The results of the
District Level Household and Facility Survey-4 for the year 2012-13,
commonly known as DLHS-4, are out and it shows that among the 18
states and 3 UTs, the percentage of moderate wasting for children
below 5 years is highest among Maharashtra (i.e. 34.1%). Similarly,
in case of severe wasting and moderate underweight, the situation is
worst in Maharashtra as compared to the rest (Please check the chart
below).
The above outcomes may be
shocking for those who got pleased with the state's decent
performance in reducing stunting (i.e. too short for age) among
children under 2 years, and expected similar trends for the rest two
measures, namely wasting (i.e. too thin for height) and underweight
(i.e. too thin for age).
Earlier, the provisional
results of the Comprehensive Nutrition Survey (CNS) in Maharashtra
during 2012, done jointly by the state's Department of Women and
Child Development, International Institute for Population Sciences
(IIPS) and UNICEF, found that the percentage of children under 2
years affected by stunting came down drastically to 22.8% in 2012
(under CNS) from 39.0% in 2005-06 (under NHFS-3).
Since the publication of
CNS results, a lot many international reports, authored by renowned
economists and health experts, had praised the state for reducing
malnutrition among children, although there were critical reports too
by the media on high malnutrition levels prevailing particularly
among tribal children in parts of Melghat in Amravati, Jawahar and
Mokhada in Thane and urban slums of Mankhurd and Shivajinagar in
Mumbai.
Since the DLHS-3 done in
2007-08 (& published in 2010) did not provide information on
malnutrition, DLHS-4 can be straightway compared with NFHS-3 for the
states whose latest nutritional data is available now.
On doing so, we get that
moderate stunting among children below 5 years in Maharashtra has
reduced from 46.2% in 2005-06 (NFHS-3) to 30% in 2012-13 (DLHS-4)
while severe stunting came down from 19.1% to 14.7% during the same
duration, but prevalence of moderate wasting nearly doubled and
severe wasting quadrupled in the 7 years span for children below 5
years.
Although prevalence of
moderate underweight in Maharashtra for children under 5 years
remained almost the same between NFHS-3 and DLHS-4, severe
underweight increased slightly during the same time period.
Performance of
various states under DLHS-4
In terms of prevalence of
'moderate wasting' among 18 states and 3 UTs, Maharashtra (34.1%)
performs the worst and Nagaland (10.8%) performs the best. Except for
Andhra Pradesh, Arunachal Pradesh, Kerala, Nagaland and Sikkim, the
prevalence of 'moderate wasting' is higher in rural areas as compared
to urban areas. The rural-urban divide is maximum in Andaman and
Nicobar Islands.
The percentage of 'severe
wasting' is highest in Maharashtra (20.0%) and lowest in Nagaland
(5.2%). The prevalence of 'severe wasting' is higher in rural areas
as compared to urban areas, except for Himachal Pradesh, Kerala,
Nagaland and Sikkim. The rural-urban divide is maximum in Puducherry.
In terms of prevalence of
'moderate stunting', Meghalaya (41.7%) performs the worst and Goa
(18.7%) performs the best. Except for Goa, Himachal Pradesh,
Karnataka, Maharashtra, Puducherry and Telengana, the prevalence of
'moderate stunting' is higher in rural areas as compared to urban
areas. The rural-urban divide is maximum in Tripura.
The percentage of 'severe
stunting' is highest in Meghalaya (23.1%) and lowest in Goa (8.4%).
The prevalence of 'severe stunting' is higher in rural areas as
compared to urban areas, except for Andaman and Nicobar Islands,
Arunachal Pradesh, Goa, Haryana, Karnataka, Punjab, Sikkim and
Telengana. The rural-urban divide is maximum in Meghalaya.
In terms of prevalence of
'moderate underweight', Maharashtra (38.7%) performs the worst and
Kerala (20.9%) performs the best. Except for Karnataka, the
prevalence of 'moderate underweight' is higher in rural areas as
compared to urban areas. The rural-urban divide is maximum in Andaman
and Nicobar Islands.
The percentage of 'severe
underweight' is highest in West Bengal (15.4%) and lowest in Sikkim
(5.4%). The prevalence of 'severe underweight' is higher in rural
areas as compared to urban areas, except for Goa. The rural-urban
divide is maximum in Andaman and Nicobar Islands.
(No comparable data between NFHS-3 and DLHS-4 is available for A & N Islands, Chandigarh, Pudducherry and Telengana.)
What is there to
learn from Maharashtra on stunting?
Although nothing definite
can be said about reduction of malnutrition among children under 5
years between NFHS-3 and DLHS-4, there are certain important lessons
that can be learnt from Maharashtra.
A commentary published in
Economic and Political Weekly entitled: Progress in Reducing Child
Under-Nutrition: Evidence from Maharashtra by Sunny Jose and KS
Hari (2015) informs that nutritional interventions through the
Rajmata Jijau Mother-Child Health and Nutrition Mission, which began
in 2005, played a crucial role in reducing prevalence of stunting
among children below 2 years in Maharashtra. However, the decline in
malnutrition levels was confined largely to children belonging to two
or three age groups and the interventions helped reduce stunting the
most, but not wasting and underweight.
Jose and Hari have
observed that in the 6 years span (between NFHS-3 and CNS), stunting
among children below 2 years belonging to Scheduled Tribe (ST)
households declined by 25.3 percentage point from 52.9% in 2005-06 to
27.6% in 2012. However, stunting among children below 2 years from
Scheduled Caste (SC) and Other Backward Caste (OBC) households
declined much lesser than that among ST children.
A similar trend could be
observed in the case of underweight. However, in the case of wasting,
the decline is highest among children from SC households as compared
to the children from other 2 communities i.e. ST and OBC.
Girls have performed
better than boys (both sexes below 2 years) in terms of decline in
stunting, wasting and underweight between 2005-06 and 2012.
Jose and Hari inform that
the nutrition & health mission of Maharashtra launched a
dedicated programme to bring down child undernutrition through a menu
of interconnected measures, ranging from monitoring the nutritional
status of pregnant women to ICYF practices and vaccination, among
others.
In a note given in the
Global Nutrition Report 2014 of IFPRI, Prof. Lawrence Haddad
from IDS Sussex has explained the following key factors that helped
in reducing stunting among children under 2 years in Maharashtra:
* Economic growth and
poverty reduction helped in reducing malnutrition in the state.
Maharashtra has a modest track record in transparency, anti-corruption
efforts, and service delivery.
* Spending on nutrition
doubled from a low level, and vacancies among frontline workers in
the Integrated Child Development Services (ICDS) scheme dropped
dramatically
* The decline in stunting
was broad based and was greater—absolutely and proportionately—for
the least wealthy, the least literate, and those with the worst
access to improved water sources.
* The determinants that
improved the most between the NFHS-3 and CNS surveys were the age of
mother at first birth, maternal underweight, maternal literacy,
coverage of antenatal visits, delivery in the presence of birth
attendants, child feeding practices, and access to ICDS.
* Underlying determinants
were reasonably supportive: women’s decision-making status inside
and outside the home was high; the Public Distribution System (PDS),
which distributes subsidized food to poor people, suffered from
slightly less leakage than the all-India average; and female
education rates were high and rising.
* The state’s Nutrition
Mission was seen as a signal of high-level political commitment to
nutrition improvements and helped coordinate different sectors at
village and policy levels.
Caveat: Data
comparability and Methodology
A caution for readers
about DLHS-4 is that the data provided by it on stunting, wasting and
underweight does not take into account data of those (big) states
where malnutrition levels have traditionally been higher (such as
Bihar, Madhya Pradesh etc.), as shown by the last 3 National Family
Health Surveys (NFHS).
The DLHS-4 data is based on a much smaller survey (in terms of sample size) as compared to DLHS-3. The former has covered the better performing states but left out 9 such states where most malnourished children of India are concentrated. However, as pointed above, DLHS-3 did not provide information on the 3 measures of nutrition.
Both the DLHS and NFHS
surveys have been done in India under the auspices of Ministry of
Health and Family Welfare where IIPS played a key role.
Since the state-wise
malnutrition figures based on the Rapid Survey on Children (RSOC),
conducted by the Ministry of Women and Child Development in
partnership with UNICEF India, is not yet available in the public
domain, the publication of the DLHS-4 data providing updated
nutritional trends in a few select states is definitely a welcome
step. (Please see the alert: Child Malnutrition declining, though not fast enough).
However, media reports suggest that publication of NFHS-4 would have
done justice to the absence of comprehensive and comparable data
since 2005-06.
References
District Level Household
and Facility Survey-4 (DLHS-4) in 2012-13,
Comprehensive Nutrition
Survey (CNS) in Maharashtra
National Family Health
Survey-3 (NFHS-3) in 2005-06,
District Level Household
and Facility Survey-3 (DLHS-3) in 2012-13,
Child Malnutrition
declining, though not fast enough
Progress in Reducing
Child Under-Nutrition: Evidence from Maharashtra -Sunny Jose and KS
Hari, Economic and Political Weekly, Vol-L, No. 3, January 17, 2015,
Panel 2.3: How
did Maharashtra cut child stunting? by
Prof. Lawrence Haddad (page no. 13) in Global Nutrition Report
2014: Actions and Accountability to Accelerate the World's Progress
on Nutrition, IFPRI,
http://www.im4change.org/siteadmin/tinymce//uploaded/Global%20Nutrition%20Report%202014.pdf
Beyond the Great Indian
Nutrition Debate-Sonalde Desai and Amit Thorat, Economic and
Political Weekly, Vol-XLVIII, No. 45-46, November 16, 2013,
The fuzzy numbers on
child malnutrition, Livemint, 14 October, 2014,
Fewer kids under 2 years
of age malnourished in Maharashtra, but tribal pockets still lag
-Madhavi Rajadhyaksha, The Times of India, 16 November, 2013,
http://timesofindia.indiatimes.com/india/Fewer-kids-under-2-years-of-age-malnourished-in-Maharashtra-but-tribal-pockets-still-lag/articleshow/25857173.cms
Image Courtesy: Shambhu Ghatak