India must strengthen ICDS, midday meals to tackle paradox of falling nutrition outcomes amid rising GDP

The COVID-19 pandemic has shifted policy focus to health in an unprecedented manner. Expenditures on health systems and developing targeted health care policies are beginning to get their due in policy discussions as well, and with good reason.

There is a broad consensus among multilateral institutions (e.g. the World Bank) as well as researchers and activists, that the development of human capital (especially via investment in health) is as critical for a country’s growth as financial or physical capital. Intuitively, a healthy population can enhance the skill and productivity of a nation.

However, it is pertinent to ask how we measure health. Measuring health at one point of time can be challenging, although researchers usually measure quantitative changes in health in terms of the height and weight of an individual (i.e. physical development). On the basis of these components,  the various measures are summarised as stunting, wasting and underweight. Stunting (height for age) measures the cumulative deprivation from birth, wasting (weight for height) is a measure of short-term nutritional deficiency and underweight (weight for age) measures both stunting as well as wasting. A recent study by the World Bank finds that stunting may actually have a huge economic cost. Their findings suggest that stunting in early childhood leads to developmental deficiency and thus lower productivity.

The data on stunting, wasting and underweight are usually collected from Demographic and Health Surveys, a collection of nearly 400 surveys across 90 countries. In India, these data are collected under the aegis of the National Family and Health Survey (NFHS), which is a nationally representative dataset covering health, fertility, and other characteristics in rural and urban India. The graph below shows the proportion of children who are stunted in various rounds of NFHS, separately for rural and urban India. Overall, it would appear that child stunting is on the decline in both urban and rural areas over the past two decades. There have been many associations drawn between protective factors for a child’s nutritional status, including the mother’s decision-making autonomy, household wealth, and others.

Source: StatCompiler, DHS

Most recent data from the NFHS-5 (2018-19) has been released for phase I for 22 states. The report shows that for most of the states the stunting rates have actually increased. According to the report, 16 states out of 22 states have recorded an increase in the wasting and underweight rates which represents long-term deprivation. Overall, as the below figure shows, there is a 1 percent increase in stunting on average across the states for which data was released. There are similar, marginal increases reported if we consider all-India average measures for underweight, wasting, and severe wasting.


This is particularly concerning, as the world (including India) has, in recent years, developed a wide set of strategies to reduce stunting and adverse child nutritional outcomes in a major way.  The puzzle is the falling health standards alongside improvements in living standards brought about by an increase in GDP growth rates. This showcases the deep division within the country in terms of living standards. As mentioned before, some of the major determinants of child undernutrition are mother’s nutrition and sanitation. All these variables are closely linked to stunting, wasting or underweight. It might be important to have a close look at these variables in the long run instead of solely focusing on the ways to increase food availability.

Another fundamental reason for India’s falling nutrition standards is the excessive focus on energy sufficient diet instead of a nutritious diet. This can have deleterious consequences for the development of human capital in India. In light of the COVID-19 pandemic, and a prolonged lockdown that has affected food security and consumption patterns in a major way, there are likely to be severe longer-term consequences. A report finds that for example, in Madhya Pradesh, more than 80 percent of the women workers reported a decline in food consumption due to the lockdown.

Even prior to the pandemic, data from the NSSO indicated that consumption expenditure had declined by 3.7 percent between 2011-12 and 2017-18. one of the biggest worries is of course the government’s response. The percentage of  GDP spent by India on health has been low (1.2 percent) compared to countries like China (2.7 percent), and the average in Latin America and Caribbean (3.8 percent) and even the world average (6.5 percent).

However, it would appear that the stellar performance of the Indian economy in the last decade (barring the past year) and the reduction in the poverty rate did not have much of an impact on health conditions in the country. Among the South Asian neighbours, India’s performance in terms of health has been dismal. India is usually compared with China in terms of GDP growth rate, but parameters such as the proportion of children who are underweight or under 5 mortality rate cast a gloomy picture for India.When we look at the international data, we find that the proportion of underweight or malnourished children in India is close to the Asian average but more than various poorer countries in sub-Saharan Africa.

Comparison between India and China on selected indicators

India China
Infant Mortality Rate 47 13
Under 5 Mortality Rate 61 15
Underweight 43 4
Stunted 48 10
Public expenditure on health as a proportion of total health expenditure(%) 1.2 2.7

Source:Dreze and Sen (2013)

This low spending on health has made our country more vulnerable to external shocks arising from poor health. In spite of the various efforts of the government, there have been setbacks on the nutritional front as can be seen from the NFHS-5. Even as discussions on capitalising on India’s demographic dividend continue, the importance of investing in child health cannot be underscored enough. This can be done by strengthening the already existing delivery mechanisms such as the Integrated Child Development Services (ICDS) and Mid-Day Meal schemes. Both these programmes have an immense capacity to make an impact on nutrition and child health.

In recent years, however, there has been a fall in the public expenditure as a percentage of GDP on both these schemes. Besides, the pandemic poses further challenges, especially for vulnerable groups and populations that are hard to reach. The biggest challenge today is to consolidate existing programmes of work, devoting more financial resources, and improving accountability among the public health workers. In a democratic set up such as India, we have all the more reasons to implement and improve the quality of life especially the children who are the future citizens of the country.

Chakraborty is a PhD Scholar in Economics at North Bengal University and Independent Researcher at Monk Prayogshala, Mumbai. Tagat is with the Department of Economics at Monk Prayogshala, Mumbai.

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