India's disadvantaged lack nutrition, except we don't know how much

India’s national nutrition-specific programmes reach various social groups nearly equally, data show, and differences between uptake and delivery for all groups are small too. Yet more people from Scheduled Tribe and Scheduled Caste communities remain undernourished, as successive National Family Health Surveys have shown.

During the ongoing COVID-19 crisis, the link between social identities and access to health services has been well documented in the United States and Brazil--the two countries most affected besides India--with socially vulnerable groups such as blacks and indigenous peoples having been disproportionately affected.

In India, caste is a dominant aspect of an individual’s social identity and can similarly determine access to crucial health and nutrition services. But official sources such as the National Family Health Survey (NFHS) reports do not provide these details. Details showing outcomes of nutrition programmes for individual social groups--including scheduled castes and tribes--at the national, state and district levels, are not provided in a readily readable or usable format.

If such disaggregated data were made available--say, if we knew how much access Scheduled Caste groups in a particular district have to safe drinking water and sanitation, or how many women from Scheduled Tribe communities in a given district were anaemic--policy-level reforms could be implemented, such as increasing the number of Anganwadi centres in SC- and ST-dominated districts, or employing more Anganwadi workers from SC and ST communities.

In this first story in our series on gaps in public data, we examine how the lack of social identity information in the NFHS’s nutrition reports makes it difficult for policy makers and development partners to optimally design and implement nutrition programmes to target the marginalised groups that have the worst nutrition indicators. It also prevents scrutiny of these shortfalls, especially crucial to address the disproportionate impact of the global nutrition crisis created by the COVID-19 pandemic on socially disadvantaged groups.

Undernutrition and inequity

Months prior to COVID-19, traveling across a few districts in central and western Odisha to understand how accessible state-run nutrition services are, we visited numerous tribal hamlets where the first thing we noticed was the lack of National Rural Health Mission (NRHM) Anganwadi centres close to where people lived. Some centres were as far as 8 km from people’s homes.

In the course of our conversations, we found that pregnant and lactating ST women rarely received maternal healthcare services on Village Health Nutrition Days, given the distances that Anganwadi workers would have to travel. Several SC families narrated stories of discrimination against women and children, making their experience of accessing nutrition very unpleasant, despite NRHM “guarantees” of “better health outcomes” especially for “those belonging to marginalised and vulnerable communities”.

Both immediate (‘nutrient-specific’) factors such as access to nutrient-rich food and caregiving practices and underlying (‘nutrient-sensitive’) factors such as poverty and access to health services determine undernutrition and nutritional inequities, which are well explained in the Global Nutrition Report 2016 that covered 193 countries.

India’s largest and official nutrition survey, the National Family Health Survey (NFHS), however, does not publish data on several immediate and underlying factors disaggregated by social groups--such as caste, tribal or religious identities--at the national, state or district levels. Where such data are collated, they are not made public in a usable format, preventing closer examination that could reveal inefficiencies and improve reach to disadvantaged communities.

Nutritional disparities 

SC and ST communities remain worse off in nutrition outcomes than other groups, the latest NFHS-4 conducted in 2015-16 found, as had NFHS-2 (1998-99) and NFHS-3 (2005-06). SC and ST children show stunting and underweight levels and ST children wasting levels higher than children of all groups taken together, according to NFHS-4. More SC and ST women are anaemic than women of all groups.

It is well established that nutrition interventions for mothers and children in the first 1,000 days after birth are critical. The NFHS assesses levels of stunting (low height-for-age) in children, an indicator of chronic undernutrition, reflecting inadequate nutrition over a long period; wasting (low weight-for-height), an indicator of acute undernutrition reflecting inadequate nutrition in the period immediately before the survey; and underweight (low weight-for-age), a composite index of height-for-age and weight-for-height which assesses both acute and chronic undernutrition in children.

SC and ST children show stunting levels of 42.8% and 43.8%, respectively, while all groups taken together record a lower 38.4%, according to NFHS-4. Similarly, a greater proportion of SC (39.1%) and ST (45.3%) children are underweight compared to all groups (35.8%). SC children show levels of wasting (21.2%) just above all groups at 21%; ST children show 27.4%.

For maternal nutrition outcomes such as anaemia among women, SC and ST groups show much higher levels at 55.9% and 59.9%, respectively, compared to all groups at 53.1%.

Marginal difference in coverage of nutrition interventions

Tackling undernutrition requires a focus on both immediate (nutrition-specific, such as micronutrient and food supplementation, and treatment of childhood diseases) and underlying (nutrition-sensitive, such as women’s literacy levels and age at marriage, access to health care, safe drinking water and sanitation) causes, said a 2013 report in The Lancet medical journal.

India’s national nutrition-specific programmes--such as for micronutrient and food supplementation and treatment of childhood diseases--reach various social groups nearly equally, according to NFHS-4. Differences between uptake and delivery for all groups are small too.

For instance, the proportion of all mothers who took iron and folic acid (IFA) tablets for at least 100 days in 2015-16 was 30.3%, according to NFHS-4, versus 28.6% for SC women and 26.8% for ST women. Supplementation of Vitamin A was 59.5% for children from all groups against 60% for SC children and 59.4% for ST children.

The proportion of children who had diarrhoea and received oral rehydration salt (ORS) was 50.6% overall, compared to 51.1% for SC children and 55.3% for ST children. Further, the uptake for supplementary nutrition programmes was higher among SC and ST women and children compared to all groups, NFHS-4 data on food supplementation for both women and children show.

Despite these small differences in uptake between various social groups, higher levels of undernutrition persist among SCs and STs, indicating failure to address the underlying nutritional determinants such as access to health care and safe drinking water.

Inadequate data

The underlying determinants of health and nutrition--the main reference point for policy makers and practitioners when designing nutrition interventions--include food security, women’s literacy levels and age at marriage, and access to healthcare and safe drinking water and sanitation. 

Our analysis of NFHS-4 data shows a six- to 15-percentage-point difference in literacy levels of women from different social groups, with SC (62%) and ST (53%) women seeing lower levels than women from all groups (68.4%). There is also a seven-15-percentage point difference between women with at least 10 years of education from different social groups, with SC (28.2%) and ST (20.2%) women at much lower levels than women from all groups (35.7%).

However, NFHS reports do not provide data disaggregated by social groups at the all-India level for some of the other underlying factors, including women’s access to maternal health services and household employment status, poverty level and access to electricity, drinking water and sanitation facilities.

While the NFHS does collect such data, it does not present them in its published reports. The raw data collated and made public require specialised, costly software and technical ability to access, preventing wider scrutiny to detect problems that result in poor nutrition outcomes among disadvantaged groups.

Caste a dominant social identity but data caste-blind

In India, caste is a dominant aspect of an individual’s social identity, and can also determine access to crucial health and nutrition services. Our field experience in Odisha indicated that caste-based discrimination limits SC/ST communities’ access to government services.

Several studies including this 2009 report based on NFHS-3 findings point to caste-based discrimination in access to public health services and schemes related to food security of school children, leading to worse nutrition, health and mortality indicators among children from disadvantaged castes. In some cases, among children with similar education and standard of living, the health status of children from SC and ST communities is lower than that of their counterparts from higher castes.

The risk of anaemia is higher in disadvantaged castes and caste is an independent determinant of childhood anaemia, another study based on NFHS-3 findings suggests. The top 10 districts in India with the highest prevalence of stunting have a sizeable population of SCs or STs, indicating a correlation between social identity and prevalence of under-nutrition, a study based on NFHS-4 data found in May 2018.

India’s official data, however, do not adequately prioritise the role of social identity in achieving health and nutrition equity. Most robust datasets are either not asking the key questions around disaggregation or not releasing respondent or household level data in time, a research paper found in June 2014. The National Sample Survey, for instance, collected social identity data, i.e. on SCs and STs, on nutritional outcomes in its 68th round conducted between July 2011 and June 2012, but did not present the caste-disaggregated data in its survey report, the research paper noted.

Bureaucrats, nutritionists and planners have remained oblivious of caste-based barriers and other such social variables in nutrition, wrote Veena Shatrugna, former deputy director of the National Institute of Nutrition, a central government research institute in Hyderabad. She pointed out that the National Nutrition Monitoring Bureau (NNMB) report until 1990 was caste blind. When caste data first appeared in 1994, it did not provide a complete explanation for the nutritional status of SCs and STs.

Our own analysis of literature on the impact of social identity, specifically caste, revealed that the lack of data disaggregated by social group, e.g. religion and caste, constrains understanding of nutrition levels and their determinants among these groups.

Disaggregated data and COVID-19

The disproportionate impact of the COVID-19 pandemic on populations vulnerable on the basis of race across various countries was examined in a paper published in the International Journal for Equity and Health in June. The perspective from India, however, refers only to economic vulnerability to COVID-19, not inequality due to social identities such as caste.

The COVID-19 pandemic has induced a global nutrition crisis, straining healthcare systems and diverting resources from regular nutrition services (such as antenatal care, micronutrient supplementation and management of acute malnutrition) towards tackling COVID-19. Ensuring the availability and affordability of a nutrition-rich diet has become more difficult, with household incomes having fallen and more people pushed into poverty. In low and middle-income countries such as India, the pandemic’s effect on health and nutrition services could cause more maternal and child deaths, and greater prevalence of wasting, a study published in The Lancet in July cautioned.