INDIA’S PROGRESS AGAINST CHILDHOOD UNDERNUTRITION: EARLY REFLECTIONS ON THE NATIONAL FAMILY HEALTH SURVEY-5

NFHS-5 survey provides an important emerging picture of the trends in malnutrition in India (Image courtesy: POSHAN team)

Children's heights are a bellwether indicator for all the things that can go wrong, or right, in society.   As, Jef Leroy, senior research fellow at IFPRI put it, poor child growth is like a smoke alarm - it tells you there is a fire burning somewhere. It can take some detective work to figure out where that fire is, what the source is, and to identify what it will take to put the fire out. What we know from the just-released first set of state fact sheets from the fifth round of the National Family Health Survey (NFHS) is that India certainly has smouldering fires. Careful analyses of the state data, followed by deeper analyses of the district-level data and finally, the unit-level data can help tell us both where the fires of malnutrition are burning and also can help us begin to understand the potential causes in different contexts.

On Saturday, December 12^th, the National Family Health Survey 5 (NFHS-5) released state and district factsheets for 22 states and union territories.  Our research team did a rapid analysis to examine trends between the NFHS-4, done in 2015-16, and the NFHS-5 in 2019 for select nutrition and health outcomes. We also examined trends in the available data on immediate and underlying determinants of nutrition. And finally, to assess trends in the reach of key interventions, we examined available insights on the coverage of nutrition interventions.

Together, these factsheets from the extensive NFHS-5 survey provide an important emerging picture of the trends in malnutrition in India. Understanding the reasons for these trends will require much more work to explain fully.  However, when these early findings are examined against what we know about the determinants of child undernutrition in India and the drivers of change in malnutrition, they do reveal several key trends and help identify directions for further inquiry and action.

Here are key highlights from our rapid analysis:

First, on malnutrition outcomes for children and adults: (1) There is a stagnation or worsening of child anthropometric outcomes (stunting, wasting and underweight) across several states but notable improvements in some states, including the large state of Bihar. (2) There are improvements in mortality indicators in most states, with more states improving on infant mortality and under-five mortality than neonatal mortality; (3) Anemia has increased in most states for children, adolescents, non-pregnant women and men but has declined in many states among pregnant women. (4) Overweight has increased in most states and among all population groups, including children under-five, adult women and adult men.

Second, on the immediate determinants of child undernutrition, exclusive breastfeeding and adequacy of complementary foods have improved, although the achieved levels are still too low, and there is much room for improvement. A mixed picture emerges in early initiation of breastfeeding and in timely introduction of complementary feeding, with several states seeing a decline.  Maternal nutrition, a known immediate determinant of child outcomes at birth, remains a challenge.  Despite reductions in maternal underweight, the levels of maternal anemia are high across many states.  Unfortunately, an increase in women’s overweight is a real challenge in many states and does have implications for the health of newborns and infants.

Third, on underlying determinants of child undernutrition, we see large and consistent improvements across all states in water and sanitation indicators, reaching high levels of coverage.  This is very promising.  There is also a consistent, but small, improvement across states in women’s education and in marriage before the age of 18 years for those 20-24 years of age.  However, there remains much room for improvement, especially early marriage, which we and others have shown previously is a key challenge area for nutrition.  On the final important determinant of childhood undernutrition – poverty and food security - unfortunately, there are no data in the fact sheets to say anything about improvements in poverty, food insecurity or reductions in economic inequity over this period.  However, evidence of economic challenges in the 2014-19 timeframe, including high levels of unemployment and food inflation point to the likelihood of large numbers of households affected negatively during this period.

Fourth, on the reach of key interventions in the health and nutrition sector, including some of those promoted by India’s National Nutrition Mission, we find a mixed picture but a generally positive trend. Overall, intervention coverage improved in most states, including for early antenatal care and previously stubborn indicators such as the consumption of iron supplements during pregnancy. Interventions that require attention are the completion of four antenatal care visits, the use of zinc with oral rehydration solution. Little is known about the reach of interventions delivered by the Integrated Child Development Services (ICDS), such as food supplementation, health and nutrition counselling and screening for malnutrition, since findings on these are not reported in the state fact sheets.

The stagnation in anemia and the consistent increase in overweight are major concerns for India’s progress towards eliminating all forms of malnutrition.  Much more inquiry will be needed in those areas, where we have fewer success cases to learn from.  However, from IFPRI’s Stories of Change initiative on success cases in malnutrition, and from the Exemplars in Global Health, we have insights on actions from many countries and states within India that successfully reduced stunting in the last decade or so.  In our research in Odisha, Chhattisgarh, Tamil Nadu and Gujarat, we find that successful stunting reduction came primarily from improvements in the following three areas:

1. Delivery of high impact health and nutrition interventions, especially to pregnant women and young children;
2. Investments in girls and women through their lives, reflected in attained education, reduced early marriage, improved maternal nutritional status and access to health and nutrition care;
3. Equity-enhancing social programs to reduce poverty and improve food security, as well as consistent economic growth.

Even as we await the second wave of the NFHS-5 (due only in the middle of 2021) and the release of the unit-level data for more diagnosis, there is no time to lose on action.  As India looks ahead in the context of a pandemic that is having dire economic and social consequences, here are some recommendations from the consensus-based Commitment to Action from India’s nutrition policy community:

1. Ensure that nutrition stays on top of the policy, political, bureaucratic and social agenda - all of us have a role to play here!
2. Continue to strengthen existing health and nutrition services to deliver high impact interventions already in the National Nutrition Mission framework - these must reach every woman, every child now and for the next several years.
3. Finance adequately for nutrition: this is budget season in India and health/nutrition and social welfare programs to reach the vulnerable must receive top priority.
4. Ramp up quickly to tackle the underlying poverty, food security, and gender issues because these have been central to addressing poverty and food security in successful cases around the world.
5. Invest in data. Without knowing how well, or how poorly, families with young children are doing, we are flying blind.
6. Strengthen the focus on reaching every 1000-day household with the full suite of existing programs in India's public support portfolio.

In closing, on tackling child undernutrition, this is not the time to seek new magic bullets – we know enough to know that there are none for outcomes such as child growth.  However, it is time to make sure that all the available information and evidence at our disposal, both on what drives success and on where the challenges lie in these states in India, are deployed to their full potential.  There is ample proof from many states across in India that gives us hope that change is possible in improving child undernutrition.  Bihar’s success must give us hope and energy - even small changes in places with large populations, can help to deliver success for India.

The challenge ahead – both on research and on action – is massive.  We invite researchers across India and globally, therefore, to join hands with us to continue to explore the NFHS-5 and other data sets.  Together, we should aim to deliver a collective set of insights on all forms of malnutrition to help provide direction to solving what remains one of India’s biggest challenges.

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These early analyses and interpretations were shared in two reflections meetings attended by over 180 people from 36 organizations across India.

A recent version of the slides shared at the webinars this past week is available HERE.  A video from one of the reflections meetings is available HERE

IFPRI is continually working to update the analysis.  Our team will be happy to share the most updated findings on regular intervals with the research and policy community. If you are interested in collaborating with us or wish to receive the most updated slide-deck, please write to IFPRI-POSHAN@cgiar.org.