Malnourishment is not seen as a condition that needs to be treated even though it kills a huge number of persons
The lack of awareness is the reason that increases in income alone are less likely to be effective in reducing malnutrition or improving access to better sanitation and hygiene. Photo: Priyanka Parashar/Mint
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Economists Abhijit Banerjee and Esther Dufloin their book Poor Economics recount the story of meeting a Moroccan farmer Oucha Mbarbk. When asked what he would do with more money, his answer was that he would buy more food. But what surprised the authors was why he bought a television and DVD player when he so desperately needed money to buy food. The issue is why people prefer to spend on entertainment and not on food. The paradox that we have more households with mobile phones than with toilets is very similar. This is not just a matter of individual choice, but is fundamental to understanding why some interventions work and others do not.
The story of the Moroccan farmer is not an isolated case and is a long-standing puzzle in the Indian context and that of many other developing countries. Why is that richer states do not necessarily have better nutrition outcomes compared with poorer states? Why is it that West Bengal and Assam have larger percentage of households with toilets than Maharashtra or Gujarat? Why is it that our performance in reducing malnutrition is so low even though poverty has come down drastically and the Indian economy grew at an average of more than 7% for many years? Why increases in incomes do not get translated into better nutritional outcomes or spending on toilets, water or food? One possible reason is that the poor do not see the lack of sanitation, clean drinking water or malnutrition as something that affects them.
For most people in the rural areas, malnutrition is hardly seen as a problem. Most of them are not even aware that they are malnourished. Most women in rural India would not even know that they are anaemic even though one of out every two of them is anaemic. Nor is it easy to identify a child as wasted, stunted or underweight simply by looking at him. But the mere fact that the poor are not able to see these as essential conditions for a better living does not mean that they are unimportant. The fact that a malnourished person is less productive and, therefore, more likely to be poor also leads to the existence of poverty-nutrition traps in developing countries. But unlike other vulnerabilities malnutrition also affects future workers. Malnourished mothers are more likely to produce malnourished children and a malnourished child is more likely to be malnourished in adult life.
But why don’t they see it as a problem. This is simply because malnourishment is not something which is seen as a life threatening matter. People do not see malnourishment as a condition that needs to be treated or ameliorated even though it is probably the single biggest killer in the country. When a malnourished child dies because of cholera, diarrhoea or some other infection it is the immediate illness that is seen as the cause. But what they don’t realize is that a malnourished child is more likely to die of these illnesses than a healthy one. Eventually, they end up spending more money on these illnesses than on being healthy and nourished. A similar situation prevails when people do not invest in toilets. While they see a mobile phone as an essential tool for livelihood, they do not think that better sanitation is as important for their well-being. It is not unusual to find middle income farmers in rural areas with motorcycles and other such assets, but lacking toilets in their homes.
This lack of awareness is the reason that increases in income alone are less likely to be effective in reducing malnutrition or improving access to better sanitation and hygiene. And this is also the answer to why direct cash transfers are less likely to have an impact on malnutrition outcomes than other direct interventions that ensure that children eat food at school and at day care centres. This is also the reason why direct delivery of foodgrain through the public distribution system is more likely to have an impact on malnutrition outcomes than cash transfers. This is simply because the foodgrain once purchased by the household is more likely to be consumed whereas cash transfer of the same amount may not lead to any increase in food intake. Empirical evidence from the national sample survey data also shows that if the implicit subsidy on foodgrain is given as cash, it is only half as likely to increase the foodgrain consumption compared with the delivery of the same transfer as foodgrain.
This incidentally has also been confirmed by the pilot study undertaken in a locality in Delhi. The study did not find any conclusive evidence that households that opted for cash transfers instead of in-kind transfer such as foodgrain did any better in terms of overall consumption of foodgrain. The results of a similar survey in Madhya Pradesh point in the same direction.
The question of cash versus food will emerge with the government moving towards a cash transfer regime for subsidies on kerosene, liquefied petroleum gas and fertilizers. It is too early to say what would be the impact of these changes. The evidence on food is clearly in favour of using in-kind transfers
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