Close to 1.3 million children die every year in India because of malnutrition, according to the World Health Organization (WHO). Ninety nine per cent of all under-five deaths occur in developing countries, with the most common causes of death being pneumonia, diarrhoea and malaria. These are illnesses to which children are particularly vulnerable, especially when they are malnourished, a condition that weakens their immune systems. Malnutrition contributes to more than a third of all child deaths.
Worldwide, over 100 million children are underweight. While it is a serious problem in sub-Saharan Africa, even higher rates of stunting are found in South Asia, particularly in India. Along with Nepal and Bangladesh, India has the world’s highest rate of malnutrition.
One way to fix the problem is to teach mothers about the right nutrition for their children or to incentivize them through conditional cash transfers. Distributing information is an important part of a solution, although it does not always lead to behavioural changes. Mothers are advised that when their child has diarrhoea they should increase their child’s fluid intake and continue to feed them normally. According to the National Family Health Survey (NFHS) -3, nine out of 10 mothers do not follow this recommendation. In fact, four out of 10 mothers actually reduce their child’s fluid intake.
Medical solutions to the problem of malnutrition include de-worming and nutritional supplements. De-worming campaigns are quite effective and have been conducted in many daycare centres and health encampments. The treatment has been especially popular in Kenya and other parts of Africa, and now in India, the practice has become compulsory in all schools. Popularly used nutritional supplements include vitamin A, zinc, iron, and various minerals. In addition, iodised salt has been a popular weapon of the government of India as it continues to try and promote its consumption over normal salt.
There is also a behavioural approach, which has very little to do with the advances in science and technology, but instead attempts to simply alter the behaviour of mothers and workers who interact with the child. This includes giving children the right type and amount of nutrition. We can focus on trying to change behaviour towards calorific food and encourage the consumption of a variety of foods.
My research focuses on the slums that surround the city limits of Chandigarh, a union territory located in northern India. About 50,000 people live in these slums. Less than 5% of the houses have working water filters. At the same time, however, 70% of the households own mobile phones. The people living in these slums are typically migrants from rural areas where wages are extremely low. The mothers in this treatment group are women who send their children to daycare centres in the slums.
India is home to the world’s largest child care programme, Integrated Child Development Services (ICDS), which started in 1978. There are currently over one million of these daycare centres (anganwadis) run by the government across India. Each daycare centre serves around 30 children on an average. The children go to the centre every morning at 9 am and are fed their midday meals by daycare workers. The meals are prepared by a good local agency that the government hires on contract. The workers are given training on child health and nutrition when they are hired by the government.
Another aspect of the daycare workers’ responsibilities is to visit and communicate with the mothers whose children attend the centre, giving them advice on how to keep their children healthy. The daycare centres offer two potential channels by which to help children living in the slums. The first is by the distribution of the midday meal and the second is by providing information and counsel to the mothers. However, a World Bank report on the ICDS finds leakages in the provision of meals and almost no effective communication between workers and mothers. A total of 145 daycare centres were sampled for this study.
The experiment tackles the question of whether it is the lack of information on nutrition given to mothers, or the lack of child care worker motivation that makes child malnutrition persist. The total children weighed twice (before and after an intervention) were 4,101 with around 1,000 in each one of three treatment groups (subject to an intervention) and a control group (not subject to any intervention). In the first treatment group, mothers receive recipe books written in Hindi. As around half of these mothers cannot read, the information is also distributed to other family members, including fathers, older sons and daughters. Government workers may also assist by reading and sharing information from the recipe book. The recipe book is designed with the help of a local nutritionist and contains 10 recipes, which provide an array of vitamins and minerals as well as sufficient calories.
In the second treatment group, I provide incentives for child care workers to perform better. They are paid bonuses of Rs.100 for each child whose weight they successfully increase so that he or she is no longer classified as malnourished after three months. For each child under their care, the workers are given a goal card with the weight at which the child will no longer be considered malnourished. If a child at a normal weight becomes malnourished, however, I subtract Rs.100 from the total. This motivates the worker to make the necessary household visits.
To test how the two types of treatments interact, the informational and incentives treatments are combined in the third group. Complementarity may exist if incentivized workers are able to be more effective with nutritional information available to the mother. On the other hand, one of the two treatments may be sufficient for improving weight. A separate set of centres form the control group where no intervention is assigned.
Results show that malnutrition is reduced significantly in three months for children in the combined treatment group by 4.2% but there are negligible effects in the individual treatment groups. The combined treatment effect persists for a year even after the incentives are removed after three months. One estimate suggests that the country gains Rs.20 for every rupee spent on the combined treatment in terms of increase in future wages for these children due to an improvement in health and attendance.
I believe that policy recommendations should be based on evidence from experiments and that increasing fixed wages to child care workers will not solve the problem. Similarly, offering performance pay is likely to be ineffective unless mothers have nutritional information available to them. Not only does this empower them, but it also facilitates communication between mothers and workers which enables a behavioural change to occur. Mothers receiving the combined treatment feed their children more protein and calories. A small push is required on both the demand side as well as the supply side to target child malnutrition in India. Further experimentation in development economics can bring us closer to understanding how this serious problem can be fixed efficiently and permanently.
Reprinted with permission from ISB Insight, the quarterly research publication of Indian School of Business (ISB) and Ideas for India (www.ideasforindia.in), a policy portal.