Though correlated, these are not necessarily synonymous and each needs specific ameliorative action.

Doubts have been raised by Indian authorities about the methodology and conclusions reached in the widely used Global Health Index. The joint study for 2021, put out by Concern Worldwide, UK and Welthungerhilfe, Germany, puts India at the 101st position out of 116 countries. This compares against the earlier ranking of 96th. The rankings, which place India behind even Pakistan, Bangladesh and Nepal have, understandably, been questioned and have also drawn the ire of both political leadership and social scientists. This slippage was reported at a time when the nation is relatively food secure, government-warehouses are brimming with grains and a fairly robust mechanism for free and subsidised cereal-distribution is in place. However, since the 2021 GHI was compiled, corroborative official data has also come to light on the extensive prevalence of malnutrition and poverty in India.
The details of the just released 5th round of the official National Family & Health Survey (NHFS) that covered the period 2019-21, points out that the fertility rate is now below the replacement level for the first time. That implies the population has stabilised and the noticeable increase witnessed incessantly for decades has ceased. The net replacement rate at 2 is now below the 2.1 threshold for maintaining the population at the previous level. This is true across all states. With this lower fertility rate, the population below 15 years of age is declining and demographically, the country is becoming “older”.
As per NFHS, the overall sex ratio reportedly improved in 2019-21 with there now being 1,020 women to 1,000 men. This is as much a result of the improvement in life expectancy of women as in the sex ratio. No doubt the sex ratio at birth (SBR) has marginally grown from 919 in 2015-16 to 929 in 2019-21; however, it is short of the natural SBR of 952 girls per 1,000 boys. The slow improvement in this parameter remains linked to the persistent preference for sons in Indian families. In fact, the small change in SBR might also be attributable to the significant migration of menfolk to their village-homes during the first wave of Covid 19 when the Phase 2 of the Survey was underway.
In comparison to the last survey in 2015-16, the recent NFHS survey has revealed that anaemia in children and women is now significantly higher. More than 50% of children and women (including pregnant women) were found to be anaemic, with a higher number of children now experiencing wasted and stunted growth. There is also a marked difference of outcomes amongst the 10 states surveyed in phase 1 between June 2019 and January 2020 (before the onset of Covid 19 in India) and the 10 states surveyed in phase 2 between January 2020 and April 2021. While the states in the first phase have shown a decline since 2015 in the nutritional status of children—particularly across the major states including Kerala—the states in the second phase have not demonstrated any fall, including in the large states of Uttar Pradesh and Tamil Nadu. Jharkhand, otherwise at the bottom of the Niti Aayog’s recently compiled Poverty and Hunger Indices, has recorded improvement in nutritional status. The NHFS study also points towards a higher incidence of obesity, both in men and women.
Last week’s released report on poverty by the government think tank Niti Aayog has a related finding of consequence. Its multi-dimensional study of poverty (MPI) using NHFS data of 2015-16 is based on 3 equally weighted indicators—health, education and standard of living. Each of these three in turn has four specific indicators such as nutrition, child and adolescent mortality, years of schooling, housing, assets and bank accounts under them. Aggregating the score on each such individual marker, it puts the prevailing national poverty-incidence at 25.1% of the population. For the first time, a government agency has adopted multiple criteria and taken an aggregated approach along the lines of research by bodies such as United Nations Development Programme & Oxford Poverty and Human Development Initiative. All previous estimations of poverty were either based on nutrition intake or income earned, with people below a defined quantum of food intake or income deemed to be poor.

Given it was the first MPI endeavour, the new Niti Aayog measure may not yet allow seamless comparison over time. However, the total figure of about 325 mn poor citizens is worrisome and depicts that poverty, in absolute terms, is higher than in any of the earlier 5 official assessments, viz. Planning Commission’s Working Group of 1992, Y.K. Alagh’s group in 1997, Lakdawala’s in 1989, Tendulkar’s in 2009-10 and Rangarajan’s in 2011-12. At 25.1%, Niti Aayog’s PMI is lower than the 29.8% estimated in 2009-10 by Prof Suresh Tendulkar, but higher than the assessment by Dr C. Rangarajan for 2011-12. In densely populated states of Bihar, Jharkhand and Uttar Pradesh, the proportion of poor people is an astounding 52%, 42% and 38% of the population, respectively. Madhya Pradesh comes in at the fourth position at 37%, with Meghalaya at fifth at 33% poverty. Using only one indicator i.e. nutrition, the national level of is higher at 38%; that represents 480 mn citizens or the 1.3 bn total population.
As per the Fifth NHFS, the number of anaemic children below 5 years has risen from 59% to 67%, while the number of anaemic women increased from 53% to 57%. In men, anaemia went up from 23% to 25%. The number of anaemic teenaged girls (between 15 and 19 years of age) increased by 5% to 59%, and in pregnant women between 15 and 49 years it went up marginally from 50% to 52 %. An incidence of up to 20% is classified as moderate, with anything above it deemed severe and causing several health-debilities. All Indian states except Kerala fall in the severe category with the prevalence among male adults ranging from 39% in Kerala to 80% in Gujarat. Among the larger states, West Bengal reported the highest number (71%) of anaemic women. Unfortunately, the progress that had been seen till 2015-16 in reducing under-nutrition has now reversed with the share of the anaemic in both genders having risen.
It should be pointed out that the NFHS data, however, is not entirely conclusive. Anaemia is commonly characterised by low levels of iron in the body. It is also believed to result from a lack of nutrition and inadequate intake of fresh fruits and vegetables, as well as a deficiency of B-12 vitamin. All the three indicators of malnutrition employed in the Survey which usually occur together—stunting (low height for age), wasting (low weight for height) and underweight (low weight for age)—have not worsened compared to 2015-16 in any of the Phase 2 states. On the other hand, in states surveyed prior to Covid19 striking India, there were varied results with respect to one or two of these three indicators of malnutrition. 6 of the 10 states experienced higher stunting, 5 saw an increase in wastage, and 7 saw a higher than before ratio of underweight children.
Bihar, the state with the highest level of poverty, has worsened on all indicators with a prominently high rate of stunted and wasted children. This number is 50% higher than Tamil Nadu (surveyed in Phase 2), which has a poverty rate of only 5% compared to Bihar’s 52%. Country wide, the share of children under 5 who were stunted, wasted or underweight has marginally declined; however, every third child still suffers from chronic undernourishment and every fifth child is acutely malnourished. Acute malnutrition in young children has increased in Telangana, Bihar and the northeastern states, while there has been improvement in Haryana, Jharkhand and Chhattisgarh. Bihar had the highest prevalence at 41% of underweight children, followed closely by 40% in Gujarat.

Recurrent or chronic malnutrition, as witnessed in both the fourth and fifth rounds of NHFS, is clearly associated with hunger, poverty, poor maternal health and nutrition, frequent illness, inappropriate feeding, poor care in early life and poor access to nutritious food. Hunger, a form of food deprivation by itself, is not causing the rampant under-nutrition and neither is poverty, which adversely impacts purchasing power. Both remain important determinants but their impact varies across nations. Poor health services, conception at a young age, low education, and poor access to suitable water, sanitation and hygiene are significant contributory factors. All such causes have serious immediate and long term health impact. As Prof. Ashwini Deshpande of Ashoka University observes, “these prevent children from reaching their physical and cognitive potential.”
The rise in the number of overweight children, as is also reflected in the NHFS data, points towards malnutrition with serious health consequences in the form of non-communicable diseases like diabetes and high blood pressure, both of which weaken the immune system. Overall, the number of overweight men has risen by 4% to 23% and in women by 3% to 24%. The rise in its incidence, particularly pronounced in cities, is consequently as much a cause of concern.
To effect any noticeable improvement in the status of malnutrition, simultaneous action is needed to address each of these determinants—this includes better food availability, augmentation of purchasing power, and effecting a host of improved health, social and personal practices. The longer we delay addressing these in a focused manner, the more difficult it will be to tackle them in the future. The debilitating effects of a “business as usual” approach would pull down individuals as well as the nation alike. Unlike some systemic issues, the measures to be undertaken in this case are broadly known and well tested domestically. A handful of states in the south have benefitted both economically and socially by timely action on key policies. However, given the limited resources and wherewithal available to many Indian states, greater national level engagement, combined with an effective decentralised approach in devising strategies that zero in on outcomes, is the call of the day.
Dr Ajay Dua, a progressive economist, is a former Union Secretary.
Part 2 of the article discussing the pros and cons of strategies and measures to address the three related issues will follow.