By Qrius
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Anupma Mehta
The year 2020 has become synonymous with COVID the world over but for India, it signifies another health risk calling out for attention. The State and district level findings of the fifth round of the National Family Health Survey (NFHS-5), conducted in 2019-20, and released recently, raise serious concern about the status of childhood nutrition in the country. The NFHS, a large-scale survey conducted throughout India in four earlier rounds in 1992–93, 1998–99, 2005–06, and 2015–16, provides State and national level information on various health indicators, including fertility, nutrition, infant and child mortality, reproductive health, prevalence of anaemia, and utilisation and quality of family planning services. NFHS-5 covered 6.1 lakh sample households to provide estimates for 707 districts, with data for its first phase encompassing 22 States and Union Territories.
One of the most promising results in NFHS-5 is the successful use of contraception to control the Total Fertility Rate (TFR), which has declined to touch the replacement rate in almost all States and UTs. The survey, however, red flags the issue of child malnutrition, with the Government hard put to explain the worsening nutrition status among the country’s children vis-à-vis the previous NFHS. This is especially worrisome as most other indicators of child health like optimal vaccination rates, reduction in under-5 and infant mortality, and rise in institutional deliveries, exhibit promising trends.
Deterioration in Childhood Health Parameters
One of the most promising results in NFHS-5 is the successful use of contraception to control the Total Fertility Rate (TFR), which has declined to touch the replacement rate in almost all States and UTs. The survey, however, red flags the issue of child malnutrition, with the Government hard put to explain the worsening nutrition status among the country’s children vis-à-vis the previous NFHS. This is especially worrisome as most other indicators of child health like optimal vaccination rates, reduction in under-5 and infant mortality, and rise in institutional deliveries, exhibit promising trends.
Deterioration in Childhood Health Parameters
Another piece of data that stands out like a sore thumb in NFHS-5 is that the prevalence of anaemia has multiplied in nearly 70 per cent of the States, across different age groups. The survey indicates that in 18 States, at least one in every three pregnant women is anaemic despite a substantial increase in the consumption of iron and folic acid tablets. Most global studies demonstrate that maternal anaemia is one of the key causes of foetal as well as childhood malnutrition. It is also well known that the failure to initiate timely breastfeeding after delivery and to sustain it through the first six months of an infant’s life subsequently leads to undernutrition. NFHS-5 found that only ten of the surveyed States showed an improvement in the rates of early initiation of breastfeeding, and even more alarmingly, only one-fourth of the infants in all States were reportedly receiving adequate nutrition through breastfeeding.
So, how can a nation that aspires to become a $5 trillion economy within the next few years ensure that its children are healthy and well-fed? The answer lies in tackling three indicators of undernutrition among a nation’s child population—stunting (low height for age); wasting (low weight for height); and being underweight (low weight for age). Children with these anthropometric failures are also more likely to suffer from severe diarrhoea and acute respiratory infection than their healthier counterparts.
While addressing these three parameters is imperative for ensuring adequate child nutrition, some of the NFHS-5 results are counter-intuitive and necessitate out-of-the-box thinking to find viable solutions. For instance, Goa, the State with the highest per capita income in the country, reported an increase in stunting to 25.8 per cent in the current survey from 20.1 per cent in NFHS-4. And Kerala, the most literate State, which also enjoys the tag of being a welfare State, showed a rise in stunting from 19.7 per cent to 23.4 per cent during the corresponding period. Other developed States like Gujarat and Maharashtra also recorded similar trends. In sharp contrast, Bihar, widely believed to be less advanced than its peers, has proved to be an outlier, with an impressive performance in bringing down the incidence of stunting from 48.3 per cent in NFHS-4 to 42.9 per cent in the current NFHS. Albeit NFHS-4 had recorded 62 million stunted children in India, accounting for 40 per cent of the global share of stunting. But there was still room for some satisfaction, as between the two previous NFHS rounds in 2005-06 and 2015-16, the country had managed to lower its share of stunted children by nearly 10 percentage points. These gains have apparently been frittered away in the last five years with current figures clearly showing that children born between 2014 and 2019 are more malnourished than the previous generation.
These findings call for a deeper dive into the reasons for the widespread and rising prevalence of malnutrition across the country. Key IHDS Findings The NFHS figures are largely corroborated by data from the India Human Development Survey (IHDS), carried out by the National Council of Applied Economic Research (NCAER) in collaboration with the University of Maryland, USA, in two phases, in 2004-05 and 2011-12, respectively. The IHDS is a nationally representative multi-topic survey administered to over 41,000 households in 1503 villages and 971 urban neighbourhoods across the country in the first wave, with a re-contact rate of 82 per cent in the second wave. The IHDS dataset is not only the largest source of panel data for children in India, but also the only single source for anthropometric data, dietary intake, and household income and expenditure. A comprehensive analysis of IHDS data in conjunction with the successive NFHS findings suggests that poor nutrition adversely affects the physical and cognitive development of children, and consequently their productivity and progress in later life. It is also worth exploring whether apart from anthropometric factors, other causalities like maternal autonomy, female literacy, financial status, and social background play a role in mitigating or aggravating child undernutrition in households. For instance, a well-educated mother, who enjoys some autonomy in her home, would ensure better care and nutrition for her children whereas a Below the Poverty Line (BPL) household is unlikely to generate sufficient resources for providing a healthy diet to its children. The IHDS also offers evidence that open defecation and poor hand hygiene are two of the leading factors responsible for stunting among children. An assessment of IHDS data shows that the incidence of children being underweight and stunted in households with acceptable hygiene levels, even if they were in the low income category, were much lower, at 25.3 per cent and 35.2 per cent, respectively, as compared to the much higher corresponding figures of 29.2 per cent and 38.8 per cent, respectively, in households with similar income levels but poorer hygiene standards. Further, IHDS-II found that 26 per cent of the married women surveyed were living in families wherein men ate first, clearly indicating that women are more likely to be under-nourished than their male counterparts. This also makes them susceptible to nutritional deficiencies like anaemia, which have a cascading effect on the health of the children they nurture, especially during pregnancy and lactation.
Half-hearted Solutions With the persistence of the problem, several solutions have been explored and proposed at the policy levels, but how far have they worked? Two of the most prominent measures for facilitating better nutrition and health for households included the passage of the historic National Food Security Act (NFSA) by the Government in 2013, and strengthening of the Integrated Child Development Services (ICDS). The NFSA, believed to be one of the largest safety net programmes in the world, legislated the availability of 5 kg of cereals per person per month at prices ranging from Re 1 to Rs 3 per kg to about 67 per cent of India’s population. The ICDS is a Centrally-sponsored scheme aiming at holistic development of children below 6 years of age, pregnant women, and lactating mothers by providing them a consolidated package of health and education services. A sub-programme, the Supplementary Nutrition Programme (SNP), is also administered under the ICDS. What then accounts for worsening child health in the country despite the implementation of these measures? One explanation is that economic challenges caused by mounting unemployment and rising food inflation during the period 2014–19 have led to declining household incomes, compromised dietary intakes, and consequently deteriorating child health outcomes. It is also posited that notwithstanding the policy announcement of ramping up the ICDS, in reality, it suffers from many gaps such as degenerating infrastructure, insufficient human resources including ASHA and Anganwadi workers, and declining budgetary allocations—one study by the Accountability Initiative has claimed that the SNP component of the ICDS received only 44 per cent of the requisite funds in 2019-20. All these factors have ostensibly aggravated food insecurity among indigent households, with child nutrition becoming the biggest casualty in this situation. The COVID pandemic has understandably grabbed most of the Government’s attention, becoming the single largest health focus in the country currently, but as India moves ahead to deal with this challenge, it would do well to simultaneously focus on the health of its most precious human resource, its children
While addressing these three parameters is imperative for ensuring adequate child nutrition, some of the NFHS-5 results are counter-intuitive and necessitate out-of-the-box thinking to find viable solutions. For instance, Goa, the State with the highest per capita income in the country, reported an increase in stunting to 25.8 per cent in the current survey from 20.1 per cent in NFHS-4. And Kerala, the most literate State, which also enjoys the tag of being a welfare State, showed a rise in stunting from 19.7 per cent to 23.4 per cent during the corresponding period. Other developed States like Gujarat and Maharashtra also recorded similar trends. In sharp contrast, Bihar, widely believed to be less advanced than its peers, has proved to be an outlier, with an impressive performance in bringing down the incidence of stunting from 48.3 per cent in NFHS-4 to 42.9 per cent in the current NFHS. Albeit NFHS-4 had recorded 62 million stunted children in India, accounting for 40 per cent of the global share of stunting. But there was still room for some satisfaction, as between the two previous NFHS rounds in 2005-06 and 2015-16, the country had managed to lower its share of stunted children by nearly 10 percentage points. These gains have apparently been frittered away in the last five years with current figures clearly showing that children born between 2014 and 2019 are more malnourished than the previous generation.
These findings call for a deeper dive into the reasons for the widespread and rising prevalence of malnutrition across the country. Key IHDS Findings The NFHS figures are largely corroborated by data from the India Human Development Survey (IHDS), carried out by the National Council of Applied Economic Research (NCAER) in collaboration with the University of Maryland, USA, in two phases, in 2004-05 and 2011-12, respectively. The IHDS is a nationally representative multi-topic survey administered to over 41,000 households in 1503 villages and 971 urban neighbourhoods across the country in the first wave, with a re-contact rate of 82 per cent in the second wave. The IHDS dataset is not only the largest source of panel data for children in India, but also the only single source for anthropometric data, dietary intake, and household income and expenditure. A comprehensive analysis of IHDS data in conjunction with the successive NFHS findings suggests that poor nutrition adversely affects the physical and cognitive development of children, and consequently their productivity and progress in later life. It is also worth exploring whether apart from anthropometric factors, other causalities like maternal autonomy, female literacy, financial status, and social background play a role in mitigating or aggravating child undernutrition in households. For instance, a well-educated mother, who enjoys some autonomy in her home, would ensure better care and nutrition for her children whereas a Below the Poverty Line (BPL) household is unlikely to generate sufficient resources for providing a healthy diet to its children. The IHDS also offers evidence that open defecation and poor hand hygiene are two of the leading factors responsible for stunting among children. An assessment of IHDS data shows that the incidence of children being underweight and stunted in households with acceptable hygiene levels, even if they were in the low income category, were much lower, at 25.3 per cent and 35.2 per cent, respectively, as compared to the much higher corresponding figures of 29.2 per cent and 38.8 per cent, respectively, in households with similar income levels but poorer hygiene standards. Further, IHDS-II found that 26 per cent of the married women surveyed were living in families wherein men ate first, clearly indicating that women are more likely to be under-nourished than their male counterparts. This also makes them susceptible to nutritional deficiencies like anaemia, which have a cascading effect on the health of the children they nurture, especially during pregnancy and lactation.
Half-hearted Solutions With the persistence of the problem, several solutions have been explored and proposed at the policy levels, but how far have they worked? Two of the most prominent measures for facilitating better nutrition and health for households included the passage of the historic National Food Security Act (NFSA) by the Government in 2013, and strengthening of the Integrated Child Development Services (ICDS). The NFSA, believed to be one of the largest safety net programmes in the world, legislated the availability of 5 kg of cereals per person per month at prices ranging from Re 1 to Rs 3 per kg to about 67 per cent of India’s population. The ICDS is a Centrally-sponsored scheme aiming at holistic development of children below 6 years of age, pregnant women, and lactating mothers by providing them a consolidated package of health and education services. A sub-programme, the Supplementary Nutrition Programme (SNP), is also administered under the ICDS. What then accounts for worsening child health in the country despite the implementation of these measures? One explanation is that economic challenges caused by mounting unemployment and rising food inflation during the period 2014–19 have led to declining household incomes, compromised dietary intakes, and consequently deteriorating child health outcomes. It is also posited that notwithstanding the policy announcement of ramping up the ICDS, in reality, it suffers from many gaps such as degenerating infrastructure, insufficient human resources including ASHA and Anganwadi workers, and declining budgetary allocations—one study by the Accountability Initiative has claimed that the SNP component of the ICDS received only 44 per cent of the requisite funds in 2019-20. All these factors have ostensibly aggravated food insecurity among indigent households, with child nutrition becoming the biggest casualty in this situation. The COVID pandemic has understandably grabbed most of the Government’s attention, becoming the single largest health focus in the country currently, but as India moves ahead to deal with this challenge, it would do well to simultaneously focus on the health of its most precious human resource, its children
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Anupma Mehta is Editor at the National Council of Applied Economic Research.
Views expressed in this article are personal.
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