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Journal ArticleDOI

Notes on the Differing ‘States’ of Child Undernutrition in Rural India

01 Jul 2009-IDS Bulletin (Blackwell Publishing Ltd)-Vol. 40, Iss: 4, pp 9-15
TL;DR: In this article, the authors explored the underlying political and institutional factors that may account for these differences, and showed the strong correspondence between measures of the capacity, responsiveness and accountability of different state governments and their performance in improving the nutrition of children.
Abstract: There are now striking differences between major states of India in terms of their performance in reducing undernutrition among children. This article explores the underlying political and institutional factors that may account for these differences, and shows the strong correspondence between measures of the capacity, responsiveness and accountability of different state governments and their performance in improving the nutrition of children.

Summary (2 min read)

1 Introduction

  • In spite of the indications that some progress has been made in India in recent years in the reduction of poverty (see Himanshu 2007), as other articles in this issue of the IDS Bulletin also note, little if any progress has been made with regard to malnutrition among children.
  • There are, however, striking differences in the incidence of child undernutrition in rural areas across the major Indian states -although the available evidence suggests that there was little variation between them in the early 1970s, when the proportion of children who were underweight was as high as 70 per cent in rural areas in most states.
  • Some states have done very much better than others over the past quarter century or so, in reducing this most serious constraint on the expansion of human capabilities in India (Table 1 ).
  • The purpose of this article is to suggest explanations for these inter-state differences that may be investigated further and tested once more data become available.
  • The authors particular concern is to examine underlying political and institutional variables that strongly influence the proximate and immediate drivers of nutrition status.

2 The politics of malnutrition

  • The hypothesis that the authors wish to explore is that differences between states in terms of the reduction of malnutrition among children, are underlain by differences between their political regimes.
  • As Harriss showed in earlier work (2003) , the authors may first differentiate between Indian states in terms of the political representation of different castes/classes (this formulation reflecting the view that while caste and class are certainly not equivalents, there is considerable overlap between the categories), and second, the nature of political competition in them.
  • There are also differences of degree between states when they are assessed along a scale between 'clientelist politics' on the one hand and 'programmatic politics' on the other.
  • The records of the states considered in this article, with regard to the reduction of undernutrition among children, quite strikingly bear out this analysis.
  • In varying degrees the CPI(M) in Kerala and West Bengal, the Dravidian parties in Tamil Nadu and possibly the Telugu Desam party in Andhra Pradesh display these characteristics.

4 Conclusion

  • The authors offer only presumptive evidence in this article, but although only descriptive, the data do show strong connections between the varying character of the political regime across states and government performance in regard to services that influence the nutrition status of children, and these with the trends of reduction of undernutrition.
  • The authors note that there are two major sources of data on undernutrition in India: the results of the work of the National Nutrition Monitoring Board (NNMB) of the National Institute of Nutrition, which extend back to the 1970s, and those of the National Family Health Survey, referred to earlier, and of which the first round was conducted in 1992-3.
  • There are gaps for some states for some years in the NNMB, and in the WHO series that the authors use in this analysis -which is supplemented by reference directly to the NNMB for 2000-01.
  • These parties are the Communist Party of India-Marxist (CPI-M) in West Bengal and Kerala -where it has, however, regularly alternated in office with Congress-led formations -and the Dravidian parties in Tamil Nadu that have pursued policies that can fairly be described as 'populist'.

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1 Introduction
In spite of the indications that some progress has
been made in India in recent years in the
reduction of poverty (see Himanshu 2007), as
other articles in this issue of the IDS Bulletin also
note, little if any progress has been made with
regard to malnutrition among children. It is
striking that between the second round of the
National Family Health Survey (NFHS) conducted
in 1998–9 and the third, of 2005–06, the
percentage of children classified as underweight
(considered to be the more comprehensive
anthropometric measurement of malnutrition:
Deaton and Drèze 2009) declined only marginally
at the all-India level from 46.7 per cent to 45.9 per
cent. There are, however, striking differences in
the incidence of child undernutrition in rural areas
across the major Indian states – although the
available evidence suggests that there was little
variation between them in the early 1970s, when
the proportion of children who were underweight
was as high as 70 per cent in rural areas in most
states. Some states have done very much better
than others over the past quarter century or so, in
reducing this most serious constraint on the
expansion of human capabilities in India (Table 1).
Between 1974 and 2001 Kerala succeeded in
reducing the level of child undernutrition by 57 per
cent, Andhra Pradesh by 45 per cent and Tamil
Nadu by 43 per cent, whereas Orissa managed a
reduction of only 25 per cent and Madhya Pradesh
less than 10 per cent.
Due to inadequacies in the available data, no-one
has yet been able to construct a long enough time
series at the state-level to enable serious
econometric analysis with immediate, proximate
and underlying determinants of nutrition status to
explore the reasons for variations across states.
The purpose of this article is to suggest
explanations for these inter-state differences that
may be investigated further and tested once more
data become available. Our particular concern is
to examine underlying political and institutional
variables that strongly influence the proximate
and immediate drivers of nutrition status. Walton,
in his contribution to this issue of the IDS Bulletin,
distinguishes between ‘immediate drivers’ of
nutrition status (nutrient intake and health
status), ‘influences on local behaviour’ (household
economic resources, local public goods and local
health system) and ‘contextual influences’
(including distributional wealth dynamics, public
policy choice and implementation). We are
concerned with the factors that underlie the
differences in these contextual influences across
major states. Data limitations mean that we are
able to deal only with the states of Andhra
Pradesh, Gujarat, Karnataka, Kerala, Madhya
Pradesh, Maharashtra, Orissa, Tamil Nadu and
West Bengal. Although this set of the major states
quite clearly fails to represent North India, it does
at least include one of the ‘BIMARU’ states in
Madhya Pradesh, and another chronically poor
state in Orissa. It also includes a fair
9
Notes on the Differing ‘States’ of
Child Undernutrition in Rural India
John Harriss and Neha Kohli
Abstract There are now striking differences between major states of India in terms of their performance in
reducing undernutrition among children. This article explores the underlying political and institutional
factors that may account for these differences, and shows the strong correspondence between measures of
the capacity, responsiveness and accountability of different state governments and their performance in
improving the nutrition of children.
IDS Bulletin Volume 40 Number 4 July 2009 © 2009 The Authors. Journal compilation © Institute of Development Studies
Published by Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

representation of the differences in political
regimes across Indian states – differences that
help to explain policy differences and variation in
the quality of programme implementation.
2 The politics of malnutrition
The hypothesis that we wish to explore is that
differences between states in terms of the
reduction of malnutrition among children, are
underlain by differences between their political
regimes. As Harriss showed in earlier work
(2003), we may first differentiate between Indian
states in terms of the political representation of
different castes/classes (this formulation
reflecting the view that while caste and class are
certainly not equivalents, there is considerable
overlap between the categories), and second, the
nature of political competition in them. The
analysis suggests, therefore, that there are
important differences between states in terms of
the extent to which their political systems allow
for voice on the part of poorer, lower caste/class
people. There are also differences of degree
between states when they are assessed along a
scale between ‘clientelist politics’ on the one
hand and ‘programmatic politics’ on the other.
Of course, there is no Indian state in which
clientelist politics of accommodation play no part
at all in political mobilisation, but the analysis
suggests that there are differences of degree
between states. The states in the present
analysis were categorised as follows:
1 States in which upper caste/class dominance
has persisted and the Congress Party has
remained strong in the context of a stable
two-party system (‘traditional dominance’
rather than politics of accommodation vis-à-vis
lower classes):
z Madhya Pradesh
z Orissa
2 States with middle caste/class-dominate
regimes, where Congress has been effectively
challenged but has not collapsed and there is
fairly stable and mainly two-party competition
(the politics of accommodation vis-à-vis lower
classes have continued to work more or less
effectively):
z Andhra Pradesh
z Gujarat
z Karnataka
z Maharashtra
3 States in which lower castes/classes are more
strongly represented and where the Congress
lost its dominance at an early stage (clientelism
may persist but the leading political parties
have well-defined programmes):
z Kerala
z Tamil Nadu
z West Bengal
Harriss and Kohli Notes on the Differing ‘States’ of Child Undernutrition in Rural India
10
Table 1 Percentage of children who are underweight (WHO dataset)
States 1974–9 1988–90 1991–2 1995–7 1998–9 Reduction
(2000–1)
*
1974–2001 (%)
Andhra Pradesh 73 65 57 56 41 (40) 45
Gujarat 73 69 66 62 49 (55) 25
Karnataka 72 70 65 54 46 (48) 33
Kerala 68 43 40 26 28 (29) 57
Madhya Pradesh 70 65 n/a n/a 58 (64) 9
Maharashtra 76 64 71 58 n/a (55) 28
Orissa 72 71 64 57 56 (54) 25
Tamil Nadu 68 61 57 40 38 (39) 43
West Bengal n/a n/a 64 n/a 45 (50) 22
Source WHO (2008)
1
.
*The figures in brackets are from the National Nutrition Monitoring Board for 2000–1.
†The figure for reduction for West Bengal is from 1991–2.

In the original analysis of these differences and
their implications, it was hypothesised that those
states in which lower castes/classes are more
strongly represented and where Congress
dominance was replaced at an early stage by
more or less strongly programmatic political
parties,
2
would be found to have been the most
effective in regard to poverty alleviation. The
middle caste/class dominated party regimes,
continuing to pursue clientelist politics of
accommodation, it was argued, would be less pro-
poor, and the states with still upper caste
dominance even less so. The records of the states
considered in this article, with regard to the
reduction of undernutrition among children,
quite strikingly bear out this analysis. What we
will argue, therefore, is that while Michael
Walton’s overall analysis of the politics of
malnutrition in India – that the central problem
around public action to tackle malnutrition is
that such action is poorly aligned with political
and administrative incentives – appears to have
explanatory mileage, the differences between
states show what can be achieved by
programmatic parties with the characteristics
that Kohli identified in his comparative research
on West Bengal, Karnataka and Uttar Pradesh in
the 1980s (Kohli 1987, and see Harriss 2003:
205). The party regimes most likely to
accomplish pro-poor distribution, he argued, are
likely to have the following characteristics:
(1) coherent leadership; (2) ideological and
organisational commitment to exclude
propertied interests from direct participation in
the process of governance; (3) a pragmatic
attitude toward facilitating a non-threatening as
well as a predictable political atmosphere for the
propertied entrepreneurial classes, and (4) an
organisational arrangement that is
simultaneously centralised and decentralised, so
that the regime is ‘in touch’ with local society
but not subjected to local power holders. In
varying degrees the CPI(M) in Kerala and West
Bengal, the Dravidian parties in Tamil Nadu and
possibly the Telugu Desam party in Andhra
Pradesh display these characteristics.
3 Trends in undernutrition and their
determinants
We note, first, broad consistency between the
trends in undernutrition across states shown in
Table 1 and a variety of factors that are among
the more important proximate determinants of
nutrition status, having to do with childcare
(influenced by female literacy), local public
goods (water supply and sanitation), and the
local health system (immunisation and
institutional deliveries). We also note
correspondence with an index of institutional
performance across Indian states derived by
Mayer (2001) from a factor analysis model, and a
measure of the elasticity of rural poverty (as
defined by the conventional income measure)
with respect to growth (using data for the period
1958–97) calculated by Besley et al. (2005).
We find a close correspondence (Table 2)
between levels of undernutrition and vaccination
coverage in the rural areas across states, with
Orissa as an outlier (52 per cent of children in
Orissa of 12–32 months having received the
recommended vaccination, more than in Andhra
Pradesh, Karnataka and Maharashtra). If we
take the NFHS data on the incidence of
institutional deliveries as another single
snapshot indicator of the quality of health
services then, again, there is a clear
correspondence with states’ varying
performances in reducing child undernutrition
(with West Bengal, here, an apparent outlier).
There is a similarly close correspondence
between variations in female literacy and in
trends in the reduction of undernutrition
(though Maharashtra and Orissa have done
relatively better in regard to female literacy than
in the reduction of undernutrition); and there is
a broad correspondence between indicators of
the quality of local public goods – availability of
safe drinking water and of sanitation – and the
trends in reduction of undernutrition, though
Kerala is a puzzling negative outlier in regard to
drinking water, and Tamil Nadu with regard to
sanitation.
The overarching factor among the proximate
determinants of nutrition status is that of
income (an indicator of ‘household economic
resources’), which is likely strongly to influence
food security and dietary intake, access to health
care and the quality of the health environment,
and to have an influence upon the quality of
childcare. As our indicator here we consider the
elasticity of rural poverty with respect to growth
(from Besley et al. 2005). The virtue of this
measure is that it suggests that there exist
significant institutional differences between
states that account for whether or not growth is
inclusive and broad-based. It is one measure of
IDS Bulletin Volume 40 Number 4 July 2009
11

Harriss and Kohli Notes on the Differing ‘States’ of Child Undernutrition in Rural India
12
Table 2 Trends in undernutrition and some proximate and underlying determinants
State Underweight Underweight Children 12–23 Children of 12–23
Rural households Rural households Female literacy Rural poverty Mayer
reduction 2005–6 months who have months with
with access to with access to (%) 1999–2000 elasticity of (2001)
1974–2001 (%) (NFHS) received Inst’nal deliveries safe drinking toilet 2001 (%) (Sengupta 1991) growth Index
*
recommended (%) (NFHS) water 2001 (%) (Indiastat 1958–97
vaccines 2005–6 (Indiastat 2008a) 2008b)
(%) (NFHS)
Kerala 57 26 69 99 17 81 86 –1.19 1
Tamil Nadu 43 32 84 87 85 14 53 –0.62 2
West Bengal (22)
42 63 34 87 27 52 –1.29 6
Average 50
33 72 73 63 41 64 –1.03
AP 45 35 43 61 77 18 43 –0.77 7
Karnataka 33 48 40 42 81 17 44 –0.41 5
Gujarat 25] 41 52 57 77 22 47 –0.67 4
Maharashtra 28 42 50 51 68 18 55 –0.38 3
Average 33 42 46 53 76 19 47 –0.56
Madhya Pradesh 9 63 32 20 62 9 35 –0.37 9
Orissa 25 46 52 35 63 8 42 –0.71 8
Average 17 54 45 28 63 9 39 –0.54
*Mayer’s index is of institutional performance and was constructed with a factor analysis model taking account of six indicators: hospital beds/1,000; PDS share 1987–8;
teachers/school 1991; % villages electrified; % girls 6–<11 in school; IAS transfers after >1 year
†Figures for West Bengal from 1991–2 only ‡Average excludes West Bengal

government capacity. In the context of an overall
correspondence between this measure of the
elasticity of poverty with respect to growth and
performance in regard to reduction of
undernutrition Tamil Nadu stands out as having
done relatively well in regard to nutrition, in
comparison with its performance in poverty
reduction, while both Gujarat and Orissa have
evidently done less well in improving child
nutrition than they have done in reducing
poverty. It appears likely from the data of Table 2
that these variations may be explained as being
the outcome of differences in the provision of
public services, and in the quality of bureaucratic
performance. Tamil Nadu does well in regard to
hospital births, and stands second only to Kerala
in regard to ‘institutional performance’ – which
can be taken as a measure of the ‘responsiveness’
of government to citizens’ needs. Orissa, on the
other hand, has done poorly in these respects;
while Gujarat, in spite of its greater wealth than
the other states under consideration here (save
for Maharashtra, which is another ‘high income’
state), has done quite poorly in terms of the
provision of public services affecting the
nutrition of children.
A final set of factors that should be considered
concerns interventions that have a direct impact
upon the nutrition of children. The most
important of these in India is the distribution of
foodgrains through the public distribution
system (PDS). Although regarded by some
analysts as ineffective (as Walton argues in his
article in this IDS Bulletin), it is certainly a moot
point as to whether it has not made an important
contribution to reducing malnutrition in those
states in which it has been most fully
implemented. The PDS has clearly been
ineffective in states such as Bihar and Uttar
Pradesh, where there is a long history of only
very limited distribution of food grains under the
Scheme; but it is reasonable to wonder whether
it has not been effective in the Southern states.
Of course correlation (in this case between PDS
performance and trends in the reduction of
malnutrition) does not constitute causality. But
the correlation at least suggests the possibility of
a causal link. Although we lack a consistent data
series on the distribution of food under the PDS
to demonstrate the point conclusively, available
published data relating to the 1980s and 1990s
(before the introduction of the targeted PDS in
1997) show that the states that have done well in
reducing undernutrition among children are also
states that have made the most extensive use of
the PDS. An analysis by Tyagi (1990) for the
single year 1988–9, comparing ‘desired
distribution’ (taking account of poverty,
agricultural production and income levels) and
‘actual distribution’ through the PDS showed
that in Kerala, followed by West Bengal, Tamil
Nadu and Andhra Pradesh, actual distribution
was higher than ‘desired’, and that in Karnataka
the two were at parity. In Gujarat, Maharashtra,
Orissa and Madhya Pradesh actual distribution
was below ‘desired’ (see Table 7 in Harriss 2003:
224). Data presented by Swaminathan in her
study of the PDS show that Andhra, Tamil Nadu,
Kerala, West Bengal and then Karnataka
between them accounted for about half of the all
India offtake of foodgrains under the PDS in the
1990s (Swaminathan 2000, Tables 4.1 and 4.2),
and have generally had the highest per capita
offtake among the major states from the early
1970s (Swaminathan 2000, Tables 4.3 and 4.4).
These data do show, however, that both
Maharashtra’s and West Bengal’s offtakes have
tended to decline over time, while Orissa’s has
latterly increased (after the introduction of the
targeted PDS). Following the introduction of
targeting large numbers of those unquestionably
in need are being excluded from the PDS –
especially so in Kerala, followed by Orissa and
Maharashtra. Now Tamil Nadu alone maintains
a universal system of public distribution
(Swaminathan 2008).
4 Conclusion
We offer only presumptive evidence in this
article, but although only descriptive, the data do
show strong connections between the varying
character of the political regime across states
and government performance in regard to
services that influence the nutrition status of
children, and these with the trends of reduction
of undernutrition. There are of course many
intervening variables, but the patterns we have
traced are striking in their consistency, and the
three dimensions they represent – capacity
(reflected in the elasticity of poverty with respect
to growth), responsiveness (shown up in the
index of institutional performance) and
accountability to poorer, lower caste/class people
(which is what the typology of political regimes is
based upon) – are the hallmarks of good
governance.
IDS Bulletin Volume 40 Number 4 July 2009
13

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References
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Journal ArticleDOI

320 citations


"Notes on the Differing ‘States’ of ..." refers background in this paper

  • ...IDS Bulletin Volume 40 Number 4 July 2009 13 In view of all that is known about the quality of public action in Kerala from the work of Dreze and Sen (1989) the relative success of the state in reducing malnutrition among children is unsurprising....

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MonographDOI
22 Jan 1987
TL;DR: Kohli et al. as mentioned in this paper compared three state-level Indian governments of the late seventies: Communist-ruled West Bengal, Karnataka under the Congress Party, and Uttar Pradesh under the Janata Party in terms of their success in redistributing agricultural land and creating employment for the rural poor.
Abstract: This analysis of the role of government in eradicating India's rural poverty raises a whole series of crucial contemporary issues relating to the state, its degree of autonomy in the developing world and the problems of effecting genuine redistributive reform. The particular importance of the book is that it focuses attention on the nature of ruling political parties as an important factor influencing the success or failure of redistributive and welfare politics in a democratic capitalist setting. Dr Kohli compares in detail three state-level Indian governments of the late seventies: Communist-ruled West Bengal, Karnataka under the Congress Party, and Uttar Pradesh under the Janata Party. Comparing these in terms of their success in redistributing agricultural land and creating employment for the rural poor, the author argues cogently that well-organised, left-of-centre parties in government - like that in West Bengal - are the most effective in implementing reform.

300 citations

Journal ArticleDOI
TL;DR: In spite of India?s rapid economic growth, there has been a sustained decline in per capita calorie consumption during the last twenty-five years as mentioned in this paper, and while the decline has been largest among better-off households, it has taken place throughout the range of household per capita total expenditure.
Abstract: In spite of India?s rapid economic growth, there has been a sustained decline in per capita calorie consumption during the last twenty-five years. While the decline has been largest among better-off households, it has taken place throughout the range of household per capita total expenditure. For both adults and children, anthropometric indicators of nutritional status in India are among the worst in the world. While these indicators have shown improvement over time, the rate of progress is slow relative to what might be expected based on international and historical experience. This paper presents the basic facts about growth, poverty and nutrition in India, it points to a number of puzzles, and it sketches a preliminary story that is consistent with the evidence. The reduction in calorie consumption cannot be attributed to declining real incomes, nor to any increase in the relative price of food. Our leading hypothesis, on which much work remains to be done, is that, as real incomes and wages have increased, leading to some nutritional improvement, there has been an offsetting reduction in calorie requirements due to declining levels of physical activity and possibly also to various improvements in the health environment. If correct, this analysis does not imply that Indians are currently adequately nourished; nothing could be further from the truth. Calorie intake has serious limitations as a nutritional intake; while calories are extremely important, there are too many sources of variation in calorie requirements for standard, invariant, calorie-norms to be usefully applied to large sections of the population. We conclude with a plea for better, and more regular, monitoring of nutritional status in India.

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Frequently Asked Questions (7)
Q1. What are the contributions mentioned in the paper "Notes on the differing ‘states’ of child undernutrition in rural india" ?

This article explores the underlying political and institutional factors that may account for these differences, and shows the strong correspondence between measures of the capacity, responsiveness and accountability of different state governments and their performance in improving the nutrition of children. IDS Bulletin Volume 40 Number 4 July 2009 © 2009 The Authors. As Harriss showed in earlier work ( 2003 ), the authors may first differentiate between Indian states in terms of the political representation of different castes/classes ( this formulation reflecting the view that while caste and class are certainly not equivalents, there is considerable overlap between the categories ), and second, the nature of political competition in them. The states in the present analysis were categorised as follows: 1 States in which upper caste/class dominance has persisted and the Congress Party has remained strong in the context of a stable two-party system ( ‘ traditional dominance ’ rather than politics of accommodation vis-à-vis lower classes ): Madhya Pradesh Orissa 2 The analysis suggests, therefore, that there are important differences between states in terms of the extent to which their political systems allow for voice on the part of poorer, lower caste/class people. Of course, there is no Indian state in which clientelist politics of accommodation play no part at all in political mobilisation, but the analysis suggests that there are differences of degree between states. 

The overarching factor among the proximate determinants of nutrition status is that of income (an indicator of ‘household economic resources’), which is likely strongly to influence food security and dietary intake, access to health care and the quality of the health environment, and to have an influence upon the quality of childcare. 

These parties are the Communist Party of India-Marxist (CPI-M) in West Bengal and Kerala – where it has, however, regularly alternated in office with Congress-led formations – and the Dravidian parties in Tamil Nadu that have pursued policies that can fairly be described as ‘populist’. 

The Tamil Nadu story is less well known, although the quality of provision of public services in the state, and the performance of its bureaucracy, have long been recognised, and latterly it has been marked by a strong commitment to social welfare (reflected, for instance, in the maintenance of the universal PDS). 

In the context of an overall correspondence between this measure of the elasticity of poverty with respect to growth and performance in regard to reduction of undernutrition Tamil Nadu stands out as having done relatively well in regard to nutrition, in comparison with its performance in poverty reduction, while both Gujarat and Orissa have evidently done less well in improving child nutrition than they have done in reducing poverty. 

The analysis also confirms the importance of the public distribution system, and lends support to Madhura Swaminathan’s criticisms (2008) of the introduction of targeting. 

Following the introduction of targeting large numbers of those unquestionably in need are being excluded from the PDS – especially so in Kerala, followed by Orissa and Maharashtra.