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The nutrition security system at the household level: Policy implications

Satinder Bajaj

Household nutrition security is the assurance that the family will receive food and health care commensurate with the requirements of its individual members. In the vulnerable section of the population who are below the poverty line (38.7% in India), women play a central role in child care and food processing even when their economic roles require extensive time and physical energy. Any new effort at women's development must divert their time and energy from other activities. The policy implications of nutrition security for families have at their core the empowerment of women to enable them to break the vicious cycle in which they find themselves. The limited resources of time, energy, and income within the framework of cultural and economic conflicts have rendered women's development programmes ineffective in a number of countries, including India [1].

In this paper the background, intervention programmes, and nutritional status of Indian women are examined in order to suggest a policy strategy that can enable women to participate in the national development programmes designed to secure the family's health and nutrition.

Background

In India a relatively low value is given to the life of a female. Sex-specific death rates are higher for female children in both rural and urban areas (see FIG. 1. Sex-specific death rates for children 0-4 years old in India, 1971- 1983 (Source: Office of the Registrar General of India)). Female infants, toddlers, and preschoolers tend to be more malnourished than males (table 1). The sexwise morbidity patterns also show that more females suffer from nutritional deficiencies as well as infectious diseases (see FIG. 2. Sex-specific morbidity patterns among children in India, 1985 (Source: "The girl child in India: Data sheet on health," National Media Centre and UNICEF, 1985)).

TABLE 1. Malnutrition in children in Punjab (percentages)

Education

A wide gap between male and female literacy (see FIG. 3. Sex-specific literacy rates in India, 1901-1981 (Source: Census of India. 1981)), analysed in conjunction with enrolment at the primary and middle school level (see FIG. 4. Sex-specific enrolment at primary (º 1-5) and middle (º 6-8) levels of education in India (Source: Selected educational statistics. 1983, 1984. 1985. Department of Education, Government of India)), indicates that literacy differences continue through the life span of these girls. The lack of relevance of the material taught and the requirement for girls to stay at home to take care of siblings and share in household chores are some of the reasons for low admission and a higher drop-out rate amongst girls. An educational policy that aims at a socially relevant content and teaching that provides self-confidence and a psychological uplift to girls is desirable, as are well targeted programmes [3].

Economic contribution and support

Most women in the work force in India (94%) operate within a highly exploited sector characterized by long working hours, lack of skills, low productivity, and no job security (National Commission of Self-employed Women). There is very little organization in the form of trade unions to enable women to bargain for better conditions. An important reason for women's acquiring low-skill jobs is lack of training that could improve their employment status. The major systems employing rural women in India that enjoy government support (table 2) show that most effort is focused on male workers. Women are viewed as indirect beneficiaries through the male members of their families. At construction sites women are highly exploited through loan and credit bondage, and they frequently work in alien and unhealthy surroundings that disturb the physical and social security of the family. Data for domestic work are not available in the national data system. However, girls under the age of ten are often employed to act as mothers" helpers. Figures of 1.68 million female workers and 0.62 million male domestic workers have been reported [4]. While unmarried girl children acting as domestic help may be fed better than they might be at home, the married domestic working woman must often neglect her own family.

TABLE 2. Numbers employed in the large employment systems (thousands)

Source: Various departments of the Government of India.

In order to improve the employability of women, a purposeful human-resource policy aimed at improving training facilities for women is urgently needed. There is also a need to have a clearly defined labour policy to enable women to receive direct benefits for their families.

Forty-five government schemes in 17 ministries and departments in India for women represent a piecemeal approach. The schemes range from relief oriented (short-stay homes) to supportive (working women's hostels) or mixed (such as TRYSEM). Most of these are not as effective as they were visualized to be because they do not reach a large number of the most deprived women in the unorganized sector.

Because time is a major constraint in the participation of women in programmes, cognizance needs to be taken of all work performed by women, including domestic work. There is a clear need for evolving a strategy that will improve women's working conditions and also generate free time.

Intervention for growth and development

Two periods of growth make children vulnerable. Infancy, characterized by total dependency, is important for formation of self-concepts and later self-worth. A comprehensive programme for the family and the community is required to strengthen this period. Unless the whole family participates in giving children, both boys and girls, a sense of worth, any intervention will be superficial. A girl must fight against her family and community if they do not share her sense of self-worth.

Physical-growth monitoring during infancy provides a powerful tool for identifying and preventing malnutrition. It can also be a platform for maternal and community education on requirements for normal growth and development [5].

The second crucial period for growth is adolescence. During this time the girl prepares for her adult role of carrying the burden of dowry, early marriage, and teenage pregnancy. An estimated 10%-15% (approximately 25 million) of annual births in India are to teenage mothers. The malnourished state of teenage girls is complicated by the nutritional demands of the pubertal growth spurt and early pregnancy [6]. Added to these factors are the pressures of a shift to her in-laws' house, dowry demands, and the possible birth of a girl child. A clear policy and targeted programmes are required for adolescent girls that recognize these problems and aim at their alleviation in order to build women's confidence and enable them to secure good nutrition and health for their families [7; 8].

Nutrition intervention programmes

An important and direct intervention that takes into consideration the pregnant and nursing women in India is the Integrated Child Development Services (ICDS) scheme. This provides supplementary food, tetanus immunization, and iron and folic-acid supplements as well as health and nutrition education. The nutritional basis for food supplements are dietary surveys revealing energy deficiency in the diets of low-income pregnant and nursing mothers. Actual measurements of energy intake and expenditure of pregnant and nursing women showed a deficit in the energy balance of those from the lower and middle income groups during the third trimester of pregnancy [9].

The deciding factor in determining energy balance among these women is their obligatory expenditure. Since the lower income groups must expend most of their energy earning their livelihood, they cannot afford to reduce their activity. Clearly, extra energy intakes and more opportunity to rest are indicated for these women.

Adequate maternal weight gain is essential for normal-birth-weight infants. Women engaged in hard physical labour during pregnancy often do not gain adequate weight and deliver low-birth-weight babies [10] with higher perinatal and infant morbidity and mortality. Maternal mortality accounts for the largest proportion of deaths among women in their reproductive period. Maternal mortality in India is 400 to 500 per 100,000 live births, with the figure in some rural areas as high as 1,000 to 1,200 per 100,000 Anaemia, haemorrhage, toxaemia, sepsis, and abortion are the causes reported [4]. More than a third of the live births are of the fourth order or more. It is obvious that the important needs of women are respite from pregnancy, more rest, and better health care. While the ICDS programme tries to address these problems, coverage and awareness of it is limited [11; 12].

Apart from the ICDS, a number of other programmes are intended to support family nutrition. These include the National Anaemia Prophylaxis Programme [13], the National Goitre Control Programme [14; 15], the National Programme for Prevention of Nutritional Blindness due to Vitamin A Deficiency [16], the Mid-day Meal Programme [17; 18], the Special Nutrition Programme [19], the Applied Nutrition Programme [20], and the Chief Minister's Noon Meal Programme [21]. These direct nutrition interventions vary in their immediate direct impact and in their indirect outcomes. Some are more sharply focused than others. Each is very limited in coverage compared with the need.

Supportive interventions

Antipoverty and employment programmes offer support to vulnerable households. In India, interventions designed during the last two decades aim at meeting both regular shortfalls in food arising from income gaps and shortages in poor crop years and during off seasons when lack of physical access reinforces income shortage, rendering the hard-core poor most vulnerable. These interventions, which include public distribution systems and public employment programmes, often fail to affect the nutritional status of at-risk families [22].

Nutritional status

Studies on the energy balance of 300 female subjects, including manual workers, educated working women (teachers and researchers), and housewives, showed that manual workers had shorter heights and lower weights and obtained most of their nutrient requirements from cereals [23]. The working women and upper-class housewives consumed more fats, milk. and milk products as well as vegetables. The manual workers expended most of their energy and time earning their livelihood (see FIG. 5. Expenditure of time and energy by women during various routine activities (Source: Ref. 23)) and spent the least time in household activities (including child care). The educated working women spent more time in household activities than housewives whose main job was housekeeping. Improving time availability and wage earning capacity are important steps in assuring nutrition security. As a policy it is possible to attach such interventions as child spacing and family planning to educational strategies.

Policy implications

In devising a functional nutrition policy, targeting is of major importance [24]. To identify target households, information is needed to determine the conditions under which the families require intervention and the extent to which malnutrition in such households is due to uncertain food availability, disease, or social discrimination. An important step for the government is to set up a policy research unit to provide a continuous flow of information for this purpose.

A woman-centred policy for improving the nutritional status of vulnerable families is evident in most health and nutrition schemes in India. Evaluation of these schemes shows that a desirable impact can be achieved only if improvements are made, particularly at the operational level. When the delivery systems are examined, many conceptual ambiguities are evident. One is that women and children are the target groups for intervention but are missing at the policy planning level. There needs to be a built-in component to enable women to actually participate. The community-participation component in most of these schemes appears to be appended as an afterthought. In the ICDS scheme, for instance, a referral service is one component of the plan for improving health; yet this is missing at the operational level because there is no infrastructure for referral [25].

Education

Educational-policy literature focuses on food production, purchasing power, and poverty problems [26; 27]. It is rare to come across research on education to transform behaviour. The educational system in general and nutrition education in particular assume that the target audience is ignorant and that resources are not adequately utilized. Such one-way transfer of knowledge, even when sophisticated social advertising methods are used, does not create the desired change in behaviour. Educators should be involved in a two-way flow of knowledge for problem solving [28; 29].

Education that encompasses all aspects of training and brings about attitudinal changes is essential if women are to be enabled to improve household nutrition security. Although educational materials are expensive to produce, very little research goes into the methodology of communication. Trained people must be found who are able to popularize technical information and knit it together with indigenous knowledge. This can then be presented to the target audience in such a way as to result in a two-way Row of information.

In order to illustrate the importance of a people-centred method of communication, Indi Rana has drawn attention to the use of pictorial language. It is commonly believed that pictures are universally comprehended; therefore funding agencies spend large sums of money on them to communicate with an illiterate audience. In an experiment in Orissa, Rana asked four women of varied educational backgrounds to draw their version of six messages on water and sanitation. It is interesting to note that the women drew from their knowledge of reality' with a serial time perspective (fig. 6). Their pictures had their own stylized code (such as flowers to represent cleanliness and squiggles to represent dirt). They did not draw from the vanishing-point perspective but more broadly, as is characteristic of the folk art in many countries. The emotional ambience and community relationships were important and integral parts of their drawings. If existing posters and charts are compared to this result, the inadequacy of conventional communication materials becomes evident.

Access to indigenous knowledge and a people centred educational strategy would appear to be time consuming and cumbersome, yet this need not be the case. It is possible to draw generalizations across cultures and time from a wide range of information. Proper classification and adaptation can form the basis for dialoguing. A fresh look at training is also required to make it more participatory and meaningful within the context of the people's lives.

Conclusions and prospects

The woman, despite her low socio-economic status in most developing countries, is the central figure for participating in development programmes meant to elevate the nutritional status of families. Empowerment of women through a two-way flow of education and direct focus of economic programmes can enable women to participate actively in establishing and maintaining nutrition security at the household level. Without economic power and self-confidence for women, household nutrition security remains precarious.

The government must spend money, technical expertise, and time to plan economic programmes intended to benefit women directly. A continuous flow of information on community needs and indigenous knowledge is required to establish a system that will feed into the participatory training and exchange of knowledge.

Acknowledgements

The work of my doctoral students, some of which is presented here, is acknowledged and appropriately referenced. The pictorial language data from the field research of Ms. Indi Higham Rana presented in figure 6 is acknowledged with thanks.

References

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