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Consumption pattern, not economic shock behind 'poor' child health indicators

By Neeraj Kumar, Arup Mitra*

The findings of the latest round of National Family Health Survey (NFHS-5) conducted in 2019-20 covering 22 States/UTs under Phase-I present a somewhat disappointing picture of children’s health in India. Majority of the experts, based on prima facie evidence, just highlighted the deteriorating sign of child health in terms of increase in proportion of stunted and underweight children in most of the phase-I states/UTs over last two rounds of NFHS (2015-16 to 2019-20).
Several authors concluded that the poorer child health outcomes during last five years are either due to economic slowdown, deteriorating public health care systems, or due to adverse effects of poverty, unemployment and the economic shocks India experienced. However, a careful examination of NFHS-5 data shows considerable improvement in close to 100 of the 131 indicators associated directly or indirectly with child health and social welfare.  
Along with an increase in the proportion of stunted (low height for age), wasted (low weight for height) and underweight (weight for age) children in most of the phase-I states over past five years, we see a larger increase in proportion of overweight children in almost all the states during the same period.
We also find evidence of falling mortality rates, enormous improvements in sanitation and hygiene facilities, improved breastfeeding and dietary pattern among infants and toddlers, higher immunization coverage, better utilization of maternal care facilities and increased government’s support in terms of higher utilization of insurance and financing scheme.
All these evidence, contrary to the widely spread narrative around deteriorating children’s health, neither suggest reversal/stagnation in gains in child mortality trends, nor made us conclude that poorer child health outcomes are caused by ill effects of economic slowdown, poverty, unemployment, economic shocks or due to deteriorating public healthcare system.

Child nutrition

The four key indicators, measuring cumulative status of child nutrition -- stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and overweight, in children below 5 years of age -- show a mixed pattern. Deterioration in these indicators suggests acute or chronic child under-nutrition.
Child stunting worsened in 13 of the 22 phase-I states/UTs. Maximum increase of 8 percentage points in the level of child stunting is witnessed in Tripura from 24.3% in 2015 to 32.3% in 2019. Likewise, Goa saw an increase in child stunting level by 5.7 percentage points to 25.8% in 2019 from 20.1% in 2015.
Gujarat and Maharashtra witnessed marginal increase in the level of stunting by 0.5 percentage points and 0.8 percentage points respectively. Kerala, which had the lowest level of child stunting (19.7%) in 2015, witnessed an increase of 3.7 percentage points and is now replaced by Sikkim in this ranking. Sikkim shows improvement in the level of child stunting to the tune of 7.3 percentage points from 29.6 in 2015 to 22.3% (lowest) in 2019.
Sixteen of the 22 states saw an increase in the proportion of underweight children below age 5 in 2019 as compared to 2015. These include Nagaland where 26.9% children are underweight in 2019 as compared to 16.7% in 2015. Himachal Pradesh, Kerala and Telangana showed increase of 4.3 percentage points, 3.6 percentage points and 3.4 percentage points respectively. Bihar causes surprises with improvement in this indicator from 43.9% to 41% over the same period.
Child wasting became worse in 12 of the 22 states/UTs. Maximum increase in the level of child wasting is witnessed in Ladakh from 9.3% in 2015 to 17.5% in 2019 followed by Nagaland and Jammu and Kashmir (J&K) by 7.8 percentage points and 6.8 percentage points respectively. Karnataka shows maximum improvement where child wasting rate came down from 26.1% to 19.5%.
Another cumulative child health indicator -- the proportion of overweight children under 5 -- is hardly discussed in any of the recent articles highlighting deteriorating child health, despite the fact that this indicator worsened in almost all phase-I states/UTs. Only two UTs show marginal improvement. Even overweight/obesity among men and women has gone up in most states.
Exploring the root cause of deterioration in this indicator may unveil a different story. A story not based on the arguments floating around that increase in prevalence of stunted and underweight children in many states is due to economic slowdown, low employment and incomes, or due to poor health care facilities. Let us have a look at the following indicators:

Child mortality

Neonatal, Infant and Under-Five Mortality Rates (NMR, IMR and U5MR) across most Indian states declined in the past 5 years. To be precise, 15 states/UTs of the 22 states saw steep reduction in all these three child mortality indicators. Sikkim, Jammu & Kashmir, Assam and Ladakh witnessed a steep reduction in all NMR, IMR and U5MR with magnitude of reduction in the range of 10.3 percentage points to 21 percentage points.
IMR and U5MR declined in 18 of the 22 states/UTs. Sikkim and Mizoram saw decline in IMR by 18.3 and 18.8 percentage points respectively, while U5MR declined by 21 and 22 percentage points respectively in these two states. The four states/UTs of Tripura, A&N, Manipur and Meghalaya recording an increase in all the three child mortality indicators are the worst performing states in terms of these child mortality indicators. Overall the picture is, however, improving; certainly it doesn’t look as bad as portrayed.

Immunisation

Full immunization drive among children aged 12-23 months have substantially improved across the states/UTs. We look at 10 key vaccination indicators across the 22 phase-I surveyed states/UTs covering children age between 12-23 months who are fully vaccinated and protected against key childhood diseases based on different information criteria.
Over the past half a decade, there has been expeditious increase in full immunization coverage in many states/UT. Of these 220 instances (10*22), immunization coverage improved in 155 cases. The improvement was to the tune of over 10 percentage points in 11 of the 22 states/UTs and in another 4 states/UTs between 5 to 9 percentage points during the said period. More than two-third of children are fully immunized in all the States and UTs except Nagaland, Meghalaya and Assam.
In almost three-fourths of districts, 70% or more children aged 12-23 months are fully immunized against childhood diseases. The percentage increase in children 12-23 months receiving 3 doses of penta or hepatitis B vaccine, from about 64% in 2015 to 84% in 2019 across all 22 states/UTs, is a good story to tell. Sikkim, Kerala and Goa show declines in immunization coverage but these states already had high levels of coverage.

Breast-feeding, diet of infants, toddlers

We examine 5 key indicators viz. percentage of children under age 6 months exclusively breastfed, children age 6-8 months receiving solid or semi-solid food and breastmilk, breastfed children age 6-23 months receiving an adequate diet, non-breastfed children age 6-23 months receiving an adequate diet, and total children age 6-23 months receiving an adequate diet across the 22 states/UTs. In 73 of these 110 (5*22) cases, improvements in breast-feeding and dietary pattern of the children are witnessed.
The proportion of children aged 6-23 months receiving an adequate diet improved in 17 of the 22 states/UTs surveyed. This along with an increase in overweight children indicates that it is not the quantity but quality of diet which needs focus and further examination. That is, more than income levels of households, how they spend their incomes, what they offer their children and the quality and nutrition value of offered / available food items need to be seen.

Maternal care facilities

We also track the following 6 key indicators over the two NFHS rounds across the 22 states/UTs: proportion of mothers who had an antenatal check-up in the first trimester, who had at least 4 antenatal care visits, whose last birth was protected against neonatal tetanus, who consumed iron folic acid for 100 days or more and for 180 days or more when they were pregnant, and who received postnatal care from a professional health personnel within 2 days of delivery.
Of these 132 instances, the proportion of these maternal care indicators improved in 97 cases. For example, proportion of mothers who had an antenatal check-up in the first trimester increased consistently in 17 of the 22 states/UTs surveyed (others witnessed marginal decline). Similarly, the proportion of mothers who received professional postnatal care increased in 18 of the 22 states/UTs. These improvements do not suggest deteriorating maternal health care facilities.

Sanitation, hygiene facilities

Enormous improvements in sanitation and hygiene facilities, and access to electricity and clean fuel for cooking, are witnessed in all the states. Only in Sikkim, marginally fewer households have access to electricity, improved sanitation facilities and improved drinking water source. That is, standard of living and basic infrastructure support are improving at quite a fast pace at pan India level.
Other indicators such as the number of households covered under a health insurance/financing scheme increased, on an average, from 26% in 2015 to 37.2% in 2019 in all the states/UTs surveyed. Still low but significantly improving in 16 of the 22 states/UTs. Average education level is also improving across the states.
All these factors put together, which directly or indirectly determine general wellbeing of an average household and thereby dietary pattern of children, show signs of improvement across the states/UTs. Now, looking at the status of cumulative child health indicators, the questions arise: what exactly constitute diet of children under five? What is the micronutrient content of their diet? What is the structure of consumption pattern of an average household? And how these three indicators performed during past half a decade.

Compulsion to spend on non-food items

There is a possibility that the consumption of nutritious food is on the decline. Both the demonstration effects and compulsions to spend for non-food items may have raised the consumption of junk food or prompted households to make compromises on the consumption of nutritious food items.
The fact that the low income households may have to spend on education and curative heath care of the children forces many to downgrade the quality of food while the quantity might have been maintained. Hence, it is time to probe into these directions and identify the areas of possible interventions so that the out of pocket expenditure that the households incur does not involve significant trade-offs in relation to the quality of food children consume. 
India is moving away from the diet which comprised what is known as a poor man’s protein to consumption of less nutritious fancy food
To improve food security and nutrition, India has already implemented the Public Distribution System, the Integrated Child Development Services and the Mid-day Meals programme, which are amongst world’s three largest programs. India’s economy has also grown substantially and steadily since 1991. And, yet half of India’s children under 5 were stunted in 2005-06 (NFHS-3).
This number was 38.4% in 2015-16 (NFHS-4) and now the average stunting level stands at approximately 32% in the 22 states/UTs surveyed in 2019-20 (NFHS-5), which is still high. India cannot afford to have these many children consuming less nutritious and low quality food. If the demographic dividend has to be reaped and the productivity of the future labour force has to be enhanced today’s children who are tomorrow’s youth must be able to access supplies of quality food. A few suggestions to help reduce malnutrition level in India are presented below.

Brazil's zero hunger programme

The centrepiece of the Brazil’s Fome Zero (Zero Hunger) programme is Bolsa Familia, a conditional cash transfer programme which encourages low-income Brazilians to send their children to clinics and school. It is learnt that the success of such program requires extensive participation of civil society along with coordinated action by all areas of government at federal, state and municipal levels.
Recipient families report access to increased quantities of food and more diverse diets. Brazil’s school feeding program is also one of the largest in the world and provides free meals in all public schools like India’s Mid-day meal scheme. This programme encourages purchase and use of locally produced fruits and vegetables from local smallholders as much as possible.
This enhances not only the nutrition content in children’s diet but also small farmers’ incomes and school enrolments. Brazil mandates fortification of all of its wheat and corn flour with iron and folic acid by law since April 2004 to meet its anemia control targets.
Micronutrient malnutrition in Indian children should be tackled through improving dietary diversity, and supplementation or mandatory food fortification. A few examples have shown evidence of the feasibility and effectiveness of biofortified vitamin A-rich crops such as orange sweet potato for increasing maternal and child vitamin A intake.
Nutrition-sensitive interventions in agriculture, social safety nets, early child development, and education must be adopted. A combinations of all these high-priority targeted efforts has helped Brazil reduce food insecurity and malnutrition. 

Initiatives in India

An initiative started in a remote border district of Mizoram developed edible terrace gardens in schools and anganwadi centres. Children are encouraged to consume more fruits and vegetables during their mid-day meals. This not only improved self-sufficiency in fruits and vegetables at low cost, but also improved nutrition value of children diet. UNICEF’s community-led Nutrition Gardens in Chhattisgarh also sets a good example in promoting nutrition levels and reduction in incidence of diseases associated with malnutrition.
Farmers in rural Odisha have utilized their backyard spaces to grow seasonal fruits and vegetables. This has also increased participation by women and an improvement in their economic conditions with the sale of produce. A study from rural Maharashtra suggests that nutri-gardens/community gardens have tremendous potential to decrease malnutrition in children.
Above all, parental awareness and schooling must be on top priority to improve nutrition outcomes. Anganwadi centres and other grassroots social activists must be tapped to include nutrition related information in their discussions with parents. All schools must include nutrition sensitive curricula for prevention and treatment of undernutrition or obesity.
Counselling on breastfeeding and complementary feeding, meaning of complete diet, vitamin A campaigns, relevance of iron in pregnancy, sanitation and hygiene, deworming for kindergartens, and most importantly, growth monitoring through widespread awareness are essential to reduce malnourishment in children.
Civil society’s proactive participation, fortification of essential food items with legal provisions, popularizing community/kitchen organic-gardens, awareness about low cost nutritious food, growth monitoring of children, ill-effects of fast/packaged food, through widespread media campaigns with special focus on vulnerable groups may help curb micro-nutrient deficiencies and improve child health in India. Particularly among the low income households the meaning and implications of junk food and less nutritious diet will have to be explained intensely.
The misconceptions about food, particularly being led by the commercial advertisements, will have to be cleared. Else, a rise in consumption expenditure per capita will not ensure good health and improvement in productivity. It is important to realise that India is at the crossroads, moving away from the diet which comprised what is known as a poor man’s protein to consumption of less nutritious fancy food.  
---
Neeraj Kumar, a member of the Indian Economic Service, is deputy director with the Ministry of Finance, Government of India; Arup Mitra is professor of Economics with the Institute of Economic Growth, Delhi. Views expressed are personal

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