Ms. Veena Rao is a former Secretary, Ministry for the Development of the North Eastern Region, Government of India. Over a career spanning more than three decades, she has served in senior roles in both the Government of Karnataka and the Government of India and has worked closely with multilateral institutions such as the United Nations, the World Bank, the Asian Development Bank, and the Global Alliance for Improved Nutrition (GAIN).
She has worked primarily in the development sector – at the intersection of governance and human development – with a focus on public nutrition and public health, water and sanitation, literacy and gender, livelihoods, and poverty reduction. As Joint Secretary in the Department of Women and Child Development, then in the Ministry of Human Resource Development, she has made valuable contributions in shaping India’s policy discourse on public nutrition and micronutrient deficiency.
Following her retirement from government service, she conceptualised and led the Karnataka Comprehensive Nutrition Mission – a pioneering multi-sectoral initiative demonstrating structured convergence at household level across health, nutrition, education, and women’s empowerment – to improve health and nutrition outcomes across the life cycle.
Ms. Rao currently heads the Auro Centre for Public Nutrition, Public Health and Public Policy, a vertical of the Sri Aurobindo Society, where she continues to work on advancing evidence-based and community-driven approaches to strengthening India’s human-capital foundations.
In this conversation with The Policy Edge, Ms. Rao reflects on the design, evidence, and policy lessons emerging from the Karnataka Comprehensive Nutrition Mission. She discusses why inter-generational public health and nutrition interventions should be positioned as a foundational element of human development strategy to enhance the effectiveness of investments in education and skills.
What were the main factors that went into conceptualizing the Karnataka Comprehensive Nutrition Mission?
In my role as Joint Secretary, Department of Women and Child Development, I came to recognise that intergenerational nutritional status forms the foundational layer of healthy human capital – both cognitive and physical. There is strong scientific evidence linking the nutritional status of adolescent girls to maternal health, foetal development, early childhood nutritional status and brain development. These early-life conditions, in turn, shape adolescent learning capacity, future skills, earning potential, and the strength of the demographic dividend.
However, our development programmes are not designed to address this life-cycle convergence effectively in implementation. Programme design and delivery have still not acquired the minimal convergence within the silos, and continue to address outcomes at individual life stages rather than inter-generationally and across life cycle.
What was different about the design, strategy and interventions adopted by the Karnataka Mission as compared to the strategies under implementation in ongoing health and nutrition programmes?
The Karnataka Mission was designed specifically to operationalise the required intergenerational interventions into practice. It focused on three root causes of poor community nutritional and health status: information deficit, calorie-protein-micronutrient deficit, and a self-perpetuating intergenerational cycle linking undernourished adolescent girls, anaemic mothers, and low-birth-weight infants.
Accordingly, the Mission simultaneously addressed the health and nutritional needs of children, adolescent girls, and pregnant and lactating women. A vital institutional add on was the appointment of a Village Nutrition Volunteer (VNV) – a woman from each village trained to perform core village-level intervention functions.
To bridge the information deficit prevalent in the community – especially among subsistence-level households – and bring about behaviour change, we undertook a sustained, multi-layered public awareness campaign. This Information, Education and Communication (IEC) effort employed interpersonal communication at the household level as one of the core pillars. The focus was on promoting healthy nutritional practices within household budgets, proper child, adolescent and maternal health care, and creating demand for ongoing government health and nutritional programmes, namely, immunisation, Vitamin A supplementation, and consumption of iron and folic acid tablets, with a special focus on sanitation, for which there is very low demand in backward regions.
Next, to bridge the calorie-protein micronutrient deficit among poorer households, appropriate fortified multigrain food supplementation for the three target groups was produced by local women Self Help Groups.
Many programmes speak of convergence. But the difficult part is monitoring. What design choices did the Mission make to address this issue and where did it take calculated risks?
Design choices were dictated by design imperatives. Convergence was ensured through monitoring which was embedded directly into the Mission’s design and strategy. We performed real time monitoring of health and nutrition indicators including underweight, stunting and wasting among children; body mass index of adolescent girls; pregnancy weight gain; and the incidence of low-birth-weight babies.
In practice, real-time monitoring was achieved by issuing every targeted household a card, which not only recorded the beneficiaries’ health and nutrition status at regular intervals, but also recorded whether ongoing programme interventions – such as immunisation and Vitamin A supplementation, anaemia control, water and sanitation programmes – were actually reaching the household. The VNV would inform village- or block-level supervisors if there were any supply side problems and try to get them resolved speedily. The VNV also sensitised and motivated families about low-demand programmes such as Swachh Bharat, by explaining its positive health impact on the household.
This real-time data built into the design itself, enabled us to monitor and strengthen household-level convergence effectively. So, the Mission reduced implementation uncertainty, by making delivery failures visible and actionable at the earliest.
Much of the common understanding on the nutrition, health, and human capital triad is based on the data from National Family Health Survey (NFHS) and Sample Registration System (SRS) data. How do the results from the Mission data augment this common understanding?
NFHS and SRS are periodic, cross-sectional surveys, and do not provide longitudinal real-time data. The Karnataka Mission captured real-time data on multiple cohorts, for a continuous period of three years, for children, adolescent girls, and mothers.
Several new findings have emerged from the real-time data analysis, which do not find place even in the WHO/UNICEF protocols. A few examples illustrate this clearly.
For children, we observed constant transitions between stunting, underweight, and wasting as interventions progressed. That is, a child who could overcome stunting, could still be underweight or wasted, or vice-versa. More specifically, stunting emerged as the catchment category for children who improved out of wasting and underweight, even as some stunted children improved and became non-stunted. Hence there was a clear evidence that if the number of stunted children who become non-stunted is lower than the number of wasted and underweight children who improve and become stunted, then stunting can actually increase during implementation. These transitions are not trackable in periodic, cross-sectional surveys like the NFHS. Hence, greater research is required regarding the trends, duration and sequence of transitions. This also underscores the need for policy and programmes to view these indicators in an integrated and holistic manner.
Another interesting finding that emerged was that children with higher baseline height were more vulnerable to wasting. Similarly, among adolescent girls, moderate thinness became the catchment area – absorbing both those who improved from severe thinness and those who deteriorated from normal BMI.
Maternal outcomes showed similarly clear patterns. We observed that maternal BMI at the time of pregnancy confirmation was positively and significantly associated with newborn birth weight. In practical terms, improvements in maternal BMI at pregnancy confirmation were associated with a lower risk of low birth weight and a higher likelihood of healthy-birth-weight infants.
The novelty of these findings extend beyond the Karnataka mission, pointing to new directions for further research and validation.
Looking beyond Karnataka, is the Mission’s design scalable? And, how does it add to India’s development strategy, particularly in aspirational districts?
The Mission’s design is scalable – we can definitely adopt a similar intergenerational, multisectoral approach for poorer households across aspirational districts. It should be a national priority to focus on the bottom-of-the-pyramid population, whose human development indicators remain abysmal and enable a transition from a subsistence state to a productive state within a generation.
The stakes for India’s development are high, as without sustained improvement in health and nutrition, our immediate and future demographic dividend risks becoming a liability. Targeted intergenerational investment, by contrast, is associated with stronger learning outcomes, higher skills and productivity, and long-term gains in GDP and per capita income – shaping the conditions under which India can move beyond a developing-nation trajectory. The alternative is a grim scenario of demographic dependencia.
Views are personal.