NFHS 4

Assessing Manipur’s Healthcare Challenges Amidst the Ongoing Crisis

It is crucial to understand Manipur’s culture and history to get a complete picture of their healthcare system and the various stakeholders involved in its development.

This is the first part of a two-part explainer on the need to assess the healthcare costs and impact of the ongoing Manipur conflict on its state-population. The Centre for New Economics Studies’ InfoSphere team, with the help of its field team, has written this piece. The piece also says that a paucity of local data remains a challenge. The conflict situations exacerbate these challenges, making any data analytical exercise a difficult process. You can access the InfoSphere edition here.

Manipur occupies 22,327 square kilometres of area, with a population of 28,55,794 people, as per the 2011 Census. The state’s healthcare system is backed by the Regional Institute of Medical Sciences, a state hospital, seven district hospitals, one sub-district hospital, 16 community health centres, 80 primary health centres, 413 sub-centres and 33 private hospitals/clinics.

The state also has a fairly decent sex ratio of 987 girls born for every 1,000 boys. The ratio declines to 957 girls for every 1,000 boys for ages below six.

In the 2023-24 budget, the state increased its allocation by 10%, as compared to the previous year, to ramp up health facilities in the state.

However, it is crucial to understand Manipur’s culture and history to get a complete picture of their healthcare system and the various stakeholders involved in its development.

Evolution of healthcare in Manipur – A comparison between NFHS-4 and NFHS-5

Manipur’s healthcare system has gone through several phases of development. In the early years, healthcare was primarily limited to traditional practices and local remedies. However, with the advent of modern medicine, the state saw the establishment of government-run healthcare centres and hospitals.

The introduction of immunisation programmes and family planning initiatives further enhanced healthcare services in the state.

However, Manipur still faces plenty of healthcare issues which add to the socio-economic difficulties faced by its residents. The poor condition of the healthcare system affects some communities more than the others. These include women, children, senior citizens, and people with different ailments. Therefore, it is paramount to look at the statistics when analysing the evolution of the healthcare system in any region.

Public expenditure on healthcare

According to the National Family Health Survey (NFHS)-4, 2015-16, Manipur’s per capita public health expenditure stands at Rs 1,364. This is almost three times that of Uttar Pradesh and double the expenditure of Punjab and the national average of India.

Despite such a high expenditure, the percentage of households with any usual member covered by a health scheme or health insurance is only 3.6%, which is significantly lower than the national average of 28.7%. The coverage is even more limited in the hilly districts, with Senapati, Ukhrul, and Chandel having coverage rates of only 0.6%, 1%, and 1.1%, respectively.

This indicates that a majority of Manipur’s population pays for medical expenses out of their own pockets, leading to financial burden and challenges in accessing quality healthcare.

Source: Team InfoSphere

Source: Team InfoSphere

Source: Infosphere

Health indicators

According to NFHS-4, Manipur’s infant mortality rate (IMR) stands at 22, which is lower than the national average of 41. The figures indicate a better infant health outcome in the state compared to the country as a whole.

Moreover, Manipur has the highest prevalence of HIV among the adult population in the country, with a rate of 1.15%. This is four times the all-India average and indicates a significant public health challenge in the state.

Further, over half of the deliveries in private health facilities in urban Manipur are performed by a caesarean section, while the percentage is lower (30%) in public health facilities.

Also read: Medicine Shortages, Uncertain Educational Futures: Manipur Is Reeling Under Many Impacts of Violence

Health manpower and infrastructure

According to NFHS-4 and District Level Household and Facility Survey 4, Manipur has one of the highest number of nurses per capita in the northeast, after Kerala. This indicates a relatively better availability of nursing staff for healthcare services.

Source: Infosphere

Insights from NFHS-5

Of the total surveyed households in the NFHS, around 72% had access to basic drinking water services. However, only 20.5% of the households had water piped into their dwelling, yard or plot. Around 62% of households in Manipur had basic sanitation service (improved facilities not shared among households) while 32% had limited sanitation services (improved sanitation facilities shared by two or more households).

As few as 0.5% of households in the state had no sanitation facility and used open spaces or fields.

According to NFHS-5, the total fertility rate (TFR) in Manipur was 2.17 children per woman; it was 2.38 in rural areas and 1.84 in urban areas. This was a decline from the TFR of 2.61 children per woman recorded in NFHS-4. Knowledge of contraceptive methods was almost universal in the state.

Among married women, the use of contraception rose steeply from 23.6% in NFHS-4 to 61.3% in NFHS-5. However, only 18.2% of the women used modern methods of contraception such as sterilisation, pill, intrauterine devices, injectables, or condoms.

In NHFS-5, the infant mortality rate (IMR) was 25, (meaning 25 deaths before the age of one per 1,000 live births). In NFHS-4, IMR was 21.7. The under-five mortality rate during the period remained nearly the same at around 30, (meaning 30 deaths before the age of five per 1,000 live births).

Medical teams have been constituted in each of the affected districts in Manipur to provide overall healthcare services to the victims at the designated relief camps. Regular health check-ups are conducted at all the designated relief camps across the state, and those who are seriously ill are promptly transferred to the nearest hospitals by ambulance services.

Additionally, healthcare services for women and children, including lactating mothers and infants, are provided under the maternal health and child health programmes.

Source: Infosphere

The report notes that 68.8% of children in Manipur, aged 12-23 months, received all basic vaccinations against tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. Only around 2.8% of children (aged 12-23 months) in the state had not received any vaccinations.

Nearly 42% of children (aged between six and 59 months) in the state suffered from anaemia – a substantial increase from the NFHS-4 estimate of 22.8%.

The report notes that 63.8% of women used cloth, 80.9% used sanitary napkins, 3.9% used locally prepared napkins, 0.7% used menstrual cups and 0.1% used tampons. Thirty-seven per cent of women (aged between 18 to 49 years) in the state reported having experienced either physical or sexual violence and 4% reported having experienced both. However, only 3% of women who had experienced such violence sought help.

It is important to put some of these numbers in perspective.

A district-level insight from the NFHS surveys and other sources may help provide greater depth to our team’s analysis, however, access to these figures and granular details remains a challenge. Our team also faced these challenges. If we could overcome these challenges, through better (high frequency) data, it would have been helpful for both context and analysis.

Assessing the socio-political and economic situation in a conflict-affected area leads to an understanding of the demographic’s public health scenario, too. In the case of Manipur, too, many issues highlighted in this piece have been exacerbated by the conflict – and its impact on the youth, women, children and elderly, who have all been badly affected by the ethnic violence.

The second part of this series shall reflect more on the role of other factors responsible for the healthcare implications of the ongoing conflict.

Deepanshu Mohan is Professor of Economics and Director, Centre for New Economics Studies (CNES), Jindal School of Liberal Arts and Humanities, O.P. Jindal Global University. Amisha Singh, Aditi Desai, Shalaka Adhikari, Samragnee Chakraborty, Shilpa Santhosh and Vasudevan are Research Analysts with CNES and members of the InfoSphere Team. The authors thank Dr Samrat Sinha for his constant guidance, help and support. The previous field studies from the team’s work on Manipur can be accessed here, here, here, and here.

Hindu Men Have Highest Number of Multiple Sexual Partners, Sikhs Second: NFHS-5 Data

Comparison of NFHS-4 and 5 data reveals that the trend of having multiple partners is on the rise among men.

New Delhi: Among men of all religions, Hindus rank at the top when it comes to having multiple sexual partners in India. They are followed by Sikhs, Christians, Buddhists, Muslims and Jains, in descending order.

The Wire‘s analysis of National Family Health Survey-5 (NFHS-5) data reveals that Hindu men, who chose to have partners outside of marriage or were in live-in relationships, had 2.2 ‘mean number of sexual partners in their lifetime’.

Sikhs and Christians had 1.9, while Buddhists and Muslims had 1.7, on an average. Jains had the lowest mean number of 1.1.

Those with multiple sex partners and who have unprotected intercourse are at the highest risk of acquiring an infection of the Human Immunodeficiency Virus (HIV) or of getting affected with other sexually transmitted diseases – something that the Survey also states.

The Survey was conducted by Mumbai-based International Institute of Population Studies for the Union government in 2019-20. As many as 1.01 lakh men out of a total of 8.25 lakh respondents across 29 states and seven Union Territories took part in the Survey.

The findings of NFHS-5 are a departure from that of NFHS-4 (conducted between 2015-16). The NFHS-4 had revealed that Christian men (2.4) had the highest mean number of sexual partners followed by Buddhists and Muslims (2.1) and Hindus (1.9).

Overall also, the tendency among men to have multiple partners has gone up from 1.9 in the NFHS-4 period to 2.1 in the NFHS-5 period.

The NFHS-5 also tried to find what percentage of men had intercourse with someone who was neither their wife nor somebody they lived with, in the 12 months preceding the survey. As many as 7.8% of all the participating Buddhist men said yes to this question. They were followed by Sikhs (6.0%), Hindus (4.0%), Christians (3.8%) and Muslims (2.6%). On a whole, the Survey found that 4% of men in India had sexual activity with women who were neither their wives or someone they lived with in the 12 months preceding the survey.

It should be noted here that this question was different from the one with which men were asked about the mean number of sexual partners they have had in their lifetime.

The biggest concern regarding those having multiple sexual partners is that of unprotected sex. Muslim men, who reported having intercourse with multiple partners in the 12 months before the NFHS-5 was conducted, recorded the highest use of condoms – 64.1%. They were followed by Hindus (60.2%), Buddhists (58.2%) and Christians (44.7%).

As far as wealth quintiles and the practice of multiple partners was concerned, there was not much variety. As many as 2.0-2.5% men among ‘lowest’, second, middle and fourth quintiles revealed that they engaged in this practice. Among categories, it was found to be the highest among men belonging to Scheduled Tribes (2.4%) followed by Other Backward Classes (2.2%) and Scheduled Castes (2.1%). Less than 2% men belonging to ‘others’ category in the castes figured in this list, according to NFHS-5.

Among states, Meghalaya ranks at the top followed by Sikkim and Andhra Pradesh.

Men who had multiple sex partners did not necessarily recognise them as spouses. Times of India had reported earlier on the practice of polygny – having more than one wife – having been found to be highest among Muslims (1.9%) but, as The Wire analysis found, Hindu men had the maximum number of sexual partners in their lifetime. Polygny among Hindu men was reported to the tune of 1.3%.

Muslims can legally have more than one wife in India, as per the Special Marriage Act. However, the Hindu Marriage Act prohibits the same for Hindus and others.

A research brief on NFHS-5 has, however, indicated that in contrast with the rising trend of having multiple sexual partners among men, polygny was on the decline, if one compared the NFHS-4 and NFHS-5 numbers. “With the exception of nine states (Chandigarh, Delhi, Punjab, Rajasthan, Jharkhand, Meghalaya, Tripura, Maharashtra, and Puducherry) the rate of polygyny decreased in almost every state from 2015-16 to 2019-21,” the authors noted in the brief.

The highest prevalence of polygynous marriages though was found in Meghalaya (6.1%) and Mizoram (4.1%).

The only parameter on which polygynous marriages were in line with men having multiple sexual partners was the area of residence. On both fronts men living in rural areas reported more instances than their counterparts in urban areas.

What Impacts Child Malnutrition in India and Why We Need to Be Aware of These Factors

India loses 4% of its GDP annually due to malnourishment and hence, the objective of economic development cannot be met without addressing the issue of child malnutrition.

India has achieved remarkable levels of economic growth, and yet, despite all the progress, it continues to host the highest number of malnourished children in the world.

Child malnutrition is classified as ‘undernutrition’ (inadequate consumption of calories) and ‘overnutrition’ (excess consumption of calories). Of these, undernutrition leads to low height-for-age or stunting. It is known as the most sinister form of child malnutrition because unlike the loss of weight, height cannot be readily gained back. Hence, it is an indicator of chronic childhood malnutrition, which can lead to irreversible mental and physical damage that is even transmitted to the next generation.

To understand the gravity of this problem, we note one-third of stunted children, globally, are Indian. The implication is that India loses 4% of its GDP (gross domestic product) annually, and hence the objective of economic development cannot be met without addressing the issue of child malnutrition.

The research suggests that tackling child malnutrition requires a multi-faceted approach, for example, improving the quantity and the quality of dietary intake, levels of sanitation, maternal health and education, access to social safety net programmes etc. Based on these important findings, the government had established programmes like Integrated Child Development Services (ICDS) that provides comprehensive health and nutrition services to children under six and pregnant and lactating mothers, mid-day meals to school-going children, Swachh Bharat Mission that is aimed to eliminate open defecation, among others programmes.

And yet, despite these measures, the NFHS-5 data revealed that child malnutrition in India is worsening (see figure 1). Thirteen out of the 22 states have witnessed a reversal in stunting outcomes. Experts have commented that this is due to a decline in budgetary allocation towards children’s health and nutrition schemes (here), while others suggest that it could be due to the slowdown in economic growth (here).

Also read: An Overlooked Strategy to Remedy Malnutrition

Given the rising burden of child malnutrition and budgetary concerns, there is substantial merit in understanding the relative importance of the factors impacting child malnutrition. This can help the policymakers redirect their focus on interventions that will yield the maximum benefits to child health.

Figure 1: Percentage of stunted children below age 5 in NFHS-5 (2019-20) and NFHS-4 (2015-16)

We use data from the NFHS-4 survey for almost 90,000 children below five. Further, we use NHFS-4 variables to construct ten groups that are used to explain the child malnutrition under UNICEF’s framework: age of the child (in months; from 0-5 years), gender, occurrence of infections, medicinal intake, birth characteristics (size and weight at birth), their food intake (breastfeeding and dietary diversity), child environment (open defecation level at the village, access to benefits from welfare schemes, improved drinking water, household size), mother’s characteristics (height, BMI, education, and age at marriage), her environment (access to benefits from ICDS centres during pregnancy, health insurance) and socio-economic controls (wealth, place of residence, etc.).

Our outcome variable is height-for-age z-scores (HAZ scores), i.e. the height gap of a child from the median child with the same age and gender. HAZ score below (above) zero means that the child is worse off (better off) than the median child (here).

To estimate the relative contribution of these ten towards the HAZ scores for our analysis, we use an econometric technique called the Shapley-Owen decomposition, which is useful to calculate the marginal contribution of variables, especially when all the variables are interlinked.

Also read: How Caste Discrimination Impacts Child Development and Stunting in India

After running the decomposition on ten groups, we find that the child’s HAZ scores, child’s age is the most important followed by mother characteristics (and within this group, mother’s height), and socio-economic controls. Our results are in line with the well-established finding in the literature that stunting happens in the first 24 months, and hence it holds the maximum contribution.

In a similar vein, it is unsurprising that the next most important variable is the mother’s height as genetics always had an important role in determining heights. This leads us to recommend that additional efforts should be expended to provide adequate nutrition to children from conception till two years (i.e. the first 1,000 days of life). Next, prioritising the nutritional needs of girls among these children will help India break the pattern of inter-generational transfer of stunting, as mothers who faced stunting in childhood are shown to have under-developed uteruses, which leads to the reproduction of stunted children.

Figure 2: Relative contribution of the determinants of child malnutrition towards children’s height-for-age z-scores

While ICDS’s POSHAN Abhiyaan mentions the importance of adequate nutritional intake during the first 1,000 days of the child’s life, the programme, much like other welfare schemes for children and women, have been receiving budgetary cuts for the past few years. This issue has been raised by noted economists, and our findings also provide rigorous evidence to support the call for enhancing the budgetary allocation for programmes like ICDS which are responsible for providing requisite antenatal healthcare to the mothers and optimal quantity and quality of diets to the children.

Similarly, our analysis also echoes the recommendation of economists who have attributed the rise in child malnutrition to the slowdown in economic growth in recent years. Socio-economic controls are the third most important determinant of HAZ scores. It represents the ability of the household to access diets that are optimal in calories and nutrition, healthcare and general living conditions, all of which, jointly determines children’s health. Therefore, while the supplementary nutrition programmes should be strengthened, their impact on the child health outcomes will be most effective when India is also witnessing a faster economic growth.

Payal Seth is a consultant at Tata-Cornell Institute, Cornell University and a research scholar at Bennett University. Palakh Jain is an Associate Professor at Bennett University.

NCRB Plus NFHS-4 Data Paints a Dire Picture for Women in Odisha

Odisha contributed to 5.6% of all crime against women in 2017 – the second-worst state in the country on this front.

The National Crime Records Bureau (NCRB) recently released data for the year 2017, which underscores the fact that the rate of crimes against women in Odisha continues to be high. The state contributes to about 3% of India’s population but, with 94.5 cases of crime against women per lakh people, Odisha also contributed to 5.6% of all crime against women in 2017. It ranks as the second-worst state in the country on this front.

When you read the NCRB data together with the women’s welfare parameters in the fourth National Family Health Survey (NFHS), conducted in 2015-2016, it gets worse.

Between 2012 and 2018, the incidence of rape cases in Odisha rose from 7.2 per lakh women to 9.7 per lakh women.

In both 2016 and 2017, Odisha came first in the crime category of ‘attempt to disrobe’ and fourth in the number of dowry deaths. In the six years from 2012, 2,921 women have been killed (2.6 and 2.3 per lakh in 2012 and 2018 respectively) for dowry-related issues in the state.

In the NFHS-4 report, 35.2% of women in the state reported having faced spousal violence. Observers have noted upward trends in both the kidnapping and molestation of women since 2000. The figure of 20.5 cases of molestation per lakh women in 2012 nearly doubled to 39.1 cases per lakh women in 2016.

Violence against women is a complex issue, rooted in gender-based discrimination, gender stereotypes, social norms and access to health care. This is why we need the help of health and social workers to work against the normalisation of such violence, from individual women to the community at large.

In the UN’s ‘framework to underpin action to prevent violence against women’ the organisation published in 2017, some steps include promotion of gender equality at an early stage, empowering women, ensuring economic independence, working with boys and men, raising awareness through media, and legislative and procedural reform. But the NFHS-4 report shows how implementing these changes can be a steep task in Odisha.

The female literacy rate in the state is 67.4%. By the time girls turn 15, their school attendance drops to 63%. In fact, only 13% of women in the 15-49 years age group completed 12 or more years of schooling and 28% of women in the same category never attended school. The state government needs to do more to improve these numbers if education is to be a defence against violence against women.

Similarly, 25% of women in Odisha are not exposed to any form of media and only 19% read a newspaper at least once a week, knocking against the government’s traditional modes of creating awareness and mobilising communities.

One workaround is to empower women to become part of more decisions. A little over a fifth of Odisha’s women get married before the legal age (18 years), and a larger fraction have no say in the choice of their partner. A similar fifth of all women don’t participate in decisions about their health, while just 39% had access to a personal mobile phone.

(Fewer than half (47.4%) had access to hygienic safety products during menstruation while just about half (51%) in the 15-49 age group were anaemic.)

These figures are particularly important for their connection with the state’s ubiquitous patriarchal beliefs. About a third of the men think contraception is women’s responsibility, nearly as many think women who use contraceptives are promiscuous, and only 20% of women are allowed to go by themselves to a market, a health facility or generally outside their community’s residence.

So deep is the conditioning that 30% of all married women reported having been slapped by their husbands; 41% of men and 59% of women think this is okay. Moreover, 82% of adults of both sexes want at least one male child.

Odisha created history in the 2019 Lok Sabha elections by becoming the first state in India to elect women as a third of its political representatives. The state government also recently embarked on an ambitious ‘5T mission’, to use technology, transparency, team work, time and transformation for better governance.

In light of the NCRB and NFHS-4 data, it is imperative that these Ts have independent verticals to address women’s issues.

Sambit Dash teaches in Melaka Manipal Medical College, Manipal Academy of Higher Education (MAHE), Manipal. He comments on public policy, healthcare, science and issues of social interest. He tweets at @sambit_dash.

Why Undernutrition Persists in India’s Tribal Population

There is as yet no specific policy to address the issue and streamline the government’s efforts across sectors.

The prime minister launched the National Nutrition Mission in March this year with an objective of accelerating improvements in nutrition levels in India, for which annual targets have been set for reduction in levels of stunting, undernutrition, anaemia and low birth weight, to be achieved by year 2022.

This reduction in key undernutrition indicators would not be possible without improving the nutrition status of the most nutritionally-deprived communities – the Scheduled Tribes (STs). The recently released NFHS-4 report again brought home the widely anticipated truth that, despite improvements, the undernutrition among STs has remained poor, and much higher than that for all groups taken together. As per the report, in India, 44% of tribal children under five years of age are stunted (low height for age), 45% are underweight (low weight for age) and 27% are wasted (low weight for height).

The high levels of hunger and malnutrition among tribal people received considerable attention after reports of malnutrition deaths among children in pockets inhabited by tribal people, specifically in states like Odisha, Maharashtra and Madhya Pradesh. The policy response in such scenarios is either denial or action for immediate redressal, with little thought about the long-term strategy to alleviate the situation. Moreover, the discussion on the policy framework to address the issue in a sustained manner has not received the attention it deserves, in the popular discourse.

It is widely accepted that undernutrition results from multiple causes, which can be categorised as immediate (inadequate diet and disease), underlying (household food insecurity, poverty, poor access to health and WASH services) and basic causes (overall social, political and economic environment). In case of tribal people, additional factors like discrimination, geographical isolation, limited access to public services, cultural differences, among others, add to the existing deprivations faced by them across sectors. Given their high dependence on government provisioning of essential services across sectors, additional efforts are required to overcome some of the challenges that are specific to STs and improve their access to these essential services in nutrition-related sectors.

In the last decade or so, initiatives have been taken by the government to reach out to tribal people and increase their access to public health and nutrition services, which are crucial for addressing immediate causes of undernutrition. These include relaxing population norms in tribal habitations for setting up of anganwadi and mini-anganwadi centres under Integrated Child Development Services scheme; or setting up of the health centres under the National Health Mission (NHM), taking into account the scattered and sparse population in a number of tribal habitations. In addition, some states have introduced state-specific schemes specifically for tribal people; such as Maharashtra’s APJ Abdul Kalam Amrut Aahaar Yojana, a full-meal scheme for pregnant and lactating women and Village Child Development Centre for severely undernourished children.

Also read: Without Tackling Hunger and Malnutrition, India’s ‘Acche Din’ Will Remain Stunted

However, shortage of basic infrastructure as well as human resources for delivery of these schemes, constrain the quality as well as outreach of these services in tribal areas.

As per the Rural Health Survey 2017, there is an overall shortfall (difference between required and in-position) of 21%, 26% and 23% respectively for sub-centres, Primary Health Centres (PHCs) and Community Health Centres (CHCs) in tribal areas at the all-India level. This shortfall is much higher in tribal-dominated states; for example, the shortfall for PHCs is 52% in Rajasthan, 53% in Madhya Pradesh, 58% in Jharkhand, 36% in Telangana and 30% in Maharashtra.

The issue is compounded by the acute and persistent shortage of personnel to deliver these services in tribal areas. For example, the same survey reveals that in tribal areas, the vacancy of doctors in PHCs is as high as 28%, and for nursing staff at PHC and CHC levels it is 22% at the all-India level, with significant shortfall and vacancies in tribal-dominated states. These shortages are compounded by high rates of non-functionality of the health centres, absenteeism of personnel for delivery of services, as well as unavailability of basic drugs and equipment. For example, NFHS-4 revealed that 57% of STs expressed concern that no drugs would be available at the health centres, and 42% felt that distance from health facilities restricts their access to medical advice or treatment.

In this regard, we may note that the availability of budgetary resources play an important role in addressing these deficits. Apart from general flow of funds, to ensure targeted policy driven budgets for STs, the government of India initiated a strategy of Tribal Sub Plan (TSP) in 1974. As per the TSP strategy, the Union and state governments had to earmark plan funds for tribal people at least in proportion to their share in the total population of India (8.6% as per Census 2011) or of respective states. The objective was to ensure separate funding to address specific development deficits in tribal areas.

However, the allocations for TSP never met the mandate and TSP allocations remained much below the prescribed norm. For example, Singh and Sethi (2017) in their analysis of TSP outlays for nutrition-related ministries show that between 2014-15 to 2016-17, the Union government was allocating only around 4.4% of its plan budget under TSP (against the norm of 8.6%).

Also read: India’s Silent Emergency – Malnutrition

Moreover, with the merger of plan and non-plan heads of expenditure in Union Budget 2017-18, the future implementation strategy for TSP is uncertain. So far, the Union government has not shown any inclination to introduce a revised policy for TSP to ensure targeted flow of funds for STs.

As a policy, TSP can be used to address challenges in access to food, potable water, sanitation facilities, quality health services and other facilities in tribal areas which together lead to poor nutrition among tribal women and children. TSP can be used to fill in the critical gaps in resources to ensure quality and outreach of interventions across nutrition-related sectors, and thus address the multiple causes of undernutrition.

Despite tribal undernutrition being a persisting concern over the years, there is as yet no specific policy to address the issue and streamline the government’s efforts across sectors. The efforts at both Union government and state levels remain fragmented and lack effective implementation. While some states have shown initiative to introduce specific schemes, the approach remains limited to tackling immediate issues relating to diet and disease, and does not sufficiently address the larger issues of poverty, food insecurity at household level, landlessness and shrinking livelihoods, among others.

In this context, the government needs to play a more proactive role and form a policy for coordinated action across ministries, such as tribal affairs, women and child development, agriculture, rural development, drinking water and sanitation, and human resource development (education), to inform and strengthen their efforts towards tackling tribal undernutrition.

Saumya Shrivastava works with the Centre for Budget and Governance Accountability (CBGA), New Delhi, where she engages with a range of issues in the domain of government policies and budgets.

This article originally appeared on India Development Review.

To Fix Childhood Stunting in India, Focus on Women’s Health: Study

Researchers found that low women’s BMI could explain almost a fifth of the difference between high and low burden stunting districts.

New Delhi: At 63 million stunted children, India has one-third of the world’s population of stunted pre-schoolers. This means the global struggle against stunting is not going to change for the better unless India acts seriously.

With stunting, as with several other social and development outcomes, women play a key role. This has been highlighted by a new research, the authors of which have conducted a deep examination into freshly released government data from the National Family Health Survey 4 (2015-2016).

“Women-related factors contribute to more than half of the factors we analysed, which are linked to stunting. This is not new news. But the fact that this still has to be said as news is a concern. When women are not tended to, we are looking at discrimination across the life-course,” says Purnima Menon, senior research fellow at the International Food Policy Research Institute (IFPRI), and lead author of this study.

The research by IFPRI is also being reviewed by the NITI Aayog, with whom they have entered into an agreement to provide analytical and technical support on related issues. This study could find a place in discussions at the National Nutrition Mission, as well as some use in NITI Aayog’s plan to give targeted social sector interventions in 100 “aspirational districts”.

The paper has tried to understand the geographical burden of stunting across districts, using data from the National Family Health Survey 4 (2015-2016). It has also relied on Census data from 2011. Indian researchers have not had access to district-level data for the country for about ten years, and the paper says that this “lack of disaggregated stunting data at the district level has been a challenge for policy and programme strategies in a decentralized governance system”.

What role do women play in childhood stunting?

Stunting in early childhood is a marker of poor nutrition. It is calculated in children under the age of five.

India did see an improvement in stunting between 2006 and 2016 – stunting declined from 48% to 38.4%. But across states, the range remains challenging, from 12.4% to 65.1%.

In fact, north India alone is keeping the global average high – 52.6 million stunted children are in north India, while 8.1 million of them are in all southern states combined.

Credit: IFPRI

“The key to South Asia’s high rates of child malnutrition is not to be found in the obvious,” said a UNICEF publication released 21 years ago, co-authored by the former director general of the Indian Council of Medical Research, Vulimiri Ramalingaswami.

The authors began their paper by going through a number of factors which could intuitively be linked to malnutrition, such as poverty or food production. The authors instead said, “the exceptionally high rates of malnutrition in South Asia are rooted deep in the soil of inequality between men and women.”

Little appears to have changed in these basic underlying factors, ensuring that the basic phenomenon of poor nutrition and subsequently, of stunting, remains.

Menon recalls this 1997 paper and calls for attention to the gender dimension.

“Research shows that it may not be new policy that we need – there are wide disparities within the same policy geography. Some states, or some districts within states, perform well, and some don’t, even under the same policy. What we need remains proper implementation of these policies,” she says.

The paper has examined immediate and underlying determinants and nutrition-specific as well as nutrition-sensitive interventions.

Across districts, they examined eight factors which contribute to the difference in stunting prevalence between very high burden and low burden districts: women’s body mass index, women’s education, age at marriage, antenatal care, children’s diet, assets, open defecation and household size.

Just the first four, which are related to women, account for 46% of the factors which impact stunting.

“Variables reflecting women’s well being – BMI, education, early marriage and access to ante natal care – explain close to half the difference between high and low stunting districts,” says the paper. The authors say that “Discrimination against women is a widely suspected cause of India’s unusually high rate of stunting.”

For example, nearly a quarter of women in India have low BMI. And while more than 40% of children were breastfed within an hour of their birth, only 55% were exclusively breastfed. Early marriage and thus early childbearing is more likely to lead to pre-term babies as well.

“A focus on addressing women’s nutrition emerges as a key priority area in our analyses,” says the study.

Their research found that low women’s BMI could explain almost a fifth of the difference between high and low burden stunting districts, which corroborates existing research on maternal undernutrition being a major determinant of poor fetal growth and childhood stunting.

“India faces a critical challenge because preconception undernutrition among women can influence birth outcomes and child growth,” says the paper.