Where the household food security efforts are complemented with inputs that focus on the health and care-related preconditions for adequate nutrition, the response is discernible even among the less severe forms of malnutrition. Future nutrition-relevant actions should support a mix of programmes directed at all three clusters of underlying nutrition problems. All of these efforts must, nonetheless, be targeted to those who are nutritionally needy and the nutritional agenda must be explicitly recognized and cited in all poverty-alleviation or food-security programmes. Overall, a four-pronged short-term approach is necessary to alleviate nutritional problems until overall development through long term measures of food production, employment, education and fertility control make these approaches unnecessary. This approach would include:
i) Improving household food security
There is an urgent need for improvements in programmes that aim to reduce household food insecurity, current attempts in this area, such as the Public Distribution System (PDS) and the National Rural Employment Programme (NREP) having had some, though limited success. Better rurally-targeted PDS schemes such as those implemented in the states of Tamil Nadu (and to a lesser degree in Andhra Pradesh) have been more successful than the less-precisely targeted PDS in the rest of the country. Without a stricter targeting of needy households, escalation in programme costs in any case renders its sustainability questionable, particularly in the current economic climate. Mismatches in PDS inputs vis-a-vis poverty levels are just as likely to be within-state as between-state, thereby underscoring the necessity for revision/re-orientation of allocation criteria and enforcement. Once the PDS is located in the right block, it can be self-targeted on the poorest households through disbursement through fair-price shops of less-preferred foodgrains (e.g. millets as opposed to rice), which are the staples of these poorest groups, but not the less-poor.
The nutritional impact of asset-endowment poverty alleviation schemes such as the Integrated Rural Development Programme (IRDP), it is argued here, have been very limited. On the other hand, the wage-employment schemes such as the National Rural Employment Programme (NREP) are likely to have had a greater nutritional impact. The NREP certainly offers potential for driving future nutritional improvements providing a guarantee of an increased number of days work per year to fewer poorer people (particularly women) in resource-poorer areas can be achieved through more decentralized planning. The assets generated should also be those that would support future livelihoods in these poor communities.
ii) Improving health and care factors
In some states such as Tamil Nadu, the preschool child (in TINP areas) seems to be better insulated (than other states/national averages) against the effect of household food insecurity, possibly because of the combined protective effect of a well-targeted, implemented and monitored nutrition programme, along with good rural health services, immunization and nutrient-prophylaxis.
Less precisely targeted nutritional interventions such as the Special Nutrition Programme (SNP) and the Noon Meals Programme (NMP) are not likely to have had a major impact on nutrition among the most vulnerable. Programmes such as the NMP have immense (disturbing) potential for gathering massive momentum and appeal, particularly when initiated on a surge of populist politics. Once this takes place, the chances of reversing the "commitment" become bleak even if serious distortions in the social services sector occur at the cost of other deserving programmes, including in particular those relevant to nutrition.
Integrated nutrition and health programmes are relevant and appropriate but could be strengthened. Strengthening should be in terms of strict targeting for younger (1-3 years) children and women during pregnancy/lactation belonging to poverty groups. Area targeting, which is in practice, should be supplemented with household and individual targeting to focus the benefits and reduce the cost of these programmes, namely supplementary feeding, massive dose of vitamin A and iron/folic acid distribution etc. The lessons learnt in programmes like TINP should be utilized fully to optimise results. The weak points in implementation however, such as poor inter-departmental coordination, irregular monitoring, systematic evaluation without adequate arrangements for feedback and corrective action, should be eliminated through instituting an effective MIS (Management Information System) at District/Taluk/Block/village level.
Improvements in the nutritional status of young rural children seen during the last decade, in the absence of a notable increase in income levels and dietary energy levels of households speak of the beneficial impact of these expedient short term nutrition-related approaches. Although it is difficult to delineate the relative contribution of direct nutritional inputs (from the health care and educational efforts), to the improvement observed, the presence of a nutrition component probably also results in greater acceptance of other ongoing health programmes. Recent ICDS evaluations have shown that supplementary feeding can provide an incentive for obtaining community participation in health programmes.
iii) Combating gender discrimination
From the above discussion of nutrition-relevant actions, the involvement of women is clearly prominent. For so many reasons (see Gillespie and Mason 1991 for example), the capabilities of women and the resources which they control are crucial contributing factors to nutritional outcomes. Set against this, the problem of gender discrimination looms. Although it may not be as marked and pernicious as in northern India, gender bias and female infanticide has been documented as a real problem in Tamil Nadu (George et al. 1992; see discussion in Part I). What can be done to alter deeply-rooted gender relations that result in such practices? A holistic approach is required for changing such a complex system of values about girls and women, and extensive study of the underlying social dynamics (such as marriage payments, marriage links among villages, womens economic opportunities, etc) would be helpful in constructing needed pro-female policies aimed at raising the social and economic status of women, and hence reducing female infanticide. Scholarships for women, special emphasis on women in poverty alleviation schemes, reservations in local community organizations for women are some possibilities. Gender relations are not set in stone. One example of beneficial change in Tamil Nadu was womens use of their voting power to reinstate prohibition.
iv) Facilitating involvement of the nutritionally-vulnerable social groups
For obtaining enlightened participation of the nutritionally-vulnerable sections of the community, pre-programme interaction involving appropriate means of communication (mass media and inter-personal), adjusting time and place of service delivery to suit the peoples convenience and giving due regard to cultural sensitivities are some essential concerns. A continuing programme of Information, Education and Communication (IEC) as part of nutrition and primary health care programmes would help sustain benefits. The IEC component, even in a tightly monitored programme like the Tamil Nadu Integrated Nutrition Programme (TINP) has been found wanting in the strength needed for creating a lasting impact.
Overall, future efforts directed at nutritional improvement must strike a balance between direct nutrition interventions and poverty alleviation schemes. However, both strategies must concentrate on tighter targeting i.e. improved area, community/family and individual targeting based on both poverty (preferably ultra-poverty) and nutritional criteria. Such recommendations must necessarily be complemented with two other crucial changes in programme design - a greater flexibility to accommodate area-specific needs, and improved monitoring, evaluation and accountability. Greater community involvement is another requisite which may, nevertheless be facilitated by the increase in design flexibility. The socio-political and economic environment is conducive to such reforms. Further, if interventions are to be closely linked with poverty and nutrition criteria, existing means for generation of reliable, representative, and continuous information on these indicators will need to be strengthened.