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High Economic Growth has not Translated into Superior Nutritional Status for India

April 1, 2009


Despite experiencing unprecedented economic growth during the last decade, South Asia including India, has the highest rates of malnutrition and the largest numbers of undernourished children in the world. Undernourished children have higher rates of mortality, lower cognitive and school performance, are more likely to drop out of school, and as adults are likely to earn lesser incomes.

Addressing the causes of undernutrition is particularly important as it impedes productivity, economic growth and poverty reduction. The prevalence of underweight children in India is among the highest in the world. WHO estimates that about 49 percent of the world’s underweight children, 34 percent of the world’s stunted children and 46 percent of the world’s wasted children, live in India.

The World Bank earlier this month launched a South Asia Regional Development Marketplace (DM) on Nutrition. The Development Marketplace aims to identify and fund innovative ideas that deliver improved nutrition to infants and young children during their first two years of life, as well as to pregnant women. It will create a platform for civil society and grassroots organizations to share their experiences and innovative ideas on how to improve nutrition among the poor in South Asia with the broader development community.

Malnutrition is a “not-so-silent” emergency in India. According to the National Family Health Survey 3 (NFHS III, 2005-06), about a third of India’s children are born underweight, about 44 percent of children under five are underweight, 48 percent are stunted, 20 percent are wasted and 70 percent are anemic.

Its prevalence varies across states, demographic and socio-economic groups. Madhya Pradesh, Bihar and Jharkhand have the highest malnutrition rates; malnutrition levels are higher in the rural areas, although even in urban areas a third of the children are underweight. Scheduled tribes and scheduled castes have the highest malnutrition rates.

Sixty percent of children from the poorest quintiles are stunted, with rates decreasing as incomes rise. Yet in the middle income quintile too, half of all children are stunted. The most recent data shows that there are no significant gender differences in malnutrition (see Figure 1).

Over the past decade, progress in reducing malnutrition in India has been limited; in fact, anemia has increased (see Figure 2). Similarly, undernutrition in women has declined minimally (from 36 percent in 1998-99 to 33 percent in 2005-06), but anemia has, during the same period, increased from 52 to 56 percent. Undernourished mothers are more likely to give birth to low birth weight babies, who begin life with a disadvantage.

Child Undernutrition: A South Asian “Enigma”

While poverty is often the underlying cause of child malnutrition, the superior economic growth experienced by South Asian countries compared to those in Sub-Saharan Africa, has not translated into superior nutritional status for the South Asian child. Income inequality could help explain what average economic growth figures may conceal, yet inequality is not significantly worse in South Asia than in Africa.

Agricultural performance is an important underlying determinant of child nutrition, yet per capita food production is almost equal if not slightly greater in South Asia. While some suggest genetics could help explain the small stature of South Asian children, growth curves of children from well-off Indian families follow the same pattern as those of adequately nourished children in other parts of the world. So the question remains, what factors in South Asia could help explain the large numbers of malnourished children compared to other regions in the world?

Many explanations have been given for this so called “enigma”. They include:

Low birth weight: Approximately a third of all children born in South Asia are of low birth weight (LBW) compared to 15 percent in Sub-Saharan Africa. Evidence in South Asia indicates that women eat fewer meals per day than men, and eat last in their households. In India, about a third of the women are undernourished and about 56 percent are anemic.

Infant and young child feeding (IYCF) practices: In Africa, growth faltering is rare in infants younger than 6 months, but for many South Asian children, it is common at four months. In South Asia, the percentage of children 6-9 months of age receiving complementary foods in addition to breast milk is 53 percent, compared to 68 percent in Sub-Saharan Africa. Less than 25 percent of babies are put to the breast within one hour of birth as recommended and only 23 percent are exclusively breast fed for six months as recommended.

Poor household hygiene: The overall poor hygiene in South Asia increases the burden of childhood illnesses, which in turn depresses a child’s appetite, inhibits nutrient absorption, increases calorie consumption during fevers and in fighting infection, and, as a result contributes to child malnutrition.

Status of women: About 43 percent of currently married women in India are employed (as opposed to 99 percent of men), with only 64 percent of them earning cash. In terms of decision making – one in six women who earn cash do not participate in the decision of how their earnings are used; only 27 percent make decisions about their own health care by themselves; and only 11 percent make decisions by themselves about visits to their own family or relatives (NFHS 3).

The World Bank Response

Inasmuch as child undernutrition represents the “non-income” face of poverty, most global and country focus has been on the income poverty target, and the development community has failed to act decisively on this “forgotten MDG target.”

In South Asia as well as in other regions, the World Bank, in collaboration with other Development Partners, is increasing its role in combating malnutrition. It is expanding its capacity to generate country-specific knowledge on the magnitude of the problem, its causes and constraints.

More recently, the Bank has initiated an organization-wide effort to scale-up work on nutrition. This will enable countries to respond to the current nutrition crises, and to build programs to ensure good nutrition for children, women and men in the medium and long term. This will include the World Bank’s support to the Integrated Child Development Services (ICDS) program in India, which is the country’s primary response to child malnutrition.

Indeed, there is an urgent need to build a strong, healthy and well-nourished population that can make the most of the education and employment opportunities available in today’s rapidly globalizing world.

Scale of the Problem

Reductions in the prevalence of malnutrition over the past several years have been small – the prevalence of underweight children has only fallen from 43 percent to 40 percent between 1998/99 and 2005/06;

Child malnutrition is a leading cause of child and adult morbidity, mortality, cognitive and motor development. It is estimated to play a role in about 50 percent of all child deaths, and more than half of child deaths from malaria (57 percent), diarrhea (61 percent) and pneumonia (52 percent). Overall, child malnutrition is a risk factor for 22.4 percent of India’s total burden of disease;

In India, child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices, and has its origins almost entirely during the first two to three years of life;

However, the commonly-held assumption is that food insecurity is the primary or even sole cause of malnutrition. Consequently, the existing response to malnutrition in India has been skewed towards food-based interventions and has placed little emphasis on schemes addressing the other determinants of malnutrition.