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India’s Malnutrition Enigmas:
Why They Must Not Be a Distraction
from Action
Lawrence Haddad
Institute of Development Stud...
India has one
of the highest
child stunting
rates in the
world

UNICEF
2013
Lawrence Haddad, IDS Sussex
India is home to about 40% of
global stunting

Lawrence Haddad, IDS Sussex
Trends in child undernutrition in India are
not inspiring given rapid economic growth

Lawrence Haddad, IDS Sussex
Outline
• Indian stunting rates are higher than Africa’s and
have a weak connection to economic growth
• 10 possible cause...
Lawrence Haddad, IDS Sussex
Incredible !ndia
Paradox of economic growth and child growth
• Only China has grown faster than India over
the past 15 yea...
Economic growth
• The ability of growth to reduce poverty has
held firm in the past 15 years
– Datt and Ravallion 2010 pub...
Economic growth in India: not working for nutrition
153

112.5
100
1993/4

Real GDP/Cap

2004/5
Percent infants not underw...
1. Do the international nutrition standards
apply to India?

Does India Really Suffer from Worse Child Malnutrition Than S...
Panagariya on international
standards for
height and weight for age
“The central problem with the current methodology
is t...
Panagariya’s
comparisons are not
tight enough
What does a tight comparison show?
WHO Multicountry study of growth trajectories in
comparable communities, children 0-2 y...
Can these improvements happen in one
generation?
A recent review of the human and animal evidence (Martorell
and Zongrone ...
2. What about birth order?

There is no
difference in
wasting and
stunting between
Africa and India
on First-borns

The Pu...
3. What about Gender of Child?

The Puzzle of High Child Malnutrition in South Asia
Seema Jayachandran and Rohini Pande, J...
Gender influences post-natal allocation of
resources, but pre-natal allocation of resources not
correlated to eventual sex...
4. What about open defecation?
Direct Effects
and
Externality
Effects

How much international variation in child height ca...
5. Disconnects between Indian agriculture and
nutrition of infants?
ZHA=f(AgGrowth + other variables… )
Not significant
ZH...
Proportion of under
5’s who are
underweight

6. Women’s status?

Source: Smith et. al. 2003, IFPRI Research Report IDS Sus...
Recent study on Women’s Autonomy
Arulampalan, Bhaskar, Srivastava June 2012

• Construct a latent variable of “Women’s Aut...
7. Declining calorie intake?
Deaton and Dreze (2009)
–
–
–
–

changes in relative prices
demographic patterns
food habits
...
8. Lack of complementary feeding options
for infants?
Veena Rao (2012)
– the market for foods that are complements to brea...
9. Relatively Ineffective Nutrition Interventions?
• Coverage of essential nutrition interventions is low ~ 30-40%
(P. Men...
10. Weak Nutrition Governance?
• The biggest puzzle of the 10: why doesn’t the GoI make
it a higher priority?
• Government...
India scores low on the commitment to hunger
reduction and to nutrition improvement

The Hunger And Nutrition Commitment I...
Research gaps
• How to improve service delivery (coverage and quality)?
• How to improve accountability and reduce corrupt...
A Maharashtra Miracle?
• Stunting rates for children under 2 declined from 39% to 23%
between 2005 and 2012 (3 times the r...
Conclusions
• 10 enigmas and puzzles—some can be discounted,
most not
• We don’t know much about their relative importance...
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India’s Malnutrition Enigmas: Why They Must Not Be a Distraction from Action

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In this Dudley Seers Memorial Lecture, IDS Director, Lawrence Haddad, examined the persistent challenge of malnutrition in India and assessed what more can be done to effectively tackle the challenge. The lecture was chaired by Prakash Shetty, Chief Executive of Leveraging Agriculture for Nutrition in South Asia.

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India’s Malnutrition Enigmas: Why They Must Not Be a Distraction from Action

  1. 1. India’s Malnutrition Enigmas: Why They Must Not Be a Distraction from Action Lawrence Haddad Institute of Development Studies Sussex, UK Lawrence Haddad, IDS Sussex
  2. 2. India has one of the highest child stunting rates in the world UNICEF 2013 Lawrence Haddad, IDS Sussex
  3. 3. India is home to about 40% of global stunting Lawrence Haddad, IDS Sussex
  4. 4. Trends in child undernutrition in India are not inspiring given rapid economic growth Lawrence Haddad, IDS Sussex
  5. 5. Outline • Indian stunting rates are higher than Africa’s and have a weak connection to economic growth • 10 possible causes? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. International growth standards do not apply to India Son preference First child preference High levels of open defecation Poor status of women Disconnects between agriculture and nutrition Declining calorie consumption Undersupply of complementary infant feeding products Nutrition interventions are not effective Weak nutrition governance Lawrence Haddad, IDS Sussex
  6. 6. Lawrence Haddad, IDS Sussex
  7. 7. Incredible !ndia Paradox of economic growth and child growth • Only China has grown faster than India over the past 15 years (IMF) • At current rates of progress, India will meet its Millennium Development Goals on nutrition in 2043 – China has already met them – Brazil likely to meet them by target date of 2015 (Victora 2011) Lawrence Haddad, IDS Sussex
  8. 8. Economic growth • The ability of growth to reduce poverty has held firm in the past 15 years – Datt and Ravallion 2010 published in EPW and WBER • But no connection between economic growth and child nutrition – Subramanyam et. al. 2011 using 3 waves of NFHS published in Public Library of Science - Medicine Lawrence Haddad, IDS Sussex
  9. 9. Economic growth in India: not working for nutrition 153 112.5 100 1993/4 Real GDP/Cap 2004/5 Percent infants not underweight Source: growth data, Table 1, Topalova 2008; nutrition data, NFHS Lawrence Haddad, IDS Sussex
  10. 10. 1. Do the international nutrition standards apply to India? Does India Really Suffer from Worse Child Malnutrition Than Sub-Saharan Africa? Arvind Panagariya. May 4, 2013 vol xlviiI no 98 18 EPW Economic & Political Weekly Lawrence Haddad, IDS Sussex
  11. 11. Panagariya on international standards for height and weight for age “The central problem with the current methodology is the use of common height and weight standards around the world to determine malnourishment, regardless of differences that may arise from genetic, environmental, cultural and geographical factors.” Lawrence Haddad, IDS Sussex
  12. 12. Panagariya’s comparisons are not tight enough
  13. 13. What does a tight comparison show? WHO Multicountry study of growth trajectories in comparable communities, children 0-2 years Differences between countries are small and statistically insignificant Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP. Acta Pædiatrica, 2006; Lawrence Haddad, IDS Sussex Suppl 450: 56!/65
  14. 14. Can these improvements happen in one generation? A recent review of the human and animal evidence (Martorell and Zongrone 2012) concludes: “nearly normal lengths can be achieved in children born to mothers who were malnourished in childhood when profound improvements in health, nutrition and the environment take place before conception” Such profound changes might be beyond public policy, but this has nothing to do with standards. Lawrence Haddad, IDS Sussex
  15. 15. 2. What about birth order? There is no difference in wasting and stunting between Africa and India on First-borns The Puzzle of High Child Malnutrition in South Asia Seema Jayachandran and Rohini Pande, July 2012 Lawrence Haddad, IDS Sussex
  16. 16. 3. What about Gender of Child? The Puzzle of High Child Malnutrition in South Asia Seema Jayachandran and Rohini Pande, July 2012 Lawrence Haddad, IDS Sussex
  17. 17. Gender influences post-natal allocation of resources, but pre-natal allocation of resources not correlated to eventual sex outcome (not shown) The Puzzle of High Child Malnutrition in South Asia Seema Jayachandran and Rohini Pande, July 2012 Lawrence Haddad, IDS Sussex
  18. 18. 4. What about open defecation? Direct Effects and Externality Effects How much international variation in child height can sanitation explain? Dean Spears. Lawrence Haddad, IDS Sussex December 12, 2012
  19. 19. 5. Disconnects between Indian agriculture and nutrition of infants? ZHA=f(AgGrowth + other variables… ) Not significant ZHA=f(AgGrowth +AgGrowth*Indian States+ other variables… ) Significant Not significant “This could perhaps suggest that agricultural growth typically does reduce stunting prevalence, but has not done so in India. “ Developmental Drivers of Nutritional Change: A Cross-Country Analysis. DEREK D. HEADEY. World Development Vol. 42, pp. 76–88, 2013 Lawrence Haddad, IDS Sussex
  20. 20. Proportion of under 5’s who are underweight 6. Women’s status? Source: Smith et. al. 2003, IFPRI Research Report IDS Sussex 131 Lawrence Haddad,
  21. 21. Recent study on Women’s Autonomy Arulampalan, Bhaskar, Srivastava June 2012 • Construct a latent variable of “Women’s Autonomy” – Autonomy in economic, physical, decision making and emotional areas • Use NFHS3 2005/6 data • Stunting, Wasting are dependent variables • Find: – Maternal autonomy reduces stunting and wasting only for children <3 years, but increases it for children over 3 years (thought to be lack of adequate child care as women work) W. Arulampalam, Dept Econ, U. Warwick. Lawrence Haddad, IDS Sussex
  22. 22. 7. Declining calorie intake? Deaton and Dreze (2009) – – – – changes in relative prices demographic patterns food habits calorie requirements Smith (2013) – Household Food Consumption Surveys collected by the National Statistical Office do not capture increasing shares of foods purchased outside the home! Lawrence Haddad, IDS Sussex
  23. 23. 8. Lack of complementary feeding options for infants? Veena Rao (2012) – the market for foods that are complements to breast milk for children in the 7-24 month age range is inhibited through the 1992 Indian Infant Milk Substitutes, Feeding Bottles and Infant Foods Act – “the prohibitions that apply to advertising and marketing of breastmilk substitutes and infant foods below the age of 6 months also apply to the complementary and weaning foods so essential for proper nutrition and health of children older than 6 months” Lawrence Haddad, IDS Sussex
  24. 24. 9. Relatively Ineffective Nutrition Interventions? • Coverage of essential nutrition interventions is low ~ 30-40% (P. Menon 2009, IDS Bulletin) • ICDS: new evidence to show positive impacts, but could be much more efficient (E. Kandpal 2011, World Development) • MMS: good impacts on nutrition (Singh 2008), but wrong age group (4-5 year olds) for early undernutrition Source: Haddad, L. Why India Needs and National Nutrition Strategy 2011. British Medical Journal. Lawrence Haddad, IDS Sussex
  25. 25. 10. Weak Nutrition Governance? • The biggest puzzle of the 10: why doesn’t the GoI make it a higher priority? • Government and civil society not well supported – Need stronger accountability mechanisms: macro and micro to radicalise civil society and shift norms – Need slimmer & more frequent surveys to track nutrition outcomes – data are 10 years old!!! – Need a revamp of how nutrition is taught within higher education: focus on breadth and leadership • Need a focal point at senior level within Federal GoI. – The PM’s National Nutrition Council took 1000 days to have its first meeting! Lawrence Haddad, IDS Sussex
  26. 26. India scores low on the commitment to hunger reduction and to nutrition improvement The Hunger And Nutrition Commitment Index (HANCI 2012): Measuring the Political Commitment to Reduce Hunger and Undernutrition in Developing Countries. April 2013. Dolf te Lintelo, Lawrence Haddad, Rajith Lakshman Karine Gatellier, Institute of Development Haddad, IDS Sussex Lawrence Studies
  27. 27. Research gaps • How to improve service delivery (coverage and quality)? • How to improve accountability and reduce corruption? – Which institutions are important for horizontal and vertical coherence? – Which mechanisms work (macro and micro)? – Data (will real time data on nutrition outcomes make a difference?) • Understand if/why is agriculture is seemingly disconnected • With new NFHS data, try to compare relative impacts of girl preference, open defecation, women’s status, governance variables (get away from single issue explanations) • Maybe NFHS4 will unveil the riddle wrapped in an enigma and show strong declines in stunting as for Mahrashtra! Lawrence Haddad, IDS Sussex
  28. 28. A Maharashtra Miracle? • Stunting rates for children under 2 declined from 39% to 23% between 2005 and 2012 (3 times the rate for all India between 1998 and 2005!) • Causes? Modest improvements across the Board – – – – – Poverty Water and Sanitation Frontline health worker employment rates Health service utilisation State Nutrition Mission • Conclusions? – Maharashtra is a relatively wealthy state, relatively well governed. If stunting can’t decrease here it can’t decrease anywhere in India – The changes in determinants are modest, but across the Board. They are not so exceptional that this could not happen elsewhere – We think the Nutrition Mission really mattered
  29. 29. Conclusions • 10 enigmas and puzzles—some can be discounted, most not • We don’t know much about their relative importance in different contexts • There are some for which we have less data and analysis related to nutrition (e.g. discrimination based on caste and class) • Perfect storm of disabling factors (or is it?) • Biggest puzzle is why the GoI isn’t more concerned • Must not let engimas be distractions from action Lawrence Haddad, IDS Sussex

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