Improving nutrition in India : policies and programs and their impact

WDP-49 4 J E World Bank Discussion Papers Improving Nutnrtion in India Policies and Programs and Their Impact K. Subbarao ,'A  RECENT WORLD BANK DISCUSSION PAPERS No. 1. Public Enterprises in Sub-Saharan Africa. John R. Nellis No. 2. Raising School Quality in Developing Countries: What Investments Boost Learning? Bruce Filler No. 3. A System for Eva'luatinq the Performance of Government-Invested Enterprises in the Republic of Korea. Young C. Park No. 4. Country Commitment to Development Projects. Richard Heaver and Arturo Israel No. 5. Public Expenditure in Latin America: Effects on Poverty. Guy P. Pfeffermann No. 6. Community Participation in Development Projects: The World Bank Experience. Samuel Paul No. 7. International Financial Flows to Brazil since the Late 1960s: An Analysis of Debt Expansion and Payments Problems. Paulo Nogueira Batista, Jr. No. 8. Macroeconomic Policies, Debt Accumulation, and Adjustment in Brazil, 1965-84. Celso L. Martone No. 9. The Safe Motherhcood Initiative: Proposals for Action. Barbara Herz and Anthony R. Measharn TAlso available in French (9F) and Spanish (9S)I No. 10. Improving Urban Employment and Labor Productivity. Friedrich Kahnerl: No. 11. Divestiture in Developing Countries. Elliot Berg and Mary M. Shirley No. 12. Economic Growth and the Returns to Investment. Dennis Anderson No. 13. Institutional Development and Technical Assistance in Macroeconomic FPolicy Formulat:ion: A Case Study of Toqo. Sven B. Kjelistrom and Ayite-Fily d'Almeida No. 14. Managing Economic Policy Change: Institutional Dimensions. Geoffrey Lamb No. 15. Dairy Development and Milk Cooperatives: The Effects of a Dairy Project in India. George Mergos and Roger Slade No. 16. Macroeconomic Policies and Adjustment in Yugoslavia: Some Counterfactual Simulations. Fahrettin Yagci and Steven Kamin No. 17. Private Enterprise in Africa: Creating a Better Environment. Keith Marsden and Tferese Belot No. 18. Rural Water Sup1 and Sanitation: Time for a Change. Anthony A. Churchill, with the assistance ot David de Ferranti, Robert Roche, Carolyn Tager, Alan A. Walters, and Anthony Yazer No. 19. The Public Revenue and Economic Policy in African Countries: An Overview of IssLes and Policy Options. Dennis Anderson No. 22. Demographic Trends in China from 1950 to 1982. Kenneth Hill No. 23. Food Import Dependence in Somalia: Magnitude, Causes, and Policy Options. Y. Hc;sein Farzin No. 24. The Relationship of External Debt and Growth: Sudan's Experience, 1975-1984. Y. HDssein 1Farzin No. 25. The Poor and the Floorest: Some Interim Findings. Michael Lipton No. 26. Road Transport Taxation in Developing Countries: The Design of User Charges and "aKes for Tunisia. David Newbery, Gordon Hughes, William D.O. Paterson, and Esra Bennathan No. 27. Trade and Industrial Policies in the Developing Countries of East Asiai. Amarendri 13hattacharya and Johannes F. Linn No. 28. Agricultural Trade! Protectionism in Japan: A Survey. Delbert A. Fitchett No. 29. Multisector Framework for Analysis of Stabilization and Structural Adjustment Polcies: The Case of Morocco. Abel M. Mateus and others No. 30. Improving the Quality of Textbooks in China. Barbara W. Searle and Michael Mertaigh with Anthony Read and Philip Cohen (Continued cn the insidl back covE .  - 49K z World Bank Discussion Papers Improving Nutrition in Idia Policies and Programs and Their Impact K. Subbarao The World Bank Washington, D.C.  Copyright C( 1989 The World Bank 1818 H Street, N.W. Washington, D.C. 2043:3, U.S.A. All riglhts reserved Manufactured in the United States of America Secondl printing May 1990 Discussion Papers are not formal publications of the World Bank. They present preliminary and unrpolished results of country analysis or research that is circulated to encourage discussion and comment; citation and the use of such a paper should take account of its provisional character. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. Any maps that accompany the text have been prepared solely for the convenience of readers; the designations and presentation of material in them do not imply the expression of any opinion whatsoever on the part of the World Bank, its affiliates, or its Board or member courntries concerning the legal status of any country, territory, city, or area or of the authorities thereof or concerning the delimitation of its boundaries or its national affiliation. Because of the inforrmality and to present the results of research with the least possible delay, the typescript has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. The material in this publication is copyrighted. Requests for permission to reproduce portions of it should be sent to Director, Publications Department at the address shown in the copyright notice above. The World Bank encourages dissemination of its work and will normailly give permission promptly and, when the reproduction is for noncommercial purposes, without askinLg a fee. Permission to photocopy portions for classroom use is not required, though notification of such use having been made will be appreciated. The complete backlist of publications from the World Bank is shown in the annual Index of Publications, which contains an alphabetical title list and indexes of subjects, authors, and countries and regions; it is of value principally to libraries and institutional purchasers. The latest edition of each of these is available free of charge from Publications Sales Unit, Department F, The World Bank, 1818 H Street, N.W., Washington, D.C. 20433, U.S.A., or from Plablications, The World Bank, 66, avenue d'Iena, 75116 Paris, France. K. Subbarao, a professor of economics at the Institute of Economic Growth in New Delhi, is a consultant to the World Bank. Library of Congress Cataloging-in-Publication Data Subbarao, K. IMproving nutrition in India. (W:rld Bank discussion papers ; 49) Bibliography: p. 1. Nutrition--Government policy--India. 2. Malnutri- tion--India. I. Title. II. Series. TX360.I4S83 1989 363.8'0954 89-5556 ISBN 0-8213-1192-1  iii ABSTRACT This paper attempts a disaggregated analysis of existing data sets pertaining to nutrition in India and identifies the priority geographical areas, social and age groups for possible nutrition interventions; analyzes the effectiveness of public responses to the nutrition problem as reflected in the distribution of expenditures, and the impact of one major direct and one indirect nutrition intervention; and discusses the outstanding nutritional issues. The broad conclusions are that there is substantial empirical evidence to suggest wide variations in the distribution of malnutrition across regions, age and social groups and by gender; that the direct nutrition expenditures remained modest in the past, and that the distribution of even the modest expenditures has not at all been sensitive to the observed variations in the intensity of malnutrition; and that there appears to be considerable scope for improving the productivity of expenditures by strengthening and reorienting the existing programs and also lby reducing the prevailing mismatch between expenditures and what we know about the distribution of need. Overall, the paper argues the need for striking a proper balance between needs, potential demand and available resources. This paper was written as a background paper for the 1989 Country Economic Memorandum for India, when the author was working in the Country Operations Division of the Bank at their Resident Mission in New Delhi.  ACKNOWLEDGEMENT I wish to thank Sajitha Bashir for painstaking assistance and unfailing intellectual involvement in this research project. During the early' stages of this study, I have benefitted from discussions with C. Gopalan, N. Prahlad Rao, R. Radhakrishna, G. Sastry and Urmil Sharma. For many constructive comments and suggestions on earlier drafts, I am indebted tc Bela Belassa, Alan Berg, Pe?ter Berman, Nat Colletta, David Greene, James Hanscn, Sawon Hong, Richard He!aver, Samuel Lieberman, Michael Lipton, Dan Ritchic and Richard Skolnik. Successive drafts of this paper were cheerfully and competenitly typed by J'asvir Bhasin. I am solely responsible for the viesWs expressed in this paper.  Table of Contents Page No. I Introduction 1 II Distribution of Malnutrition by Region, Social Status, Age and Sex ............................ 3 a) Household-level average nutrient intake by region and social status .................... 3 b) Incidence of malnutrition among children in different regions and social groups ......... 12 c) Distribution of Malnutrition by Sex ............ 21 III Public Policy .................................. 24 a) Size and Distribution of Direct Nutrition Expenditures ................................... 26 b) Expenditures and Sustainability of interven- tions: A case study of Andhra Pradesh .......... 34 IV The Effectiveness of Major Direct and Indirect Nutrition Interventions ........................ 38 a) Integrated Child Development Services (ICDS). 38 b) Public Distribution System ..................... 66 V ConcLusions and Implications for Policy ........ 74 References Appendices  List of Tables Table No. :?ave Hlo. 1. State-vise calorie intake (Kcal/cu) 1975-80 Average (Ruiral) by Social Class 4 2. Calorie Consumption of the ultra-poor and the Average: Mean and Growth rate 1975-80 7 3. Summary Nutritional Status of Households in Rural Bihar by Social Class (% Distribution).... 9 4. Intake of E:nergy as % of RDA in ICRISAT villages (Lean and Surplus Seasons, 1976-77).... 10 5. Mean Energy Intakes in Rural and Urban India, 1987 (per Cu per day) .12 6. Nutritional Status of Children (1-5 years) in the selected states by weight-for-age (%) 13 7. Summary Nutritional Status by Age (% Distribution) in Bihar Villages 15 8. Percentage of Malnourished (Gr. III + IV) children in IC'DS Projects by Caste Status, 1981. 16 9. Percentage of Malnourished (Gr. III + IV) children (0-36) months of Scheduled Castes and Tribes in ICDS Projects of location, 1981 17 10. Regional Profile of Malnutrition among Children 19 11. Calorie Inadequacy among Adult Males and Females (Percent of Population) .23 12. State-vise D)istribution of Nutrition Expendi- tures ............................................ 28 13. Outlay and Expenditure - Seventh Plan - 1985-90 Nutrition .30 14. Statevise Distribution of Children fed under various feeding programs....................... 15. Percentage of Severely Malnourished children in ICDS Project Areas (Base line) in 1984 and corresponding State averages (1982) ..2  16. State-vise Position of ICDS 1986-87 ............ 43 17. Impact of ICDS on Nutritional Status Children in grades III & IV malnutrition 47 18. Distribution of ICDS Project Areas by changes in the StaLtUS of malnourished (Gr. III + IV) children: 1979-80/80-81 over 1984-85 .48 19. Characteristics of some ICDS Project Areas Deterioration .50 20. Supplementary feeding under ICDS by Social Class, 1981 ......... : ........................ 52 21. Staff Position - Paramedical Functionaries in ICDS PHCs reported as on 31st March, 1987 54 22. Staff Position - Health Functionaries - Medical Officers ICDS PHCs reported as on 31st March, 1987 55 22. ICDS: Recruitment & Training of Personnel in Central Sector Projects: 1987 57 23. PDS Supplies and Population below Poverty line. 70   I. Introduction 1.1 Since India's independence, the country's major development effort has been to improve the living standards of its poor. Substantial progress has been made on a number of fronts, the most fundamental being a large increase in life expectancy. This is due not only to a reduced incidence of number of major diseases, but also to better food availability and distribution, of which the most obvious manifestation has been the complete elimination of famines in times of even severe droughts such as the last year's. While, over several decades, the poverty incidence has not shown a clear trend, the Seventh Plan reports that the latest data indicate a fall from 48.3% in 1977 to 37.4% in 1983. Any discussion of India's still pervasive malnutrition problem must begin by recognizing these achievements. 1.2 The nutrition status of India's population and the methodological issues pertaining to its measurement have been the centre of controversy and much debate in India.1 There has, however, not been a systematic delineation of the distribution of nutrition levels in India by region, social status, age and sex. Since the policy debate on nutrition interventions in India has so far been conducted with a data base fairly aggregated at all-India level or state-level, there has also not been a critical assessment of the diverse state-level responses to the nutrition problem. This paper aims to fill these gaps. tThe principaL contributors to the debate were Sukhatme (1982) and Dandekar (1982). For a good, recent review of this debate, see Kakwani (1986 a). Depending upon the methodology chosen, the extent of malnutrition is estimated at 50 to 25 percent of population. Most earlier studies estimate the extent of malnutrition by taking the "household" as a unit of observation. Kakwani's estimate based on individuals, rather than households, came close to 50% for the year 1971-72. In this paper, we followed the usual 2400 calorie norm for adults and the Gomez classification and the Indian Academy of Paedetricians (IAP) classification for children. These have been defined at relevant places. It may be noted that relative distribution by region, age, sex and social status attempted in this paper will not be affected by the choice of the methodology for measuring malnutrition.  2 The paper begins with a review of diverse data sets. The disaggregated analysis identifies the priority geographical areas and social groups for nutrition interventions (Part II). This is followed by an ara:.ysis of the various public responses to the nutrition problem, done on the basis o:. th(e following criteria: ( a) whether or not the distribution of expenditures corresponded to needs, and whether or not the interventions are slustainable :in the long run; (Part III); and (b) whether or not the major interventions in operation for a sufficiently long time have been successful in reaching the identified malnourished groups/regions (Part IV). Most of the analysis concentrates OnL two programs: the Integrated Child Development Services (ICDS), by far the most extensive dlirect nutrit:ion intervention attempted in India since Independence; 2 and the Pufblic Distribution System (PDS), an indirect approach for impr:cving nutrition that involves large Central and state budget expenditures and whose importance in policy clebates has grown following the drought of 1987. PooI- reliability of existing data base makes it difficult to assess fully the expenditure effectiveness of these programs in terms of physical performlance. Hence, physical performance data are suitably supplemented by a qualit:ative assessment of the chosen interventions. The last section contains a summolry of the main findings, and a discussion of the outstanding nutritional issues What need to be resolved in the near future. 21 am aware that ICDS has objectives other than nutrition such as pre-schoot, and my description of the program as a "mntrition intervention" is an approximation. A more detailed description of the program is given in Section IV.  3 I. Distribution of Nutritional status by Region. Social Status. Aae and Sex. To know that malnutrition is widespread and severe in India hardly requires a detailed analysis of data. But to know the appropriate means for reducing it, and to know where and when the means will be effective, requires a disaggregated analysis of the data. This section attempts such an analysis. (a)Household-level average nutrient intake, by region and social status 2.1 The data generated by NNMB, after due correction so as to render them comparable over time and across regions,3 are very useful for estimating the mean intakes of nutrients for various classes of households in different parts of rural India. One problem with NNMB data is they are somewhat dated - the last published survey is for 1982; the disaggregated data are available only up to 1980-81.4 The results of the combined NSS-NNMB survey of 1983 have not yet been released. We used the disaggregated NNMB data sets for the years 1975-1980. Of the ten states for which NNMB data are available, Tamil Nadu experimented with a number of direct nutrition interventions, the most important being the Chief Minister's Nutritious Meal Program (CMNMP) for school children, since 1982, and Tamil Nadu Integrated Nutrition Project for pregnant and lactating women and children of 6-36 months age in 9 districts since 1982-84. In 1983, Andhra Pradesh introduced a major indirect intervention (i.e., Rs. 2 a kilo rice scheme). The 3The representativeness of the NNMB Sample is ensured by a rigorous multistage sampling procedure evolved by Dr. C. R. Rao, the then Director of the Indian Statistical Institute. The major criticism of NNMB data has been that it has suddenly switched from Harvard scale of normalcy to the Hyderabad (Indian) scale of normalcy since 1976. The data examined in this paper are derived using the some scale of normalcy over the entire period 1975-80. For an excellent summary of the sampling procedure, and the particular merits of this data source for drawing inferences regarding the regional distribution of malnutrition, see Srikantia (1988). 4It must be noted that most other data in India are also dated. * Nationat Nutrition Monitoring Bureau  4 relative nutrition situation among the remaining states may not have changed much since 1980. The drought of 1987 probably worsened the nutrition situation of the ultra poor (the bottom two deciles) - but this cannot be empirically demonstrated at this time, given the time lags in the release of nutrition data. We used NNMB data because they are still very relevant: not only not much has changed in many states but also the social-class disaggregation is rich enough. to desel:vi art analysis. 2.2 The calorie intake (Kcal/cu) data averaged for all households for the 1975-80 period for ten states are presented in Table 1, along with the Table 1 State-wise calorie intake (Kcal/cu) 1975-80 Average (Rural) by Social Class Calorie Intake of Calorie intake of Scheduled Castes Scheduled Tril:e3 as percent of as percent of State State Recommended State Recommendled States Average Average Daily Allowance Average Daily All.owance (2400) (2L01)) Karnataka 2837 86.6 102.4 SS Andhra Pradesh 2517 96.3 101.0 SS - Orissa 2324 94.1 91.0 96.3 93.3 Tamil Nadu 2293 88.7 84.7 SS - Maharashtra 2286 85.6 31.5 98.1 93.5 West Bengal 2227 98.7 91.5 92.2 85.5 Gujarat 2211 98.0 90.3 92.4 85.1 Madhya Pradesh 2160 92.5 83.3 89.4 80.5 Uttar Pradesh 2123 97.2 86.0 SS - Kerala 1942 94.1 67.4 SS SS: Small Samjple Source: Computed from disaggregated NNMB data.  5 averages for the scheduled castes and tribes.5 Communities belonging to these castes and tribes (so called because these castes and tribes were listed in a Schedule of the Indian Constitution) have historically suffered from social and economic deprivation. Prior to Independence, some of these castes were regarded as "untouchables". Although untouchability has long since been abolished, these castes and tribes continue to be at the bottom of the social hierarchy in India, and as such, deserve a separate treatment from a nutritional perspective. Two points deserve to be stressed. First, the average calorie intake was lower than the recommended allowance of 2,400 Kcal/cu in all states except Karnataka and Andhra Pradesh. Second, the average Kcal/cu conceals the fact that in all the states the Kcal/cu of the scheduled castes and tribes was lower than the state average which itself was lower than the recommended allowance. In particular, the intakes of scheduled castes in Kerala, Maharashtra, Tami'L Nadu, Madhya Pradesh and Uttar Pradesh, and tribes in Madhya Pradesh, Gujarat and West Bengal, were alarmingly low. Considering that the decline in the poverty ratio was the lowest among these social groups (see C.H.H. Rao), their nutrition probably has not improved much since 1980/81. 2.3 The relatively high average intake for Karnataka, which has a high poverty ratio, and a substantial area in India's arid (dry) zone, remains a puzzle. The very low calorie average for Kerala shown in the NNMB data will remain a puzzle especially because the infant mortality rate and the death rate are the lowest in this state. Recent evidence, however, suggests the 5In this paper, we did not analyse the time trends averaged for all-India or for states, since our focus is on a disaggregated analysis. These time trends averaged for all sample households within each state, and for all ten states together, have been analysed by NNMB themselves, who noted a steady decli-e in the incidence of malnutrition between 1974 and 1982. Their findings, although disputed by many, are still in concordance with the poverty incidence data from the 1977 and 1983 National Sample Surveys.  6 prevalence of high levels of malnutrition and morbidity in this state despite a reduction in infantinortality (see Panikar and Sonam). Kerala's very pocr agricultural performance (registering a negative rate of growth recently) and very high Eree market retail rice price (40% higher than all-India rice pi-Ice) could also have contri'buted to the observed low calorie consumption in Ke:-ala. 2.4 Disaggregated NNMB data are also available according to per capita income (Rs. per day) groups. From these data, we estimated the trends in calorie initake for the 'ultra poor', (roughly corresponding to 65% of the poverty-level income) and compared with the average for all income groups. 6 These are shown in TabLe 2, along with the relevant socio-economic indicators. Our interest is primarlly in knowing whether or not the ultra poor's nutr:i.ent intake has improved; and if so which states registered a better performance.7 2.5 Data pooled for all the states (see Table2) shows no trend increase in the calorie-intake of the ultra-poor during 1975-80, although for all income groups, shows a modest trend increase.8 Again, Karnataka and Andhira Pradesh show high average for the ultra poor, but no trend growth.9 By ccn:rast, Kerala's ultra poor have a low average calorie intake but this has shown cl substantial and significant trend increase during 1975-80, which was higher than average. It is possible that Kerala's public distribution systen (see P.1S. George) may have contributed to the observed positive trend growth in nutient 6Since the data correspond to discrete income groups, the cut-off points for the ultra poor are not exactly 65%. 7We are aware of the problem arising out of short time span. Fortunately the initial and terminal years were "normal" years. It must be stressed that we are using the trend growth rates essentially for cross-sectional (inter-state) comparisons. 8See also footnote 5. 9It may be noted that NNMB's findings of high average calorie consumption by the ultra poor in Karnataka is contradicted by NSS data for the bottom three deciles for the same state for comparable time period (See Gupta, 1987).  7 intake of the ultra poor, partly mitigating the adverse effects of the high rural free market prices of rice noted above. Table 2 Calorie Consumption of the untra-poor and the Average: Mean and Growth Rate 1975-80, along with state-wise socio-economic indicators State Category Mean Growth Per capita Total Popu- Literacy Urban Net Sown Calorie rate income Popu- lation rate Popu- Area Intake 1975- at current lation den- 1981 lation Irrigated 1975-80 80 prices 1981 sity 1981 1983/84 in Rs 1983 (mill) 1981 (M) (M) (%) Pooled Ultra-poor 2255 Nil (9 states) Average 2352 0.8* Kerala Untra-poor 1723 3.3* Average 1942 1.6 ns 1761 25.5 655 70.4 18.7 11.9 Tamil Ultra-poor 2052 2.0* Nadu Average 2293 1.7* 1827 48.4 372 46.8 32.9 42.9 Karna- Ultra-poor 2401 Nil taka Average 2517 Nil 1957 37.1 194 38.5 28.9 14.3 Andhra Ultra-poor 2756 Nil Pradesh Average 2837 Nil 1955 53.5 195 29.9 23.3 32.0 Maha- Ultra-poor 2229 1.1* rashtra Average 2286 Nil 3032 62.8 204 47.2 35.0 10.5 Gujarat Ultra-poor 2117 1.8* Average 2211 1.5* 2795 34.1 174 43.7 32.2 22.3 Madhya Ultra-poor 1972 Nil Pradesh Average 2160 1.7 ns 1646 52.2 118 27.9 20.3 14.0 West Ultra-poor 2227 1.3 ns Bengal Average 2277 -1.7 ns 2231 54.6 615 40.9 26.5 33.0 Uttar Ultra-poor 2065 -2.6* Pradesh Average 2123 -1.7* 1567 110.9 377 27.2 17.9 57.4 * Statistically significant ns Not significant Source: Computed from disaggregated NNMB data sets. 2.6 Apart from Kerala, in Tamil Nadu the ultra-poor's calorie intake also registered a significant trend increase. The average for all income groups also suggests a trend increase in Tamil Nadu. Both Maharashtra and Gujarat have registered a trend increase for the ultra-poor. In the states of Madhya Pradesh, West Bengal and Uttar Pradesh, the ultra-poor did not register any trend growth in calorie intake. In Uttar Pradesh, the ultra-poor and the average all showed a  8 statistically significant negative growth over the period 1975-80. 2.7 The differences in calorie intake across the states reflect differences in such factors as food lprice levels, the extent of access to publicly distributed food, differences in foocd habits and quality of food consumed, the general ec:onomic performance of the state, etc. Quite clearly there appear to be forces op-rating in the states of Kerala, Tamil Nadu, Maharashtra and Gujarat contributing so an improvement in the calorie intake of the ultra poor, although their level is 1bwest imn Kerala. The present stat:e of knowledge does not enable one to systematical:Ly analys,e the factors contributing to the improvement of nutritional status of the ultra poor Iln these states. 10 One can only hazard a guess. The first two states are wel;l known for their twin programs of noon meals and an effective public distribution system; Maharashtra for her food--wage linked Employment Guarantee Scheme, and Gujarat for her more than average economic performance. 2.8 Recent studies have shown that rural poverty is heavily concentrated in the arid zone and in the eastern states and among the scheduled castes.(C.H.E. Rao, 2R. cit.) An assessment of the nutrition situation in Bihar can be done wit'i data on a sample of rural Bihar households in twelve villages spread over all the six regions of thLe state for the year 1981 drawn from recent Working Papers oF1 ILO, While there were inter-v:lllage differences in average calorie intakes, the study noted that there was little evidence of higher intakes in the more advanced viliages, 10At the Level of aggregation of states, the number of observations are too small for statistical anal isis. ALso, some of the states (e.g., Uttar Pradesh) are very large, with considerable intra-state varia:i)n. District-wise calorie-intakes for the ultra poor and average are available for 1980-81, a normal year. An attempt was made to explain intetr-district variation in the calorie-intake (Appendix A). The uLtra-p,)o-'s calorie consumption was positively correlated with the per capita food production of the district, and the eiel of development of the district. Data for more districts and overtime are needed for more reliable analysiis of inter-district variation in caloi-ie intakes.  9 Social-class differences in calorie intakes appeared more prominent than either regional or seasonal differences. According to this source, nearly a half of the landless agricultural labour households, the majority of whom belong to the scheduled castes, suffered from varying degrees of malnutrition. (See Table 3). The sharp decline in the percentage of acutely malnourished between the landless labor Table 3 Summary Nutritional Status of Households in Rural Bihar by Social Class (% Distribution) * Class Normal Wasted Stunted Acute N Agricultural Labor 43.7 31.0 15.1 10.2 270 Agricultural Labor tied 45.6 28.6 14.5 11.3 103 Poor-Middle peasant 57.6 27.9 9.3 5.2 73 Middle peasant 75.4 17.1 4.9 2.0 90 Big peasant 57.3 31.1 8.3 3.3 243 Landlord 70.6 20.6 8.4 0.3 164 Non-Agricultural/ No Activity 45.2 31.4 11.8 11.6 49 All 53.5 28.4 11.3 6.8 992 * The norms used by the authors for defining "normal" "stunted", etc are as follows: Height for age Weight for age over 85% over 85% "normal" less than 85% over 85% "stunted" over 85% less than 85% "wasted" less than 85% less than 85% "acute" Source: P. H. Prasad. et al, "The Pattern of Poverty in Bihar" (World Employment Programme Research), Working Paper No. 152. class and small peasant class suggests the vulnerability of the former class to malnutrition. The substantial variations in calorie intake between socio-economic groups suggest that these are not be due to mere statistical fluctuations, but reflect differences in the groups' command over resources.  10 2.9 For the arid zone in Maharashtra and Andhra Pradesh, ICRISAT data provide information on nutrient intake in four villages in lean season and in surplu;s season for the mid-1970s. Thes(e data are retabulated and presented in Table 4. Four points Table 4 Intake of Energy as % of Recommended Daily Allowance (RDA) in ICRISAT villages in Lean and Surplus Seasons, 1976-77 Nutrient Intake in the Arid Zone: Percentage of Sample Consuming Less than 50% of RDA Farm-size Age Group Aurepalle Dokur Sholapur Akola group (in years) ------------- ------------- -------------- ----- ------- Lean Surplus Lean Surplus Lean Surplus Lean Suirplus Landless 1-3 46.2 29.4 42.9 26.7 76.5 44.4 27.'1 40.0 Laborers 4-6 40.7 34.8 0.0 8.7 77.5 20.0 0.0 10.2 and small 7-12 20.0 15.8 7.7 0.0 87.0 7.1 0.0 7.8 farmers 13-18 Males 0.0 10.0 0.0 9.1 88.9 22.2 0.0 2.4 13-18 Females 7.7 5.3 0.0 5.3 90.2 6.7 0.0 6.3 >18 Males 7.3 15.6 0.0 6.6 87.1 4.0 1.61 2.6 >18 Females 23.9 15.9 2.9 2.9 95.2 10.4 2.0 3.0 Medium 1L-3 14.3 30.0 0.0 25.0 75.0 30.8 20.0 36.B farmers 4-6 33.3 11.1 0.0 0.0 78.1 7.7 0. C 4.5 7-12 8.3 0.0 0.0 8.3 95.5 0.0 0.0 10.3 13-18 Males 20.0 0.0 0.0 0.0 94.4 0.0 O.C 0.0 13-18 Females 0.0 0.0 0.0 0.0 95.8 0.0 O.C 0.0 >18 Males 11.5 7.1 22.2 0.0 89.8 0.0 o.C 1.4 >18 Females 4.2 0.0 0.0 3.2 94.9 2.9 0.0C 4.3 Large 1-3 100.0 0.0 40.0 25.0 78.3 28.6 22.2 44.8 farmers 4-6 0.0 0.0 0.0 13.0 58.8 0.0 0.0 23.3 7-12 17.4 0.0 0.0 14.8 81.8 0.10 3.6 6.8 1:3-18 Males 20.0 0.0 0.0 3.8 91.5 0.0 0.0 14.3 13-18 Female 10.0 10.0 0.0 0.0 85.4 0.0 0.0 7.7 >L8 Males 19.4 5.3 0.0 0.0 83.6 0.0l 2.9 9.5 >18 Females 7.7 0.0 0.0 6.3 90.7 2.6 0.0 2.9 Source: Data retabulated from ICRISAT Research Bulletin No. 7, 1984. deserve to be noted. First, as in Bihar, the percentage of the energy-de:lizient individuals among landless labor and small farm households in all age groatp;; was * International Crops Research Institute for Semi-Arid Tropics.  11 quite high. Second, the proportion of energy-deficient persons varied across villages as it did in Bihar (the highest being in Sholapur, Maharashtra), and across age groups, with a high proportion among children in the age group 1-3 of landless labour households in all the villages. Third, the percentage of energy-deficient people was lower in the surplus season. Fourth, a high proportion (ranging from 25 to 45 percent) of children in 1-3 age group in all villages and among all social groups, rich as well as poor, and in both lean and surplus seasons, were having energy intakes of less than 50% of recommended daily allowance."1 The last aspect is discussed further in the next section, which focuses on malnutrition among children. 2.10 We have so far examined the location of malnutrition among the rural households. It would be useful to compare these with the nutritional status of social groups in urban India. A summary position of rural and urban India is presented in Table 5. Three points deserve to be noted. First, the urban groups in general were no better off than rural groups. Second, the energy intakes of urban slum dwellers were no better than those of rural landless and Harijans. Third, the rural rich (10 acres and above) appeared to have higher intakes than the urban high income groups. There could be many reasons for this difference: the easier accessibility of food to the rural rich, higher calorie-consciousness of the urban rich, etc. t1The very high numbers for the Lean season in Sholapur and for 1-3 age children of large farmers in Aurepalle are very puzzling, and as such undoubtedly raise questions regarding reliability of this data source - the only source available for the arid zone.  12 Table 5 Mean Energy Intakes in Rural and Urban India, 1987 (per Cu per day) Urban 1 /a 2 /b Rural HIG 2000-3085 /c 2600 10 acre Land Holding 2375-3100 2000-2675 /d 2420 5-10 acre 2100-2860 Land Holding Landless 1865-2310 MIG 1880-2715 2365 LIG 1760-2665 2230 IL 1900-2510 2245 SL 1760-2290 2010 E'arijans 1600-2460 ======-- -- --- - - = = _ _ ==_= = _ = = = = _ = __ _= = === = = :- /a Range oi- means for various cities. /b Pooled average for the group. Zc Means of: various cities /d Trivandrum, Bangalore excluded. Legend: HIG = High incorme group MIG = Medium income group LIG = Low income group IL = IndustriaL Labour SL = Slum DwelLers Source: NNMP, as reported in Kamala S. Jaya Rao (1985) b) Incidence of malnutrition among children in different Regions and social groups. 2.11 Information on the nutritional status of children in the age giD2ip 1-5 years old is also available from the surveys carried out by NNMB. While thcsie data are available at the state-level, unfortunately the social--class disaggreget:on of malnourished children is not available. State-wise data are presented in Table 6^ These data show substantial improvements in the nutritional status of childrea onLy in two states, viz, Kerala and West Bengal. In all other states, the ahana2>t over time were marginal. As for inter-state differences, severe malnutritio>: amoag children seemed higher in Andhra Pradesh, Gujarat, Karnataka, Madhya PE^z.deslh, Maharashtra and Orissa. But these are state-level averages with their )liviou s  13 limitations. Yet, can we learn anything more from these state-level average figures? 2.12 In Figure 1,* the calorie-protein adequacy of all household members is juxtoposed against those averaged for children 1-4 years of age, for ten major states which NNMB surveys covered. In a number of states, the percentages of children with adequate calorie-protein intakes were much lower than the corresponding percentages for households. The map also shows that even in the agriculturally (and otherwise) prosperous states like Andhra Pradesh, nearly a half of the children were suffering from calorie-protein inadequacy; the proportion was much higher in the poor eastern states of Orissa, West Bengal, Table 6 Nutritional Status of Children (1-5 years) in the selected states by weight-for-age (percentage) La Normal Mild Moderate Severe State 1975-79 1982 1975-79 1982 1975-79 1982 1975-79 1982 Kerala 16.4 31.8 45.3 49.3 33.5 17.4 4.8 1.5 Uttar Pradesh 18.8 - 48.3 - 26.8 - 6.1 - Tamil Nadu 14.6 16.1 43.6 44.1 35.3 34.6 6.5 5.2 West Bengal 10.6 21.3 43.0 55.7 39.6 23.0 6.6 0.0 Karnataka 9.9 13.8 43.0 43.4 39.5 37.2 7,7 5.6 Andhra Pradesh 13.3 12.6 42.2 43.0 36.7 38.5 7.8 5.9 Orissa 15.3 13.0 42.1 35.8 33.3 42.3 9.3 8.9 Gujarat 9.8 11.7 37.8 28.7 43.0 44.4 9.4 15.2 Maharashtra 9.3 13.6 37.4 38.8 42.0 40.7 11.3 6.9 Madhya Pradesh 12.0 - 36.3 - 40.2 - 11.5 - ,a Gomez classification, as shown below: < 60% weight for age: Severe 61-75% weight for age: Moderate 76-90% weight iEor age: Mild > 90% weight for age: Normal Source: National Nuatrition Monitoring Bureau as quoted in UNICEF (1983) and Uttar Pradesh. Economic development of a state does not seem to protect children It may be noted that NNMEB's figure pubLished in 1980 gave data for chiLdren 1-4 years, whereas in later years data were released for children 1-5 years.  14 CA,LORIE-PROTEIH ADEQUACY OF HOUSEHOLDS - INDIA Source: UNNB Reporl (19801 Hlh', iydefabod, India (~~~~~~ ) NoE7 QzDL;buL /-yV/iX297eJ- UTTAR I) S/TAPRADESH f U '9zw ~~~~MADHYA F t * / <PRADESH PEJ. GJARNAT m60 RSE. 47 > TAMIL X0 -50 . -3ATA PR OT AEIJkLAELECY 16Ii'ncli ic nsliiirto of Nutritior.. TaTriobo7 HyderdDH PE, Indio. as given zin Anderson (1987)  15 from malnutrition to the same extent as it does for adults. In the arid zone (excluding Rajasthan for which we have no information) nearly 60% of the children suffered from calorie-protein inadequacy. Of the remaining states, sample survey data for 1981-83 on Bihar's children (see Table 7) showed that nearly a half of the children aged less than 54 months suffered from a nutritional deficiency; the proportion rose sharply to 78% for children of the age group 6-18 months. Although the nutritional status of 53.5% of all members of the households was normal, only 22.8% of the children in the age group 6-18 months was normal; acute malnutrition was also concentrated in this age group. Table 7 Summary Nutritional Status by Age (% Distribution) in Bihar Villages* Age Normal Wasted Stunted Acute N 6 Months but less than 18 22.8 42.5 22.8 11.9 41 18 Months but less than 54 36.7 33.1 19.3 10.9 248 54 Months but less than 114 52.5 31.0 9.9 6.6 419 114 Months or more 76.3 17.9 3.7 2.2 279 All 53.5 28.4 11.3 6.8 992 * For definitions of "normal", "wasted", etc., See footnote to Table 3. Source: P. H. Prasad, et.al., "The Pattern of Poverty in Bihar" (World Employment Programme Research) Working Paper No. 152. 2.13 Because the data depicted in Figure 1 are state-wise averages, it is not possible to infer about the nutrition status of children of specific social groups. For example, within large states such as Madhya Pradesh and Andhra Pradesh, there is a significant concentration of tribals in some districts; in Maharashtra the proportion of urban poor is high in the western districts. These categories would need a separate (disaggregated) treatment at the district level. Similarly, the arid zone within Karnataka, Maharashtra and Andhra Pradesh also deserves a separate treatment. Fortunately, the data on the third and fourth-degree malnutrition among  16 children collected by the ICDS monitoring authorities and the data on ICRISAT villages reported earlier (Table 2) can be used for this purpose. 2.14 The ICDS monitoring authorities have collected information on the nutritional status of children by caste status and by location. These are available for 1981 at the leve:L of aggregation of a state for 15 states, ard at a district-levrel for 1984-85, and separately for children 0-3 years and 0-l. years. These are retabulated and presented in Tables 8, 9 and 10. Table 8 Percentage of Malnourished (Gr. III + IV) children in ICDS Projects by Caste Status, 1981 La Average Scheduled Castes Scheduled Tribes Sn. 0-36 0-72 0-36 0-72 0-36 0-72 No. State months months months months moniths monl:hs 1 ANDHRA PRADESH 9.6 8.6 10.4 8.3 9.9 7.5 2 BIHAR 31.8 31.7 39.5 40.9 -- - 3 GUJARAT 7.3 6.2 6.0 3.9 11.7 - 4 HARYANA 4.6 3.5 5 HIMACHAL PRADESH 5.3 4.3 7.0 9.3 6 KARNATAKA 8.8 8.3 10,1 8.5 5.0 2.5 7 KERALA 7.7 7.8 11.0 10.2 17.5 15 6 8 MADHYA PRADESH - - - - 24.3 12 7 9 MAHARASHTR.A 15.8 13.3 16.7 14.8 23.7 20 7 10 ORISSA 16.7 13.0 19.0 16.8 11 PUNJAB 8.6 8.2 13.9 12.3 12 RAJASTHAN 8.2 8.7 17.3 12.1 8.1 7.6 13 TAMIL NADIJ 8.1 6.4 10.1 7.1 14 UTTAR PRADESH :L3.1 10.5 17.1 13.2 16.3 13.4 15 WEST BENGAL :L9.9 17.3 26.5 21.3 17.0 12.1 la ICDS authorities follow the Indian Academy of Paediatrics (IAP) classific:aAion, as shown below: < 50% weight for age: Grade IV malnutrition 51-60% weight for age: Grade III malnutrition 61-70% weight for age: GradeII malnutrition 71-80% weight for age: Grade I malnutrition > 80% Normal Source: Compiled from Child in India. A Statistical Profile, Ministry of Welfare, Government of India. * Integrated ChiLd DeveLopment Services.  17 Table 9 Percentage of Malnourished (Gr. III + IV) children* (0-36) months of Scheduled Castes and Tribes in Rural/Uraban/Tribal ICDS Projects, 1981 (%) Sn. No. State Average Rural La Tribal ab Urban /c 1. Andhra Pradesh 9.6 11.0 10.8 10.3 2. Himachal Pradesh 5.3 8.1 12.4 26.3 3. Maharashtra 15.8 27.3 14.3 16.4 4. Uttar Pradesh 13.1 30.8 13.9 20.8 5. West Bengal 19.9 16.2 33.8 /a and /c Children of Scheduled castes Lb children of scheduled tribes * IAP classification (defined in footnote to Table 8). Source: Compiled from Child in India. A Statistical Profile, Ministry of Welfare, Government of India. Care was taken to see that the ICDS Projects for which information was tabulated for 1980-81 were those which became operational during the period 1978-80, so that the data are comparable across the states. Before the findings are discussed, it is worth noting that the ICDS data may be expected to be more accurate in reflecting the differences in the geographical location of malnutrition across the states/projects than in capturing the age-specific levels of malnutrition in a given area. This is because, ICDS has so far been less successful in reaching the  18 under-threes than three-to-six-year-olds,12 so that the levels for the former may have been under-estimated. Bearing this in mind the following findings ara worth stressing. First, the proportion of malnourished children among the scheduleti ^astes and scheduled tribes was higher than the average in most places (see Tabl.e 8). Second, a comparison of the data for 0-36 months and 0-72 months shows that Niith few exceptions the percentages of malnourished children were higher for the grcup 0-36 months even among the scheduled castes and tribes. Third, the location - riral or urban or tri'bal - does not seem to significantly alter the above finding, as can 'be seen from Table 9 wherein the break up is presented for the five states fo:- which data are available. For example, the children of scheduled caste's and tr:ites in all locations have either equal to, or higher than average percentage of c1lildren malnourished. Fourth, in terms of percentage of malnourished children of I:ribals in Andhra Pradesh, Kerala, Uttar Pradesh, West Bengal and Madhya Pradesh an,d those of scheduled castes in Bihar, Orissa, Rajasthan, West Bengal and Uttar :'.radesh suffered fromi very high levels of severe (third and fourth degree) malnutri:ion. 2.15 More recent data for 1984 (see Table 10) only confirm the above findings. For this year, we have tabulated the percentage of malnolurished ctildreni for those ICDS project/district areas which became operational 10-12 months 'DEfore the date of data collection, so that these numbers could well serve as control group depicting the nutritional status of children in these districts/areas for the period 1983-84. A basic limitation of this data, however, is that further disaggre;,,ation for scheduled castes is not available, but the tribal situation can be guessel from the location of the projects. The disaggregated project-wise information is s~iown 12See Part IV of this paper for a discussion on this aspect.  19 in Table 10, along with the area in which the project was located (tribal, rural or urban). Table 10 REGIONAL PROFILE OF MALNUTRITION AMONG CHILDREN Percentage Severely of Malnourished (grades III & IV) children* in ICDS Project Areas during 1984-85 /a PERCENT CHILD MALNOURISHED MORTALITY DISTRICT RATE /c CHARACTERISTICS TYPE OF ------------- ---------- --------------------------- Sn DISTRICT PROJECT 0/3 3-6 0-2 0-5 SC + ST Id AVA le IRR/f No STATE NAME lb POP 1 2 3 4 5 6 7 -------------------------------------------------------------------------__--__----------------- X Rs. X 1 ANDHRA PRADESH Guntur Rural 8.80 11.30 99 142.00 13.00 317.00 39.00 Vizianagaram Tribal 22.20 32.50 169 196.00 19.00 61.00 30.00 2 KARNATAKA Dharwar Rural 15.40 12.90 124 182.00 15.00 307.00 6.00 Mysore Rural 17.20 10.80 109 149.00 24.00 270.00 17.00 3 TAMIL NADU Ranyakumari Urban 5.70 4.60 70 80.00 5.00 161.00 52.00 Salem Urban 5.70 0.30 74 101.00 20.00 245.00 22.00 4 KERALA Mallapuram Rural 1.20 4.30 66 104.00 9.00 355.00 57.00 Palghat Rural 0.70 4.00 74 116.00 19.00 421.00 57.00 5 MADHYA PRADESH Jabalpur Rural 34.40 16.90 220 265.00 29.00 152.00 5.00 Dhar Tribal 26.00 17.30 138 174.00 59.00 350.00 7.00 6 UTTAR PRADESH Pratapgarh Rural 14.60 13.00 163 211.00 22.00 222.00 28.00 Kheri Rural 6.10 3.10 154 187.00 27.00 587.00 10.00 7 RAJASTHAN Bharatpur Rural 12.40 n.a. 214 252.00 24.00 369.00 20.00 Banswara Tribal 14.20 0.70 170 169.00 25.00 235.00 7.00 8 MAHARASHTRA YaystMal Rural 22.30 25.10 177 227.00 26.00 264.00 2.00 Nanded Urban 12.00 10.20 87 107.00 21.00 289.00 3.00 9 GUJARAT Valsad Tribal 4.60 3.30 91 96.00 57.00 192.00 13.00 Baroda Tribal 7.30 5.60 115 129.00 31.00 206.00 21.00 10 ORISSA Cuttack Rural 3.20 2.80 196 204.00 21.00 271.00 32.00 11 WEST BENGAL Nadia Rural 21.30 12.20 115 149.00 28.00 268.00 33.00 Bankura Tribal 6.50 8.20 77 89.00 40.00 427.00 33.00 12 HARYANA Hissar Rural 6.70 4.20 120 146.00 22.00 901.00 64.00 Bhivani Rural 5.50 0.70 114 129.00 18.00 558.00 20.00 /a The data in columns 1 and 2 are taken from ICDS Project-wise Progress Report for 1984185, for those Projects which which were sanctioned during 1983/84. As such, these figures reflect the nutrition sitution atiabout the commencement of ICDS in these districts. lb R = Rural; T = Tribal; U = Urban. to District-wise Child Mortality Rates for 1981 for the age groups less than two and less than five years were made available for the first time in the occasional Paper No. 5, 1988, Office of Registrat General, Ministry fo Home Affairs.