The key indicators of health and nutrition from the fifth round of the National Family Health Survey, conducted in 2019-’20, paint a disconcerting picture. Gains in child nutrition, reflected in the previous rounds, conducted in 2005-’06 and 2015-’16, have been reversed in several states. With the pandemic and the economic crisis, nutritional indicators are likely to worsen further.
Between 2015-’16 and 2019-’20, stunting in children under five increased in six of the 10 large states – Gujarat, Himachal Pradesh, Kerala, Maharashtra, Telangana and West Bengal. Stunting, or low height-for-age, is considered an indicator of cumulative nutritional deficiencies from conception, and of the long-term health of the child. Child wasting, or low weight-for-height, and being underweight, or low weight-for-age, reflect more short-term nutritional deficiencies. These indicators also worsened or remained unchanged in seven of these 10 states.
The trends are in line with the indications of rising rural poverty and food insecurity that emerged in the National Sample Survey Organisation’s 2017-’18 survey on consumer expenditure, which has now been buried. The data in the survey showed a fall in real food expenditure in rural areas between 2011-’12 and 2017-’18 – a trend seen for the first time in 40 years. During this period, the real wages of regular wage or salaried workers declined and that of rural workers remained stagnant.
The triple burden of malnutrition
Data from the National Family Health Survey also show an increase in the proportion of overweight children across states between 2015-’16 and 2019-’20, although the numbers are low. This reinforces a pattern that has already been noted – the triple burden of malnutrition in India. Undernutrition for large sections of the population co-exists with obesity for a small section of the population and pervasive micronutrient deficiencies. The disaggregated data are not yet available but we know from earlier surveys that children who belong to Scheduled Castes and Scheduled Tribes have significantly worse nutritional parameters and mortality rates than other children.
The nutritional indicators of Indian children were already among the worst in the world, with around 35% of them stunted or underweight or both in 2015-’16. This is worse than several poorer or slower-growing countries in the world, including some in sub-Saharan Africa. According to the World Health Organisation’s global targets tracking tool, India falls in the red zone in the incidence of child stunting and wasting.
The factors that determine how much nutrition children get include the disease environment, the education, health and nutrition of women, parental education, access to public services and household amenities, and the use of sanitation facilities. While the National Family Health Survey suggests improvements in access to basic amenities, we show in a recent working paper that access is still very limited. In 2018, 67% of the population did not have access to piped drinking water, 21% did not have access to toilets, and 40% did not have access to LPG. In urban areas, the heads of only about 21% of slum-dwelling households held a ration card.
A hunger crisis
The data for the National Family Health Survey were collected before the pandemic hit India. The pandemic and ensuing the lockdown created a serious humanitarian crisis as cash, food and work grew scarce. The Central government launched the Pradhan Mantri Garib Kalyan Anna Yojana soon after the lockdown was declared in March. Under this scheme, beneficiaries of the public distribution system were entitled to an additional 5 kg of foodgrain. The scheme was extended till November but then discontinued, even though the crisis of food insecurity is far from over.
Hunger and malnutrition continue to be acute problems even months after the lockdown ended. Hunger Watch, a survey of over 4,000 people from vulnerable and marginalised communities across 11 states conducted by the Right to Food campaign, found that about 27% of the respondents sometimes went to bed without eating in September-October. Moreover, 71% reported that the nutritional quality of their food had worsened from what it had been before the lockdown.
The most humane and effective response would be to continue with additional food support through a universal and improved public distribution system that includes pulses, coarse grains and edible oils.
Strengthen public distribution
While the allocation of additional foodgrain under the Pradhan Mantri Garib Kalyan Anna Yojana was a welcome initiative, Jean Drèze, Reetika Khera and Meghana Mungikar have pointed out that millions are excluded from the public distribution system, which is based on outdated Census figures.
Up to 67% of the population is to be covered under the National Food Security Act. Using the population projection for 2020 – over 1,371 million – the number of people covered under Act should have been around 919 million. However, only 804 million people were identified under Pradhan Mantri Garib Kalyan Anna Yojana for additional foodgrain allocation from July to November. That is, around 115 million people who could have been covered under the National Food Security Act were excluded. Even among the identified beneficiaries, there are reports of exclusion errors because of biometric identification or other administrative reasons.
According to the latest available consumer expenditure survey data (2011-12), exclusion errors, or poor households excluded from subsidised rations, are lower in states that expanded the coverage of the public distribution system. Providing 10 kg of foodgrain per person per month to 80% of the population, or 1,097 million people, through the public distribution system would require 11 million tonnes of foodgrains. This is only around one-third of the excess foodgrain, over and above the buffer norms, available in the central pool in October 2020.
There is evidence that in states where the public distribution system works well, there have been nutritional gains for children as well as potential catch-up growth through the mid-day meals scheme. Nutrition deficiencies in children could be reversed with school meals that include eggs. In several states, eggs are currently not on the mid-day meal menu.
The pandemic has underlined the importance of the public distribution system, the midday meal scheme and India’s current food policy set-up. We need to strengthen them further to counter rising hunger and undernutrition. The required resources are readily available.
Anjana Thampi and Ishan Anand teach at Jindal Global Law School, O. P. Jindal Global University, Sonepat.
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