Even though India is striving to become a world power, it still has more malnourished people, especially children, than any other country notwithstanding some notable progress in recent years. India lags far behind poorer neighbours such as Bangladesh and Nepal in terms of child vaccination rates, breastfeeding practices, incidence of open defecation, access to safe water, and related indicators. Such is the situation that Uttar Pradesh, India’s largest state, stands still at the place where it was a decade ago. What bothers one is the poor show of Gujarat, which is the only one among the more developed states to perform worse than the national average in reducing the numbers of child stunting cases and underweight children.
Thanks to the Rapid Survey on Children (RSOC), a nation-wide sample survey of over one lakh households conducted by the United Nations agency for children, Unicef, and the Ministry of Women and Child Development, that the government can now renew its approach to give special emphasis on access and utilization of services under the Integrated Child Development Scheme (ICDS). While the field work of the survey was undertaken between November 2013 to March 2014, the draft national and state level fact sheets in respect of key indicators on maternal and child health and nutrition, and usage of ICDS services were prepared during August 2014.
Tamil Nadu, West Bengal, Uttarakhand and Tripura are the only states which have reduced the proportion of underweight adolescent girls according to the survey findings. The state-level numbers reveal that while some states have made remarkable progress in battling child malnourishment, others have made little progress despite a decade of high growth. Almost all states have performed poorly in reducing the number of underweight adolescent girls. Uttar Pradesh, as discussed, still has the highest levels of child stunting, with over 50 per cent of the children under the age of five underdeveloped, meaning that their height is more than two standard deviations less than the expected height for their age for that population. Jharkhand, meanwhile, has the highest number of underweight children under the age of five, meaning their weight for age is more than two standard deviations less than what would be expected.
Interestingly, Kerala remains the best performing state in the number of child stunting cases, while the north-eastern states of Manipur and Mizoram have the lowest numbers of underweight children. Delhi and Mizoram reduced child stunting at the fastest rate between 2004-05 (when the last official National Family Health Survey was conducted) and 2013-14.
While Madhya Pradesh and Bihar still have high levels of underweight children, both states reduced these numbers at fast rates along with Himachal Pradesh. No state reported an increase in the proportion of children underweight or stunted, a significant reversal from past trends.
The survey findings show that at the national level, stunting is higher in rural areas (41.7 per cent) than in urban areas (32.1 per cent), as is the case for underweight children.
At the national level, the RSOC findings point to some outstanding trends. For instance, the proportion of underweight children has dropped from 42.5 per cent a decade back, to just under 30 per cent at present. There have been similar improvements on stunting, wasting and other measures of malnutrition. While the national immunisation rate has risen, the rate of open defecation is down from 55 per cent of households to 45 per cent.
More often than not, the social and health indicators across India follow predictable patterns. In states with higher incomes, those nearer the coast and farther south, most health indicators are better. This perhaps is the reason that Kerala and Tamil Nadu are typical high achievers. Conversely, in landlocked states, poorer ones and in the north, social and health results are usually worse. Uttar Pradesh, Bihar and Jharkhand thus fall in this category. On the other hand, north-eastern states are often outliers, both poor and landlocked but often with high rates of literacy and better health. While everywhere has seen a reduction in the share of underweight children and in stunting, it is unusual that on occasion higher incomes do not correlate with the biggest health gains. For instance, Maharashtra and Gujarat are states with relatively prosperous people, but Maharashtra’s nutrition levels are better than Gujarat’s. This is also true for rates of immunisation and of open defecation. It seems to be a case of better governance. The Maharashtra government has put more emphasis on tackling nutrition problems, for example among its adivasi, or tribal, population, than its Gujarat’s counterpart.
According to experts, two important factors are worth looking at. Lower rates of open defecation correlate well with reduced malnutrition. When children live and play in clean environments they are less likely to be infected with parasites and resultantly, are able to better absorb nutrients. And states that focus on helping girls and young mothers probably do better at breaking long-term cycles of malnutrition. Where teenage girls have a low body-mass index, there seems a greater likelihood that mothers will give birth to undernourished children. Proper nutrition for girls and women should, therefore, be a priority if new born and infant health is to be improved.
While the recent release of summary findings from the RSOC has created remarkably little interest in the mainstream media, the main focus of attention so far has been the uncaring performance of Gujarat in matters of health and nutrition. There has also been some speculation about the reasons for the Central government’s ostensible unwillingness to release the findings. The confidential contents of the findings, however, are in public domain now, thanks to the opposition Congress for disclosing them. Jairam Ramesh of the Congress quoted figures from the survey that showed Gujarat lagging behind many states in key parameters. He accused the Centre of deliberately suppressing the survey findings to hide the failure of the ‘Modi Model’ of development and also to hide the major advancement made during the UPA rule in checking child malnutrition.
Politics apart, the reluctance in revealing the full contents of the study is unfortunate as there is so much to learn from the survey, for social reasons, better policy planning and effective program targeting. According to Jean Dreze, a Belgian-origin development economist who has been influential in Indian economic policymaking for last couple of decades, the RSOC can be regarded as some sort of substitute for a fourth National Family Health Survey (NFHS). It may be noted that the third NFHS was conducted almost ten years ago, in 2005-06. Continued delays in the completion of the fourth NFHS have created a huge gap in India’s social statistics, even as all other South Asian countries conducted regular national health and nutrition surveys. Fortunately, the RSOC survey seems to be modelled on NFHS, generating a wealth of health and nutrition statistics that can be usefully compared with the corresponding findings from the third NFHS. By and large, the results from RSOC look like relatively good news for India. They suggest a noticeable progress in many aspects of maternal and child nutrition between 2005-06 and 2013-14. But the advancement is patchy — fairly fast in some areas, sluggish in others.
Meanwhile, the rapid survey findings underscores the fact that India is steadily catching up with its poorer neighbours, at least in some respects. The findings also suggest that the areas of rapid progress (such as safe delivery and vaccination) are those where serious action was initiated during the last decade or so. Hence, the need of the hour is to combine these initiatives and extend them to other fields where there is still no sign of rapid improvement. But unfortunately, financial allocations for the ICDS were cut by 50 per cent or so in the last Union budget, sending a bad signal about policy primacies.
“Health policy is a mess of confusion and inertia, with the Health Ministry and NITI Aayog talking at cross purposes. The Central government is brazenly ignoring its legal obligation to provide for maternity entitlements under the National Food Security Act. Even the sanitation budget has been quietly reduced, soon after the Prime Minister made tall promises of India being open-defecation free within five years,” observes Dreze.
India has a model in Southeast Asia to look up to. Much before the ASEAN region started to make headlines globally for its sustained high growth, the governments in these countries, especially, Singapore, Malaysia, Thailand and Indonesia heavily invested in primary healthcare and education in order to ensure that future generation of workers and healthy and educated. It was this healthy generation which made the rapid economic rise possible for these nations. The same feat was repeated by China which invested heavily in its healthcare over last three decades. As India wants to grow fast and become a major economic power, it needs healthy workers in very large numbers which is not possible without ensuring an effective primary healthcare system that works even in remote parts of the country. A healthy child makes a healthy and smart worker of tomorrow which is the core of a stronger nation.