We take pride in India’s economic growth. Our social development indicators, however, especially in health, fall far behind. This is an issue of both rights and development. No major country has achieved economic take-off without addressing health and education. In all this, a vital but neglected issue is stunting, a manifestation of malnutrition. This article examines this issue.

Malnutrition affects a child’s cognitive development and physical growth. Her system devotes its limited energy to functioning of essential organs, leaving little for growth, social interaction and learning. The World Bank estimates that a 1% national shortfall in height can translate into a 1.4% loss in economic productivity. McGregor and Cheung of the International Child Development Steering Group found stunted children earn 20% less as adults.

Malnutrition is variously measured. “Underweight” means low weight for age. Stunting is low height for age. “Wasting”, their composite measure, is low weight for height. Underweight is straightforward and commonly used. Low birth weight is more common among South Asian children than their global peers (28% versus 16%). However, with exclusive breastfeeding for the first six months, right complementary feeding till two and consistently adequate diets thereafter, weight can be restored.

The challenge with stunting is that it is difficult to reverse. As many as 46.8 million—29% of the world’s stunted children under the age of five—live in India. A low birth-length baby fed properly can gain some height. A child too short at age one can also, but it is practically impossible to reverse after age two. Therefore, prevention of stunting is key. The problem has remained invisible partly because, practically, height is difficult to measure in the field for large numbers of children.

Stunting is caused by a combination of factors—nutrition (mother and child), sanitation and other environmental factors. A gene mutation possibly causing stunted growth has also been identified by Eric Vilain of UCLA. Given this mix, some experts feel that only broader economic development can address stunting.

But poorer countries, not prominent at world economic forums, do better than India. Consider Bangladesh: it has emerged as a major success story in combating stunting. In 1992, Bangladesh had an under-five stunting percentage of 74.5% versus India’s 57.1%. By 2014, their rate of stunting was lower—36.4% compared to India’s 38.7%. This nation has performed strongly on nutrition-sensitive growth through pro-people investments in women’s empowerment, education, health access and nutrition. Peru is not an economic powerhouse but it dramatically reduced stunting from 37.2% in 1990 to 14.6% in 2014. That country turned the corner when they moved beyond traditional feeding-based interventions to broader inter-sectoral interventions across nutrition, food security, water, sanitation and health. On the other hand China, a frequent benchmark for fast economic growth, reduced stunting from 38% in 1992 to 9.4% in 2010. India has reduced stunting, but slowly. (Source: The World Health Organization)

Under-five stunting in India’s wealthiest quintile is as high as 26.7% according to the Rapid Survey of Children, 2013-14. In this case, resource availability wasn’t the issue. Dietary diversity and quality were. These examples suggest that economic development is a necessary but insufficient condition to counter stunting. What is crucial is that development must be woman and child friendly and sustained over generations.

There is no one simple solution. The nation has the tools for success—programs like the National Health Mission, the new National Nutrition Mission (NNM) and the Swachh Bharat Mission. These are certainly woman and child friendly in stated intent. The NNM aims to reduce under-five stunting by 2% per annum and ultimately decrease prevalence to 25% by 2022.

The problem, however, is not lack of policy or programs, but in India’s public health implementation. Doing must match grand declarations of intent. If frontline workers can work with good data, program design is informed by ground realities, communities are better informed and empowered and facilities are adequate, entrenched issues like stunting can be tackled.

As this column has been emphasizing, implementation at the grassroots is key.

Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok.