Poor sanitation and low social status of women impede India's fight against malnutrition
Malnutrition has been one of the enduring enigmas of contemporary India. Despite years of rapid economic growth, child malnutrition rates remained unchanged for years. After years of stasis, there seems to be some sign of progress in India’s battle against malnutrition, although malnutrition rates remain high.
A Mint analysis based on provisional state-wise data from a recent national survey shows that some of the most malnourished states of the country have witnessed the sharpest fall in the proportion of underweight children. But when it comes to stunting (low height for age), considered an indicator of chronic undernourishment, the ranking of states remains precisely the same as it was a decade ago.
While improvement in poverty rates could have played a role in reducing the burden of malnutrition, there is very little evidence to suggest that state interventions, either in the form of broad-based programmes such as the public distribution system (PDS) for foodgrains or targeted child nutrition programs such as the Integrated Child Development Services (ICDS) played a major role in fighting child malnutrition, as the charts given indicate. The recent data seems to corroborate earlier research on malnutrition in India that highlighted two key drivers of malnutrition in: the absence of sanitation, which leads to rampant spread of diseases, and the low social status of women, which is reflected in low birth weights.
A nationwide survey called the Rapid Survey on Children (RSOC), conducted by the ministry of women and child development in 2013-14 in league with Unicef, showed that the proportion of underweight children in India was 29.4%, and that of stunted children 38.7%. While these figures indicate high levels of under-nutrition, they show a marked improvement over what the last nationwide survey, the National Family Health Survey (NFHS), had reported in 2005-06: the ratio of underweight children at 42.5%, and the ratio of stunted children at 48%. While the aggregate figures were reported by the government to the International Food Policy Research Institute (IFPRI) last year, leading to a dramatic improvement in India’s rank on the hunger index released annually by the institute, the ministry did not publish any details relating to the survey for a year after it was completed.
After The Economist published provisional state-wise results of the survey, the ministry of women and child development put up a fact sheet about the survey on its website earlier this month. The Union government also said that the state-level estimation methodology is still being examined.
The fact sheet seems to suggest that the RSOC survey had a large sample size, and a sampling methodology similar to the NFHS. It is, therefore, worthwhile to compare the trends revealed in the latest survey (sourced from The Economist) with the trends reported by NFHS nearly a decade ago.
Like almost everything else in India, malnutrition rates vary widely across states and income groups. But it is heartening to note that some of the most malnourished states of the country saw the biggest gains in underweight rates over the past decade. Madhya Pradesh and Bihar, the states with the highest rates of underweight children, saw the sharpest fall in underweight rates over the past decade, as the chart below highlights.
Most states in the North-East saw big improvements in rates of stunting, albeit on a high base. The ranking of states in 2013-14 was identical to the ranking in 2005-06. Inter-state variations in rates of stunting are as pronounced as they were a decade earlier.
While poverty is not the only cause of malnutrition, it is an important cause, not just because poor people may lack adequate food but also because the poor often have less time and resources to care for their children. Not surprisingly, the proportion of malnourished children among the lowest wealth quintile is significantly higher than the proportion of malnourished children among the highest wealth quintile. But the difference between the two extreme wealth quintiles seems to have narrowed over the past decade, the latest data suggest. The proportion of underweight children among the lowest wealth quintile declined 14.5 percentage points to 42.1% while the same proportion among the highest wealth quintile fell 1.1 percentage points to 18.6%, compared to the previous decade.
The past decade saw the biggest decline in poverty rates in the history of independent India. And it is likely that nutrition levels improved as even the poorest had access to greater resources than in the past.
While there is a clear link between wealth and nutrition at the household level, the link is much weaker when one looks at countries or states. India, for instance, has higher malnutrition rates than many poorer countries, such as those in Africa. Within India, some of India’s richest states, such as Maharashtra and Gujarat, have higher proportions of underweight children than some of India’s poorer states such as Assam and Uttarakhand.
An analysis of states where the decline in poverty was faster than the national average between 2004-05 and 2011-12 shows that the link between poverty reduction and improvements in nutrition is at best a weak one. While some of these states, such as Bihar and Madhya Pradesh, saw rapid gains in nutrition, others such as Odisha and Tripura saw only modest gains, as the chart below shows.
The past decade also saw significant improvements in the PDS, as an earlier Plain Facts column had pointed out. But there does not seem to be any strong link between improvements in PDS and improvement in nutritional outcomes. Improvements in PDS have been calculated as the financial equivalent (at constant prices) of the increased foodgrains people availed of in rural India across states. The implicit income transfer through PDS is based on estimates by economist Andaleeb Rahman of the Indian Institute for Human Settlements, Bengaluru. As the chart below shows, states which have led gains in PDS, such as Chhattisgarh and Odisha, have seen modest gains in nutritional outcomes. Many states with less improvements in PDS have fared better in nutritional outcomes.
The past decade also saw rapid expansion of India’s biggest intervention to fight child malnutrition, the ICDS. A 2011 evaluation report of the ICDS by the Planning Commission ranked states on the basis of an index of ICDS performance. The index is a composite one that takes into account factors such as the average number of days beneficiaries received nutritional supplements, the proportion of mothers who consulted ICDS workers when their children fell sick and the average attendance during surprise visits by the evaluating team.
As the chart below shows, there is little evidence to suggest that states that rank high on ICDS performance have improved nutritional outcomes. A high rank on ICDS performance indicates better performance in the chart, while high ranks in stunting and underweight ratio indicate low level of stunting and underweight, respectively. Thus, a rank of 1 on ICDS performance indicates the best performance among all the major states considered, while a rank of 1 on stunting indicates the lowest level of stunting among all states considered.
Two factors that do seem to affect under-nutrition are open defecation and the status of women. States with low rates of open defecation seem to have better nutritional outcomes, while states with high rates of open defecation seem to have worse nutritional outcomes, as the chart below shows. In the absence of sanitation facilities, children face a hostile environment and frequently fall prey to common infectious diseases which reduce their ability to absorb nutrients and grow.
The chart also indicates that states with high proportions of low birth weights tend to have worse nutritional outcomes. Low birth weight babies start life with a nutritional disadvantage, and many of them remain underweight even as they grow up. High incidence of low birth weight babies is a reflection of the low social status of women, who do not receive adequate nourishment or care prior to childbirth. It does not appear to be a coincidence that most states with low ratios of low birth weight babies are also states with relatively higher sex ratios.