How malnourished are Indian children?

It is important to have clear benchmarks in order to measure socio-economic progress. However, a blanket application of global standards in India does not always present the true picture. This article illustrates this issue by exploring “stunting” as a measure of child malnutrition. This metric has been recently at the centre of a controversy related to the Global Hunger Index (that this name is itself misleading is another debate).

According to the National Family and Health Survey (NFHS) 2019-20, the prevalence of stunting in the 0-5 year age bracket is 35.5% (rural 37.3%; urban 30.1%). This is down from 38.4% in 2015-16, and sharply lower than 48% in 2005-06. While it is heartening to see progress, the indicator suggests that over a third of Indian children suffer from stunting. Is this a true reflection of the ground situation?

Stunting is defined as “low height-for-age” and is associated with chronic undernourishment. The global benchmark used in India is derived from the World Health Organisation (WHO), but how did WHO arrive at the benchmark? It turns out that it is based on a Multicentre Growth Reference Study (MGRS) done in 1997-2003. This was a combination of a longitudinal sample of 1743 infants aged 0-24 months, and a cross-section of 6697 children aged 18-71 months. The samples were drawn from six countries: India (South Delhi), Oman (Muscat), Ghana (Accra), Brazil (Pelotas), Norway (Oslo), and US (Davis). The WHO then pooled the data to create a global benchmark range for childhood growth.

A sample of 1490 from India was taken from South Delhi on the grounds that children from this relatively affluent neighbourhood have access of adequate nutrition and healthcare, thereby reaching their full growth potential. Interestingly, even in the original study, the Omanis and Indians were consistently shorter than the others. For example, at age 60-62 months, the average Ghanese child was 112.55 cm, Brazilian 111.15 cm and Norwegian was 110.64 cm compared to 108.78 cm for the Indian and 109.55 cm for the Omani. In other words, the best-fed Indian child was shorter than the average even in the benchmark study!

As can be seen, the MGRS study uses a very small sample taken from just six arbitrary countries to create a global one-size-fit-all benchmark. There is no reason given for the selection of these six countries that leaves out the large populations of East and South-East Asia who are generally shorter. Indeed, countries like Indonesia have had to devise their own benchmarks.

Even in India, the medical profession has long been aware that the WHO benchmark is unsuitable for the country and has come up with alternative growth charts. When one set of these indigenous benchmarks was applied by Vaman Khandilkar et al (2021) on the NHFS 2015-16 data, the prevalence of stunting in India dropped from 38.4% to 27%.

A more recent paper by SV Subramanian et al (2023) similarly compares NHFS 2019-20 to an indigenous standard. The benchmark is based on the observed growth trajectory of urban middle and upper-middle class children in five geographical zones of the country. The disaggregation has the advantage of allowing for state-wise measurement of stunting based on more localised benchmarks.

Subramanian et al found that all-India stunting in 2019-20 declined to 24% when the indigenous benchmark was used. The differences are even larger in individual states. For example, stunting in Andhra Pradesh went from 28% based on the WHO benchmark to 19% using the local upper middle-class standard; Maharashtra from 33% to 23%, Uttar Pradesh from 37% to 27% and so on.

Interestingly, the same discrepancy shows up when WHO and local standards are used for another indicator of malnutrition – “wasting” (i.e. low weight-to-height). The prevalence of wasting in 2019-20 is 19% using the WHO standard but only 9% when using the local upper-middle class standard.

As can be seen, the blanket use of the global benchmark overstates India’s child malnutrition problem. This is not to suggest that malnutrition is not a serious issue. The percent of malnourished children is high even using the local standard, but effective policy-making requires accurate measurement.

The problem with one-size-fit-all WHO benchmarks is well known and was highlighted over a decade ago by Prof. Arvind Panagariya. Countries such as Indonesia, US and even European countries like Britain have developed local benchmarks. Unfortunately, India’s own government data collection agencies inexplicably continue to use the WHO standards. Equally puzzling is the insistence of economists on using inappropriate global standards when the medical profession has moved on.

This brings us to a broader issue. Many of the heated debates about India’s development indicators are related to poor data-collection, inappropriate benchmarking, outdated methodologies, and inordinate delays in publication. We will explore a few more such issues in subsequent articles.

(Sanjeev Sanyal is Member, Economic Advisory Council to the Prime Minister; Dr. Srishti Chauhan is Young Professional, EAC-PM)