Child nutrition: India may be reversing decades of progress, show govt data

India could be seeing an increase in child undernutrition, reversing decades of gains, early data from the just-released first phase of the latest National Family Health Survey (NFHS) indicate. If subsequent phases display similar trends, this would represent the first increase in child stunting--low height for age--in 20 years. More infants now receive immunisations, data released on December 12 show.

On the positive side, fewer women in 15 of the 22 states and union territories (UTs) for which data were released reported that they experienced marital violence compared to 2015-16, when the last round of the survey was conducted. However, more young women in nine states--compared to 2015-16--reported that they had experienced sexual violence as children, the data show.

The National Family Health Survey is a nationally representative household survey that covers over 400,000 households, asking questions around marriage, fertility, vaccinations and health status, among others. It is India's chief source of health data and is used to evaluate the progress of health schemes and improvements in health--particularly of children and women.

Child under-nutrition has worsened in many states

Globally, three key indicators are used to measure child under-nutrition: stunting (a lower-than-expected height for age), wasting (lower-than-expected weight for height), and underweight (lower-than-expected weight for age). India has the largest number of stunted children in the world, and among the highest share of stunted children of any country outside sub-Saharan Africa. However, between 2005-06 and 2015-16, two previous rounds of the NFHS, India made substantial progress, lowering the share of stunted children by nearly 10 percentage points.

However, the latest fifth round of NFHS indicates that the last five years could have reversed many of these gains. The share of stunted, wasted and underweight children has grown in the majority of states for which data have been made available. Rates of stunting have risen in rich states such as Kerala, Gujarat, Maharashtra, Goa and Himachal Pradesh, all of which had lowered their rates of stunting in the previous decade.

If the all-India rates of child stunting were to rise, as the Phase-I data indicate, this would represent the first increase in child stunting since 1998-99. (Past data on child nutrition were for children aged three years and below, while the data for the fourth and fifth rounds of NFHS report these figures for children under five, making a direct comparison with this year difficult; however, the rates of child stunting for children below the age of three declined from 1998-99 to 2005-06.)

Variables including mother's nutrition, sanitation, child's weight at birth and infant nutrition play a role in stunting; hence increases in stunting are not necessarily a referendum on the health or nutrition policies of the current government, Purnima Menon, senior research fellow at the International Food Policy Research Institute, cautioned. "But it's not good news," she said, adding that stunting of children born between 2015 and 2019 likely reflected, in part, the economic slowdown of the last few years.

We spoke at length with Purnima Menon, senior research fellow at the International Food Policy Research Institute, where she is theme leader for South Asia Nutrition Programs in IFPRI's Poverty, Health, and Nutrition Division and director of POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India), an initiative to support evidence-based nutrition policy. Menon serves on advisory groups for the State of the World's Children and the Global Nutrition Report, for which she studies changes in child nutrition data across the world, including in India.

"I think what we are seeing right now is the impact of the economic slowdown of the last few years and some of those economic shocks that were experienced," Menon told IndiaSpend, "This survey was conducted in 2019, and the data is for children aged 0-5, so what we are looking at is children who were born in 2015-19 and the health of their mothers while pregnant. I think we are now going to need to study what went on in the lives of these households over these five years that has resulted in such poor outcomes in terms of child stunting."

Children's nutrition would improve with better sanitation, better implementation of schemes such as the Integrated Child Development Services (ICDS), but economic growth is equally important, Menon said. "I don't think there is a single country anywhere in the world where child stunting has gone down without economic growth. We have seen this in the Indian success states that we have studied too--in Tamil Nadu in previous years for instance, we have seen a functioning ICDS, good state welfare nets, but also economic growth."

The NFHS data show an improvement in sanitation, and expanded coverage of schemes like the ICDS, but this is a three-legged stool, and if people are simply not earning enough to live well, you are not going to see improvements in nutrition, Menon said.

The increase in child stunting is "extremely worrying", Menon said: "I think you would be hard pressed to find any country in the world that has actually seen outcomes worsen in terms of stunting." Periods such as the Dutch famine of 1944-45 that followed an economic blockade at the end of the second World War caused economic shocks that severely impacted health outcomes, she said, adding, "I think there are parts of India where we really do not know how people have been living and how they have experienced the impacts of the last few years."

The NFHS-5 data now released was collected in 2019, and would not account for the food insecurity experienced in 2020 following the lockdown, Menon pointed out. "We urgently need large sample surveys conducted by the governments--perhaps every three months, even over the phone--to understand what is going on with respect to food insecurity and under-nutrition," she said.

Vaccination gains have reversed some losses of the early 2000s

Of the 22 states and UTs surveyed in phase 1 of NFHS-5, 18 have reported an increase in their rates of child vaccination--at least 17 states and UTs now report that more than 70% of children under the age of two are fully vaccinated. This means they have received at least one dose of the BCG vaccine, which protects against tuberculosis; three doses of the DPT vaccine, which protects against diphtheria, pertussis (whooping cough) and tetanus; three doses of the polio vaccine; and one dose of the measles vaccine. Goa and Kerala are among the states that have reported small declines in rates of child vaccination over the last five years.

The overall gains in child vaccination have, to some extent, offset the declines of the early 2000s. Between 1998-99 and 2005-06, six of these 22 states--including Goa and Kerala--had reported declines in their rates of child vaccination. Over the next 10 years, most states reported big increases in their vaccination rates with only two reporting a decline (see chart below). The last five years appear to have built on those gains, with vaccination rates rising further.

With vaccinations against COVID-19 expected to be rolled out in India next year, some lessons from past NFHS rounds could be instructive. Privilege circumscribes who is more likely to receive vaccinations--children from higher income homes, and families with better educated mothers more likely to have their early childhood vaccinations completed, and completed in the right time, according to the NFHS 4. Boys have been slightly more likely than girls to receive vaccines, as have been more children in urban than rural areas, and the first children of larger families compared to later born children, the data show.

Sikh children and upper-caste children have been most likely to be fully vaccinated and Muslim and Buddhist children the least. However, location overrides some of these disadvantages; Muslim children in Kerala have been more likely to receive vaccines than Hindu children in Gujarat, for instance.

Marital violence could be declining, sexual assaults on children rising

Many major states--except Karnataka--have reported a substantial decrease in the physical and/or sexual violence that women report having experienced within a marriage, the new NFHS data show. Past NFHS data show that spousal violence was higher in rural than urban areas, higher in poorer states, and highest among poorer people. In 2015-16, nearly a third of all married women aged 18-49 said that they had experienced spousal violence, a further decline from 2005-06.

However, more young women in nine of the 22 states and UTs reported having experienced sexual violence as children than in 2015-16. In 10 of the states and UTs, over 5% of young women reported having experienced sexual violence as children. The numbers are a stark indicator the level of under-reporting of sexual violence; in 2019, just over 47,000 FIRs were registered under the Protection of Children from Sexual Offences Act, an estimated one FIR for every 10,000 children.

Some progress in government schemes

The data show an expansion in access to toilets in most of the surveyed states. However, most states do not report any significant increase in the population covered by health insurance. However, health officials, in their introduction to the report, caution that the survey would have been unlikely to have captured the impact of the Ayushman Bharat programme instituted in September 2018, which provides a health insurance cover of upto Rs 5 lakh for 100 million poor families.