by Neha Raykar, Public Health Foundation of India
Recently, I attended a policy seminar titled ‘Transforming Food and Nutrition Landscape in Assam’ on 29th March 2017 in Guwahati, Assam. The dialogue was co-organized by the Inter-Agency Group, Assam and Coalition for Food & Nutrition Security and was attended by about 50 stakeholders comprising senior policymakers from Government of Assam and Government of India, as well as representatives from local NGOs, educational institutes, and bilateral agencies.
The purpose of the seminar was to discuss the current status of health and nutrition in Assam and identify and prioritize policy actions for investments that would accelerate improvements in the state, with special attention to the most vulnerable populations of migrants and tea garden workers that have the worst health outcomes and are often beyond the reach of public schemes. State policymakers shared their insights on the complex reasons for historically poor health outcomes in the state and some of the biggest challenges including:
- leakages in program implementation,
- corrupt practices in recruitment of frontline health workers,
- misinformation about appropriate feeding practices and diets, and
- poor quality of food supplied through schemes such as ICDS and Mid-Day Meals in the absence of infrastructure for quality checks.
My presentation titled ‘Commitments and actions on achieving the Sustainable Development Goals (SDGs) and World Health Assembly (WHA) health and nutrition targets ’ was aimed at providing an overview of Assam’s performance on the WHA nutrition indicators. I also presented projections of the required rates of progress if the state were to meet the specific WHA targets by 2025. For instance, as per the latest round of the National Family Health Survey (NFHS-4) conducted in 2014-15, 36.4% of Assam’s children under five years of age are stunted. This is a significant reduction at an average annual rate of 2.4% from a rate of 46.5% as reported in the previous round of the survey (NFHS-3) conducted in 2005-06. However, in order to achieve the WHA target of 40% reduction in the number of under-five children who are stunted by 2025, the state would have to achieve reduction in stunting prevalence at an average rate of 3.9% per year – significantly higher than the current 2.4%. This would clearly require accelerated multisectoral efforts including better implementation of the state government’s current initiatives to improve health, nutrition and sanitation, particularly in the socially and geographically marginalized areas of the state.
Recent data on coverage of key essential health services also shows large gaps in services related to IFA supplementation of women and children, full immunization, and supplementary nutrition to pregnant mothers and under-three children through the ICDS. Underlying social determinants such as women’s education and age at marriage, and environmental factors related to WASH are other priority areas of improvement; for example, only 26% of women between 15-49 years of age have 10 or more years of schooling (national average – 36%), a third of the women between 20-24 years are married before the age of 18 years (national average – 27%), and 38% of Assam’s households practice open defecation (national average – 46%).
The NFHS-4 district-level fact sheets indicate large variations in nutrition indicators as well as their multifactorial determinants across the districts of Assam. Analysis of unit-level data, whenever that becomes available, will be critical to understanding the gaps and challenges at a more disaggregated level and inform block- and district-level administrators in identifying priority actions in local settings. Additionally, the availability of regular, periodic, reliable data on outcome, coverage, and process indicators at a disaggregated level is also imperative to fix accountability and commitment of local administrators and program implementers and thus becomes an important piece of the puzzle to solving the state’s food and nutrition challenge.
I am currently a fellow at the George Washington University’s Leaders for Health Equity program which includes international fellows from diverse professional backgrounds with one common mission – to be a champion for health equity across gender, race, ethnicity, class, and caste. The program, among other things, has further motivated me to view India’s myriad public health challenges with a steady equity lens that I now carry to any discussion on public health. As expected, the discussion at the Assam policy seminar also underscored the need for equity efforts toward better health and nutrition, especially in underserved geographical areas and socially disadvantaged groups such as households residing in the vulnerable ‘char’ areas (i.e. settlements along the state’s rivers) and tea plantations. Of particular concern seems to be the health status of tea garden workers and their families where infant and maternal mortality rates, adult life expectancy, and most other health and nutrition indicators are considerably worse than the state average as highlighted by the health and social welfare officials present at the seminar. High prevalence of alcohol addiction and associated health risks including liver cirrhosis and high rates of TB and malaria incidence are some of the leading causes of mortality in these areas. It is surmised that a large proportion of the workforce residing in the tea gardens, including women, are casual workers and hence deprived of benefits provided by plantation owners to regular full-time employees. The multiple current and upcoming initiatives by state departments of health as well as social welfare that are specifically targeted toward these workers, if designed and implemented effectively, could play a vital role in addressing health inequities in the state. At the cost of repetition, monitoring and evaluating these initiatives with sound data will be crucial to learn lessons and improve policy design for the future.
Lastly, it is impossible to think of accelerating improvements in health and nutrition without empowering women through education and thereby improving their agency over household decisions and resources. Poor health of adolescent girls, early age at marriage and childbirth, high anemia prevalence in pregnant mothers are some of the known predictors of adverse health outcomes in children, thereby setting in motion the intergenerational transmission of poor health. Assam’s record for most of these indicators is worse than the national average as well as most other states in the Northeast region. Discussions at the policy seminar also highlighted the role of women as agents of change and the need for better information, communication, and education efforts around feeding practices and healthy diets as important initiatives toward behavior change.
 WHA projections were sourced from the ‘Data Note’ prepared by Amrutha Jose for POSHAN, IFPRI, March 2017.