Malnutrition India
Image Credits: The Darjeeling Chronicle

India is facing an unprecedented nutrition crisis and children are the ones most severely impacted. Even before the multiple shocks caused by the pandemic, India was not on its way to meet the Sustainable Development Goal 2 to end hunger and all forms of malnutrition. To make matters worse, data released from the first phase of the National Family Health Survey 2019-2020 (NFHS 5) indicates reversal of any gains India had made in child malnutrition in the last few decades.

Child undernutrition or malnutrition is measured on three key indicators: stunting (a lower-than-expected height for age), wasting (lower-than-expected weight for height), and underweight (lower-than-expected weight for age). While the prevalence of undernutrition in India had reduced from 13.4% in 2003 to 8.4% in 2014, it has stalled at 8.4% from 2014-2018. 

Unfortunately, the latest round, NFHS 5, provides grim data on both input as well as outcome-based malnutrition in children. With a sample of some of the most populous states, Gujarat, Maharashtra, Bihar, West Bengal and Karnataka and comparing the data on Stunting, Wasting and Underweight prevalence between NFHS 4 (2015-16) and NFHS 5 (2019-20), it is evident that progress has mostly stalled or deteriorated on almost all three indicators (Figures 1, 2 and 3). The first phase of the survey has covered only 18 states, but it would not be a reach to extrapolate these findings to the remaining states. 

Figure 1: Stunting in children under five. 

Source: National Family Health Survey 2019-20

Figure 2: Wasting in children under five. 

Source: National Family Health Survey 2019-20

Figure 3: Underweight prevalence in children under five. 

Source: National Family Health Survey 2019-20

A complicated combination of social safety nets in the form of the Public Distribution System (PDS) under the National Food Security Act, POSHAN Abhiyan, ICDS services, anganwadi centres and the world’s largest school-meal programme has done little to improve India’s standing on health and nutrition indicators.

Child malnutrition is a multi-faceted problem, intertwined with several other factors. Apart from the obvious causes like poverty, access to healthcare and food or nutritional security, child malnutrition is also correlated to lack of safe drinking water, sanitation and sociological issues like gender disparity. In India, mothers are still considered the primary caretaker of children. When these mothers do not have any agency, reproductive or otherwise, it leads to a vicious cycle of undernutrition in pregnant women, lactating mothers and as a result, their children. Unfortunately, the impact of climate change, environment degradation and pollution on nutrition levels in children, while undeniable, is still under-researched. In India, child malnutrition is also correlated to factors like caste, family’s education level and housing structure. In all this, it is imperative to acknowledge that the root cause of any kind of malnutrition is poverty.

The causal link between child malnutrition and several of these developmental indicators is well established and the consequences are clear. Malnourished children suffer from developmental delays, vulnerability to diseases and stunted growth, turning into adults who struggle with pursuing meaningful work. As several studies have demonstrated, there is a direct link between child nutrition and economic development.  The economic growth of countries like the UK, France etc., in the last two centuries, is attributed to improvement in human capital indicators through investment in nutrition and health. One study estimates the economic costs of malnutrition in India at 0.8-2.5 percent of GDP.

The NFHS 5 paints a dismal picture but the findings need to be interpreted with a sense of foreboding. The pandemic’s disproportionate impact on the lives of India’s poor has undeniably exacerbated undernutrition across all sections of the affected population, both adults and children. While government data on this is awaited, the Right to Food campaign’s Hunger Watch survey across 11 states and 3,500 households found that 71 percent respondents reported that the nutritional quality of food had worsened during the lockdown. 66 percent reported that the quantity of food consumption decreased. 

Despite the Supreme Court order urging all states to continue mid-day meals in schools and ICDS services in anganwadi centres for children, pregnant women and lactating mothers, the National Human Rights Commission found that in most states, schools and anganwadi centres remained closed during the lockdown. The closure of anganwadi centres also severely disrupted the delivery and uptake of various immunization programmes and schemes. WHO has warned that by stalling these immunization drives, we are trading one health crisis for another. Above all, the pandemic has led to disruption in healthcare services considered to be non-essential, leading to unavailability of healthcare providers and protective equipment. Even when services are available, people have not been able to access them because of transport interruptions, economic hardships, restrictions on movement, or reluctance to be potentially exposed to the virus. As a result, we lost ground on what little progress had been made in improving child malnutrition in the country.  

ICDS and allied schemes, tasked with improving health and nutrition, suffer from various implementation issues. Lack of adequate infrastructure, logistic supply issues, lack of awareness and proper utilization by the local people, poor monitoring and corruption in food supplies, to name a few. The soundness of a policy is measured on outcomes and not just inputs and good intentions. As various studies have indicated, these programmes have not been delivering the expected results, and the pandemic has proven that they were not well placed to deal with situational exigencies. 

Once the anganwadi centres and schools were shut down, the delivery of these schemes stalled. While implementing these drastic measures to prevent further spread of the virus was justified, the states could have at least provided delivery of dry rations to households or cash transfers as a stopgap solution. 

A standard diet of rice, wheat and pulses provided by PDS or mid-day meal scheme will never be able to fulfill the nutritional requirements of growing children. Situations like the pandemic highlight the inadequacies of in kind transfer schemes like ICDS and PDS, and the benefits of cash transfer schemes. Without going into the intricacies of the cash versus in-kind transfer debate, cash transfers during the pandemic would have allowed people to invest in a diversified diet and better quality of food, while giving them the option to save for the future. 

Maternal health and child nutrition are intrinsically linked. Evidence suggests a strong correlation between child nutrition and utilization of maternal health services such as antenatal care visit, institutional delivery, and postnatal care services, as well as practicing breastfeeding. Restoring interventions for pregnant and lactating women, such as food and nutrition supplements, Vitamin-A, Iron and Folic Acid supplements, antenatal care, and ICDS benefits at the time of breastfeeding will mitigate the risk of child undernutrition in the first 1000 days of birth. In the long term, strengthening maternal healthcare will contribute to improving child malnutrition.  

The backbone of all the governmental health, nutrition and early learning initiatives are the Anganwadi Workers and Anganwadi Helpers, who provide immunization, health check-up and supplementary nutrition services for children, pregnant women and lactating mothers.  Currently, a total of 13.77 lakh anganwadi centres are operational with 12.8 lakh workers and 11.6 lakh helpers. By deeming their contribution “voluntary social service”, state governments have been able to get away with grossly underpaying them. If ICDS and other schemes are to work, Anganwadi workers and helpers need to be incentivised for their work, either through performance based incentives or regular bonuses. A 2017 Study conducted to understand the correlation between incentives for anganwadi workers and the nutritional status of children under their care found that performance pay reduced underweight prevalence by 5 percent and improved height by one centimeter over three months, whereas fixed bonuses had limited impact. 

Child malnutrition perpetuates the cycle of poverty, increasing healthcare costs, reducing productivity of the workforce, and hence, slowing economic growth. The true burden of child malnutrition will have a sobering effect on India’s dream of achieving a $5 trillion economy by 2024. It is disconcerting to note that we do not yet have an estimate of the impact of Covid-19 and the ensuing lockdown on these indicators. While food and diet have an intrinsic importance, they are not the only factors that need to be addressed. India has considerable buffers to meet any food security shocks, but the nutritional and health status of the poor and marginalised communities have not improved owing to this. Essentially, dietary interventions alone, without any income growth, will not accelerate reduction in malnutrition. As the economy attempts to recover lost ground, the government needs to reimagine child nutrition as a policy priority. Although schemes like POSHAN Abhiyan, ICDS, PDS etc. have been instrumental in providing nutrition support to children and women from low income backgrounds, the pandemic has proven that these are ill equipped to deal with widespread disruptions to economic activities and health systems.

Read more: Maternal Mortality Ratio in India: How far have we come?

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The opinions expressed in this essay are those of the authors. They do not purport to reflect the opinions or views of CCS.