Explained: How India’s war on undernutrition fails to address the root causes
The recent launch of the government’s food fortification programme and Poshan Abhiyaan brings our attention to the incidence of undernutrition in India, which takes the form of stunting (low height-for-age), wasting (low weight-for-height) and underweight (low weight-for-age) through the interaction of these three indices—height, weight and age. Data on undernutrition for children under the age of five from the National Family Health Survey (NFHS) of 2005-06 and 2015-16 illustrates some worrying trends, even though, as opposed to macroeconomic indicators, social development indicators change gradually over a relatively longer period of time in response to policy interventions. Accordingly, the results of these interventions are reflected with a lag. That being said, there is no denying the fact that the incidence of undernutrition in children in India is high.
But any attempt to understand these trends in isolation, without looking at other variables that are inextricably linked to undernutrition, is likely to be misleading. Thus arises the need to backtrack and study the root causes of undernutrition and its interplay with other variables—from a more holistic, rational and analytical vantage point.
First, let’s talk about undernutrition. Its incidence in children, who belong to the most vulnerable segment of the population, is a robust indicator of the nutritional status of any country. Given its impact on children’s cognitive and mental development, the effects of acute undernutrition are most pronounced for them. As shown in the accompanying graphic, the proportion of children under five years of age in the stunted and underweight category has witnessed a marginal decline in the previous decade. On the other hand, the statistics on wasting and severe wasting present an even more abysmal trend—displaying a relative increase for both categories during the same period. Now, let’s consider the trends of other social indicators like infant mortality rate (IMR) and under-five mortality rate (U5MR).
Historically, childbirth has been dangerous for both women and infants, despite largely preventable causal factors. But, in the recent years, the government has made major strides in healthcare—in terms of budget allocation, healthcare schemes and health outcomes. Accordingly, sustained efforts towards addressing some of the significant causal factors of high IMR have resulted in its consistent decline from 55.7 (2005) to 32 (2017), as shown in the graphic. First, according to the NFHS data, the percentage of institutional deliveries has nearly doubled from 38.75% (2005-06) to 78.9% (2015-16) through the support of initiatives such as Janani Suraksha Yojana. Second, interventions in neonatal (in the first 28 days of birth) and post-neonatal healthcare (from the first 28 days of birth to one year) like improved breastfeeding practices have also played a pivotal role in bringing down child mortality. Furthermore, with the launch of path-breaking government schemes such as the National Rural Health Mission and the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy, we are inching closer to the Sustainable Development Goals (SDGs) target of our commitment to end preventable deaths of infants and mothers by 2030.
However, one must understand that protecting infants from mortality begins even before they are born—it can be achieved by administering requisite prenatal care interventions. And in the case of India, prenatal maternal health and nutrition are yet to receive adequate attention.
Meanwhile, the commensurate decline in U5MR has taken place at a visibly faster pace than IMR—this seems very promising. U5MR for India is now almost at par with the global average of 39—potentially owing to the strides in immunisation coverage and other factors. According to UNICEF India, another significant cause of U5MR is acute undernutrition, accounting for 38% of the deaths. The declining trend of U5MR is, therefore, indicative of some progress in reducing undernutrition in children, coupled with more significant government initiatives such as child immunisation and Swachh Bharat Abhiyan (for sanitation and hygiene). To state it simply, at its nascent stages, the government policy on children’s health has prioritised the survival of children at birth and beyond the threshold of age five—and has achieved appreciable results, particularly in the recent years. The next logical step would involve shifting focus of government policy towards tackling the incidence of undernutrition, especially among surviving children—first ‘survive’ and then ‘thrive’, as advocated by the World Health Organisation (WHO).
On one hand, IMR and U5MR are declining, and on the other hand, the burden of undernutrition in children in absolute numbers is on the rise, or is slowly declining. When looked at together, there is a logical flow explaining the interplay of these trends.
A lower IMR and U5MR means that the total population of surviving children has increased in absolute numbers. As a consequence, the total proportion of undernourished children has also increased in absolute numbers.
So, what then explains this apparent increase in under five undernutrition?
The government policy has focused on significant causal factors of IMR and U5MR, like postnatal healthcare ensuring higher survival rate of children. However, other important factors like nutritional status of adolescent girls (future mothers) and prenatal nutrition have received scant attention. Nutritional status runs in a viscous intergenerational cycle with adolescent girls with poor nutritional status later becoming undernourished pregnant women, who, in turn, are likely to give birth to children who are stunted, wasted or underweight. As a result, the high number of undernourished mothers are likely to give birth to undernourished children. In fact, according to the NFHS-4 report, children born to women with low body mass index (BMI less than 18.5 kg/m2) have a higher likelihood of being stunted, wasted or underweight. Therefore, the central argument is simple. First, the higher survival rate of children, due to declining IMR and U5MR, has resulted in a higher population of children. Second, the relatively poor nutritional status of pregnant women has resulted in the birth of undernourished children. These two factors taken together potentially have a high explanatory power with respect to the overall increase or relatively lagged decline in the incidence of undernutrition (stunting, wasting and underweight) in children.
Undoubtedly, India is still grappling with the institutional causes of stunting, wasting and underweight. Therefore, attempting to engineer a reduction in undernutrition in India without confronting the root cause is likely to be an illusory/hollow attempt. As per the balanced growth path theory, for growth to be sustainable, all key economic variables must move at the same pace. In the social development context, now that the survival of children is being taken care of, there is a need to design policy intervention with an all-encompassing focus on bringing down the incidence of undernutrition in adolescent girls, pregnant women and young children. This would ensure that IMR, U5MR, and the incidence of stunting, wasting and underweight simultaneously start declining.