India’s economic growth in recent decades has co-existed with alarming levels of chronic hunger and stunting. The country ranked 94th among 107 countries in the Global Hunger Index 2020, way behind many other developing countries. Now, new data suggest that child malnutrition might be worsening—fewer children in India are dying, but those who survive are more malnourished and anaemic in many states.
The fifth National Family Health Survey (NFHS-5) released its first results in December, 2020, offering data from 22 of 36 states and union territories in India (the remaining data are expected in mid-2021). The findings raise troubling questions about the country’s handling of its child malnutrition challenge. In 13 of 22 states and union territories, stunting in children under 5 years increased since the last survey (NFHS-4) in 2015–16, and wasting increased in 12 states and union territories. Some states struggle with a high dual burden of both wasting and stunting.
Notably, the NFHS-5 data relate to the pre-pandemic period, and despite improvements in sanitation and immunisation. Between NFHS-4 and NFHS-5, the under-5 and infant mortality rates have decreased in 18 states and union territories, but 16 states showed a rise in underweight and severely wasted under-5 children. The slideback in nutrition has affected both rich and poor states, although the degree varies between states, between districts in the same state, and between rural and urban areas.
While nutritionists and health experts await more complete and granular data to better understand the situation, some worrying trends leap out. “The stalling of progress in child undernutrition is a huge concern. It is unusual to see this and signals a need for a deep look at the data across geographies and socioeconomic groups”, says Purnima Menon, senior research fellow at the International Food Policy Research Institute (Washington DC, USA).
The reversal in child nutrition could be the cumulative result of a range of factors—from macro-level economic shocks, to weakened social protection, and endemic structural issues. “Overall, given that this period (2016–19) has been one of slowdown in economic growth rates, stagnant rural wages, high unemployment, and increasing inequality, it does seem plausible that this has had an impact on livelihoods—and hence food security for many households [and the worsening of nutritional outcomes]”, says Dipa Sinha (Ambedkar University, Delhi, India), who is part of a civil society-led Right to Food Campaign.
According to Sinha, it is also important to recognise that public programmes for food security, social protection, and nutrition were not able to provide the cushion needed at times of economic distress. The NFHS collects data on how many children are enrolled in government programmes, whether they are receiving supplementary nutrition, and so on. When these data become available, they can be compared with the Integrated Child Development Services (ICDS) coverage data to get some idea of how those services are performing. There is some evidence pointing to a decline in the number of beneficiaries of the Supplementary Nutrition Programme, which comes under ICDS, in the past 3–4 years, she adds.
The ICDS is the Indian Government’s flagship programme that attempts to provide basic education, health, and nutrition services for early childhood development. But expenditure on the Supplementary Nutrition Programme has decreased by 6% between 2015–16 and 2016–17, according to Accountability India, an initiative of the leading thinktank Centre for Policy Research (New Delhi, India).
Although sanitation and other health indicators (such as immunisation) have improved in many states, Menon stresses that multiple determinants need to be tackled to improve child nutrition—not just programme coverage, not just household income, and not just sanitation.
One worrying trend is intergenerational malnutrition. The high prevalence of anaemia among women of childbearing age heightens the risk of low-birthweight infants and infant anaemia. In Assam, a poor state in eastern India, 36·5% of rural children aged 6–59 months and 45·7% of pregnant women aged 15–49 years were found to be anaemic in 2015–16, increasing to 68·6% and 55·9%, respectively, in 2019–20. Importantly, the state was improving on many key nutritional indicators, including anaemia, among children and pregnant women between 2005–06 and 2015–16.
“Intergenerational malnutrition has been India’s big public health and nutrition woe for several decades now. The recent survey (NFHS-5) confirms that yet again”, says Shweta Khandelwal, Head of Nutrition Research at the Public Health Foundation of India (PHFI, New Delhi, India). There will be much greater clarity when there are detailed household-level or individual-level data. “Often there is clustering of risk factors in households—an obese mother can have a stunted child and vice versa. Anaemic women entering pregnancy often have low-birthweight babies [who are] then fed excess calories to catch up. But this predisposes them towards non-communicable diseases, especially if they don’t get a diverse and balanced diet”, she added. A plethora of issues interact with each other and make matters worse for public health and nutrition, and Khandelwal stresses that nutrition needs to be integrated at each phase of the lifecourse with other sectors such as health, education, hygiene, and environment.
What leaps out from the early NFHS-5 data is worsening anaemia and malnutrition even in the traditionally better-performing states in human development. For example, in Kerala, 39·4% of children aged 6–59 months were anaemic in 2019–20, up from 35·7% in 2015–16. “It is likely that anaemia among children may have worsened based on the point estimates reported for NFHS-4 and NFHS-5. However, we will need to wait for the detailed dataset to understand the extent and significance of this increase across each state, between boys and girls, and by socioeconomic strata”, says Rakhi Dandona (PHFI and the Institute for Health Metrics and Evaluation, Seattle, WA, USA). Comparability of the methods used to assess anaemia between the two rounds of NFHS also needs to be examined.
One key emerging issue is the lack of diet diversity among India’s children and adolescents. The Comprehensive National Nutrition Survey (2016–18), the largest micronutrient survey ever conducted, revealed issues with the diet diversity and meal frequency in children, points out Dandona. The Survey also found that folate and vitamin B12 deficiencies are significant contributors to nutritional anaemia in India, in addition to iron deficiency. The extent of iron deficiency and anaemia documented are important to consider. India needs to emphasise on policies and actions that reflect the relationships between the determinants of malnutrition and anaemia, and not just focus on supplementation of iron and folic acid”, she adds.
India has attempted to address child malnutrition, including anaemia, through various policy initiatives—such as the ICDS (1975), the National Nutrition Policy (1993), the Mid-Day Meal Scheme for school-going children (1995), and the Weekly Iron and Folic Acid Supplementation programme (2012)—with some success, says Avina Sarna of the Population Council (New Delhi, India). The current government’s answer to the malnutrition problem is an ambitious programme called the National Nutrition Mission (Poshan Abhiyan), which was launched in 2018 to give momentum to earlier efforts through intersectoral convergence between the different programmes for better service delivery, with an increased focus on dietary diversity and food fortification. But its impact on the ground is not very visible. “It will take a few years to for the programme to achieve its goals”, says Sarna.
Although its goals are laudable and its vision an ambitious one, questions have been raised about the pace of its implementation. The National Nutrition Mission speaks of several achievements on its website, “but they can largely be interpreted as number of events, number of outreach activities etc”, Khandelwal told The Lancet Child & Adolescent Health. There is no concrete third-party analysis on what the government has been able to contribute in terms of reducing malnutrition of all forms and improving nutritional indicators for good.
A longstanding issue has been the lack of coordination between various ministries and departments that work on child nutrition, says Chandrakant Pandav, a member of National Council on India Nutrition Challenges. Auxiliary nurses and midwives, anganwadi workers (who work at government-sponsored mother and child centres), and frontline health workers have to work together to deliver results on the ground. This does not always happen. “There has not been much focus on community empowerment, which is critical. There has to be a public movement for nutrition security. There is little knowledge about the need for dietary diversity”, Pandav added.
“Setting up the National Council on India Nutrition Challenges under Poshan Abhiyaan was a great decision by the Prime Minister but the fact is that we have not had a meeting since October 2019”, says Pandav. “Thinking in silos has made things worse. You can’t have nutrition security without food security, and you can’t have food security without agricultural security. We need one ministry which deals with agriculture, food, and nutrition together…NFHS-5 covers a time when there has been economic shocks like demonetisation and acute rural distress. Many people may have been cutting down on food, especially nutritious food”, says Pandav. Meanwhile, many state governments in India where the ruling Bharatiya Janata Party are in power are embroiled in socioreligious battles over serving eggs to poor undernourished children in government programmes, despite the obvious nutritional benefits.
A big worry is the impact of the pandemic on an already-fragile state of child nutrition. Hunger Watch, a survey led by the Right to Food Campaign of nearly 4000 people from marginalised communities in 11 states, found that over two-thirds were eating nutritionally worse and less food in September and October, 2020, compared with the pre-lockdown period (before late March, 2020). Disturbingly, the Union Budget 2021 has slashed allocations for government schemes that directly impact nutrition, including the ICDS, midday meals, and maternity entitlements.
The troubling data from the latest NFHS is a wake-up call. Ignoring the deepening child malnutrition crisis will further erode the country’s human capital.