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Why Are Levels of Child Malnutrition Not Improving?

Results of the recently released third National Family Health Survey carried out in 2005-06 reveal that 46 per cent of India's children under three years are underweight. The NFHS-3 clearly shows limited progress in ensuring universal health services and care to children under three years of age (especially to newborns) and to mothers and women. Preliminary results confirm the continuing neglect of health, inadequate reach and efficacy of health and childcare services.

Insight

Why Are Levels of Child Malnutrition Not Improving?

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Economic and Political WeeklyApril 14, 20071338population. Children who are more thantwo standard deviations below the re-ference median on any of the indices areconsidered to be undernourished, andchildren who fall more than three standarddeviations below the reference median areconsidered to be severely undernourished.Available data from NFHS-3 offer esti-mates of undernourished children – thatis,the proportion of children moderatelyand severely underweight, stunted andwasted.The three indicators of undernourish-ment provide somewhat different infor-mation about the nutritional status ofchildren.2Height-for-age (stunting) is ameasure of linear growth retardation.Stunted or short children are those who aremore than two standard deviations belowthe median of the reference population interms of height-for-age. This indicatorcaptures chronic under-nutrition as it re-flects a failure to receive adequate nutri-tion over a long period of time or fromchronic or recurrent diarrhoea. Height-for-age status therefore does not vary with theseason in which data are collected. Thesecond indicator, weight-for-height (orwasting) captures the thinness of childrenand indicates the prevalence of acutemalnutrition. Wasting is typically the resultof a failure to receive adequate nutritionin the period immediately preceding thesurvey; and to that extent, the results maycapture seasonal variations in food supplyor recent episodes of illness. The thirdindicator, weight-for-age (underweight)captures elements of both stunting andwasting, that is chronic as well as acuteunder-nutrition.This article makes use of the preliminaryNFHS-3 Fact Sheets to comment on levelsand trends in the key indicators relatingto children’s health and nutrition as wellas associated indicators of maternal healthand women’s well-being. Three qualifica-tions, first, tabulations are presented fromNFHS-3 for 20 out of 29 Indian states.Excluded from this analysis, given theirdistinct characteristics, are Goa,Delhi,andthe north-eastern states of ArunachalPradesh, Manipur, Meghalaya, Mizoram,Nagaland, Tripura and Sikkim. Second,estimates of sampling errors for the indi-cators are not yet available; and to thatextent, data need to be interpreted withcaution. Third, interpreting trends willrequire a more careful analysis which canbe undertaken only after the detailed re-ports containing more specialised anddisaggregated data become available. Tothat extent, discussions in this article basedon preliminary data from NFHS-3 aresomewhat exploratory.Levels of Child MalnutritionOf the three indicators of undernourish-ment, the proportion of underweight chil-dren is used most widely as a comprehen-sive measure of malnutrition as it captureselements of both stunting and wasting.Many aspects of life and development arereflected in this one statistic – includingthe income and education of parents, theprevalence of disease, the availability ofclean water, efficacy of health services,infant feeding practices, access to foodand care, food and dietary habits, thehealth andnutritional status of mothers,and more broadly, the position of womenin society.According to NFHS-3, in 2005-06, 46per cent of below three years of age wereunderweight, 38 per cent were stunted and19 per cent were wasted (Table 1). Thecorresponding levels of child malnutritionare much lower in sub-Saharan Africawhere 28 per cent of children below fiveyears are underweight, 37 per cent arestunted and 9 per cent are wasted. In China,only 8 per cent of similar children areunderweight and 14 per cent are stunted.3Table 1 also reveals that, in general, under-nourishment is higher among rural thanurban children. For instance, in 2005-06,the proportion of underweight children inurban areas was 36 per cent as against 49per cent in rural areas. Similarly, levels ofstunting and wasting are higher in ruralthan in urban areas.NFHS-3 offers useful insights intounderstanding the high proportion ofunderweight children in India. Table 2showing selected data on key indicatorsrelating to health and nutrition fromNFHS-3,reflects, to a large extent, thelimited access to and reach of public healthservices for women and children.Table 1: Nutritional Status of IndianChildren, 2005-06(Per cent)NFHS-3 (2005-06)UrbanRuralAll-IndiaChildren under three years who areStunted314138Wasted172019Underweight364946Note: Figures are rounded.Source: NFHS-3 Fact Sheets. Table 2: Access to and Reach of Basic Health ServicesNFHS-3UrbanRural(2005-06)Child immunisation and vitamin A supplementation* (per cent)Children 12-23 months fully immunised (BCG, measles andthree doses each of polio/DPT)445839Children aged 12-23 months who have received BCG788775Children aged 12-23 months who have received three doses of polio vaccine788377Children aged 12-23 months who have received three doses of DPT vaccine556950Children aged 12-23 months who have received measles vaccine597254Children aged 12-35 months who received a vitamin A dose in last six months212320Treatment of childhood diseases (children under three years)* (per cent)Children with diarrhoea in the last two weeks who received ORS263324Children with diarrhoea in the last two weeks taken to a health facility586556Children with acute respiratory infection or fever in the last two weekstaken to a health facility647860Child feeding practices* (per cent)Children under three years breastfed within one hour of birth232922Children aged 0-five months exclusively breastfed464048Children aged six to nine months receiving solid or semi-solid foodand breastmilk566254Children under three years who are stunted383141Children under three years who are wasted191720Children under three years who are underweight463649Maternity care (for births in the last three years) (per cent)Mothers who had at least three antenatal care visits for their last birth517443Mothers who consumed IFA (a vitamin A supplement tablet) for 90 daysor more when they were pregnant with their last child223518Births assisted by a doctor/nurse/LHV/ANM/other health personnel*487539Institutional births*416931Mothers who received postnatal care from a doctor/nurse/LHV/ANM/otherhealth personnel within two days of delivery for their last birth*366128Nutritional status of ever-married adults (age 15-49) (per cent)Women whose BMI is below normal332039Note:* Based on the last two births in the three years before the survey.Source:NFHS-3 Fact Sheets.
Economic and Political WeeklyApril 14, 20071339In 2005-06, for instance, only 44 percent of children of 12-23 months werefully immunised. Despite the importanceof breastfeeding and appropriate feedingfor preventing malnutrition, only 23 percent of children under three years werebreastfed within one hour of birth andlessthan half the babies (46 per cent) aged0-5 months were exclusively breastfed.Equally striking is the low proportion ofchildren of 6-9 months – 56 per cent – whoreceived solid or semi-solid food and breastmilk. It is well known that frequent ill-nesses during early childhood and failingto treat them properly seriously affects thenutritional well-being of children. Datafrom NFHS-3 reveal that only 26 per centof children with diarrhoea were given oralrehydration salt (ORS) and barely two-thirds (64 per cent) of children sufferingfrom acute respiratory infection or feverwere taken to a health facility. This showsboth the poor reach of public health ser-vices and also the limited accessibility ofsuch services to children. With only oneexception, namely, children aged 0-5months exclusively breastfed, all otherindicators reveal lower reach and accessto health services and care in rural thanin urban areas.4And this explains at leastpartially the higher levels of under-nourishment inrural than in urban areas.Alsoaffecting the health and nutritionalwell-being of children is the status ofwomen’s health and their access to mater-nal care services. Here again, NFHS-3reveals some glaring shortfalls. In 2005-06,barely half (51 per cent) of mothers acrossthe country had received at least threeantenatal care visits during pregnancy;andless than half (48 per cent) of birthswere attended to by a trained birth atten-dant which includes a doctor, nurse, ladyhealth worker (LHW), auxiliary nursemidwife (ANM) and other health person-nel. At the same time, data reveal that one-third of Indian women have a Body MassIndex (BMI) that is below normal suggest-ing overall undernourishment and poorhealth status.5The levels of undernourishment varywidely across Indian states. Table 3presents data on the proportion of stunt-ing,wasting and underweight amongchildren below three years across Indianstates.The proportion of underweight childrenvaries, for instance, from less than 30 percent in Punjab, Kerala and Jammu andKashmir to over 50 per cent of childrenin Chhattisgarh, Bihar, Jharkhand andMadhya Pradesh. The proportion ofstuntedchildren is the lowest in Kerala(21 per cent), Tamil Nadu (25 per cent)and Himachal Pradesh (27 per cent) andthe highest in Gujarat and Bihar (both42per cent), Chhattisgarh (45 per cent)and Uttar Pradesh (46 per cent). Theextent of wasting among children istheleast in Punjab (9percent), AndhraPradesh and Assam (both 13 per cent)andsurprisingly Uttar Pradesh (14 per cent)whereas it is maximum in Bihar (28 percent), Jharkhand (31 per cent) andMadhya Pradesh (33 per cent). Propor-tions of underweight children are consis-tently higher in rural than in urban areasacross all Indian states (Table4). The ruraland urban differential in the proportion ofunderweight children is the largest inChhattisgarh, West Bengal and Jharkhand.What accounts for the interstate differ-ences in the levels of undernourishment?Table 5 presents data from NFHS-3 onsome key public health indicators for twosets of Indian states – four states with thelowest proportion of underweight childrenand four states with the highest proportionof underweight children. By and large, inthe four states with the lowest proportionof underweight children – Punjab, Kerala,Jammu and Kashmir and Tamil Nadu –provisioning of health services, care ofchildren especially newborns and thenutritional status of women are better thanin the four high malnutrition states ofChhattisgarh, Bihar, Jharkhand andMadhya Pradesh.For instance, the proportion of fully-immunised children varies between 60 and81 per cent in the low malnutrition statesand between 33 and 49 per cent in the highmalnutrition states. In the low malnutritionstates, between 73 and 97 per cent ofmothers receive at least three antenatalcare visits; this proportion varies between17 and 55 per cent in thehigh malnutritionstates. And whereas 14-24 percentofTable 4: Rural-Urban Differentials in Child MalnutritionProportion of UnderweightNFHS-3Excess of RuralChildren below Three Years2005-06overUrbanAll AreasUrbanRural(Percentage(Per Cent)Points)1Haryana42424202Himachal Pradesh36343633Tamil Nadu33313544Assam40344175Gujarat47435076Bihar58525987Punjab27223088Maharashtra40354499Kerala292332910Rajasthan4436461011Madhya Pradesh6053631012Jammu and Kashmir2921321113Andhra Pradesh3729401114Karnataka4134451115Uttaranchal3829411116Uttar Pradesh4738491217Orissa4433461218Chhattisgarh5239551619West Bengal4430471720Jharkhand59436320India46364913Source: NFHS-3 Fact Sheets.Table 3: Malnutrition among IndianChildren below Three Years(Per cent)StuntedWastedUnder-weightNFHS-3 2005-061Punjab289272Kerala2116293Jammu and Kashmir2815294Tamil Nadu2522335Himachal Pradesh2719366Andhra Pradesh3413377Uttaranchal3216388Maharashtra3815409Assam35134010Karnataka38184111Haryana36174212West Bengal33194413Orissa38194414Rajasthan34204415Uttar Pradesh46144716Gujarat42174717Chhattisgarh45185218Bihar42285819Jharkhand41315920Madhya Pradesh403360India381946Notes: States ranked in descending order ofunderweight children. Figures have beenrounded.Source: NFHS-3 Fact Sheets.
Economic and Political WeeklyApril 14, 20071340women in the low malnutrition stateshave a BMI below normal, the proportionvaries from 40-43 per cent in the highmalnutrition states. There are, however,some exceptions that need more carefulexamination. Chhattisgarh and Jharkhandseem to be doing much better in theirefforts to promote exclusive breastfeedingin the initial years of a child’s life. Eighty-two per cent of children of 0-5 months inChhattisgarh and 58 per cent in Jharkhandare exclusively breastfed whereas in thelowmalnutrition states, the highest proportionis 56 per cent in Kerala. Also, it is distur-bing to find that Gujarat ranks among thetop five states reporting thehighest pro-portion of underweight children – a pheno-menon that needs a closer examination.Trends in Child MalnutritionProgress in reducing undernourishmentamong children over the past seven years– between 1998-99 (corresponding toNFHS-2) and 2005-06 (corresponding toNFHS-3) – has been poor. Data presentedin Table 6 show that between 1998-99 and2005-06 (i) the proportion of stuntedchildren below three years has come downfrom 46 per cent to 38 per cent – aninsignificant improvement of 8 percentagepoints over seven years; (ii) the proportionof wasted children below three years hasgone up from 16 per cent to 19 per cent;and (iii) the proportion of children un-derweight has come down from 47 per centto 46 per cent – a 1 percentage pointdeclineover seven years (as against a 5percentage point improvement between1992-93 and 1998-99). There is alsopractically no change in the rural-urbandifferentials over the last seven years inthe proportion of stunting, wasting andunderweightchildren.NFHS-3 offers useful insights into thisslow pace of reduction in the proportionof underweight children. One, vaccinationcoverage rates are far from universal in thecase of all vaccines – BCG, polio, DPTand measles. And there has been only amarginal improvement in the reach of basichealth services. For instance, Table 7reveals that only 44 per cent of childrenof 12-23 months were fully immunised in2005-06 – up from 42 per cent in 1998-99and 36 per cent in 1992-93.The national immunisation coverage inurban areas has slipped over the past sevenyears from 61 per cent in 1998-99 to 58per cent in 2005-06 and has increased onlyslightly in rural areas from 37 per cent to39 per cent. The proportion of fully-immunised children has declined duringthis period, surprisingly, in eight states –Andhra Pradesh, Gujarat, Himachal Pradesh,Table 6: Progress in Reducing MalnutritionNFHS-3NFHS-2NFHS-1Shortfall ReductionNFHS-2 (1998-99)NFHS-3 (2005-06)(2005-06)(1998-99)(1992-93)(Per Cent)UrbanRuralRural-UrbanRuralRural-1992-93 to1998-99 toUrbanUrban1998-992005-06RatioRatioChildren underthree years who arestunted (per cent)3846na–1536491.431411.3wasted (per cent)1916na–-1913161.217201.2underweight (per cent)4647529238501.336491.3Source: NFHS-2 and NFHS-3 Fact Sheets. Table 7: Trends in ImmunisationCoverageProportion of Fully-ImmunisedChildren (Per Cent)UrbanRuralIndiaNFHS-11992-93513136NFHS-21998-99613742NFHS-32005-06583944Source:NFHS-3 Fact Sheets.Table 5: Key Indicators Relating to Health and Nutrition in Low and High Child Malnutrition States(Per cent)Care of ChildrenMaternal Health CareUnder-ChildrenChildrenChildrenChildrenChildrenChildrenMothersBirthsWomenweightAged 12-23under ThreeAged0-5of6-9withwithAcuteWho Had atAssistedWhoseMonthsYearsMonthsMonthsDiarrhoeaRespiratoryLeast ThreebyaBMIisFully-BreastfedExclusivelyReceivingin the LastInfectionAntenatalTrainedBelowImmunisedwithin OneBreastfedSolidorTwo WeeksorFeverinCareVisitsBirthNormalHour ofSemi-solidWhothe Lastfor TheirAttendantBirthFood andReceivedTwo WeeksLast BirthBreastmilkORSTaken to aHealthFacilityFour states with the lowest proportion of underweight children1Punjab276010365035877353142Kerala2975555694358194100133Jammu and Kashmir296732425842787461214Tamil Nadu33815533782981979324India46442346562664514833Four states with the highest proportion of underweight children17Chhattisgarh5249258255427055444118Bihar583342857225517314319Jharkhand5935115865184636294320Madhya Pradesh60401522522969403740Note:Figures are rounded.Source:NFHS-3 Fact Sheets..
Economic and Political WeeklyApril 14, 20071341Karnataka, Kerala, Maharashtra, Punjaband Tamil Nadu – generally regardedasbetter performing states in health andeconomically more prosperous than otherstates. On the other hand, immunisationcoverage rates have shown a significantimprovement in West Bengal, Bihar,Jharkhand and Chhattisgarh (Table8).Two, children’s access to certain criticalcomponents of treatment of childhooddiseases has declined over the past sevenyears (Table 9). For instance, the propor-tion of children with diarrhoea whoreceivedORS in the two weeks preceding the surveyhad risen from 18 per cent in 1992-93 to27 per cent in 1998-99; but since then ithas fallen to 26 per cent in 2005-06.Three, critical public health messagesare simply not reaching the families withchildren. For example, in 2005-06, only23 per cent of infants aged 0-5 monthswere being exclusively breastfed in2005-06 – up from 16 per cent in 1998-99,an increase of 7 percentage points overseven years, despite the importance ofexclusive breastfeeding in the initial monthsof a child’s life.Four, there are huge gaps in women’saccess to and reach of maternal healthservices. Improvements in women’s accessto safe delivery, for instance, have beenminimal. Between 1998-99 and 2005-06,the proportion of births assisted by a doctor,nurse, LHV, ANM or other healthpersonnelwent up marginally from 42 to48 per cent; and institutional births wentup from 36 per cent to 41 per cent overthe same period.Finally, closely linked to the health andnutritional status of children is the healthof mothers. In 1998-99, 36 per cent of ever-married women of 15-49 years had a BMIbelow normal. The proportion fell margin-ally to 33 per cent in 2005-06. At the sametime, the levels of anaemia, high in 1998-99, have risen further to 56 per cent amongever-married women and to 58 per centamong pregnant women.The relative performance of states inreducing child malnutrition has been mixed.Table 10 shows the relative performanceof Indian states on the three indicators ofchild malnutrition.Over the past seven years (between1998-99 and2005-06), the proportion ofstunted children has come down in allstates except Karnataka. The proportion ofwasted children has come down in fourstates (Maharashtra, Orissa, Chhattisgarhand Karnataka) and increased in the re-maining 16 states. And finally, childmalnutrition as measured by the propor-tion of underweight children has worsenedin seven states – Gujarat, Kerala, Bihar,Jharkhand, Assam, Madhya Pradesh andHaryana. These are some puzzlingpatterns in child malnutrition that requirea closer scrutiny.What can explain the differential perfor-mance of states in reducing the proportionof underweight children? It appears thatinitial conditions in terms of socio-economicdevelopment, levels of povertyor the progress in reducing income povertyand the growth record of states do not seemto matter much. Table 11 presents somebasic socio-economic and other data fortwo sets of states. In the first set are in-cluded five “good performance” states thathave recorded the maximum gains in re-ducing the proportion of underweightchildren (Maharashtra, Orissa, HimachalPradesh, Jammu and Kashmir andChhattisgarh); and in the second set arefive “poor performance” states where theproportion of underweight children hasgone up the most (Bihar, Jharkhand, Assam,Madhya Pradesh and Haryana).Some features of these two sets of statesare worth noting. One, included in the setof “good” performers are both states withbetter-than-national-average levels of childmalnutrition – Jammu and Kashmir (29 percent), Himachal Pradesh (36 per cent) andMaharashtra (40 per cent) – and states withhigher than national average proportionsof underweight children – Orissa (44 percent) and Chhattisgarh (52 per cent). In-cluded in the set of “poor” performers arestates with better-than-national-averagelevels of child malnutrition – Assam (40per cent) and Haryana (42 per cent) – aswell as the states with higher than nationalaverage proportions of underweightchildren – Bihar (58 per cent), JharkhandTable 8: Children of 12-23 MonthsFully Immunised (BCG, Measles andThree Doses Each of Polio/DPT)(Per cent)NFHS-3NFHS-2Improve-2005-061998-99ment (+) orDeterio-ration (-)Percent-age Points1Chhattisgarh4922272Jharkhand359263Bihar3312214West Bengal6444215Uttaranchal6041196Madhya Pradesh4023187Assam3217158Jammu andKashmir6757109Rajasthan2717910Orissa5244811Uttar Pradesh2320312Haryana6563313Kerala7580-414Karnataka5560-515Gujarat4553-816Tamil Nadu8189-817HimachalPradesh7483-918Punjab6072-1219Andhra Pradesh4659-1320Maharashtra5978-20India44422Source: Computed from NFHS-3 Fact Sheets.Table 9: Trends in Access to and Reach of Basic Health Services(Per cent)NFHS-3NFHS-2NFHS-1(2005-06)(1998-99)(1992-93)Child immunisation and vitamin A supplementation*Children aged 12-23 months fully immunised (BCG, measles, andthree doses each of polio/DPT)444236Children aged 12-23 months who have received BCG787262Children aged 12-23 months who have received three doses ofpolio vaccine786354Children aged 12-23 months who have received three doses ofDPT vaccine555552Children aged 12-23 months who have received measles vaccine595142Treatment of childhood diseases (children under three years)*Children with diarrhoea in the last two weeks who received ORS262718Children with diarrhoea in the last two weeks taken to a health facility586562Child feeding practices*Children under three years breastfed within one hour of birth231610Maternity care (for births in the last three years)Mothers who had at least three antenatal care visits for their last birth514444Births assisted by a doctor/nurse/LHV/ANM/other health personnel*484233Institutional births*413426Nutritional status of ever-married adults (age 15-49)Women whose BMI is below normal3336naAnaemia among adult womenEver-married women aged 15-49 who are anaemic5652naPregnant women aged 15-49 who are anaemic5850naNote:*Based on the last two births in the three years before the survey.Source:NFHS-3 Fact Sheets.
Economic and Political WeeklyApril 14, 20071342(59 per cent) and Madhya Pradesh (60 percent). Two, in both sets, there are relativelylow and high income states. Maharashtrafeatures among the top five states thathaveachieved maximum reductions in theproportion of underweight children andHaryana – another rich state – features asthe state with the largest decline in theproportion of underweight children. Simi-larly, among the good performers is Orissa– a relatively low income state. Again,levels of poverty across the two sets ofstates are both relatively high and low.And the record of the states in reducingpoverty is also mixed. Three, there is nodiscernible pattern in the growth rates inthe per capita state domestic product in thetwo sets of states. Growth rates in the percapita income between 1998-99 and 2003-04 varied between 1.7 and 4.1 per cent inthe set of good performers; and between1.7 and 4.9 per cent in the set of poorperformers. Four, with the exception ofHaryana, where the headcount poverty ratiohas gone up between 1999 and 2005, it hasdecreased in all the other states in both sets.In the category of poor performers are thestates that show a relatively large declinein the proportion of poor, namely, Assamand Bihar. Five, among the good perform-ers are states with relatively high levels ofinfant mortality (Chhattisgarh and Orissa).Also included in the set of poor performersTable 10: Trends in Malnutrition among Indian Children below Three Years across Indian States(Per cent)StuntedWastedUnderweightNFHS-3NFHS-2ChangeNFHS-3NFHS-2ChangeNFHS-3NFHS-2Shortfall2005-061998-992005-061998-992005-061998-99Reduction1Maharashtra3840Improves1521Improves4050202Orissa3844Improves1924Improves4454193Himachal Pradesh2741Improves1917Worsens3644174Jammu and Kashmir2839Improves1512Worsens2935155Chhattisgarh4558Improves1819Improves5261146Rajasthan3452Improves2012Worsens4451137West Bengal3342Improves1914Worsens4449118Tamil Nadu2529Improves2220Worsens3337109Uttaranchal3247Improves168Worsens3842910Uttar Pradesh4656Improves1411Worsens4752911Karnataka3837Worsens1820Improves4144612Punjab2839Improves97Worsens2729613Andhra Pradesh3439Improves139Worsens37383India3845Improves1916Worsens4647Improves14Gujarat4244Improves1716Worsens4745-515Kerala2122Improves1611Worsens2927-716Bihar4255Improves2820Worsens5854-817Jharkhand4149Improves3125Worsens5954-918Assam3550Improves1313Improves4036-1219Madhya Pradesh4049Improves3320Worsens6054-1320Haryana3650Improves175Worsens4235-21Note: Shortfall reduction is calculated by assuming that the desirable proportion of underweight children is 0 per cent.Source:NFHS-3 Fact Sheets.Table 11: Basic Socio-economic Indicators for Selected StatesChange in Proportion ofShortfallPer CapitaAnnualPopulation BelowInfantLiteracy RateChildren Who AreReductioninSDPAveragethe Poverty LineMortality(PerCent)StuntedWastedUnder-ProportionatRate of2004-05AverageRateTotalMaleFemaleweightor Under-CurrentGrowthin(PerCent)AnnualDeaths200120012001weightPricesPer CapitaChange inPerChildren2004-05SDPProportion1,0001998-99 to(Rs)1998-99 toofPoorLive2005-062003-041993-94 toBirths(Per Cent)(Per Cent)2004-052005(1)(2)(3)(4)(5)(6)(7)(8)(9)Good performers in reducing child malnutrition1MaharashtraImprovesImprovesImproves20 32,1703.030-1.6367786672OrissaImprovesImprovesImproves19 13,6013.547-0.3756375513Himachal PradeshImprovesImprovesImproves17 27,4864.012-5.2497785674Jammu and KashmirImprovesImprovesImproves15 16,1901.75-6.5505667435ChhattisgarhImprovesImprovesImproves14 15,0734.1nana63657752IndiaImprovesWorsensImproves2 --28-2.058657554Poor performers in reducing child malnutrition16BiharImprovesWorsensWorsens-8 5,7724.242-2.26147603317JharkhandImprovesWorsensWorsens-9 13,0132.1nana5054673918AssamImprovesImprovesWorsens-12 13,6333.020-4.56863715519Madhya PradeshImprovesWorsensWorsens-13 14,0691.737-4.17664765020HaryanaImprovesWorsensWorsens-21 32,7124.914-3.960687356Note:Figures are rounded.Source:Column (1) is from Table 10; Column (2) is from the Government of India (2007); Column (3) is from the Central Statistical Organisation website;Columns (4) and (5) are based on the NSSO Report 508, December 2006 cited in Dev and Ravi (2007); Column (6) is from Sample Registration SystemBulletin, October 2006; and Columns (7), (8) and (9) are from the Census of India, 2001.
Economic and Political WeeklyApril 14, 20071343are states with relatively low levels ofinfant mortality (Haryana and Assam). Six,levels of female literacy do not show anydiscernible pattern. In the set of goodperformers are Jammu and Kashmir, Orissaand Chhattisgarh where female literacylevels are lower than the national average.And among the poor performers are Assamand Haryana where female literacy ratesare higher than the national average. Inshort, it is difficult to draw a generalisationin terms of the initial conditions in the twosets of states. The levels ofsocio-economicdevelopment and achievements in reduc-ing poverty or ensuring growth are mixedamong both poor and good performers.Some explanations for the differentialperformance of states can be found byexamining the trends in health provision-ing, improvements in childcare and healthstatus of women. Some broad patterns inchanges that have taken place in the twosets of states between 1998-99 and 2005-06are worth noting.One, the proportion of women whoseBMI is below normal has shown an im-provement in all the five good performingstates whereas it has declined in all the fivepoor performing states. Two, the pro-portionof children under three yearsbreastfed within one hour of birth hasshown larger improvements in the fivegood performing states than in the poorperforming states. Three, the percentageof children with diarrhoea in the last twoweeks who received ORS has shownimprovement in four of the five goodperforming states (the exception beingJammu and Kashmir) whereas it hasshowna decline in four of the five poorTable 12: Relative Performance of Selected States in Extending Reach of Child Health Services(Per cent)ShortfallChildren Aged12-23 MonthsChildren under Three YearsChildrenwithDiarrhoea inWomen Whose BMIReductioninFully-ImmunisedBreastfedwithinOnethe Last Two Weeks WhoIs Below NormalProportion ofHour of BirthReceived ORSUnderweight1998-992005-06Percentage1998-992005-06Percen-1998-992005-06Percen-1998-992005-06Percen-ChildrenPointtagetagetage1998-99 toChangePointPointPoint2005-06ChangeChangeChangeGood performers in reducing child malnutrition1Maharashtra207859-1923522933385403372Orissa194452825542935416484183Himachal Pradesh178374-921432346537302454Jammu and Kashmir155767102132114842-6262155Chhattisgarh1422492714251130421248417India242442162372726-136333Poor performers in reducing child malnutrition16Bihar-812332154-1142283943-417Jharkhand-99352691122018-34143-218Assam-12173215455163713-242737-919Madhya Pradesh-1323401891563029-13540-520Haryana-21636531222112625-12628-2Note:Figures are rounded. Percentage reduction in shortfall is calculated by assuming that the desirable goal for proportion of underweight children is 0.Source:NFHS-3 Fact Sheets.Table 13: Levels of Anaemia among Indian Children(Per cent)Anaemia amongAllNFHS-2 (1998-99)AllNFHS-3 (2005-06)Children Aged 6-35 MonthsIndiaUrbanRuralRural-IndiaUrbanRuralRural-UrbanUrbanRatioRatioChildren aged 6-35 monthswho are anaemic7471751.17973811.1Source: NFHS-2 and NFHS-3 Fact Sheets.Table 14: Children Aged 6-35 Months Who Are Anaemic(Per cent)NFHS-3NFHS-2ShortfallNFHS-3 2005-062005-061998-99ReductionUrbanRuralExcess ofRuralover Urban(Percentage Points)(1)(2)(3)(4)(5)(6)1Uttaranchal6277-21606222Himachal Pradesh5970-164960113Chhattisgarh8188-8768274Jharkhand7882-66681155Jammu and Kashmir6871-47267-56Rajasthan8082-3788037Haryana8384-2808348Punjab808008180-19Maharashtra7271166771110Orissa7472363761311Gujarat8075874841012Bihar8881876891313Andhra Pradesh7972972831114Tamil Nadu736697471-315Uttar Pradesh8574158386316Madhya Pradesh83711675851017Karnataka8371177984518Assam7763217077719Kerala5644275158720West Bengal694456587214India7974773819Ranked by Column (3).Source: NFHS-3 Fact Sheets.performing states (the exception is Bihar).Four, access to and reach of maternal healthservices have improved in both sets ofstates. Differences between the two sets ofstates are not easily discernible. Five, theproportion of fully-immunised children hasshown an improvement in nine out of the10 states being considered. Among the
Economic and Political WeeklyApril 14, 20071344good performers, the proportion of fully-immunised children has increased signifi-cantly in Orissa, Jammu and Kashmir andChhattisgarh. It has, however, declined inMaharashtra and Himachal Pradesh – bothstates with a relatively high coverage rate.In short, effectiveness in reducing childmalnutrition seems to be closely linked toimprovements in extending access to andreach of health services and care ofchildrenand mothers. It is also associatedwith improvements in the nutritionalstatus of women captured to an extent bythe proportion of women whose BMI isbelow normal.Anaemia among ChildrenAnaemia is a serious concern for youngchildren as it can adversely affect cogni-tive performance, behavioural and motordevelopment, coordination, language de-velopment and scholastic achievement aswell as increase morbidity from infectiousdiseases.6The NFHS-3 tested more than1,00,000 women and men for HIV andmore than 2,00,000 adults and youngchildren for anaemia. Haemoglobin levelsare classified into three categories: mild(10.0-10.9 g/dl), moderate (7.0-9.9 g/dl)and severe (less than 7.0 g/dl). Availabledata from the NFHS-3 give estimates ofthe proportion of children of 6-35 monthswho have some level of anaemia (includ-ing mild, moderate or severe). Table 13presents data on the proportion of childrenof 6-35 months who have some level ofanaemia – mild, moderate or severe.The proportion of anaemic children of6-35 months has risen from 74 per cent in1998-99 to 79 per cent in 2005-06. Theincrease is noticed in both rural and urbanareas though the increase is higher in ruralthan in urban areas.There are large interstate variations inthe levels of anaemia among children.Table14 presents data from NFHS-3 onlevels of anaemia among children aged6-35 months across Indian states.The levels of anaemia among childrenof 6-35 months vary from 56 per cent inKerala and 59 per cent in Himachal Pradesh,85 per cent in Uttar Pradesh and 88 percent in Bihar. West Bengal and Keralahave done well to reduce the levels ofanaemia among children over the pastseven years. But there has been an increasein levels of anaemia among children of6-35 months in seven states – Haryana,Rajasthan, Jammu and Kashmir, Jharkhand,Chhattisgarh, Himachal Pradesh andUttaranchal. The levels of anaemia are alsohigher among rural than urban children.And the rural-urban differential has wid-ened from 4 percentage points in 1998-99to 8 percentage points in 2005-06.Data also seem to suggest that states thathave done well in reducing the proportionof underweight children have also recordeddecreases in the level of anaemia amongwomen and children. Table 15 shows thetrends in levels of anaemia among womenand children in the two sets of states: goodperformers and poor performers in termsof reducing the proportion of underweightchildren.The proportion of children of 6-35months who are anaemic has come downin four out of the five states that haverecorded maximum reductions in childmalnutrition. In Orissa, a state in the set ofgood performers, the proportion ofanaemicchildren has gone up marginally from72per cent in 1998-99 to 74 per cent in2005-06. On the other hand, the proportionof children with anaemia has risen in fourof the five states where the proportion ofunderweight children has increased themost. The exception is Jharkhand wherethe proportion of anaemic children haddropped marginally from 73 per cent in1998-99 to 70 per cent in 2005-06. Amongthe good performers, the proportion ofever-married women aged 15-49 years whoare anaemic has decreased or more or lessremained unchanged in the five states. Onthe other hand, among the poor perform-ers, the proportion of ever-married womenaged 15-49 years who are anaemic hasincreased significantly in three states andcome down marginally in the other two.Concluding CommentsPreliminary data from the NFHS-3 enableus to make important observations on India’sattempts at reducing child malnutrition.One,levels of malnutrition among chil-dren below three years remain unaccept-ably high. In 2005-06, 46 per cent of belowthree years of age were underweight, 38per cent were stunted and 19 per cent werewasted. A strong rural disadvantage inchild malnutrition persists across thecountry. And there has been practically nochange in the rural-urban differentialsoverthe last seven years in the proportionof stunting, wasting and underweightchildren. Two, at the all-India level, thehigh levels of child malnutrition can beexplained in part by the limited access toand reach of health services. Equallystriking is the poor feeding habits largelyresponsible for the onset of malnutritionin the early stages of a child’s life. Andthere are glaring shortfalls in the status ofwomen’s health and her access to maternalcare services. Three, levels of childmalnutrition vary widely across Indianstates. Not surprisingly, provisioning ofhealth services, extent of childcare and thenutritional status of women are better instates with relatively low rather than highproportions of underweight children. Four,progress in reducing undernourishmentamong children over the past seven years– between 1998-99 (corresponding toNFHS-2) and 2005-06 (corresponding toNFHS-3) – has been poor.Success in reducingchild malnutritionis not so obviously dependent upon initialconditions in terms of a state’s levels ofsocio-economic development, the extentofpoverty, achievements in reducing povertyor the economic growth record. On theTable 15: Trends in Anaemia among Children and Women in Selected States(Per cent)Children Aged 6-35 MonthsEver-Married Women Aged 15-49Who Are AnaemicWho Are AnaemicNFHS-2NFHS-3NFHS-2NFHS-31998-992005-061998-992005-06Good performers in reducing child malnutrition1Maharashtra767249492Orissa727463633Himachal Pradesh705941414Jammu and Kashmir716859535Chhattisgarh88816958India74795256Poor performers in reducing child malnutrition16Bihar8188606817Jharkhand8278737018Assam6377706919Madhya Pradesh7183495820Haryana84834757Source: NFHS-3 Fact Sheets.
EPW

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