MALNUTRITION: India: why are nearly half of its children malnourished?

Meg Towle : 3.24.2011
India has more hungry people – and the highest burden of child malnutrition – than any country in the world. The 2010 Global Hunger Index designates national levels of hunger as alarming, and India scores lower than many Sub-Saharan African countries despite having a considerably higher GDP. Madhya Pradesh, the country’s lowest performing state, classifies as extremely alarming and ranks between Ethiopia and Chad internationally.
In our last blog, we discussed how India is expected to miss the MDG hunger target by a considerable margin. By 2015, less than 27% of children under five should be underweight; the last national survey reports that 43% of Indian children are underweight, and some estimates go even higher.





SOURCE: UNICEF 2009, von Grember et al. 2010
How big is India’s nutrition problem?



One third of women are underweight, and over half of married women are anaemic. About 30% of India’s children are born underweight, and by the age of five, 44% are underweight and 48% are stunted due to chronic malnutrition. India accounts for nearly 30% of all global childhood deaths attributed to chronic malnutrition.
The percentage of children under age three who are underweight has virtually not changed between 1998-1999 and 2005-2006, hovering under 50%. The percentage of women who are underweight decreased only marginally, from 36.2% to 33.0%, during the same period. More than 75% of the population lives in households with per capita calorie consumption less than the daily minimum requirements.
During this same time, India has experienced exceptional rates of economic development, edging close to 10% GDP growth. Economic growth has the potential to be nutrition-sensitive if it increases food production, increases access to health services, educates women, reduces fertility rates, and lowers household poverty. While economic growth is required for reducing malnutrition–and no low-income countries have made significant gains in nutrition without relatively rapid growth–economic growth alone is insufficient. India is the glaring example of rapid growth without commensurate gains in nutrition, as reiterated in a recent IFPRI report and study from the Harvard School of Public Health.
When we talk about India’s economic boom, it is necessary to clarify that growth has concentrated in service and technology sectors–and not in the agricultural and manufacturing sectors where the majority of the population (and especially rural India) is economically engaged. Agricultural growth is a critical component of nutrition-sensitive growth, even more so than non-agricultural growth. This is where India poses even more questions. India has had its Green Revolution–the Green Revolution that other regions with significant malnutrition, namely sub-Saharan Africa, have not yet had. Yet malnutrition rates have not changed, and in India regions with higher agricultural productivity and calorie availability also have worse malnutrition. Clearly this points to much deeper issues than food security and availability.

What are some factors of India’s persistent nutrition challenges?
Inadequate purchasing power persists in India due to insufficient employment and livelihood opportunities, land tenure, and growth in non-farm jobs—particularly for scheduled tribe and caste households. Despite India’s early Green Revolution, the agricultural and food sector is stagnating in much of India. India’s rapid urbanization and overcrowding makes households particularly vulnerable to malnutrition by further complicating access to support services, healthcare, clean water, and sanitation.
Gender equity is considered a particularly strong factor in the high rates of maternal and child malnutrition seen in South Asia; women are undervalued in society and “eat least and last.” Restricted access to resources, healthcare services, and decision-making power impacts India’s high incidence of women who are underweight and undernourished, and in turn India’s incredibly high rates of low birth weight babies. Low birth weight has significant implications for survival and an infant’s growth, development, and ability to fight illness. National rates of child anemia, calorie deficiency, and child illness also point to non-optimal feeding practices, which in turn reflects poor maternal nutritional status, economic limitations, sociocultural settings, high fertility rates, limited access to education, and oftentimes mothers’ young ages. Childhood malnutrition, and particularly under the age of two, has significant impact on a child’s lifelong physical growth and cognitive development. It is an incredible generational cycle to break.


Prevalence of stunting, underweight, and wasting in India's children. SOURCE: Paul et al. 2010

India has long suffered without a public health system that reaches the rural masses with high quality, efficient health services. India’s notably low public health expenditures compound issues of access; up to 75% of national health spending is out-of-pocket payments for care in an enormous and unregulated private sector. Childhood illness is a critical factor in nutrition, yet fewer half of Indian children receive qualified health care, and 50% under 23 months are not fully immunized. India does not have an effective strategy for managing malnutrition at community-level, both for prevention and treatment. Services in health, nutrition, and education that do exist have long had limited reach and are of poor quality and not well targeted, which we will discuss more in Part 2 of this post.
These wide factors underscore the fact that undernutrition follows lines of high and rising levels of inequity in the country. Undernutrition is substantially higher in rural than urban areas. Children from scheduled tribes have the poorest nutritional status on nearly every measure, and the highest prevalence of wasting (28%) among under-fives. The proportion of severely underweight children is nearly five times higher among children whose mothers who have no education than mothers who have 12 or more years of school.

What’s the way forward?
Each of this factors are extremely complex – but emphasizes that there are significant social dimensions to nutrition-sensitive growth. We must think beyond pro-poor growth to pro-nutrition growth, where rising incomes and government revenues not only target poverty but improvements in health, infrastructure, and education.
At the same time, it is also important to emphasize that India is an enormous and diverse country, and much of health and nutrition programming is directed at the state level. Growth-nutrition strategies will look very different across the country, and there is much work to be done in thinking through these regional challenges.
http://blogs.ei.columbia.edu/2011/03/24/india-is-booming-so-why-are-nearly-half-of-its-children-malnourished-part-1/