Listen to this article:
India has achieved remarkable levels of economic growth, and yet, despite all the progress, it continues to host the highest number of malnourished children in the world.
Child malnutrition is classified as ‘undernutrition’ (inadequate consumption of calories) and ‘overnutrition’ (excess consumption of calories). Of these, undernutrition leads to low height-for-age or stunting. It is known as the most sinister form of child malnutrition because unlike the loss of weight, height cannot be readily gained back. Hence, it is an indicator of chronic childhood malnutrition, which can lead to irreversible mental and physical damage that is even transmitted to the next generation.
To understand the gravity of this problem, we note one-third of stunted children, globally, are Indian. The implication is that India loses 4% of its GDP (gross domestic product) annually, and hence the objective of economic development cannot be met without addressing the issue of child malnutrition.
The research suggests that tackling child malnutrition requires a multi-faceted approach, for example, improving the quantity and the quality of dietary intake, levels of sanitation, maternal health and education, access to social safety net programmes etc. Based on these important findings, the government had established programmes like Integrated Child Development Services (ICDS) that provides comprehensive health and nutrition services to children under six and pregnant and lactating mothers, mid-day meals to school-going children, Swachh Bharat Mission that is aimed to eliminate open defecation, among others programmes.
And yet, despite these measures, the NFHS-5 data revealed that child malnutrition in India is worsening (see figure 1). Thirteen out of the 22 states have witnessed a reversal in stunting outcomes. Experts have commented that this is due to a decline in budgetary allocation towards children’s health and nutrition schemes (here), while others suggest that it could be due to the slowdown in economic growth (here).
Given the rising burden of child malnutrition and budgetary concerns, there is substantial merit in understanding the relative importance of the factors impacting child malnutrition. This can help the policymakers redirect their focus on interventions that will yield the maximum benefits to child health.
We use data from the NFHS-4 survey for almost 90,000 children below five. Further, we use NHFS-4 variables to construct ten groups that are used to explain the child malnutrition under UNICEF’s framework: age of the child (in months; from 0-5 years), gender, occurrence of infections, medicinal intake, birth characteristics (size and weight at birth), their food intake (breastfeeding and dietary diversity), child environment (open defecation level at the village, access to benefits from welfare schemes, improved drinking water, household size), mother’s characteristics (height, BMI, education, and age at marriage), her environment (access to benefits from ICDS centres during pregnancy, health insurance) and socio-economic controls (wealth, place of residence, etc.).
Our outcome variable is height-for-age z-scores (HAZ scores), i.e. the height gap of a child from the median child with the same age and gender. HAZ score below (above) zero means that the child is worse off (better off) than the median child (here).
To estimate the relative contribution of these ten towards the HAZ scores for our analysis, we use an econometric technique called the Shapley-Owen decomposition, which is useful to calculate the marginal contribution of variables, especially when all the variables are interlinked.
After running the decomposition on ten groups, we find that the child’s HAZ scores, child’s age is the most important followed by mother characteristics (and within this group, mother’s height), and socio-economic controls. Our results are in line with the well-established finding in the literature that stunting happens in the first 24 months, and hence it holds the maximum contribution.
In a similar vein, it is unsurprising that the next most important variable is the mother’s height as genetics always had an important role in determining heights. This leads us to recommend that additional efforts should be expended to provide adequate nutrition to children from conception till two years (i.e. the first 1,000 days of life). Next, prioritising the nutritional needs of girls among these children will help India break the pattern of inter-generational transfer of stunting, as mothers who faced stunting in childhood are shown to have under-developed uteruses, which leads to the reproduction of stunted children.
While ICDS’s POSHAN Abhiyaan mentions the importance of adequate nutritional intake during the first 1,000 days of the child’s life, the programme, much like other welfare schemes for children and women, have been receiving budgetary cuts for the past few years. This issue has been raised by noted economists, and our findings also provide rigorous evidence to support the call for enhancing the budgetary allocation for programmes like ICDS which are responsible for providing requisite antenatal healthcare to the mothers and optimal quantity and quality of diets to the children.
Similarly, our analysis also echoes the recommendation of economists who have attributed the rise in child malnutrition to the slowdown in economic growth in recent years. Socio-economic controls are the third most important determinant of HAZ scores. It represents the ability of the household to access diets that are optimal in calories and nutrition, healthcare and general living conditions, all of which, jointly determines children’s health. Therefore, while the supplementary nutrition programmes should be strengthened, their impact on the child health outcomes will be most effective when India is also witnessing a faster economic growth.
Payal Seth is a consultant at Tata-Cornell Institute, Cornell University and a research scholar at Bennett University. Palakh Jain is an Associate Professor at Bennett University.