Health

Without Tackling Hunger and Malnutrition, India's 'Acche Din' Will Remain Stunted

It helps no one, least of all the malnourished and hungry children, when India’s policy advisers make statements with a political spin that governments want to hear, rather than statements that they should hear.

In a recent media debate, NITI Aayog vice chairman Rajiv Kumar rattled off a set of figures on TV in quick succession to establish that ‘achhe din’ are now truly upon us. Kumar was reacting to the claims made by professor Amartya Sen, the 1998 Nobel Prize winner in economics, that under the NDA rule India has taken a ‘quantum leap in the wrong direction’.

With Sen sitting opposite him, Kumar bamboozled the audience with a set of impressive figures such as the GDP growth rate, the number of bank accounts opened during the NDA rule, the size of the fiscal deficit and the aggregate size of the Indian economy. On the last feature, while the World Bank in 2017 ranked India as the third largest economy in terms of the size of its GDP at purchasing power parity, behind China and the US, such a ranking is meaningless since India drops sharply on per capita GDP, making her a low income country.

The aggregate size of India’s economy has recently received considerable attention, more outside the country than inside, because of the large market that India offers through its sharply expanding middle class and the large purchasing power that the affluent households command. However, as Sen remarked, what matters is not only the size of the cake but the number of people it has to be distributed to. In an era of sharply rising in-country inequality, even per capita figures do not state the reality since people at the lower end of the income spectrum have much less of the cake than the per capita figures suggest.

The debate started with a challenge from Kumar to Sen. Kumar insisted that the basis for the debate will be ‘facts’, and he soon tried to seize the high ground by quoting statistic after statistic to prove Sen wrong in his claim. But Kumar overlooked the ‘fact’ that while Sen is justly celebrated world over as an outstanding economic theorist and philosopher, he is also one of the finest empirical researchers as shown by his data-based, ground-breaking work, for example, on poverty and famine and his study (with Sunil Sengupta) on malnutrition and sex bias. Both these studies were based on a careful marshalling of data in a manner that is in the best tradition of empirical research. The latter study by Sen and Sengupta that was published in the Economic & Political Weekly was one of the earliest attempts at studying malnutrition in India and reports on some empirical field work done by the authors at the Agro-Economic Research Centre in Shantiniketan.

A child’s upper arm being measured, to check if the child is underweight, at an Anganwadi centre in the village of Baggad, in Madhya Pradesh’s Dhar district. Credit: DFID

Partial story

The picture painted by Kumar during the debate tells only a partial, if not misleading, story. While India does quite well on aggregate figures such as high growth rates, declining poverty rates and increasing per capita income, its performance is quite dismal on maternal and child health. India is one of the most malnourished countries in the world. According to a recent report by the International Food Policy Research Institute (IFPRI), India ranked 100 in a list of 119 countries in the ‘Global Hunger Index’ (GHI). India fared only better than Afghanistan and Pakistan in Asia, whereas in global terms, it fared worse than North Korea and Iraq. None of these countries serve as a model for economic development.

As the IFPRI report suggests, India contributed single-handedly to South Asia being one of the worst performers on malnutrition and child health. Though India’s immediate neighbours in South Asia do not fare all that well in the global ranking either, they are still comfortably ahead of India with Nepal ranked 72, Myanmar ranked 77, Sri Lanka ranked 84 and Bangladesh ranked 88. At rank 64, Vietnam does much better than all the South Asian countries and exhibits a dramatic improvement in its GHI over a 25-year period, declining from a high of 40.2 in 1992 to a reasonably low score of 16.0 in 2017. All this while, India’s position on the GHI hardly improved. All these countries’ performances pale into insignificance when one looks at China, which is ranked 29th globally.

The GHI ranks countries based on four key indicators: undernourishment, child mortality, child wasting and child stunting. While a ‘wasted child’ refers to a child with a low weight in relation to international norms set by the World Health Organisation, a ‘stunted child’ refers to a child whose height is less than what it should be based on the same set of norms. More than one in five Indian children weigh too less, and more than one in three children are too short for their age. It is important to stress that these figures in the IFPRI report are not several decades old. They relate to 2017, which was well into the NDA rule, though in fairness the responsibility for this sad state of affairs must also be laid at the door of the preceding UPA government and all the governments prior to that.

In a 2014 study based on the National Family Health Surveys (NFHS) of India that was subsequently published in the American Economic Journal: Applied Economics, Michael Geruso and Dean Spears observed the close connection between lack of sanitation and failure to improve child health in India. As they note, “much of India’s population defecates in the open, without the use of toilets and latrines, spreading fecal pathogens that can make children ill.” According to Dean Spears, “Open defecation, which is exceptionally widespread in India, can account for much or all of the excess stunting in India.” The construction of toilets and improved sanitation undertaken by the NDA government as a priority, and its drive towards cleanliness through the ‘Swachh Bharat’ campaign, ought to be welcomed and deserve full support.

Lessons from Bangladesh and Vietnam

Though on measures of child malnutrition such as ‘stunting’ and ‘wasting’ it does not do all that better than India, Bangladesh has an enviable record in universal health coverage. So impressive is the performance of Bangladesh in the sphere of universal health coverage that several articles on that country’s experience were published in 2013 in the prestigious journal Lancet. In one such article entitled ‘The Bangladesh paradox: exceptional health achievement despite economic poverty’, the authors noted “steep and sustained reductions in birth rate and mortality…a pluralistic health system that has main stakeholders pursuing women-centred, gender-equity-oriented, highly focussed health programmes in family planning, immunisation, oral rehydration and child health, tuberculosis, vitamin A supplementation….” The experience of Bangladesh is all the more remarkable given that the country’s per capita income in 2017 in PPP terms was much lower than that of India, and its birth in 1971 followed a series of catastrophic events leading to its breakaway from erstwhile Pakistan. The nature of its birth as an independent nation saw the involvement of NGOs through the deployment of community health workers reaching all households. On gender equity indicators, Bangladesh outperforms all its neighbours as the only South Asian country with higher school enrolment of girls than boys, though the former’s dropout rate is much higher and by the end of primary schooling that superior record of girls’ enrolment over boys’ weakens considerably.

A young mother in Alappuzha Credit: Scott Austin

Another impressive performer has been Vietnam, whose per capita income in 2017 at PPP was lower than that of even Bangladesh. From 1992/93 to 2005/6, a comparison between the summary means from India’s National Family Health Surveys (rounds one to three), and Vietnam’s Living Standard Surveys (VLSS) and Vietnam’s Household Living Standard Surveys (VHLSS) showed that on access to such facilities as drinking water, electricity and toilet, Vietnam outperformed India even though Vietnam remained much poorer than India throughout this period on per capita income basis. In a 2008 study published in the Economic & Political Weekly in which I compared the experience of India and Vietnam in dietary diversity and undernourishment from the early 1990s to the middle of the first decade of the new millennium, I observed that “both these countries recorded high economic growth rates and large poverty reductions during the late 1990s following a set of economic reforms. However, while Vietnam recorded large reductions in its undernourishment rates, the reverse was true for India. The Vietnamese, with their intervention programmes aimed at nutrient enhancement, have managed their growth process ensuring a positive association between reduction in expenditure-based poverty and calorie-based under-nutrition, in a manner that has lessons for other high growth achievers such as India.” In the context of Rajiv Kumar’s observation that India has been experiencing a spell of high growth rates, currently the highest in the world, its failure to translate that to a significant reduction in undernutrition and in rates of stunting and wasting must be deemed a significant policy failure on the part of successive governments.

Whereas in Bangladesh NGOs played an interventionist role in promoting universal health coverage, in Vietnam there have been several private and public initiatives to enhance food security in the 1990s. For example, the government of Vietnam formulated in 1990/91 a new socio-economic strategy for the period up to 2000 designed to improve the nutritional levels for the whole community. As L.T. Hop noted in a review of nutrient enhancing programmes in Vietnam in the 1990s, published in the Journal of Nutrition in 2003, “the intervention programmes to improve production and consumption of animal source foods…have been successful. The population’s dietary intakes have clearly improved in terms of both quality and quantity.” The overall message from the comparison of Indian experience with that of Bangladesh and Vietnam is that while income advancement, high growth rates and significant declines in poverty rates are important goals to pursue, and India has done well on all three, none of these is essential or sufficient to generate significant improvement in health indicators, where India’s performance has been quite dismal.

No dearth of policies

In terms of policy initiatives, India has much to be proud of. India’s Public Distribution System (PDS), the Integrated Child Development Scheme (ICDS), the Mid-Day Meal Scheme (MDMS) and the National Food Security Act (NFSA) are examples of initiatives that can help in tackling child and maternal malnourishment. In a recent article in World Development, Jean Dreze and Reetika Khera argue that “there has been a major expansion of social security programs in India during the last 15 years or so, along with wider recognition of economic and social rights.” They review five programs that provide the foundations of a social welfare system for India: school meals, child care services, employment guarantee, food subsidies and social security pensions. Dreze and Khera note that “the record of these programs varies a great deal between Indian states, but there is growing evidence that they make an important contribution to human well-being, and also that the achievements of the leading states are gradually spreading to other states as well.” However, in a 2015 article titled ‘Enhancing nutrition security via India’s National Food Security Act’, Sonalde Desai and Reeve Vanneman sounded a note of caution by arguing that both PDS and ICDS have a limited role in improving child nutrition. Instead, they argued for “a tiered strategy in dealing with child undernutrition that starts with the identification of undernourished children and districts and follows through with different strategies for dealing with severe, acute malnutrition, followed by a focus on moderate malnutrition, could be more effective than the existing focus on cereal distribution rooted in the NFSA.” While the jury is still out on what is the most effective strategy to combat malnutrition in India, there is little doubt that the country has in place the foundations for tackling the problem.

Apart from the state of child health, another significant health concern in India is maternal health. According to data released by the ‘Global Nutrition Report, 2017’, “India is facing a serious threat of undernutrition where more than half of the women of reproductive age suffer from anaemia.” Iron deficiency is a significant cause of child stunting in India. Anaemic disorder due to iron deficiency is transmitted from the mother to the child unless early intervention is made through the provision of iron supplements and improved diet in the form of iron-rich food items. India has been much less successful than China and Vietnam in preventing mother-t0-child transmission of ill health. The ICDS through its program of immunization and provision of iron supplements to underprivileged children below the age of six years has been playing an important role in this regard, but more needs to be done to tackle iron deficiency.

Midday meal scheme in Rajasthan. Credit: Reuters

Schemes such as the mid-day meal, if implemented properly, can help tackle child malnourishment. Credit: Reuters

An unpublished research by Aparajita Dasgupta, Wafa Hakim and Muhammad Majid shows that the ban on cow slaughter in several states in the Northern and Western parts of India has had a detrimental effect on the iron intake of Dalits and SC/ST households for whom beef is an important source of iron. The research shows that “cattle slaughter bans in early life affect anaemia decades later.”

The purpose of this article is to recognise India’s failure on the health front, while pointing to the usefulness of several recent initiatives and to the lessons from countries such as Bangladesh and Vietnam that can be put to good use. One of the major challenges for the future is to make rapid improvement in India’s health indicators to bring them in line with international standards. It helps no one, least of all the malnourished and hungry children, when India’s policy advisers make statements with a political spin that governments want to hear rather than make statements that they should hear. Nothing illustrates this better than the media debate referred to above, where an opportunity was lost to acknowledge our failures and arrive at a consensus on the way forward. The role of policy advisers in highlighting issues such as health and education is all the greater in view of their near-total neglect by the mainstream political parties in setting the agenda. As the eminent economist and outstanding scholar, the late Ashok Mitra, a former chief economist to the government of India and an ex-finance minister of West Bengal once remarked, we will be in better hands if policy making was left to our grandmothers. Repositories of knowledge, experience and common sense, grandmothers are no one’s mouthpiece and have all our interests at heart.

Ranjan Ray is Professor of Economics at Monash University in Australia. He holds an MA from the Delhi School of Economics and a PhD from the London School of Economics. 

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