By Rajiv Shah*
Two recent studies – one of them by the Public Health Foundation of India (PHFI) in alliance with Transform Nutrition and UK Aid, and another by a group of scholars, Daniel J Corsi, Iván Mejía-Guevara, and SV Subramanian, and published in a top American journal, “Social Science & Medicine” – have gone a long way to clearly point towards how economic development per se cannot help fight undernourishment among India’s children.
The PHFI study, “India Health Report: Nutrition 2015”, released last month, has specifically given the example “developed” states like Gujarat which lag behind several major Indian states in child nutrition status.
Quoting latest Government of India figures, the study says that, in Gujarat, 33.5 per cent of under-five children are underweight, which is the seventh worst among 20 major Indian states. The study further says that 41.6 per cent under five children in Gujarat suffer from stunting, which is the fifth worst among 20 major states; and 18.7 per cent suffer from wasting (or low weight for height), which is the third worst among 20 major states.
Basing its analysis on the latest data (for 2014) provided by the Rapid Survey on Children (RSoC) of the Ministry of Women and Child Development, Government of India, the study’s example of Gujarat goes a long way to suggest that, to quote from the report, “economic growth cannot, by itself, reduce undernutrition.” Pointing towards “massive variables across states”, which mask recent progress in overcoming the problem of undernutrition, the study reports, in India, “38.7 per cent children under five are stunted, 19.8 per cent are wasted, and 42.5 per cent are underweight.”
Giving the example of well-to-do states, the study says, in Punjab, “which best represents the national average per capita income at Rs 49,529 (2013-14), the prevalence of stunting among children under five is 30.5 percent (lower than the national average of 39 percent).” And, interestingly, “although Tamil Nadu and Gujarat have similar levels of income, Tamil Nadu has a much lower stunting rate of 23.3 percent, while it is 41.8 percent in Gujarat.”
“These disparities”, the study says, “indicate that levels of income do not automatically translate to lower stunting, and warrants a closer look at other known developmental drivers of stunting.” It adds, “Most analyses of stunting declines confirm that economic progress alone is not sufficient to achieve significant nutritional gains.”
Thus, “from 1998–99 to 2005–2006, GDP per capita in India expanded by 40 percent in real terms. Despite the rising levels of prosperity and 18 reduced levels of poverty among millions of Indians, the proportion of stunted children under age three declined by only 6.1 percentage points in that seven-year period, from 51 to 44.9 percent.”
Citing a study of 63 countries, including India, the study says, it shows that “increases in per capita national income translated into improvements in child nutritional status only if the economic gains facilitated public and private investments that could improve conditions related to diet and disease.”
The study says, India’s “child nutrition rates have been declining, first at a slow rate between 1992 and 2006, and at an accelerated rate since 2006.” However, it underlines, “these developments are below the rate needed to meet the World Health Assembly’s targets to which India is signatory to.”
“Between 2006 and 2014, India’s stunting rate of children below five years declined from 48 per cent to 39 per cent. This decline in stunting in India is translated to 14 million fewer children and decline in wasting is translated to seven million fewer wasted children. Despite this, child under-nutrition rates in India are among the highest in the world. India is still home to over 40 million stunted children and 17 million wasted children under five”, the study adds.
The study published in the American journal “Social Science & Medicine” seeks to give further evidence, based on the authors’ surveys across India, that India’s policy makers, while identifying “risk factors” for chronic undernutrition among children disproportionately focus on “what can be termed ‘nutrition-specific’ interventions targeted at addressing the immediate causes of undernutrition.” They refuse to give necessary emphasis on “social and structural factors, including poverty reduction, improvements to socioeconomic status and maternal education.”
The study says, the issue is particularly important because, despite reduction in childhood stunting and underweight in India, the country accounts for “38% of the global burden of stunting (nearly 62 million children) underscoring the importance of reducing undernutrition in India.”
“The prevalence of childhood stunting and underweight in India remains persistently high”, the study says. “In 1992–93, amongst children aged 0–47 months, 57% and 49%, were stunted and underweight, respectively, declining to 47% and 42% in 2005–2006, and to 39% and 29% in 2013–14, the most recent year for which national data are available.”
It adds, “There appears to be momentum to make direct investments in programmes and interventions aimed at nutrition (e.g., breastfeeding, complementary feeding, micronutrient nutrition, and therapeutic and supplementary feeding), health (e.g., prevention and management of infectious diseases) and water, sanitation, and hygiene (WASH) programmes”, calls these as “considered in isolation.”
Based on a survey of 109,041 households across India, and 124,385 women, who agreed to participate in the survey, the methodology used in the study includes using the wealth index, a variable already available in the National Family Health Survey (NFHS). “The index used was derived from a weighted sum of household assets that included televisions, telephones, motorcycles/scooters, cars, mattresses, other possessions and household characteristics (e.g. windows), and materials used for wall/floor construction”, the study says.
Results of the survey suggest that “the prevalence of stunting and underweight in the study sample were 51.1% and 44.9%, respectively”, but the “levels of risk factors were common in the sample including low household wealth (28.6%), no formal education (50.0%), short maternal stature (<145 cm, 12.1%), and poor dietary diversity (31.4%).”
The survey results show that the “five most important predictors of stunting were short maternal stature, no education, lowest wealth quintile, poor dietary diversity, and maternal underweight/low BMI”; and “the five risk factors with the weakest association with stunting… were no access to safe water, unsafe disposal of stools, infectious disease prior to survey, no vitamin A supplementation and delayed initiation of breast feeding.” It adds, “For underweight, the results were largely similar with some differences in the relative ordering of risk factors.”
The authors conclude, “Our findings indicated substantially larger effects for maternal height, BMI, household wealth, education, and children’s dietary diversity and this underscores the importance of improving the overall environmental and socioeconomic conditions at the child, maternal and household levels.”