India: Malnutrition and Sanitation

 

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

 

 

India is one of the hungriest and malnourished nations in the world.

 

 

Malnutrition is a major health problem in India.  Water, sanitation and hygiene (WASH), given their direct impact on infectious disease, especially diarrhea, are important for preventing malnutrition.

 

It is said that food grows in abundance in India, but every year, India makes headlines for being one of the hungriest major countries in the world. India ranked 102 out of 117 countries in the Global Hunger Index (GHI) 2019 that is much lower than below to its South Asian neighbours such as Sri Lanka (world rank:66), Nepal (73), Bangladesh (88), and Pakistan (94). The index is calculated using four indicators that are - child mortality, undernourishment, child wasting (weight for age) and child stunting (low height for age).

 

 

The GHI report pointed out that "India is suffering from a serious hunger problem", and the situation is deteriorating very fast, as shown in Table 1. As a result, most of its children suffer from acute malnutrition. The chapter argues that improving Wash (Water, Sanitation and Hygiene) practices could be an effective strategy in reducing the level of   malnutrition and its related issues. 

 

                    Table1 India's GHI performance since 2014

Year	World GHI Ranking	Total Countries
2014	55	76
2015	80	117
2016	97	118
2017	100	119
2018	103	119
2019	102	117
Source: GHI reports

 

Malnutrition is the primary reason behind 69 per cent of the deaths of children below the age of five in India, according to the State of the World’s Children report, released by UNICEF in 2019. The report goes on to say that every second child in India, belonging to that age group, is affected by some form of malnutrition (54% or 63 million out of 118 million children in 2018). This includes stunting with 35 per cent of the children, wasting with 17 per cent, underweight with 36 per cent and 2 per cent overweight. ^[1]

Chronic malnutrition, referred to as stunting, is one of the most serious health and human development problems in India. The country has the maximum number of chronic malnourished children in the world – 1 in every 3 children is stunted. The most direct causes of stunting are inadequate nutrition (insufficient food intake or consumption of foods lacking in essential growth-promoting nutrients) and recurrent infections or chronic diseases (which cause poor nutrient intake, poor absorption and utilization, or other forms of nutrient loss), as per WHO.[2]

The real-world impacts of stunting ripple well beyond linear growth. A stunted child may also have a poorer immune system, brain function, and organ development. Performing below average in these areas may also limit their future productivity and threaten the health of their future children. In short, stunting has lifelong consequences on human capital, poverty and equity. It leads to less potential in education and fewer professional opportunities,” as per Sobha Suri, Senior Fellow, Health Initiative, Observer Research Foundation. [3]

 

And, there is no wonder that the World Bank ranked India at 115th out of 157 countries on the Human Capital Index in 2018. [4] HCI seeks to measure the amount of human capital that a child born today can expect to attain by the age of 18. According to its parameters a child born in India today will only be 44 per cent as productive as she could have been if she had enjoyed quality education and full health as well as better living environment including water and sanitation.  In other words, there are grave deficiencies in India’s human development inputs that are preventing children from reaching their full potential. As such, the productivity, measured as per capita GDP,   is very low. India became the fifth largest economy in the world in terms of GDP in 2018 but still it has a very-very low per capita GDP, as per IMF. It is placed at 119th position among 185 countries.

A study by the International Food Policy Research Institute shows that stunting prevalence varies across districts of India  (12.4-65.1%), and almost 40 per cent districts have stunting levels above 40 per cent. Such high prevalence of child malnutrition in India defies logic. 

After all, the country’s economy has doubled since 1991, when the government started counting the malnourished children. Further, the world’s largest programme to tackle child malnutrition, the Integrated Child Development Services (ICDS), has been in force in the country since 1975, much before any country, other than the US, introduced measures to tackle the problem. The Mid-day Meal Scheme was launched in the year 1995 as a centrally sponsored scheme, it provides every child within the age group of six to fourteen years studying in classes I to VIII who enrolls and attends the school, shall be provided hot cooked meal having nutritional standards of 450 calories and 12 gm of protein for primary (I-V class) and 700 calories and 20 gm protein for upper primary (VI-VIII class), free of charge every day except on school holidays. The scheme covers all government and government-aided schools and also madarsas.

Now, the country aims to achieve a malnutrition-free India by 2022, as per the National Nutrition Strategy 2017.  The plan is to reduce stunting prevalence in children (0-3 years) by about three percentage points per year by 2022 from NFHS-3 (2005-06) levels, and achieve a one-third reduction in anemia in children, adolescents and women of reproductive age.

As the stage is set for the onslaught of malnutrition, it is time to critically look at the not-so-obvious reasons for its high prevalence in the country.

The debate over the measurement or prevalence of malnutrition ignores some of the crucial determinants of childhood health. Wash (Water, Sanitation and Hygiene) is a missing link. Consider this. Malnutrition is more common in India than in sub-Saharan African countries where per capita income is much lower than that of India. This discrepancy has sparked a debate over the WHO formula which is mainly based on the intake of calories, which is usually used by countries, including India, to measure malnutrition since 2006. 

Today, India lags behind sub-Saharan Africa in terms of sanitation practices. About 56 per cent people defecated, in the open across the country before the Swatch Bharat Mission (SBM) was launched in 2014. In sub-Saharan Africa, on the other hand, only 25 per cent of the people defecated in the open in 2010, according to UNICEF and WHO. Recent health surveys in the largest three sub-Saharan countries show that 31.1 per cent of households in Nigeria, 38.3 households in Ethiopia and 12.1 per cent households in the Democratic Republic of Congo defecate in the open. This difference in sanitation practices between India and African countries explains the difference in the level of malnutrition rate.[5] 

Even in India, good sanitation practices have helped curb malnutrition, as shown in Table 2. Kerala and Tamil Nadu have higher households using toilet facilities in   comparison to other states. Madhya Pradesh and Uttar Pradesh have very high rates of under-nutrition. States with low levels of under-nutrition include Kerala, Tamil Nadu and Maharashtra, although the rate is still considerably higher than that of developed nations.

                       Table 2 Uncomfortable facts: Malnutrition and use of latrine

State	Level of malnutrition (in  %)	Households where latrines in use (in %)
Kerala	20	96.5
Tamil Nadu	26	61.2
Maharashtra	28	45.1
Andhra Pradesh	32	24.9
Karnataka	33	32.1
West Bengal	35	33.7
Odessa	36	18.0
Uttar Pradesh	43	14.0
Madhya Pradesh	44	11.9
Source: National Nutrition Monitoring Bureau, Government of India.

A survey by the National Nutrition Monitoring Bureau (NNMB), which conducts surveys in rural and tribal areas to find out the nutritional status of people, also brings out this aspect. The   Bureau was established under the Indian Council of Medical Research in the year 1972, with a Central Reference Laboratory at the National Institute of Nutrition (NIN), Hyderabad. One of the surveys 

by the Bureau found that malnutrition level among children reduced over a period of time despite less intake of food. “The improvement in nutritional status could be due to non-nutritional factors, such as improved accessibility to health care facilities, sanitation and protected water supply,” the survey concluded.

Most children in rural areas and urban slums are constantly exposed to germs from their neighbors’ faces. This makes them vulnerable to the kinds of chronic intestinal diseases that prevent bodies from making good use of nutrients in food, and they become malnourished. And that explains that in spite of poverty as compared to India, Sub-Sahara Africa has lower malnourished children as compared to India. 

That could be the reason why Narendra Modi said in a pre-election speech to mark the birthday of Mahatma Gandhi in 2013 that: India should build “toilets before temples.” To accelerate the efforts to achieve universal sanitation coverage and to put a focus on hygiene, Prime Minister Modi launched the Swachh Bharat Abhiyan (Clean India Mission) on October 2, 2014. In addition, to cleaning the streets and roads, its main objective is to reduce or eliminate open defecation through the construction of individual, cluster and community toilets by 2019, as a fitting tribute to the 150th Birth Anniversary of Mahatma Gandhi.

Since its launch on October 2, 2014, more than 86.6 million toilets have been built in India, with 513 districts and 25 states being declared open defecation free (ODF) with 98.6% of Indian households having access to toilets, according to India’s official sanitation statistics.

 

While there is no denying that millions of toilets have been built since the Clean India Mission launched in 2014, experts have skepticism about this claim.

This is in large part due to the fact that a recent WHO report estimated that in 2017, 520 million (39%) people in India were still defecating in the open. Experts wonder how, in just two short years since the report, the government of India could have created toilet access and use for all of those people? This skepticism has also been buoyed by first-hand accounts from people who continue defecating in the open because they still do not have a toilet with water supply, as per Anoop Jain, the founding director of Sanitation and Health Rights in India (SHRI), a non-profit that improves access to toilets and safe drinking water throughout rural India.[6]

Additionally, pit latrines – the government’s recommended sanitation technology in rural areas – must be emptied when full. Tankers are cost-prohibitive and often infeasible in rural areas that lack good road infrastructure. Furthermore, manual scavenging (cleaning out pits manually) has rightfully been outlawed given the myriad dangers associated with handling human feces, leaving families the only option of doing it themselves. However, the social stigma associated with handling human excrement, perpetuated by India’s caste system, deters families from doing so. This causes the pits to fill up, rendering toilets unusable, which leads people to revert to defecating in the open. As a result many of the toilets, especially in rural areas, are lying non-functional. People use these toilets for storing fodder or cow dung cakes, as noted by Jain.

In addition, India is in the midst of a water crisis. Close to half the country, about 700 million people, face high to extreme water stress. A key facet of water policy must be the induction of technology to promote reuse and store the rainwater. 

The government should take note of such issues while planning its anti-malnutrition programme.  It is suggested that the rural employment guarantee scheme (NREGA), which is the responsibility of Panchayats Raj Institutions, should be used to improve the basic amenities like water, sanitation and hygiene in rural areas. The fund allocated to the Smart Cities Mission could be used mainly to develop the basic WASH facilities in urban areas.

While toilets are an important first step for sanitation, they still need to be used. Reducing open defection requires not only the technological inputs but it requires behavioural change at the household or family level.

How to forge ahead?  Based on the available data, it is estimated that around 435 million (31%) people mainly in rural India in 2019 were still defecating in the open. Some of them even have toilets in the household premises but do not using them due to various reasons, as noted above.

 And, without focussing on this population of 90 million families, mainly comprising Dalits, other lower castes including OBCs and Muslims, India cannot think of becoming an ODF country. And, most of these are the people suffering from the incidence of malnutrition, especially stunting. We have to recognise that open defection is a problem of poverty and behavioural change. For this one has to work at the household level, as proposed in the HDPlus strategy. 

For this one has to work at the household level for behavioural change, as proposed in the HDPlus strategy.[7] 

In short, clean water, sanitation and hygiene form the backbone of an effective human development agenda, as argued by the Johns Hopkins University Water Institute. However, the challenges of providing these services in a large and heterogeneous country can be vast. Clean drinking water and sanitation are certainly not cheap. The cost of implementing these for all of India will be very large. Of course, not doing it will also have huge financial implications in terms of health and socio-economic development costs. But the big question remains – will the policymakers acquiesce?

 

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[1] Read more at:https://economictimes.indiatimes.com//news/politics-and-nation/malnutrition-behind-69-per-cent-deaths-among-children-below-5-years-in-india-unicef-report/articleshow/71618288.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

 [2] Read more at: https://www.who.int/nutrition/topics/growth_and_development/en/

 [3] Read more at: https://www.thehindu.com/opinion/op-ed/for-a-malnutrition-free- india/article26984216.ece

 [4] Refer  2018 Human Development Index (HDI) at: https://www.onlinegk.com/news-and-tips/2018-human-development-index-(hdi)

 [5] Singh, Jyotsna and Kundan Pandey (2018).  Why India remains malnourished, DownToEarth. Read more at: https://www.downtoearth.org.in/coverage/health/why-india-remains-malnourished-42697 

[6] Jain, Anoop (2020). The end of India’s sanitation crisis? Stanford Program on Water, Health & Development. Read more at:  https://water.stanford.edu/news/end-india-s-sanitation-crisis 

[7] Kothari, Devendra (2019). Nurturing Human Development: A Strategy for New India, New Delhi: Paragoan International Publishers.

Will NEP-2020 transform India into knowledge hub?

Dr. Devendra Kothari

Population and Development Analyst

Forum for Population Action

 

 

 

“Delivered well, education – along with the human capital it generates – benefits individuals and societies”

The World Bank (2019)

 

 

On July 29, 2020, the Union Cabinet approved the National Education Policy that aims to overhaul the country’s education system, and was launched on the same day, without a discussion in the Parliament. It replaces 34-year-old National Policy on Education framed in 1986. The mission of the new policy is to create “an education structure that contributes directly to transforming the country, providing high-quality education to all, and making India a global knowledge superpower”. It has received well-deserved applause in the official circle; however, the truth is that it has failed to come to grip with the main crisis of education: Being in school is not the same as learning.

The post analyses whether the new education policy will help to improve the present dismal education outcomes which have been creating obstructions in using the demographic dividend?

 

India is currently in a youth bulge phase in which inclusive, high-quality education is of utmost importance for its prosperity. India is home to a fifth of the world's youth. Half of its population of 1.4 billion is below the age of 25, and a quarter is below the age of 14. India’s young population is its most valuable asset. It provides India with a unique demographic advantage. But this opportunity will be lost without proportionate investment in human capital formation.

 

Human capital refers to the knowledge, skill sets, and experience that workers have in an economy. The skills provide economic value since a knowledgeable workforce can lead to increased productivity thus prosperity.

Currently, India is facing a learning crisis. While India has significantly increased access to education, being in school is not the same thing as learning.    Across the country, millions of children reach young adulthood every year without even the most basic skills like calculating the correct change from a transaction or understanding a bus schedule -- let alone building a fulfilling career or educating their children properly.

 

A study conducted by the USAID (2018) shows that the very foundation of learning - reading skills - is very poor across the country. Its report concludes that more kids are in school, but most can’t read even  mother tongue, as shown in Table 1.

 

                    Table 1 Parentage of students who failed to read

                     even one word correctly, 2018

State	Mother tongue (language)	Per cent failed
Uttar Pradesh	Hindi	75.9
Rajasthan	Hindi	62.5
Karnataka	Kannada	53.2
Odisha	Oriya	38.8
Uttarakhand	Hindi	30.1
Chhattisgarh	Hindi	23.2
Maharashtra	Marathi	3.8
Source: 2018 USAID Study conducted in Seven States

 

 

As such, Pratham’s annual review of school education will make you cry. Language and mathematical skills are miserable: only half our Class 5 students can read Class 2 texts; a mere 40 per cent in Class 8 can do long division. Further, India’s 15-year old children ranked 73rd out of 74 countries in the international PISA test-2009 of reading, science and arithmetic (just ahead of Kyrgyzstan). The UPA government was so embarrassed – it banned the test.

With primary school enrollment reaching around 97 per cent since 2009, the problem is now of quality, not that of numbers. More than half of India’s students can be classified as functionally under-educated or simply half-educated, and they are mainly from the poorer sections of the society studying in public schools. India has failed miserably in translating schooling into genuine learning.[1]

And, there is no wonder that the World Bank ranked India at 115th out of 157 countries on the Human Capital Index in 2018. [2] HCI seeks to measure the amount of human capital that a child born today can expect to attain by the age of 18. According to its parameters, a child born in India today will only be 44 per cent as productive as she could have been if she had enjoyed quality education and full health as well as a better living environment including water and sanitation.

It means about 56 percent of children born today in India will lose more than half their potential lifetime earnings because governments are not currently making effective investments in their children to ensure a healthy, educated, and resilient population ready for the workplace of the future. 

The World Bank placed India at a lower position (115) than Sri Lanka (74), Nepal (102) and Bangladesh (106) based on parameters like education, health and sanitation. [3] 

The issue of the quality of school education has always been side lined by our policy makers. As a result, for the first time since 2012, there is not a single Indian entry in the world’s top 300 higher learning institutes, as per the Times Higher Education’s 2020 rankings. The Indian Institute of Science (IISC) in Bengaluru—the only Indian entry in the top 300 last year—dropped into the 301-350 group. IITs in Mumbai, Delhi and Kharagpur have been placed in the 401-500 ranking bracket. Similarly, Delhi-based Jawaharlal Nehru University was ranked in the 601-800 grouping, though it is number one among central universities in NIRF 2020 rankings and is next only to IISC.

 

It appears that without taking  the current state of education, as noted above,  the NEP-2020 hastily decided its vision: “An education system rooted in (the) Indian ethos that contributes directly to transforming India, that is Bharat…making it into a global knowledge superpower (“Vishwaguru” - विश्वगुरु) with truly global citizens.”

 

To achieve the vision, the policy envisages that the current curricular and pedagogical structure of school education will undergo a thorough change to meet the developmental needs and interests of school children for their development at different stages. The NEP 2020 will give a thrust on Early Childhood Care and Education (ECCE). It will replace the 10+2 structure of school curricula by a 5+3+3+4 curricular structure corresponding to ages 3-8, 8-11, 11-14, and 14-18 years respectively. The 5+3+3+4 structure will comprise 12 years of school and three of Anganwadi or pre-school.

 

However, it does not clarify how it will be achieved. In place of this, it uses jargon or specialized technical terminology to confuse us and at the same time try to convince us   that the new education policy envisages very ambitious and fundamental education reforms.

 

There is no logic, however, to the clubbing of primary classes 1 and 2 with ECCE, run in anganwadis (whose workers are not professionally trained teachers) and in elite pre-primary schools. Similarly, clubbing classes 9-12 allows an early diversion into vocational courses of those not considered ‘able’ for more sought-after academic courses. Vocational education, however, needs creative and credible courses developed with some inputs of education, not just skills designed by the industry, as per Prof Rampal, the former dean, Faculty of Education, Delhi University.[4]

 

It appears that the policy could not figure out the real purpose of education. The main function of education is to teach one to think intensively and to think critically.   

 

In addition, the new policy focuses on multilingualism. It will give emphasis to all Indian languages, and children by learning through their mother tongue, will be benefitted, thus contributing towards the growth of the society as well as the so-called quality of education, the policy noted.

 

No doubt, the available research says, if students study in their mother tongue in early stages, it will help them in their cognitive development. One can argue that most  Chinese, Japanese and many other countries where people do not knows English but are far ahead of us in this globalised world. It is mainly that they have only one main language not like us.

 

If implemented, it will harm India’s prospect of progress. It is because,  the constitution recognizes 22 regional languages, which include Hindi but not English, as scheduled languages, that is not to be confused with the official status of the Union. Hindi and English are the only two languages mentioned on the Indian passport. I, therefore, recommend that the revised three-language formula should be adopted with a slight modification. Education in mother tongue with English as a second language to start with and any other major regional languages after 5th grade would be ideal. Looking at the importance of Hindi, I am sure that  non-Hindi speaking children will take Hindi as a third language.    

In addition, the new education policy is silent about the issue of public/government schools. India’s public elementary schools are in deep crisis, as per Prof .Arvind Panagariya, the former Deputy Chairman, NITI Aayog and Prof Geeta Gandhi Kingdon, University College, London.[5] Begin with enrolments. Nationally, the number of public schools has remained almost unchanged between 2010-11 and 2017-18. But the number of students has declined from 126.2 million to 102.3 million — a reduction of 23.9 million students. But still, the majority of students study in government schools where poor and vulnerable students study for free until the age of 14. As per the Education Ministry data, 65.2 per cent of all school students in 20 states used to go to the public schools in 2017. 

Large numbers of primary schools are single-teacher schools. In addition, teachers lack passion, accountability or commitment, are absent half the time, and so educational outcomes remain dismal year after year in Pratham surveys. As a result, even very poor people pull children out of free government schools and put them in expensive private schools that are scarcely better but give desperate parents some hope whereas most of the government schools give none. 

As such, the new education policy would have take cognizance of this situation. However, the policy emphasises and recognises the importance of private schools and intends to make it easier to establish new ones. One is forced to conclude that the new education policy is proposing closure of the public schools since it is ‘silent’ on universalizing school education and RTE. [6]

 

If we want to enhance the process of human capital, we can’t neglect the public schools. It will freeze the prospect of more than half thepopulation, who are poor and sending their children to the public school since they are free and having the best teachers looking to their selection process. To overcome the crisis, the first point to recognise is that hiring more teachers is not the solution. Instead, we need to begin involving the panchayat raj system in managing the public schools, as argued in my recent work. [7]

 

Indeed, India still is very much a low-productivity economy. For India to graduate to a high-productivity economy, it will be essential to undertake a wide array of reforms to expedite the process of human development with special reference to the disadvantageous section of the society.As such, I was expecting from the new education policy that  it will suggest  some bold and doable  steps in revamping the teaching but what  I found as it is  generally expressed in   a popular Hindi saying: khoda pahaad nikalee chuhiya (meaning: dug up a mountain to find only a mouse). 

In sum, the government doesn’t really require a policy. It requires a clear-cut defined action plan because what’s missing in education is the action on the ground. By and large, the diagnosis and prescriptions are available. Therefore, I agree with Anil Swarup, former secretary for school education and literacy, GoI that we need an action plan rather than a policy statement on education.[8]

 

It is no secret that the PM Modi wants to leave a legacy. Education reform could be his greatest legacy. He has the energy, intelligence and political shrewdness to bring change.

 

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[1] Kothari, Devendra. 2017. “Managing school education in India”, in Administrative Change, Vol. XLIV (2): 78-89.

 [2] Refer  2018 Human Development Index (HDI) at: https://www.onlinegk.com/news-and-tips/2018-human-development-index-(hdi)

 [3] Read more at: https://economictimes.indiatimes.com/news/economy/policy/india-rejects-findings-of-world-bank-report-on-human-capital-index/articleshow/66170167.cms?from=mdr

 [4] Read more at: https://timesofindia.indiatimes.com/blogs/voices/reads-like-an-impressive-wish-list-but-barters-right-to-education/

[5] Read more at: https://economictimes.indiatimes.com/industry/services/education/view-indias-public-elementary-schools-are-in-crisis-and-hiring-more-teachers-is-not-the-solution/articleshow/76249780.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

 [6]  Read more at: https://sabrangindia.in/article/proposing-closure-govt-schools-why-nep-silent-universalising-school-education

 [7] Kothari, Devendra (2019). Nurturing Human Development: A Strategy for New India, New Delhi: Paragoan International Publishers.

 [8] Read more at: https://timesofindia.indiatimes.com/blogs/melange/government-doesnt-require-an-education-policy-it-requires-a-clear-cut-action-plan-because-that-is-missing-on-the-ground/