One area where India's development falls desperately short is nutrition. Child malnutrition rates are higher in India than in many parts of sub-Saharan Africa. This column argues that there can be no excuses. Policymakers need to better understand the reasons behind this ‘national shame’ and need to start doing something about it.

India's economic transformation and growth have received much attention in recent years. What is less known is that India has also made considerable progress on many social fronts, such as fertility decline, expansion of schooling, and bridging the gender gap in education, especially at the primary and lower secondary levels. However, there is one area of human development where India has not fared particularly well: hunger and malnutrition.

Child malnutrition rates in India are extraordinarily high – among the highest in the world, with nearly one-half of all children under 3 years old being either underweight or stunted. Indeed, child malnutrition rates are higher in India than in many countries of sub-Saharan Africa, even though income levels are significantly higher – and levels of infant and child mortality are lower – in India. This phenomenon, which is true more generally of the entire South Asian region, is often referred to as the 'Asian enigma'.

A national shame

Malnutrition sets in very early in the life of an Indian child. Indeed, nearly a quarter of all children are born with a major nutritional disadvantage – low birth-weight, meaning that they weigh less than 2.5 kg at birth. Important reasons for low birth-weight are the high proportion of mothers who themselves are underweight (one-third of all pregnant women have a body mass index (BMI) of less than 18.5) and who suffer from anemia or iron deficiency (nearly 60% of pregnant women suffer from anemia).

Why is combating hunger and malnutrition so important? Freedom from hunger and malnutrition is a basic human right, and until India can provide these freedoms, its claims to successful human development are questionable. As Prime Minister Manmohan Singh said recently, the country’s unacceptably-high level of child malnutrition is a ‘national shame’.

The economic costs of hunger and malnutrition

In addition to the human cost, there is a huge economic cost to hunger and malnutrition - in terms of loss of cognitive ability, schooling, and labour productivity. Estimates, albeit rough ones, suggest that malnutrition may be costing the Indian economy the equivalent of 4%-5% of its GDP.

Perhaps surprisingly, the problem of under-nutrition in India now coexists with the problem of over-nutrition and associated non-communicable diseases for a different segment of the population. Recent medical evidence suggests that the two might be related - low birth-weight children and children who are malnourished are more likely to develop chronic illnesses, such as diabetes, as adults. India has the largest number of adults with type 2 diabetes in the world and this number is growing rapidly – having doubled over the past 10 years. Indeed, India has a higher rate of diabetes than many Western countries with much higher levels of economic prosperity.

What is surprising is that the prevalence of child malnutrition in India has remained stubbornly high even after nearly a half-century of respectable agricultural productivity growth and two decades of post-reform economic growth and prosperity in the country. This is puzzling, since rising prosperity appears to have improved other social indicators in India, such as fertility, mortality, schooling and literacy.

Adding more support to the view that child malnutrition is weakly correlated with income is the finding that among children of mothers with 10 or more years of schooling as well as among children of mothers from the top income quintile, around one-quarter are underweight. Even in a relatively prosperous and dynamic state like Gujarat, child malnutrition rates have been stagnant over the past decade.

It is not just the trends and patterns in child malnutrition that are mystifying; there is a similar puzzle about nutrient intake. The UN’s Food and Agricultural Organisation (FAO) estimates the number of ‘hungry’ people in India at 230 million,¹ which is remarkable given robust agricultural productivity growth during the last three decades. For instance, yields of food grains have doubled since the early 1970s and of ‘coarse’ cereals (such as maize, sorghum and pearl millet), which are traditionally the main foods of the poor in India, have more than doubled. Yet astonishingly, over the same period, mean calorie intake in the country has actually fallen - by about 10% in the rural areas and 4% in the urban areas.²

Income and food intake

What does this all mean? Simply that we do not yet have a good understanding of how the poor in India make their food consumption and nutritional choices. The old adage of people living to eat rather than eating to live is relevant here. Food is a fuel for the human body, and therefore its demand is partly based on caloric needs and requirements of the human body. But it does not typically take very much to satisfy these basic caloric demands of the body, even in a poor country. A very large portion of the demand for food is thus based on the non-nutritive attributes of food, such as taste, aroma, variety, and status. This means that increases in household income do not always translate into improvements in calorie consumption.

Researchers had noted this tendency as far back as 25 years ago; even in one of the poorest regions of rural India, such as the semi-arid villages of Andhra Pradesh and Maharashtra, the income gradient of calorie intake was observed to be essentially flat, despite controlling for many other observed and unobserved factors (Behrman and Deolalikar 1987). This did not mean that household food consumption did not increase with income; indeed, expenditure on food was highly responsive to income changes. What was happening was that as incomes increased, households – even very poor households that were presumably (according to most external observers’ standards) ‘hungry’ and under-nourished – changed the composition of their food intake away from staples with a relatively low-price per calorie , such as sorghum and millet, to foods with a high price per calorie, such as rice, vegetables, and sugar. This shift in consumption accounted for the larger expenditures on food, but unchanged calorie intake, with increasing income.

This same tendency has been observed more recently by other researchers, who have also found that many of the poor in India do not put as much of their money into obtaining more calories (or at least as many calories as the UN FAO might think are appropriate, see Banerjee and Duflo 2011). Indeed, quite surprisingly, as child malnutrition rates have stagnated and calorie consumption has actually fallen, mobile phone use – even among the Indian rural poor – has increased dramatically. This raises many questions, including the obvious one – why do the poor, when given an opportunity, choose to spend their additional income on luxury durables, such as mobile phones, than on the nutrition of their children? Is it because they are uninformed about the long-term economic benefits of child nutrition? Or is it because ‘expert’ assessments about the prevalence and economic cost of under-nutrition in India are essentially incorrect?

A feast of questions but a famine of answers

What does this mean for policy? There is no shortage of programmes in India aimed at improving access to food and alleviating malnutrition. In addition to the Public Distribution System, which makes some staple foods such as food grains and sugar available at controlled prices through ‘fair-price shops’, there are a number of food-for-work programmes and employment guarantee schemes, the largest of which is the Mahatma Gandhi National Rural Employment Generation Scheme (MNREGA). Among the direct nutrition supplementation programmes are the Midday Meal Scheme, which is now almost universal in all the states, and the Integrated Child Development Services (ICDS), which is the largest supplementation programme of its kind in the world (and probably the largest ever in human history). The spending on all of these programmes is huge; the central allocation for the ICDS programme alone in 2012-13 is nearly $3 billion. Many of these nutritional interventions have been evaluated (although none of the evaluations has been very rigorous); unsurprisingly, the conclusion of most studies is that, taken together, these programmes have not made much of a dent in either protein-energy under-nutrition or child malnutrition rates in the country.

A lot has been written on hunger and malnutrition in India and around the world. There are many studies on the ICDS and on the design and implementation problems that plague the programme. But the fact remains that designing an effective programme is difficult unless policymakers have a better understanding of the true prevalence of ‘hunger’ and of the causes of child malnutrition. This suggests that there is need for more research on the extent and causes of malnutrition in the country, perhaps carried out by researchers beyond just the nutrition and public health community. For instance, there is considerable scope for anthropologists and sociologists to investigate the cultural and social contexts within which the poor make their families’ food consumption and nutrition decisions. Possible questions include: Why is it that only a quarter of new mothers in India initiate breast-feeding of their infants within an hour after birth even though it is widely known that colostrum is one of the most nutrition-rich foods for infants? And why do fewer than half of Indian mothers breast-feed exclusively in the first six months, even though that is the prescribed World Health Organisation (WHO) and Government of India (GOI) recommendation? (Delayed and non-exclusive breast-feeding sets the new-born infant on the path of malnutrition very early in life.) Among other questions to address are: Is the Indian diet, which is largely vegetarian, responsible for the high rates of child malnutrition? Is the mix of foods fed to Indian infants (e.g., not very energy-dense) responsible for early onset of child malnutrition?

Reason for hope

There is, however, reason for hope. India has been successful in addressing (although obviously not completely solving) many social problems that seemed insurmountable only recently.

The clearest case in point is access to schooling. There has been an impressive expansion of schooling, especially among girls and disadvantaged social groups, during the last two decades. After being stagnant for many decades since independence, school enrolment rates expanded rapidly during the 1990s and 2000s, especially at the primary and lower secondary school level, and there is currently near-universal access to primary schooling.

There is thus no reason why India should not be able to successfully combat hunger and malnutrition. But this will be possible only if policymakers move beyond ad hoc approaches, and instead devise an informed strategy based on a good understanding of why hunger and child nutrition are so high in India relative to other countries and why they have so unresponsive to improvements in income and prosperity.

Notes:

1. The UN’s FAOdefines hunger as availability of 1,800 calories per person per day. The hungry population would be significantly larger if one were to use India’s own norms for hunger – a minimum of 2,400 calories per person per day.
2. One explanation for the decline in calorie consumption is that calorie requirements may have declined over time owing to generally improved health conditions – a result of improved water and sanitation – and lower physical activity levels – a consequence of changes in the occupational structure and of greater penetration of effort-saving consumer durables (Deaton and Dreze 2009). However, there is no strong evidence for this hypothesis.

Further reading

• Banerjee, A. and E. Duflo. 2011. Poor Economics: A Radical Rethinking of the Way to Fight Global Poverty. New York: Public Affairs.
• Behrman, J.R. and A.B. Deolalikar. 1987. “Will Developing Country Nutrition Improve with Income? A Case Study for Rural South India.” Journal of Political Economy 95(3). May.
• Deaton, A. and J. Dreze. 2009. “Food and Nutrition in India: Facts and Interpretation.” Economic and Political Weekly XLVI(7). February 14.