This crosspost from the Accountability Initiative, a research group based at the Centre of Policy Research, uses data to unpack efforts to address malnutrition – part of a broader series on social welfare gains and failures.
Despite nearly 71 years of independence, Indian children are still bound by malnutrition and poor health, a result of absolute poverty and an ineffective state. It is widely recognized that health issues from nutritional deficiencies in childhood can have a compounding effect in adult life. Inadequate healthcare can be debilitating to society at large from multiple vantage points: public participation, individual freedom and labor supply. Healthier citizens are better able to participate in public life and public activities, can choose from a larger set of opportunities, and are more capable in their jobs. Simply put, healthier individuals are able to do more, be more and contribute more. A critical question stares us in the face at this juncture: What is the actual status of child health in India?
Dire Straits for Children
There are several indicators that reflect the long-term health and nutritional experience of an individual or population. One can check whether a child is stunted, underweight or wasted. Studies have linked stunting to lower cognitive development, among other unfavorable outcomes.
In addition, cognitive development is also impaired by anemia (low hemoglobin caused by iron deficiency). Wasting is a result of acute significant food shortage and/or disease and is a strong predictor of under-5 mortality. Figures reveal that over 16 percent of children in India are severely stunted, as many as 58 percent children are anemic, while close to 7 percent are severely wasted.
These poor outcomes are in part, borne of inadequate diets – less than 10 percent children (6–23 months) receive the minimum acceptable diet. Starvation deaths still occur, as sheer poverty and deprivation have precluded a large number of people from being able to feed themselves or their children restricting their future lives. Age-appropriate vaccination coverage also remains low at 27.4 percent, thereby compounding the magnitude of the health problem. The state of child health in India is grave. Successive governments have recognized this and put into action various programs to tackle the issue.
Vital, but Falling Short
The Poshan Abhiyaan (National Nutrition Mission), launched in March 2018, has been one such step and aims to address malnutrition through convergence across ministries, improved technology and better targeting. It is premature to know of its impact, yet, critical in the battle against malnutrition have been Anganwadi Centres (AWCs) under the longstanding Integrated Child Development Services (ICDS) program that began in 1975. As part of the program, children and lactating and pregnant mothers have been eligible for cooked meals, health check-ups, and immunization services.
Even today, AWCs do not cover all children who require these services: only 1 in 2 children received any service according to National Family Health Survey 4 data. A quarter of ICDS beneficiaries are malnourished, a number that has increased from 15 percent in 2015 to 25 percent in 2017, as per analysis by the Accountability Initiative. This shows that even as ICDS coverage is expanding to include those who need it most, malnutrition remains a problem among those that avail ICDS services.
The quality of services provided continues to be weak. Out of ICDS beneficiaries, less than half received food supplements in 2015–16. Only 70 percent of Anganwadis had drinking water facilities and 63 percent AWCs had toilets.
In light of such deficiencies, funding by the government is meager. The government seems to have given short shrift to increasing the amount spent on child health, which has remained stagnant for successive years. Expenditure on supplementary nutrition declined by 6 percent between 2015–16 and 2016–17. Anganwadi workers and helpers are still treated as “honorary workers,” and are paid a lean amount. Furthermore, they are not entitled to minimum wages, according to the government. For the amount of work, and the skill required, such low pay can be distressing and as a consequence has led to strikes by workers time and again in various states to demand better pay. Additionally, of all sanctioned posts for Anganwadi workers, 8 percent were vacant as of March 2017. Vacancies are even higher among supervisors, which weakens monitoring, implying that even fully functional AWCs may not run efficiently.
Since the Anganwadi system is a critical asset in the fight against malnutrition, what are the consequences of these lapses for the poor, who critically depend on public health programs?
Wealth Is Health, in Most Cases
There is stark inequality in how children of the poor and rich survive. Out of 1,000 live births, 72 infants among people living in the lowest 20 percent don’t survive until their fifth birthday, compared to 23 for the wealthiest. For those among the poorest and worst off who do survive, more than half are stunted, and almost half are underweight. Clearly, poor and deprived children are worse off than their richer counterparts. These inequalities continue to persist later in life and affect educational and occupational opportunities, and aggressively exacerbate income and wealth inequalities even further.
The rich and privileged don’t have to depend on weak public services, and have the resources and social capital to afford quality healthcare in private hospitals, which are out of the reach of the unprivileged. The wealthiest 20 percent can afford better healthcare than the least wealthy. This seems to be true across several indicators – from access to vaccinations to malnutrition and mortality rates at various stages of childhood.
However, inequalities are not limited to wealth or income. Caste and gender marginalization persist in society, and these are reflected in child health outcomes as well. Children of lower castes, or girls, face further issues due to their marginalization by societies. Intersections of these inequalities adds to an already complex problem.
Does Time Heal All Wounds?
A look at data from the last two decades reveals the extent of the progress the country has made. Over time, especially after India liberalized its economy in 1991, the quantity and quality of services provided has improved. However, progress isn’t as smooth as one would expect. Malnutrition has reduced, but not on all indicators. There has been a 10 percentage point reduction in stunting in the decade before 2015–16. However, every second child is anemic, and the propensity of wasting has actually increased.
Compared to malnutrition, there has been marginally better progress in the survival rates of children. At the same time, under 5 mortality still remains very large. Of every thousand children born, 30 do not live beyond a month, about 41 do not live beyond a year and about 50 children will die between birth and their fifth birthday.
It is clear that despite several government programs, including the presence of ICDS since 1975, severe malnutrition in childhood has persisted over time, and is much worse for the poor and unprivileged sections of society. This has clearly restricted people from rising up the income and wealth scale, and the impact in time and money lost on private spending due to weak public nutrition services that should be easily accessible is incalculable. The current government has responded with recent programs like the Poshan Abhiyaan and the Rashtriya Swasthya Bima Yojana. The former includes a slew of activities involving at least 10 Union ministries and components as diverse as medical intervention, behavior change, capacity building of frontline workers and technological innovations, among others. The latter seeks to improve access to healthcare by providing insurance. Moreover, the renewed focus on sanitation is a welcome step. The hope, somewhat ambitiously, is to reduce stunting from 2 in 5 children to 1 in 4 children by 2022. The question is, will the government’s efforts be able to mend lapses of the past, and set the system on rapid course correction?
Avantika Shrivastava contributed to this article.