The Malnutrition Paradox: Lessons From China – Analysis


By Shoba Suri

Malnutrition has been linked to poverty and food insecurity. However, it is also a paradox leading to under-nutrition and recurring hunger and over-nutrition. The Global Nutrition Report 2018 reveals that “malnutrition is unacceptably high and affects every country in the world, but there is also an unprecedented opportunity to end it.” Malnutrition costs 3.5$ trillion per year to the global economy and child and maternal malnutrition is the largest nutrition related health burden in the world.

Globally malnutrition rates are high with 150.8 million under five children being stunted, 50.5 million children are wasted and 20 million newborn babies are estimated to be low birth weight, and on the other hand 38.3 million children are overweight. It is alarming to note that India is the top most country with the largest number of children being stunted (46.6 million) and wasted (25.5 million). India and China are also home to 2% and 7% of overweight children respectively.

India and China have many similarities, being the most populous countries accounting for two-fifth of humanity. As the fastest growing economy currently, India is ahead of China but has to outperform China consistently to reap benefits from it. As per the 2018 Global Hunger Index, (GHI) India is ranked 103rd out of 119 countries as compared to 25th rank of China. For India the level of hunger and under-nutrition worldwide falls into the serious category as compared to low level of hunger in China. The poverty rate in India in the past decade has fallen from 55% to 28%, but still accounts for largest number of people in the world faced by overlapping deprivations in health, nutrition, education, and living standards. This reduction is in parallel to that achieved by China more than a decade ago and now stands at 4%. According to the World Poverty Clock India is far behind China in achieving the progress against ending extreme poverty. India has been grappling with the problem of malnutrition for decades and a reduction will contribute significantly to poverty alleviation and economic growth.

The growing packaged food industry in India is also a major cause of concern in combating the double burden of malnutrition. According to the Access to Nutrition Index report, about 12% of the beverages and 16% of the foods sold by companies were graded as ‘high nutritional quality’, which is a cause for concern. Euromonitor predicts India to be the third biggest market for packaged food by 2020, after China and the United States.  The Government of India (GoI) needs to develop a comprehensive policy and standards on the marketing of packaged foods for improving nutrition.

Malnutrition is key to India’s greatest human development challenges.  According to National Family Health Survey 4 data, India’s rate of early breastfeeding within an hour is 41.5%, i.e. only 2 out of 5 women are able to begin breastfeeding within an hour of birth. 54.9% women exclusively breastfeed their infants, only 1 out of 2 women are able to practice exclusive breastfeeding for 6 months. Complementary feeding rates after 6 months is 42.7%, with an alarmingly low 9.6% (1 out of 10) children receive minimum acceptable diet. These early interventions which provide the critical window of opportunity to combat malnutrition, have failed to improve over decades in India.

Figure indicates unacceptably high levels of child under-nutrition with 38.4 percent of children stunted and 35.7 percent of underweight children in India. Despite plan and programme commitments since 1975 by creation of Integrated Child Development Services (ICDS) and national coverage of the mid-day meal scheme in 1995. On the other hand the number of overweight men (18.9%) and women (20.6%) has gone up in the last decade.

Analysis of malnutrition in Indian children based on wealth quintile shows steady decrease with an increase in wealth quintile with half the children from families in the lowest quintile are stunted (51%) or underweight (49%). Education level of families also plays a major role, with low cases of children malnourished among educated families compared to those with no formal education. In China it is the same trend of the poorest quintile having the highest rate of malnutrition albeit much lower than India. However the rate of malnutrition declines with living standards and inequalities tend to vary across countries.

The GoI has various nutrition policies and initiatives aligned to the Sustainable Development Goals (SDGs) on zero hunger, but these measures lack implementation. The recent National Nutrition Strategy however aims to eradicate all forms of malnutrition by 2022 has shown promise and through its National Nutrition Mission (Poshan Abhiyan) will work through synergy, convergence and community mobilization to achieve the goal. However the low budgetary allocation on nutrition makes it a tough task to accomplish.

Evidence suggests a return on investment of US$18 from every US$1 invested in reducing wasting and stunting. Thus addressing all forms of malnutrition should be the top priority of the government and policy makers.

China is also vulnerable to the double burden of malnutrition and leads the way in its multi-sectoral strategy in addressing all forms of malnutrition. China has improved on children’s health and growth over the last few decades yet faces challenge. There is a clear rural and urban divide pointing to inequalities in health and access to healthcare.  Another challenge faced by China is the growing population, accounting to 18% of the world and the growing food security concerns with 10% arable land. The contamination of water, soil, water shortages and growing food demand adds to the food crisis faced by China.  A review indicates major challenges for China in maintaining water and food security for its growing population and sustaining economic growth.

Despite this, China gets credit for achieving the Millennium Development Goal (MDG) goal 1 of eradicating extreme poverty and hunger much ahead of the deadline of 2015. This is evident from the declining trend in stunting and underweight in children in the past decade.

As far as achieving the global nutrition targets by 2030, China has contributed significantly in advancing the agenda and is progressing towards achieving two targets (stunting & anemia) as compared to zero targets on track for India. There is a lesson to learn from China for implementing the right policies at the right time in the right place.

The Global Nutrition Report has highlighted major solutions which need to be put in action, like government commitments. The Government of China (GoC) has set an example by showing commitment and political will to transform malnutrition in China. China has adopted a multi-sectoral approach shifting focus from quantity to quality of food production and also improving their food supply policy. The convergence of various sector health, nutrition and agriculture with focus on providing more nutritious and diversified crops has brought agricultural and economic success. This has enabled supply of nutritious food to its large population resulting in a reduction of stunting and wasting. The GoC has developed two plans: Healthy China 2030 with ‘health-in-all-policies’ approach and National Nutrition Plan (2017–2030), with a range of malnutrition targets including stunting, obesity, anemia, breastfeeding and folic acid deficiency among vulnerable people with disproportionate burdens.

The disparity in the growth and development between the two countries is clearly evident due to India’s poor education level and high disease burden. The above facts hold suit with Amartya Sen’s premise that “India’s low literacy rates and poor health outcomes” and “China’s investment in health and education” shows the inconsistency in development between the two countries.

Thus to conclude, the solutions are available and need to be put in to action by scaling up nutrition programmes and implementing commitments. This will help India secure the future of its children, reap the benefits of the demographic dividend and maintain strong and sustainable economic growth.

Observer Research Foundation

ORF was established on 5 September 1990 as a private, not for profit, ’think tank’ to influence public policy formulation. The Foundation brought together, for the first time, leading Indian economists and policymakers to present An Agenda for Economic Reforms in India. The idea was to help develop a consensus in favour of economic reforms.

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