Child and maternal malnutrition was India’s largest risk factor for health loss in 2016, leading to 15% of the total disease burden of the country, a study released on Tuesday showed. Air pollution was the second leading risk factor in India, contributing to India’s burden of cardiovascular diseases, chronic respiratory diseases and lower respiratory infections.

Vice Preident Venkaiah Naidu released the study on disease burden in India on Tuesday. The Indian Council of Medical Research, the Public Health Foundation of India and the Institute for Health Metrics and Evaluation prepared the report in collaboration with the Ministry of Health. This is a first state-wise report on disease burden and risk factors trends from 1990 to 2016.

The under-five mortality rate has reduced substantially from 1990 in all states, the report said, adding that there was a four-fold difference in this rate between states. The highest rate was recorded in Assam and Uttar Pradesh compared to the lowest in Kerala last year. The report said the difference highlighted the vast health inequalities between the states.

In 1990, of the total disease burden in India, 61% was due to communicable, maternal, neonatal, and nutritional diseases. It dropped to 33% in 2016.

Meanwhile, unsafe water and sanitation, which was the second-leading risk responsible for disease burden in 1990, dropped to the seventh position in 2016. The report said it contributed 5% to the total disease burden.

The Empowered Action Group faces the biggest challenge of controlling the increasing rate of non-communicable diseases as well as the infectious diseases. The group comprises eight states – Bihar, Madhya Pradesh, Chhattisgarh Odisha, Jharkhand, Uttar Pradesh, Uttarakhand and Rajasthan.

“India is committed to strengthening health data surveillance and health systems in the country. It needs both macro and micro planning,” said Union Health Minister JP Nadda, according to Hindustan Times. “This report will play a major role taking more specific action to improve the health and lives of the poor with special focus on the states that are relatively less developed.”

Contribution of major disease groups to total disease burden in India, 1990 and 2016.