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.
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