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The Comprehensive National Nutrition Survey (CNNS) report, brought out recently by the Ministry of Health and Family Welfare, assumes salience, especially against two important factors. One, the latest Global Hunger Index (GHI), 2019 ranks India at the 102nd position out of 117 countries. Two, India’s past performance in reducing child undernutrition has been rather mixed: there was a moderate decline in stunting but not in wasting. Between 2005-06 and 2015-16, child stunting and the condition of being underweight declined by 10% and 7% points, respectively. In wasting, the decline was a paltry 1% point. These factors make the CNNS (2016-2018) report timely and important.
The report covers dimensions of nutrition, some of which are new and important, and thereby heralds a new beginning in collecting national level nutrition data. It reveals that India has sustained its progress made in reducing the number of stunted and underweight children in the last decade. Despite such sustained decline, the present stunting level still belongs to the threshold level of ‘very high’. Hence, what is of urgent requirement is increasing the rate of decline. Though there is no magic policy wand to reduce stunting drastically within a short span of time, the CNNS report draws our attention to an all too familiar factor, which has not received the necessary attention.
Stunting among children under four years came down from 46% to 19%, a whopping 27% points decline, when maternal education went up from illiteracy/no schooling to 12 years of schooling completed. This phenomenal decline was also true for the number of underweight children. The difference was close to the gap between the poorest and richest wealth groups. It is next to impossible to transform poorest households into richest so soon. However, increasing the educational attainment of women significantly is certainly feasible. Women’s education, besides being of instrumental significance, has an intrinsic worth of its own. Possibly, as studies suggest, women’s secondary education might be capturing the cumulative effects of household wealth, women’s empowerment and knowledge and health-seeking behaviour.
Ending open defecation and enhancing access to safe water and sanitation are indeed appropriate policy goals, which need to be sustained. However, ending open defecation alone will not reduce stunting phenomenally, as is evident from the experience of Bangladesh. Also, the so-called Muslim advantage in child mortality in India — relatively lower child mortality among Muslims compared to Hindus — which occurs ostensibly due to the former’s better sanitation and hygiene practices, does not translate into a similar stunting advantage among Muslims. Unlike child mortality, child stunting levels remain almost the same between Muslims and Hindus.
More efforts, besides ending open defecation, are required, if we are to accelerate the decline in child stunting. One related aspect, which is yet to be firmly embedded into nutrition policy, is dietary diversity. It is important to move away from the present focus on rice and wheat, which studies denounce as ‘staple grain fundamentalism,’ of Public Distribution System (PDS), to a more diversified food basket, with an emphasis on coarse grains. It would be worth including millets in the PDS on a pilot basis, in States where stunting levels are high. Evidence suggests that dietary diversity is indeed good for reducing iron deficiency anaemia, levels of which also remain high in India. It may be useful learning from the virtues, in terms of food habits, of the marginalised than from the vices of the privileged groups. The rising obesity among the latter is a cause for concern, and is an emerging public health problem in India which demands equal attention.
What about child wasting, in which India’s past performance has been rather poor? Here, the report reveals an interesting, rather surprising, turnaround. The extent of decline in wasting is larger than that of stunting: about 4% points within 22 months. This is indeed a remarkable achievement, especially against a measly decline in wasting in the last ten years: 21% in 2015-2016 from 19.8% in 2005-2006. A closer look at the performance of States reveals that Uttarakhand, Arunachal Pradesh, Gujarat, Punjab and Haryana have reduced wasting by 10% points or more within just 30 months or less, the best performer being Uttarakhand that has reduced wasting by 14% points.
While a fair measure of decline in wasting, consistent with that of stunting, is expected, the magnitude in this case appears rather high. This is especially so, as all these five States had witnessed an increase in wasting during the last decade, between 2005-06 and 2015-16. If the decline has actually happened, then it means that many States have achieved unprecedented decline in wasting, reversing their past poor record, within a short span of time. Surprisingly, these States have not performed equally well in reducing stunting, despite the fact that wasting and stunting share many common causes. Is this ‘empirical reality’ rightly captured by the CNNS? Or, alternatively, do these estimates indicate a possibility of some sort of anomaly in data? An independent validation would not only dispel any doubt regarding data quality but also help identify the drivers of rapid reduction in child wasting in India.
Sunny Jose is RBI Chair Professor at Council for Social Development, Hyderabad. Views are personal
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