The recently released fifth round of the National Family Health Survey (NFHS-5) provides new and reliable evidence to assess some dimensions of micro-development performance before COVID struck. The survey covers health, nutrition (of mother and child) and the overall quality of lives.
In a recent piece on these pages (‘New welfarism of India’s Right’, IE, December 22) we had argued that the data illustrated significant gains achieved by the government in respect to its distinctive approach to redistribution and inclusion that we called New Welfarism. This involved the subsidised public provision of essential goods and services, normally provided by the private sector. Access to banks accounts (especially for women), clean fuel for cooking, toilets and power had increased and at a significantly faster pace since 2015 than before.
Here, we provide preliminary evidence on the health and nutrition of the child in India. Since the latest round only has data for 17 states and five Union territories, our findings cover only 54 per cent of India’s population. Madhya Pradesh, Uttar Pradesh, Punjab, Rajasthan and Tamil Nadu are notable exclusions. Another point to emphasise is this: The New Welfarism was consciously driven by the Centre and it could, therefore, reasonably claim credit for its success. In contrast, many of the child-related outcomes are also determined by state-level implementation, therefore neither success nor failure can be attributed to one source. With those caveats, we explain the data and then present our results.
The NFHS has 42 indicators related to child’s health and nutrition (there is one indicator on school enrolment which falls outside the scope of this analysis). Indicators fall into nine categories and each of these can be divided into outcomes and inputs as the table shows. For example, neonatal, infant and under-5 mortality rates can be thought of as outcomes. Similarly, all the nutrition indicators —stunting, wastage, excess wastage, underweight and overweight — as well as the prevalence of diarrhoea, acute respiratory illness (ARI) and anaemia can also be classified as outcomes. In contrast, the post-natal care indicators relating to visits made by health workers, the provision of vaccinations and Vitamin A, and the extent and nature of feeding for the child can be classified as inputs (details of the NFHS questions are available online).
The input indicators are not easy to aggregate in easy or obvious ways, so we leave that as material for future research. Instead, we present some findings on the 11 child outcomes below. First, though, some nuances. We score wasting (weight for height of children) as an improvement because even though the gains were marginal, they reversed a negative trend between 2005 and 2015. However, the wasting outcome must be treated with caution because trends on wasting move contrary to those of “severe wasting” even from 2005. There is also one indicator we have ignored, since it is difficult to classify: Underweight, where there were marginal gains, but a slowdown relative to the past.
Now, for the results, which can be summarised as: India continues to be successful in preventing child deaths, but the health and nutrition of the surviving, living child has deteriorated, somewhat worryingly.
Of the 10 outcomes, there have been improvements in four (Figure 1). It is readily apparent that India continued to make progress in preventing child-related deaths (neonatal, infants and under-5). That said, the pace of improvement in child mortality slowed down relative to the previous 10 years. For example, between 2005 and 2015, the infant mortality rate came down by nearly 2 percentage points per year while between 2015 and 2019 that pace halved to 1 percentage point per year (post-2015, the mortality lines are flatter than before in Figure 1). Whether some slowing should be expected because India is now close enough to the desirable benchmark is an open question.
Figure 2 shows the six indicators where outcomes have deteriorated. These all relate to what happens after survival: The health (anaemia, diarrhoea, and acute respiratory illness (ARI)) and nutrition (stunting, and overweight) of the child deteriorated between 2015 and 2019. In none of these cases is the aggregate deterioration driven by outliers, that is, by one or two states.
Moreover, the absolute deterioration in health and nutrition indicators must be seen against the fact that they reversed the historic trends of steady improvements. That is particularly true of the prevalence of diarrhoea and anaemia and to a lesser extent of stunting and acute respiratory illness (post-2015, the lines slope downwards whereas they sloped upwards from 2005-2015).
Several factors probably play a role in explaining these outcomes. As already noted, implementation capacity of individual states probably played an important role. Sector-specific factors such as changing diets are also implicated. But the fact of a broader deterioration in outcomes hints at the likelihood of a common factor, namely the macro-economic growth environment, which determines employment, incomes and opportunities. At the least, it is safe to conjecture that some of these outcomes are inconsistent with the narrative of a rapidly growing economy.
We mentioned earlier that the NFHS provides data on child-related inputs. These need to be examined too. Suppose it turns out that the Centre and the states have done a good job in improving the quality and quantity of inputs that go into the child, then there would be a real puzzle: Why do outcomes and inputs diverge? Indeed, as we showed in our earlier piece, the government has made great strides in providing a number of basic needs to households such as toilets, clean cooking fuel, power and bank accounts. Those developments would also serve to aggravate the puzzle of why the health and nutrition of the child in India has deteriorated.
As discussed in Chapter 5 of the Economic Survey of 2015-16, perhaps the next big welfare initiative of the government, building on the considerable success of its New Welfarism, should be a mission-mode focus on the well-being of the early child (and of course the mother), from the womb to the first five years, which research shows is critical for realising its long run potential as an individual.
This article first appeared in the print edition on January 6, 2021 under the title ‘The child in India’. Anand is graduate student at Harvard Kennedy School, Dimble is deputy director, Ashoka Centre for Economic Policy, and Subramanian is former Chief Economic Adviser, Government of India
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