play. In a recent national review meeting, key challenges voiced by 13 SFCs included, financial constraints, infrastructural challenges, staff shortage, and lack of autonomy (ToI, n.d.).
Lastly, the provision to experiment with tools like direct benefit transfers (DBT) or food coupons have not been put into practice. A commodity-heavy system like TPDS is not only expensive (Sinha, 2013) but also suffers from leakages, diversions and inefficiencies. The alternative, recognized in the Act, is to enable cash transfers to the end-users at a fair rate and allow them to procure food grains directly from the market.
The DBT modality under NFSA has only been implemented in UTs (DFPD, n.d.) of Chandigarh, Puducherry, and Dadra & Nagar Haveli (now Dadra and Nagar Haveli and Daman and Diu). Even in these UTs, study (Aadil & Rautela, 2016) indicates that end-users may not prefer cash transfers due to the insufficient amount of subsidy amount, low awareness, transaction expenses, and subsidy diversion by male members of the household.
Strengthening NFSA: Charting a way ahead
So, what can be done to improve the food-safety-net?
First, the DBT experiment for NFSA requires a more careful piloting and expansion across willing states. A dynamic nutrition-line, similar to the poverty line, can be reinforced to act as target for NFSA to achieve. Stronger “conditionalities” like linking the cash transfer to school attendance, immunization etc., can be introduced. Moreover, behaviour change communication can be introduced to reduce possible diversion of cash by households in nonfood related expenditure. Investment in high-quality monitoring and evaluation (M&E) for DBT is a must since such programs are prone to inclusion1 or exclusion errors2 (Soares, Ribas, & Osorio, 2008) globally. Countries like Mexico and Brazil present good examples of successful Conditional-Cash-Transfer (CCT) programs. Mexico and Brazil subjected their CCT programs Progresa (now Oportunidades) and Bolsa Familia to impact evaluations (Neufeld, et al.) over several years and introduced course corrections based on the findings. This led to a significant improvement in health, education, and nutritional outcomes. These successful models certainly merit a closer study and comparison with the Indian DBT.
Second, in the meanwhile, the food basket under NFSA also needs to be diversified to include more food groups. Some promising steps have been taken like inclusion of pulses under NFSA during the Covid-19 pandemic lockdown, and the expansion of the pilot scheme for distribution of fortified rice to aspirational districts. Several states have also taken the initiative to introduce millets (Suri & Das, 2018) under the TPDS. But more concerted efforts and investments will be required to mitigate the current imbalance in dietary habits and the resulting nutritional outcomes. The diversification of food groups is bound to increase the already significant public expenditure. Therefore, the current system of beneficiary targeting would be required to nudge-out ineligible beneficiaries, estimated to be roughly around 25% to 37% of total TPDS beneficiaries till 2011-12 (PRS, 2013) (PRS, 2020).
The NITI Aayog, back in 2017 through the National Nutrition Strategy had suggested several measures including, greater convergence between existing nutritionfocussed schemes, dietary diversification to include food groups rich in Vitamin A, C, and iron, strengthening of the existing monitoring and early warning systems, and greater ownership and monitoring by the local community. Some states have undertaken innovative measures in this regard, such as the MAMTA - a conditional cash transfer scheme by Odisha, wherein pregnant women and lactating mothers receive monetary support contingent on conditionalities such as registration of pregnancy, undergoing antenatal check-ups, vaccinations, etc. Chhattisgarh and Jharkhand, among others, have implemented strategies to track and counsel pregnant women and lactating mothers through community-led models
like Nava Jatan and Dular strategy. An evaluation of Dular in 2007 noted that the program resulted in increased knowledge about child feeding, nutrition, and care, and other improved health and nutritional results. Based on the findings, the government of Jharkhand expanded this strategy to cover all Anganwadi centres.
Last but not the least, the NFHS-5 has helped fill some evidence gap in absence of the NSS Household Consumer Expenditure Survey of 2017-18. Going forward, the most immediate step should be to transform from output to an outcome-focussed performance management of NFSA by capturing more information on end-user well-being. Currently, the evaluation mechanism for NFSA covers 27 states and UTs in India, reported quarterly, and undertaken by research institutions and third-party evaluators. The last quarter of evaluation for each state can include questions on dietary diversity and calorie intake for households.
Also, the quality of survey can be strengthened by including new and robust indicators (i.e., dietary diversity, overall household food security), increasing the sample size of respondents, stronger oversight, etc. Some efforts have already been made in this regard, such as indicators in the SDG India dashboard. But there is a need to logically adopt such indicators and surveys under NFSA. Expert organizations like the Development Monitoring and Evaluation Office (DMEO), NITI Aayog, and its partners, can be engaged to provide technical assistance and oversight to the entire process. The investment in M&E, costing only a fraction of the total NFSA budget, can provide the much-needed insights on outcomes more frequently, as compared to longer national-level surveys. The verticalized approach of delivering schemes to improve nutritional outcomes seems to have run its course. Given the diverse local dietary habits, which have often been distorted by over-supply of cheap food grains, the solution to India’s nutritional problem requires a systembased approach based on greater convergence between stakeholders, decentralization in its true spirit, and better data systems to drive quicker learning and course-corrections.
(The article is a joint work of authors, Mr. Vijay Avinandan, Monitoring and Evaluation (M&E) Officer, United Nations World Food Programme; Mr. Alok Mishra, Deputy Director General, DMEO, NITI Aayog, Government of India; Mr. Subham Awasthi, Monitoring and Evaluation (M&E) Officer, DMEO, NITI Aayog, Government of India)