Wednesday, October 18, 2017

"Public Health" is key to Malnutrition


    Every time a "Hunger Index" comes out, it attracts wide publicity & discussion. Nobody seems to notice, that the "Hunger index" doesn't measure "Hunger" at all. When this author found objective survey data on "Hunger" in India, both the Planning Commission and EPW vetoed its publication. Why? Possibly because it threatened too many intellectual vested interests.
    The author and consultant for the Indian part of the "hunger index" admitted, that the index is mostly about Child stunting, wasting etc, which have collectively come to be called "child malnutrition". If the real problem is Child Malnutrition, then we need to understand this problem and find solutions to it as we did over last decade.
 India's under 3 year old Child malnutrition rate(%) was double the poverty rate (%) and 20 times the per cent of hungry in India (% of households in which any member had less than two (2) full meals, on any day of the month (i.e. even one day without 2 square meals, counts as hungry) .

Child Malnutrition

There are three broad aspects of malnutrition that must be kept in mind when devising strategies for dealing with it. [i]   
1)    The ability to access such food items.  This depends on household income or ability to sustain certain levels of consumption.  The rate of Poverty (Head count ratio) is the standard indicator. 
2)    Household/family knowledge and information about good nutrition.  This includes knowledge about the locally available foods that are good from the nutrition perspective.  This can be based on, (a) traditional age old knowledge (old wives tales). (b) Ability to read coupled with availability of appropriate reading material on nutrition. (c) Access to media such as newspapers, radio and TV, coupled with propagation of such information on the radio (d) Special programs that directly educate mothers about child rearing and nutrition such as ICDS.
3)    State of health.  Even if the right kind of food and nutrition is available a child may not be able to consume and/or absorb it properly due to ill health or sickness.  For instance a child suffering from diarrhea much of the time is unlikely to be able to ingest much good and healthy food and absorb the nutrition, even if it is freely available and provided to the child by the mother/parents. Historically it has been demonstrated across many countries that public health measures like clean drinking water, sanitation, sewerage, control of communicable and epidemic diseases and public health education play an important role in reducing mortality rates at every age and across gender.  In the Indian environment access to water and toilets, breast feeding (to impart immunity in an unhealthy environment), access to sound health advice/treatment, prevalence of vaccination and availability of vitamin supplements are possible indicators.


Poverty affects cross State differences in Child malnutrition, it has to be addressed through economic growth, reform of welfare programs etc. Our research confirms that average per capita GDP is an important  determinant of poverty.[ii] It also showed that higher agriculture growth has an impact on poverty reduction in addition to its normal contribution to overall GDP growth. A special focus on agricultural growth in poorer states and in States with opportunities for productivity improvement can therefore be justified in terms of poverty removal even though it may not have any impact on overall growth. The empirical results also justify an added focus on rural roads and telecom connectivity (in addition to the general effects found earlier) to the extent that they promote the development of agriculture. Development of rural connectivity also improves market integration and labor mobility, which in turn will remove the differential and segmented impact of growth on rural and urban poverty. The research also showed that the consumption share of bottom 40% of the population is an important determinant of poverty. Targeted benefit programs should therefore focus on the bottom 40% of the population. It is essential to set up a comprehensive data base with unique IDs, photographs and Bio-metric identification, that will eliminate fraud and help identify the poorest 30% to 40% of the population.[iii]

Malnutrition Solutions

The research on cross-State differences in child nutrition outcomes shows, that the greatest social welfare benefits from direct intervention by government to improve the lot of the bottom 40% can come if it focuses on two long neglected quasi-public goods.[iv]  First, Public health including communicable disease and vector control, quality drinking water, drainage, sewerage and solid waste disposal in every city, town and village in the country. Second universal primary education and literacy to a global standard that is visible in outcomes. 
Improvement of public health education and public health facilities clearly has a positive effect on nutrition outcomes.  The ICDS program seems to have helped in providing public health education to mothers and thus contributed to the outcome.  The policy implications, however, extend beyond nutrition to other health outcomes. A comprehensive program for improving civic amenities of a public health nature to a defined standard is necessary to remove visible symbols of divide between rich and poor that slums and other neighborhoods with poor drainage and sewage create.
For every existing town, States must plan and install a modern drainage, sewerage and water supply system with water storage and purification, sewage treatment plants and garbage disposal sites.  The impact in terms of economic activity, health and nutrition can be enormous.  Government should help develop consultancy firms that can Plan and organize such systems and organizations that can compete with each other to build these systems across the country.  Once 100% coverage of towns is attained, we should extend the planning effort to semi-urban areas and villages in co-operation with Panchayti Raj institutions and NGOs.  We may not be able to match the quality of public health  and civic services routinely found in the villages of High income country’s, but we must target a quality level equal to that of middle income countries.
    This brings us back to the broader question of other quasi-public goods that are of critical importance to the poor.   Literacy can help in acquiring knowledge about hygiene, nutrition and sanitation.  Government must ensure that every citizen, has the education that (s)he is supposed to acquire with the completion of Primary education.  But this education must also be made more relevant by providing information on matters that will improve their lives (health, hygene, nutrition) and equip them to find useful information.

Cross-country Lessons

Our cross-country results show that the quality of public health, as measured by variables such as access to better sanitation and improved water sources, is an important factor in explaining cross-country variations in the prevalence of malnutrition.[v]  It indicates that improvements in environmental sanitation could have a significant impact in reducing malnutrition in India.  It also confirms the importance of primary education, particularly of females, in helping spread information and knowledge about personal hygiene, sanitation and nutrition.  Much more could however be done through appropriate school curricula and media campaigns to promote public health education.


  Once the current targets of the Swach Bharat Mission are met it should be raised to a broader and more comprehensive level: A comprehensive end-to-end water-sewage-sanitation system for the country. One that starts with clean drinking water and unpolluted irrigation water and ends in fertilizer and usable water. Similarly Union government health initiative must be focused on classic public health and public health education in schools and family health programs (like ICDS).

A version of this article appeared in the Indian express OP ed page on October, 2017 under the banner "What schools have to do with health"

[i] Virmani, Arvind, “Causes of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,  July 2007. MalnutritionChild07July.docx .
[ii]  Virmani, Arvind, “The Sudoku of Growth, Poverty and Malnutrition: Lessons For Lagging States,” Working Paper No. 2/2007-PC, Planning Commission, July  2007. ,
[iii] Virmani, Arvind, “Poverty And Hunger In India: What is needed To Eliminate Them,” Working Paper No. 1/2006-PC, Planning Commission, February 2006. .
[iv] Virmani, Arvind, “Causes of Child Malnutrition In India,” Working Paper No. WsWp 1/2007,  July 2007. MalnutritionChild07July.docx .
[v] Virmani, Arvind, "Undernurishment of Children: Causes of Cross-country Variation," Working paper No.WsWp 4/2012, October 2012 [WsWp 4/2012. Nutrition12oct.docx . 

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