Pardeshi G, Wang W, Kim J, et al. TB notification rates across parliamentary constituencies in India: a step towards data-driven political engagement. Tropical Medicine & International Health. 2021;26 (7) :730-742. Publisher's VersionAbstract


National averages obscure geographic variation in program performance. We determined Parliamentary Constituency (PC)-wise estimates of TB notification to guide political engagement.

We extracted district-level TB notification data from the 2018 annual TB report. We derived PC-level estimates by building a ‘cross-walk’ between districts and PCs using boundary shapefiles. We described the spatial distribution of the PC-wise estimates of Total Notification Rate and percentage of Private Sector Notification.

The median PC-wise Total Notification Rate was 126.24/100 000 (IQR: 94.86/100 000, 162.22/100 000). The median PC-wise Percentage Private Sector Notification was 18.03% (IQR: 9.56%, 26.84%). Only 16 (2.94%) PCs met the target of 50% private sector notification. Most of high notification rates in PCs were driven by high notification in public sector. There was geographic – both interstate and within state inter-PC – variation in the estimates of these indicators. The study identified some geographic patterns of notification – high positive outlier PCs with adjoining PCs in lower deciles of notification rates, intra-state differences in PC performance, and similarities in notification rates of adjoining PCs in different states.

In addition to regional inequality, the study identified geospatial patterns that can aid in the formulation of suitable interventions. These include decongestion of overburdened facilities by strengthening poorly performing units. The PCs with a high percentage Private Sector Notification can act as role models for neighbouring PCs to improve private sector engagement. MPs can play a crucial role in mobilising additional resources, creating awareness, and establishing inter-PC and inter-state collaboration to improve TB program performance.


Kim R, Bijral AS, Xu Y, et al. Precision mapping child undernutrition for nearly 600,000 inhabited census villages in India. Proceedings of the National Academy of Sciences of the United States of America. 2021;118 (18).Abstract
There are emerging opportunities to assess health indicators at truly small areas with increasing availability of data geocoded to micro geographic units and advanced modeling techniques. The utility of such fine-grained data can be fully leveraged if linked to local governance units that are accountable for implementation of programs and interventions. We used data from the 2011 Indian Census for village-level demographic and amenities features and the 2016 Indian Demographic and Health Survey in a bias-corrected semisupervised regression framework to predict child anthropometric failures for all villages in India. Of the total geographic variation in predicted child anthropometric failure estimates, 54.2 to 72.3% were attributed to the village level followed by 20.6 to 39.5% to the state level. The mean predicted stunting was 37.9% (SD: 10.1%; IQR: 31.2 to 44.7%), and substantial variation was found across villages ranging from less than 5% for 691 villages to over 70% in 453 villages. Estimates at the village level can potentially shift the paradigm of policy discussion in India by enabling more informed prioritization and precise targeting. The proposed methodology can be adapted and applied to diverse population health indicators, and in other contexts, to reveal spatial heterogeneity at a finer geographic scale and identify local areas with the greatest needs and with direct implications for actions to take place.
Rajpal S, Kim J, Joe W, Kim R, Subramanian SV. Small area variation in child undernutrition across 640 districts and 543 parliamentary constituencies in India. Scientific Reports. 2021;11 (1) :4558.Abstract
In India, districts serve as central policy unit for program development, administration and implementation. The one-size-fits-all approach based on average prevalence estimates at the district level fails to capture the substantial small area variation. In addition to district average, heterogeneity within districts should be considered in policy design. The objective of this study was to quantify the extent of small area variation in child stunting, underweight and wasting across 36 states/Union Territories (UTs), 640 districts (and 543 PCs), and villages/blocks in India. We utilized the 4th round of Indian National Family Health Survey (NFHS-4) conducted in 2015–2016. The study population included 225,002 children aged 0–59 months whose height and weight information were available. Stunting was defined as height-for-age z-score below 2 SD from the World Health Organization child growth reference standards. Similarly, underweight and wasting were each defined as weight-for-ageþinspace}< -2 SD and weight-for-heightþinspace}< -2 SD from the age- and sex-specific medians. We adopted a four-level logistic regression model to partition the total variation in stunting, underweight and wasting. We computed precision-weighted prevalence of child anthropometric failures across districts and PCs as well as within-district/PC variation using standard deviation (SD) measures. For stunting, 56.4% (var: 0.237; SE: 0.008) of the total variation was attributed to villages/blocks, followed by 25.8% (var: 0.109; SE: 0.030) to states/UTs, and 17.7% (Var: 0.074; SE: 0.006) to districts. For underweight and wasting, villages/blocks accounted for 38.4% (var: 0.224; SE: 0.007) and 50% (var: 0.285; SE: 0.009), respectively, of the total contextual variance in India. Similar findings were shown in multilevel models incorporating PC as a geographical unit instead of districts. We found high positive correlations between mean prevalence and SD for stunting (rþinspace}=þinspace}0.780, pþinspace}<þinspace}0.001), underweight (rþinspace}=þinspace}0.860, pþinspace}<þinspace}0.001), and wasting (rþinspace}=þinspace}0.857, pþinspace}<þinspace}0.001) across all districts in India. A similar pattern of correlation was found for PCs. Within-district and within-PC variation are the primary source of variation for child malnutrition in India. Our results suggest the importance of considering heterogeneity within districts and PCs when planning and administering child nutrition policies.
Rajpal S, Joe W, Kim R, Kumar A, Subramanian SV. Child Undernutrition and Convergence of Multisectoral Interventions in India: An Econometric Analysis of National Family Health Survey 2015–16. Frontiers in Public Health. 2020;8 :129.Abstract

In India and worldwide, there has been increased strategic focus on multisectoral convergence of nutrition-specific and nutrition-sensitive interventions to attain rapid reductions in child undernutrition. For instance, a Convergence Action Plan in India has been formed to synchronize and converge various nutrition-related interventions across ministries of union and state governments under a single umbrella. Given the large variation in number, nature and impact of these interventions, this paper aims to quantify the contribution of each intervention (proxied by relevant covariates) toward reducing child stunting and underweight in India. The interventions are classified under six sectors: (a) health, (b) women and child development, (c)education, (d) water, sanitation, and hygiene, (e) clean energy, and (f) growth sector. We estimate the potential reduction in child stunting and underweight in a counterfactual scenario of “convergence” where all the interventions across all the sectors are simultaneously and successfully implemented. The findings from our econometric analysis suggests that under this counterfactual scenario, a reduction of 18.37% points (95% CI: 16.77; 19.95) in stunting and 20.26% points (95% CI: 19.13; 21.39) in underweight can be potentially achieved. Across all the sectors, women and child development and clean energy were identified as the biggest contributors to the potential reductions in stunting and underweight, underscoring the importance of improving sanitation-related practices and clean cooking fuel. The overall impact of this convergent action was relatively stronger for less developed districts. These findings reiterate a clear role and scope of convergent action in achieving India’s national nutritional goals. This warrants a complete outreach of all the interventions from different sectors.

deSouza PN, Subramanian SV. COVID-19 across United States congressional districts. Journal of Global Health Sciences. 2020;2 (22).Abstract

The congressional district (CD) geography in the United States (US) represents a policy-relevant and a politically important scale at which to monitor the coronavirus disease 2019 (COVID-19) crisis. In this study, we present the first estimates of COVID-19 cumulative cases and deaths (per 1,000 people) and the case fatality rate as of July 13, 2020, as well as for the recent period between June 13 and July 13, 2020 using a population-weighting methodology for the 436 CDs in the US. Access to CD-level information about the impact of COVID-19 can enhance the ability of elected officials and the constituents they represent, to monitor and develop testing strategies and other measures to allow the US to open safely.

deSouza PN, Subramanian SV. COVID-19 across United States congressional districts for three cumulative time periods. 2020.Abstract
The data replicate tables and figures from "COVID-19 across United States congressional districts", by deSouza and Subramanian. (2020-07-20)
Beckerman-Hsu JP, Kim R, Sharma S, Subramanian SV. Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India. The Journal of Nutrition. 2020;150 (10) :2818-2824.Abstract

Minimum Dietary Diversity (MDD) is a widely used indicator of adequate
dietary micronutrient density for children 6–23 mo old. MDD food-group data
remain underutilized, despite their potential for further informing nutrition
programs and policies. We aimed to describe the diets of children meeting
MDD and not meeting MDD in India using food group data, nationally and
subnationally. Food group data for children 6–23 mo old (n = 73,036) from
the 2015–16 National Family Health Survey in India were analyzed. Per WHO
standards, children consuming ≥5 of the following food groups in the past
day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts;
dairy; flesh foods; eggs; vitamin A–rich fruits and vegetables; and other fruits
and vegetables. Children not meeting MDD consumed <5 food groups. We
analyzed the number and types of foods consumed by children meeting
MDD and not meeting MDD at the national and subnational geographic
levels. Nationally, children not meeting MDD most often consumed breast
milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children
meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin
A–rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other
fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting
MDD, district-level dairy consumption varied the most (6.4%–79.9%), whereas
flesh foods consumption varied the least (0.0%–43.8%). For children meeting
MDD, district-level egg consumption varied the most (0.0%–100.0%), whereas
grains, roots, and tubers consumption varied the least (66.8%–100.0%).
Children not meeting MDD had low fruit, vegetable, and protein-rich food
consumption. Many children meeting MDD also had low protein-rich food
consumption. Examining the number and types of foods consumed highlights
priorities for children experiencing the greatest dietary deprivation, providing
valuable complementary information to MDD.

Rajpal S, Kim R, Liou L, Joe W, Subramanian SV. Does the Choice of Metric Matter for Identifying Areas for Policy Priority? An Empirical Assessment Using Child Undernutrition in India. Social Indicators Research. 2020;152 (3) :823-841.Abstract

Ratio-based prevalence and absolute headcounts are the two most
commonly accepted metrics to measure the burden of various socioeconomic
phenomenon. However, ratio-based prevalence, calculated as the number of
cases with certain conditions relative to the total population, is by far the
most widely used to rank burden and consequently for targeting, across
different populations, often defined in terms of geographical areas. In this
regard, targeting areas exclusively based on prevalence-based metric poses
certain fundamental difficulties with some serious policy implications.
Drawing the data from the National Family Health Survey 2015–2016, and
Census 2011, this paper takes four indicators of child undernutrition in India
as an example to examine two contextual questions: first, does the choice
of metric matter for targeting areas for reducing child undernutrition in
India? and second; which metric should be used to facilitate comparisons
and targeting across variable populations? Our findings suggest a moderate
correlation between prevalence estimates and absolute headcounts implying
that choice of metric does matter when targeting child undernutrition. Huge
variations were observed between prevalence-based and absolute countbased
ranking of the districts. In fact, in various cases, districts with the
highest absolute number of undernourished children were ranked as relatively
lower-burden districts based on prevalence. A simple comparison between
the two approaches—when applied to targeting undernourished children in
India—indicates that prevalence-based prioritization may miss high-burden
areas where substantially higher number of undernourished children are
concentrated. For developing populous countries like India, which is already
grappling with high levels of maternal and child malnutrition and poor health
infrastructure along with intrinsic socioeconomic inequalities, it is critical to
adopt an appropriate metric for effective targeting and prioritization.

Rajpal S, Kim R, Sankar R, et al. Frequently asked questions on child anthropometric failures in India. Joe, William and Kim, Rockli and Kumar, Alok and Sankar, Rajan and Rajpal, Sunil and Subramanian, SV, Frequently Asked Questions on Child Anthropometric Failures in India (February 8, 2020). Economic & Political Weekly. 2020;55 (6).Abstract

The National Family Health Survey is analysed to develop critical insights on child anthropometric failure in India. The analysis finds non-response of economic
growth on nutritional well-being and greater burden among the poor as two
fundamental concerns. This calls for strengthening developmental finance
for socio-economic upliftment as well as enhanced programmatic support
for nutritional interventions. The gaps in analytical inputs for programmatic
purposes also deserves attention to unravel intricacies that otherwise remain
obscured through customary enquiries. On the one hand, this may serve well
to improve policy targeting, and on the other, this can help comprehend the
nature and reasons of heterogeneities and inequities in nutritional outcomes
across subgroups. Strengthening the analytical capacities of programme
managers and health functionaries is recommended.Against this backdrop,
this paper outlines key programmatic concerns that require substantial
local-level insights for strategic feedback and course corrections to achieve
accelerated reductions in child undernutrition. The issues discussed are based
on the analysis of household survey data from NFHS 2015–16.

Subramanian SV, Sarwal R, William J, Kim R. Geo-visualising Diet, Anthroprometric and Clinical Indicators for Children in India. Harvard Dataverse. 2020.Abstract

Researchers from the Geographic Insights Lab at the Harvard Center for Population and Development Studies and the Institute of Economic Growth geo-visualised diet, anthropometric and clinical indicators for children across districts in India and provide a clear snapshot of high priority districts for targeting nutritional interventions among children in India.

Liou L, Kim R, Subramanian SV. Identifying geospatial patterns in wealth disparity in child malnutrition across 640 districts in India. SSM-population health. 2020;10 :100524.Abstract

We assessed district-level geospatial trends in precision weighted prevalence
and absolute wealth disparity in stunting, underweight, wasting, low
birthweight, and anemia among children under five in India. The largest
wealth disparities were found for anthropometric failures and substantial
variation existed across states. We identified statistically significant (p < 0.001)
geospatial patterns in district-wide wealth disparities for all outcomes, which
differed from geospatial patterns for the overall prevalence. We characterized
each district as either a “Disparity”, “Pitfall”, “Intensity”, or “Prosperity” area
based on its overall burden and wealth disparity, as well as discuss the
importance of considering both measures for geographically-targeted public
health interventions to improve health equity.

Subramanian SV. It’s not yet mission accomplished on the Centre’s Poshan Abhiyaan. Mint. 2020.Abstract

While some improvement has been made by the country, efforts to ensure nutritional security are more important than ever


It’s been three years since the Government of India launched the Prime Minister’s Overarching Scheme for Holistic Nutrition, or Poshan Abhiyaan . The goal was to improve the nutritional status of children and adolescent girls, as well as pregnant and lactating mothers. The urgency was evident as a clear time-frame of three years was set, and five indicators—prevalence of low birthweight, stunting, underweight and anaemia among children and women—were identified for substantial improvement. The government showed its commitment by putting money where its mouth was; it allocated 9,046.17 crore for the mission.


The trigger to go on an all-India mission was the disconcerting statistics revealed by the fourth National Family Health Survey (NFHS-4, 2015-16) on the above indicators. The fact sheets for 342 districts from 17 states and five Union territories (UTs) from the NFHS-5 , ( conducted in 2019-20, are now out. With the exception of prevalence of low birthweight, the just released district fact sheets provide data on four of the five Poshan Abhiyaan indicators. So, how have the 342 districts done with regard to meeting the targets set?


Comparing performance across districts: Of the four indicators, stunting across districts improved the most, with 69/342 districts experiencing a decline of more than 6 percentage points (the Poshan Abhiyaan target) between the two surveys. Child underweight followed a pattern similar to stunting with 42/342 districts meeting the target. Anaemia, however, is a different story; the Poshan Abhiyaan target of a 9-percentage-point decline in three years was observed for only 18/342 (women and adolescent girls) and 20/342 (children) districts.



A Mixed Bag

Some degree of decline in the prevalence of stunting and underweight was observed in nearly half of the districts. At the same time, a little over half of them also disconcertingly experienced a reversal. In 74/342 (stunting) and 66/342 (underweight) districts, the reversal was of the same magnitude as the target (i.e., 6 percentage point), but in the detrimental direction.


Anaemia not only showed minimal improvement across districts, it reversed in 81.3% (278/342 for children) and 74.3% (254/342 for adolescent girls/women) of the districts. Disturbingly, the reversal was greater than 9 percentage points in 186/342 (children) and 139/342 (adolescent girls and women) districts.

The way forward: The following two insights emerging from the data patterns would be crucial to consider if India chooses to upgrade and implement Poshan Abhiyaan 2.0.


First, within the same state, there are districts that experienced improvement as well as reversal, especially with regards to stunting and underweight findings. It is important that an immediate effort is made to learn from both success and failure in these districts. Such learning can focus on both the distinct components of the Poshan Abhiyaan programme, as well as how synergistically they were implemented.

Second, the fact that a notable number of districts experienced improvement and reversal suggests that inequality between districts (even within the same state) has increased. This might be an unintended consequence of a concentrated focus on certain districts over others in recent years.


Prioritizing certain districts over others is inevitable in any policy formulation and implementation. An examination of the districts that experienced substantial improvement or reversal, and whether they were priority districts for Poshan Abhiyaan or not would be necessary. Learning from this should then be used to modify or tweak using other methods for prioritization, both for efficiency as well as for promoting geographic equity. Further indicator-specific prioritization is also necessary as the data reveals different patterns for anthropometric-based nutritional measures of stunting/underweight from the more direct measures of dietary deficiency.


Recent evidence also makes it clear that it would be prudent to equally focus on within-district variation, in particular between villages. Villages are not only a setting for social engagement, but also are the unit where public policies and programmes come to fruition for the target population.

The three-year time-frame of Poshan Abhiyaan, incidentally, ended this month. It is unclear what the future of Poshan Abhiyaan will be. Regardless, the NFHS-5 data makes it obvious that reducing the burden of undernutrition, especially among children and women, will need to remain a greater priority than ever before. It is, therefore, imperative that the government undertakes a rigorous assessment of Poshan Abhiyaan, including an exploration of any changes and course corrections that may be necessary.


It is critical to remember that these statistics reflect a scenario prior to the covid pandemic and the 2020 lockdown. From all accounts, these two events hurt health and nutrition services, which are vital to any child’s first 1,000 days and a core feature of Poshan Abhiyaan. Whatever form the next phase of India’s mission to eliminate undernutrition takes, reversals experienced by a majority of districts on nutrition indicators suggest that India needs to make food security a centrepiece of its overall development agenda.

Laxmi Kant Dwivedi of International Institute for Population Sciences and Weiyu Wang and Weixing Zhang of Harvard Center for Population and Development Studies assisted with this article.


S.V. Subramanian is professor of population health and geography, Harvard Center for Population and Development Studies.

Subramanian SV, Chatterjee P, Karlsson O. Lessons from COVID-19 pandemic for the child survival agenda. Journal of Global Health. 2020;10 (2).Abstract

The public discourse around the COVID-19 pandemic has been strikingly quantitative. Worldwide, the mainstream media has regularly informed the public of confirmed COVID-19 cases and deaths, including projections of worst-case scenarios drawn from esoteric epidemiological models. The prominence and visibility of data, regardless of its completeness or quality, underscored the threat of COVID-19 to policy makers and lay individuals alike. It also prompted governments to swiftly lock down their societies, despite the socioeconomic disruptions and human suffering associated with such lockdowns. The widespread media coverage of COVID-19 data and swift response from governments highlight the potency of real-time data, and contain important lessons for public health policy, which when applied, could raise the profile of other health issues and spur action among key stakeholders.

Rajpal S, Joe W, Subramanian SV. Living on the edge? Sensitivity of child undernutrition prevalence to bodyweight shocks in the context of the 2020 national lockdown strategy in India. Journal of Global Health Science. 2020;2.Abstract

The National Family Health Survey (NFHS) 2015–16, finds that every second
child in India suffers from at least one form of nutrition failure. Dichotomised
indicators of underweight and wasting based on z-score cut-off does not
provide any information regarding those children who are clustered around
the threshold and are at an elevated risk of undernutrition through any minor
weight-loss. This paper aims to estimate the effect of bodyweight shocks on
net increments in the prevalence of child underweight and wasting among
the poorest households in India. We used cross-sectional information from
NFHS 2015–16 to estimate possible increase in the prevalence of child
underweight and wasting as a result of reduction in their bodyweight. The
shocks are presumed to range from a minimum of 0.5% to a maximum
5% reduction in the bodyweight for every child from the poorest 20%
households. Various raw weight measures scenarios were developed and
transformed into age- specific z-scores using World Health Organization child
growth standards. Nutritional status of children is sensitive to smallest of the
shocks to bodyweight. In fact, a reduction of 0.5 and 1 percent in weight can
lead to substantial increase in underweight and wasting prevalence. Under a
scenario of bodyweight shock of 0.5 percent, the prevalence of underweight
and wasting will increase by 1.42 and 1.36 percentage points, respectively.
These estimates get translated into 410,413 and 392,886 additional cases
of underweight and wasting, respectively. With such high concentration of
children around the undernutrition threshold, any minor shock to nutritional
health of the children can have major implications. In the current scenario of
national lockdown and restrictions due to coronavirus disease 2019 pandemic,
it is critical to ensure an uninterrupted supply of nutritious meals and food
supplements to the poor children while arresting the infection spread.

Joe W, Subramanian SV. NFHS shows stunting increased in ‘better-performing’ Kerala, Goa. India must not lose focus. The Print. 2020.Abstract

Reducing the burden of child undernutrition has been central to the developmental goals of the Government of India. The flagship programme, POSHAN Abhiyaan, launched in 2018, provided a much-needed fillip to the nutrition agenda. Dedicated budgetary allocation, and administrative and community efforts are expected to accelerate nutritional improvements in the years to come. Until now, the latest available estimates on various measures of children’s nutritional status came from the fourth round of the National Family Health Survey, or the NFHS, conducted in 2015-16. The much-awaited statistics on the prevalence of nutritional status among children from the fifth round of the NFHS conducted in 2019 in 17 states and five Union Territories (UTs) is out.

What can we learn with regards to the progress the country is making in terms of reducing the burden of undernutrition among Indian children?

Stunting prevalence

Considering the commonly used measure of anthropometric failure as an indication of undernutrition, it is clear that there cannot be any let up to the efforts that have been put in place recently. On all three measures of anthropometric failure (stunting, underweight and wasting) the mean prevalence across these 22 states/UTs has increased (see table).

Stunting prevalence decreased in nine states/UTs and increased in 13 states/UTs. Greatest reduction occurred in Sikkim, Manipur and Bihar. However, stunting increased in Kerala, Goa and Himachal Pradesh, i.e., states typically seen as ‘better performing’. It also increased in Maharashtra, Gujarat, and West Bengal. The prevalence of underweight, meanwhile, shows reduction in six states/UTs whereas wasting reduced in only eight states/UTs.

The POSHAN Abhiyaan had set a target of achieving two percentage points per annum reduction in stunting and underweight prevalence. None of the 22 states/UTs were able to achieve these aspirational targets in stunting or underweight, with Tripura and Nagaland showing an increase of more than two percentage points per annum. It is concerning that in seven states/UTs, all the three indicators have worsened since NFHS 2015-16. These include Himachal Pradesh, Kerala, Lakshadweep, Mizoram, Nagaland, Telangana and Tripura. Only three states i.e., Andhra Pradesh, Karnataka and Sikkim showed improvements in these three anthropometric indicators.

The decline in stunting by 5.4 per cent for Bihar is a bright spot in what appears to be a disconcerting trend. We hope there are opportunities to learn from this decline that can then be useful for other states, and to ensure that Bihar sustains this trajectory of decline. Notwithstanding this welcome trend, Bihar remains the state with the highest prevalence for stunting and underweight.

With the economy shrinking in the first two quarters of FY21, the Union and the state governments will also find themselves constrained in enhancing developmental spending directly related to nutritional health and well-being. But it is important that flagship schemes of the government of India display the same commitment as before, pandemic or not. In fact, these areas need an ever-greater intent and purpose in supporting states/UTs in their mission to reduce the burden of undernutrition among children.

What needs to be done?

It should be noted that ‘averages’ in India – even at the state level – mask more than they reveal, whether it relates to the geographic differences within a state (e.g., districts) or the differences in  the prevalence across socio-economic groups. It is well known that the most crucial determinant of a child’s anthropometric status is the household socio-economic well-being. It is crucial that the POSHAN Abhiyaan should find means to enhance and optimise resource allocations with a targeted focus on the poor and deprived sections. In addition to the programmes that are directly related to nutrition (e.g., food), the time is ripe to link sector- specific initiatives with the broader goal of poverty alleviation and improving the overall standard of living through employment generation and asset creation. Since the burden of anthropometric failure is known to be a consequence of multiple factors, the response to reducing it needs to embrace this perspective by convergence across sectors.

It should be noted that the sobering statistics delivered by the latest NFHS predates the Covid- 19 pandemic and the subsequent 2020 lockdown that followed as a response. Thus, the data that got released for 22 states/UTs, especially for those that appeared to have experienced a decline, needs to be interpreted cautiously as situation may have worsened. Similarly, states that experienced an increase, the magnitude could be even greater.

The NFHS 2019-20 is currently underway in the remaining 14 states/UTs, and we may be able to use this creatively to assess the impact of the 2020 lockdown that has relegated the economy and brought widespread disruptions, impacting the lower socio-economic groups disproportionately. For the first time since NFHS started measuring nutritional status systematically, India finds itself at an elevated risk of experiencing a trend-reversal in the prevalence of stunting and underweight. It may seem that child undernutrition — at least as measured through anthropometry — is turning out to be the Achilles’ heel of India.

Kim R, Liou L, Xu Y, et al. Precision-weighted estimates of neonatal, postneonatal and child mortality for 640 districts in India, National Family Health Survey 2016. Journal of Global Health. 2020;10 (2).Abstract

Background The conventional indicators of infant and under-five mortality are aggregate deaths occurring in the first year and the first five years, respectively. Monitoring deaths by <1 month (neonatal), 1-11 months (post-neonatal), and 12- 59 months (child) can be more informative given various etiological causes that may require different interventions across these three mutually exclusive periods. For optimal resource allocation, it is also necessary to track progress in robust estimates of child survival at a smaller geographic and administrative level.

Methods Data on 259627 children came from the 2015-2016 Indian National Family Health Survey. We used a random effects model to account for the complex survey design and sampling variability, and predicted district-specific probabilities of neonatal, post-neonatal, and child mortality. The resulting precision-weighted estimates are more reliable as they pool information and borrow strength from other districts that share the same state membership. The Pearson correlation and Spearman’s rank correlation were assessed for the three mortality estimates, and the Moran’s I measure was used to detect spatial clustering of high burden districts for each outcome.

Results The majority of under-five deaths was disproportionately concentrated in the neonatal period. Across all districts, the predicted probability of neonatal, post-neonatal, and child mortality varied from 6.0 to 63.9 deaths, 3.8 to 47.6 deaths, and 1.7 to 11.8 deaths per 1000 live births, respectively. The overall correlation between district-wide probabilities of mortality for the three mutually exclusive periods was moderate (Pearson correlation=0.47-0.58, Spearman’s rank correlation=0.58-0.64). For each outcome, a relatively strong spatial clustering was detected across districts that transcended state boundaries (Moran’s I=0.61-0.76).

Conclusions Sufficiently breaking down the under-five mortality to distinct age groups and using the precision-weighted estimations to monitor performances at smaller geographic and administrative units can inform more targeted interventions and foster accountability to improve child survival

Wang W, Zhang W, Subramanian SV. Prevalence of Anemia, Underweight and Stunting in 342 Districts of India. Harvard Dataverse. 2020.Abstract

This document presents the prevalence of anemia, underweight and stunting among children, adolescent and women for 342 Districts (17 States and 5 Union Territories) of India from the fourth (2015-16) and fifth (2019-20) National Family Health Survey (NFHS) and percentage point changes between the two surveys.

Subramanian SV, Joe W. Putting food at the centre of India’s nutrition agenda. The Hindu. 2020.Abstract

The provisional verdict from the fifth round of the National Family Health Survey (NFHS 2019-20 factsheets on the burden of child undernutrition is not encouraging, with few exceptions. For the most part, this assessment has relied on the measure of a child’s anthropometry, i.e., children are defined as stunted, underweight or wasted if their standardised height-for-age, weight-for-age or weight-for-height, respectively, is more than two standard deviations below the World Health Organization (WHO) Child Growth Standards median.

However, undernutrition can also be measured by observing the adequacy and sufficiency of food or dietary intake among children. So how do Indian children fare when we bring a food measure to tell us about their nutritional status?

Diet-related undernutrition

Across the 22 States/Union Territories for which the NFHS-5 has released the factsheets, the percentage of children (aged 6-23 months) who do not meet the minimum dietary adequacy — as defined under the Infant and Young Child Feeding (IYCF) practices by WHO — is 83.9%; a decline of just over 2 percentage points from what was observed in NFHS-4 (2015-16). Thus, eight out of 10 children appear to be experiencing a dietary shortfall. It would not be surprising if this situation has worsened ( with the spread of the COVID-19 pandemic and the ensuing 2020 lockdown.

Although 17 of the 22 States/Union Territories did experience a decline, the percentage of children not meeting the dietary adequacy norms increased in five States/Union Territories. Goa experienced the largest percentage point decline (11.1%), and Jammu and Kashmir observed the highest increase in its percentage of children not meeting dietary adequacy over the last three years (76.5% to 86.4%). While there are some variations, in every State more than 75% of the children do not receive the minimum adequate diet.

Analysis based on NFHS-4 has shown that consumption of protein-rich food as well as fruit and vegetables were substantially low. Since the disaggregated child-level data on consumption of various food groups has not been released, we will have to wait to see what specific aspects are children experiencing a dietary shortfall.

Prevalence of anaemia

Fortunately, the factsheets provide the percentage of children who are anaemic — an indication of iron deficiency — and the trends should raise concern. Across the 22 States/Union Territories, anaemia prevalence among children increased by about eight percentage points from 51.8% to 60.2%. The prevalence of anaemia in childhood increased in 18 of the 22 States/Union Territories. In the majority of the States, two out of three children have possible iron-deficiency. The State-wise trends for adults are mixed, although it is clear that women are substantially at a far greater risk for anaemia than men.

The Prime Minister’s Overarching Scheme for Holistic Nutrition (POSHAN) Abhiyaan and, particularly, the Anemia Mukt Bharat, or AMB, Strategy was launched in 2018 with efforts to improve Iron and Folic Acid (IFA) supplementation, behaviour change and anaemia-related care and treatment across six target groups including pregnant women, lactating mothers, and children, and the provisional verdict is mixed for women and concerning for children.

Diet-related measures

Viewing the burden of child undernutrition from a food or dietary lens is sobering, and raises serious concerns than what has been well-revealed by measures based on anthropometry. It is time that undernutrition is not only viewed simply through the measures of anthropometric failure, but is complemented through explicit attention to diet-related measures.

A classification of nutritional status using a combined typology based on children who experience dietary failure and anthropometric failure is crucial. A recent NFHS-4 based study using this typology found that 36.3% of children who experienced a dietary failure do not show anthropometric failure. Anthropometric-centric measures thus run the risk of omitting such children from policy discussions. A combined typology is also necessary to highlight groups that may need most immediate priority (e.g., children experiencing both dietary and anthropometric failures, 44%). Indeed, the prevalence of children who experience anthropometric failure only but no dietary failure was only 9.8%.

Dietary factors can clearly be a major determinant of stagnancy in the nutritional status of Indian children. The true burden of child undernutrition thus may well be underestimated by the sole reliance on anthropometric measures. Besides, a child’s anthropometric status is a consequence of several complex factors, including inter-generational, which current policies and interventions cannot alter in the short term. Importantly, food and diet have an intrinsic importance, regardless of their impact on a child’s anthropometry. Therefore the nutrition agenda needs to be considered from “food as a right” perspective.

A disproportionate focus on anthropometric measures inadvertently precludes meaningful and direct engagement with strategies and data necessary to address diet and food security concerns. Data, available in a timely manner and in public domain, is empowering, as the NFHS has demonstrated over the last 25-plus years. But systematic and quality data on what Indians eat remains largely unknown.

Data initiative needed

It is important to emphasise that India does not have a dedicated nationally representative survey on the dietary intake and nutritional status of children or adults. A modern data initiative leveraging and combining aspects of the NFHS, the National Nutrition Monitoring Bureau and the National Sample Surveys that collected data on detailed household-level consumption and expenditure on various food items should be considered.

In summary, decluttering our current approach to reducing the burden of child undernutrition and keeping it simple with a policy goal to providing affordable (economic and physical) access to quality food items, particularly for lower socioeconomic populations groups, should be prioritised. This may serve well as India tries to realise the Sustainable Development Goals (SDGs 2 and 3) related to zero hunger and good health and well-being.

S.V. Subramanian is Professor of Population Health and Geography, Harvard Center for Population and Development Studies, Cambridge, MA, U.S. William Joe is Assistant Professor, Population Research Centre, Institute of Economic Growth, Delhi. Inputs by Abhishek Kumar, a doctoral candidate at the Central University of Gujarat.

Karlsson O, Kim R, Joe W, Subramanian SV. The relationship of household assets and amenities with child health outcomes: An exploratory cross-sectional study in India 2015–2016. SSM-population health. 2020;10 :100513.Abstract

Healthy development of children in India is far from ensured. Proximate
determinants of poor child health outcomes are infectious diseases and
undernutrition, which are linked to socioeconomic status. In low- and
middle-income countries, researchers rely on wealth indices, constructed
from information on households’ asset ownership and amenities, to study
socioeconomic disparities in child health. Some of these wealth index items
can, however, directly affect the proximate determinants of child health. This
paper explores the independent association of each item used to construct
the Demographic and Health Surveys’ wealth index with diverse child health
outcomes. This cross-sectional study used nationally representative sample
of 245,866 children, age 0-59 months, from the Indian National Family Health
Surveys conducted in 2015-16. The study used conditional Poisson regression
models as well as a range of sensitivity specifications. After controlling for
socioeconomic status, health care use, maternal factors, community-level
factors, and all wealth index items, the following wealth index items were the
most consistently associated with child health; type of toilet facilities, water
source, refrigerator, pressure cooker, type of cooking fuel, land usable for
agriculture, household building material, mobile phone, and motorcycle/
scooter. The association with type of toilet facilities and water source was
particularly strong for mortality, showing a 16-35% and 14-28% lower
mortality, respectively. Most items used to construct the Demographic and
Health Surveys’ wealth index only indicate household socioeconomic status,
while a few items may affect child health directly, and can be useful targets
for policy intervention.

Beckerman-Hsu JP, Chatterjee P, Kim R, Sharma S, Subramanian SV. A typology of dietary and anthropometric measures of nutritional need among children across districts and parliamentary constituencies in India, 2016. Journal of Global Health. 2020;10 (2).Abstract

Anthropometry is the most commonly used approach for assessing
nutritional need among children. Anthropometry alone, however, cannot
differentiate between the two immediate causes of undernutrition:
inadequate diet vs disease. We present a typology of nutritional need by
simultaneously considering dietary and anthropometric measures, dietary
and anthropometric failures (DAF), and assess its distribution among children
in India. We used the 2015-16 National Family Health Survey, a nationally
representative sample of children aged 6-23 months (n = 67 247), from
India. Dietary failure was operationalized using World Health Organization
(WHO) standards for minimum dietary diversity. Anthropometric failure was
operationalized using WHO child growth reference standard z-score of <-2
for height-for-age (stunting), weight-for-age (underweight) and weight-forheight
(wasting). We also created a combined anthropometric measure for
children who had any one of these three anthropometric failures. We crosstabulated
dietary and anthropometric failures to produce four combinations:
Dietary Failure Only (DFO), Anthropometric Failure Only (AFO), Both Failures
(BF), and Neither Failure (NF). We estimated the prevalence and distribution
of the four types, nationally, and across 640 administrative districts and 543
Parliamentary Constituencies (PCs) in India. Nationally, 80.3% of children
had dietary failure and 53.7% had at least one anthropometric failure. The
prevalence for the four DAF types was: 44.0% (BF), 36.3% (DFO), 9.8% (AFO),
and 9.9% (NF). Dietary and anthropometric measures were discordant for
46.1% of children; these children had nutritional needs identified by only one
of the two measures. Nationally, this translates to 12 181 627 children with
DFO and 3 281 913 children with AFO; the nutritional needs of these children
would not be captured if using only dietary or anthropometric assessment.
Substantial variation was observed across districts and PCs for all DAF types.
The interquartile ranges for districts were largest for BF (29.8%-53.0%) and
lowest for AFO (5.5%-13.4%). The current emphasis on anthropometry for
measuring nutritional need should be complemented with diet- and foodbased
measures. By differentiating inadequate food intake from other causes
of undernutrition, the DAF typology brings precision in identifying nutritional
needs among children. These insights may improve the development and
targeting of nutrition interventions.