Column : The malnutrition puzzle

Written by Michael Walton | Michael Walton | Updated: Mar 17 2009, 06:41am hrs
Child malnutrition in India is both shockingly high and a puzzle. Almost half of children under five are malnourished in terms of low weight for their age. Nearly 80 percent of young children suffer from anaemia. Conditions are worse than in Ethiopia, a country that is much poorer than India and infamous for its periodic food crises. If the National Family Health Survey numbers are right, malnutrition barely declined between the late 1990s and the mid-2000s, a period of rapid expansion in aggregate prosperity.All this despite the fact that India has a long tradition of food programmes and the Integrated Child Development Services (ICDS) specifically targeted at early childhood development.

So is this a story of the failure of Indias pro-market model to reach the poor, even before the coming slowdown

The malnutrition puzzle is more complex than that, and about much more than poverty. It is about failures in information, institutional functioning and distortions in political processes. Tackling child malnutrition is neither (just) about reducing income poverty, nor (just) about putting more resources into the ICDSimportant as these may be. It requires a transformational process in how the state functions and interacts with society, especially at local levels. The problem of malnutrition provides a prism on the broader failings in institutional functioning.

So what is the nature of the problem

Malnutrition is indeed higher for poor households, but many of the non-poor are also malnourished, including a quarter of children of mothers with more than 10 years education. Gujarat is much richer than Uttar Pradesh but had higher malnutrition in the mid 2000s.

Yet tackling child malnutrition is not a mystery. It is not only about food. Nutritional status is a product of the interaction between nutrient intake, child care and health status. Sheer poverty can be part of the story, but so is the micronutrient intake of pregnant mothers, breastfeeding and weaning practices, water quality, sanitation, handwashing, immunization, the quality and use of health services and so on. This is a system, affected by social knowledge and the behaviour of multiple actors. Public action involves classic public goodsnotably informationand it involves many agencies.

How well does the broader institutional system support this local system of nutritional determination In general very badly, precisely because of two pervasive features of Indias institutions: the centrality of patronage and populism as political strategies; and poorly performing state organizations, whether because of lack of incentives to respond to the needs of citizens or the disempowerment of frontline workers.

These institutional structures lead to a bias in favour of providing jobs, personal favours, local roads, a new water supply, subsidiesthings that deliver specific benefits to particular groups, and that can be credibly promised by politicians. They are biased against providing public goods, and anything involving complex organizational action. And this is exacerbated by the low political salience of childrens issuesthough this too is surely partly an informational issue.

There is significant variation across India. As the FOCUS report (on the conditions of children under six) found, anganwadis in Tamil Nadu function well, with motivated staff, high levels of responsiveness to children, and respect from the community, in sharp contrast to dismal conditions in many parts of India. This isnt because Tamil Nadu is free of patronage and populism, but because of a history of reasonable state capacity aligned with the local political and institutional system.

So what is the answer I think the Right to Food movement has the principles essentially right. Technical solutions matter, but will be like pushing on a string absent institutional change. This requires complementary action both from within the state and from social movements in the public and political spheres. This government is putting substantial more resources into the ICDS, especially in geographic areas where malnutrition is worse. It is too early to assess whether this will bear fruit. And success will depend crucially on how things play out at the local level. There is also an additional role for top-down initiatives, especially around really deep information campaigns; potentially also around food fortification, provided this can be managed in line with social need and not commercial interests and kickbacks.

This is hugely important. Malnutrition in the first year or two of life has permanent effects on long-term physical and mental development. It is a stark example of the creation of inequality of opportunitymalnourished children will have lower capabilities as adults to participate in the expansion of economic opportunities. And in the absence of concerted intervention, malnutrition is a source of the reproduction of inequality, since malnourished mothers are much more likely to have low-birth weight children.

Look out for whether local politicians campaign on delivering measurable improvements in child malnutrition in their constituencies.

The author is at Harvard's Kennedy School, The Institute of Social and Economic change and Centre for Policy Research.