A scatterplot of the percentage of stunting and net state domestic product (NSDP) per capita, with the latter serving as a proxy for each state's per capita income in Figure 1.4b. In this case, the two variables show a negative association, with poorer states having a significantly higher percentage of stunting as compared with more prosperous states. The association though has a number of outliers. For instance, Cluster 1‐ Bihar, Uttar Pradesh, Jharkhand, Meghalaya, Uttar Pradesh, and Madhya Pradesh have much higher level of stunting as expected from states of their income level. While states like Manipur, Mizoram, Tripura, and Jammu Kashmir are positive deviants with much lower percentage of stunting as compared with states with similar income level. These are states with better sanitation, literacy, and care for pregnant women. This indicates that not only income but also other socioeconomic factors might also be major contributors. The association between the percentage of stunting and the rate of economic growth for each state is shown in Figure 1.4c, which shows not much strong relationship between the two variables. Meghalaya with negative growth rate in 2014–2015 has a high level of stunting 42% but so did states like Jharkhand, Bihar, Uttar Pradesh, and Madhya Pradesh with much higher growth rate as compared to Meghalaya. Goa and Mizoram have a much higher growth rate but the percentage of stunting is not low in these states. This gives a conclusion that growth rate of a state is weakly associated with states prevalence of malnutrition. Thus, it can be concluded that despite economic progress, India has to struggle to combat malnutrition that adversely affects the country's socioeconomic progress. This is not due to food scarcity but due to the lack of equitable distribution of the available food. Food security depends not only on crop production, but also on the policies that affect food systems, from farm to table (World Food Conference 1974). To improve the diet consumption of whole population, when there is an increasing growth rate and unbalanced growth of working sectors, injecting money is not the solution. There are other challenges like inequitable distribution of income, lack of awareness and access to healthy food, climate change, slowdown of economy, and lower income levels that threaten the hunger of the countrymen.
Figure 1.4 Association of stunting prevalence with socio‐economic indicators. Note‐ (a) State‐wise percentage of BPL (based on MRP‐consumption) in rural and urban areas of India, 2011–2012 (b) Measurement at current prices based on 2011–2012 series, (c) State‐wise, (at constant prices based on 2011–2012 series).
Comparison of the states with lower stunting percentage and those with higher stunting percentage, based on seven indicators, was done viz. improved drinking water sources, improved sanitation facility, use of iodized salt, literacy among women, antenatal care, and anemia among children and women (Figure 1.5). These indicators also impact level of undernutrition in India (Ghosh 2020; Martorell and Young 2012). The interstate comparison showed that states who have higher prevalence of stunting, underweight and wastage have lower percentage of improved sanitation facility, literacy among women, antenatal care, and higher percentage of anemia among children and women as compared to states having lower prevalence of the same factors. These are the factors which influence absorption of nutrients, access to nutritious food, and care of feeding right diet to the child at the right time.
1.4 Institutional Interventions to Cope Up with Malnutrition
Nutrition is accredited as one of the important characters of human development, dealing with poverty reduction and scaling up the economy. As discussed above, a nutrition policy is needed because the attainment of food self‐sufficiency does not ensure nutrition security. India, being the leader in production of a number of food products, lags behind when it comes to the nutrition status of children. This gap between production and consumption urged a need to devise a policy that could ensure the upliftment of the nutrition status. In such situations, it is the institutional intervention that emerges as a problem solving resort to cope up with the issue. Since independence, the Government of India has taken various steps to deal with the burden of malnutrition which can also be called as the double burden of malnutrition. But, before moving to the policies adopted and executed, it is imperative to understand the mechanism of the causes of malnutrition. Malnutrition is not something that is caused by a single causal factor or habit or reason. Occurrence of malnutrition is a complex activity and is caused by a set of factors which can be majorly divided into (i) personal, (ii) socioeconomic, and (iii) administrative. Among the personal factors, the problem associated with the individual are insufficient dietary intake, inadequate absorption of nutrients, inadequate care of child and mother, and mismanagement of disease prevention and care. Factors relating to the habit of the child and mother can be rectified through women empowerment, awareness, proper diet, and medical care. The socioeconomic factors are poverty, unorganized livelihood, lack of resources, lack of access to health care, unavailability of safe drinking water, unhygienic surroundings, etc. These call for development efforts at societal level where the area administration needs to ensure the following: availability of safe drinking water, cleaning of the area, generation of employment options. The last and the foremost factor is the administration where despite the existence of suitable schemes and programmes to eradicate the existing causal effects, the implementation lags behind. Reasons like poor scheme implementation, low quality of food distributed, lack of awareness, and inadequate evaluation prevail. This implementation lacunae need to be addressed and taken care of. Policies play an important role in curbing the issue of nutrition (Hawkes 2005; Mozaffarian et al. 2018). Integrated approaches are required for solving the issues of hunger and malnutrition (Burchi et al. 2011). While formulating the policy there are three things that should be kept in mind as the policy directly increases the coverage of nutritious food, incorporates behavioral changes among mothers, targeting adolescent girls, prenatal and postnatal care and nutrition, and provision of nutrient rich food.
