The scores and ranks as estimates of triple burden of malnutrition, computed for states and districts in the respective surveys can be found in Additional File1.
3.1. Comparing the nutrition scenario in India at a different level of aggregation:
a) Nutrition scenario across State Boundaries in India:
Comparing the triple burden in states of India over three different periods of surveys, i.e. from NFHS-3 (2005-06) to NFHS-4 (2015-16) to CNNS (2016-18), a positive upward shift in the nutrition scenario at the state level is noticed, as seen in Figure 1a-c.
Based on the MANUSH scores, at the time of NFHS-3 (see Figure 1a), four states were found to fall under extremely alarming category (MANUSH score ≥0.65), namely Madhya Pradesh (0.73), Meghalaya (0.72), Jharkhand (0.70) and Bihar (0.69) on account of extremely high prevalence of stunted and wasted children below the age of five. Seven states – Uttar Pradesh (0.61), Sikkim (0.61), Chhattisgarh (0.61), Gujarat (0.59), Haryana (0.56), Rajasthan (0.56) and Odisha (0.55) were found in the alarming category as per MANUSH scores. All the seven states but Sikkim were penalized for the high prevalence of stunting, whereas Sikkim was accounted for the high prevalence of both stunted and overweight/obese children. Only four states – Punjab (0.43), Goa (0.41), Manipur (0.39) and Kerala (0.36) were found in the moderate category with MANUSH score in the range of ≥0.35 and <0.45. Manipur (weighted standardized score wasting 0.07, anemia 0.08, overweight 0.06), when compared to Kerala (stunting 0.11, wasting 0.12, anemia 0.08, overweight 0.03) fared better in all dimensions, except that of stunting (weighted standardized score 0.16), and hence was penalized on account of unbalanced development across its dimensions. None of the states were found to fall under low category (MANUSH score <0.35) while 13 states fell under the serious category (MANUSH score ≥0.45 and <0.55). Nagaland was excluded from NFHS-3 study as the anemia prevalence was not known.
Figure 1: Map of India depicting state categorization on the severity scale based on MANUSH scores calculated based on a) NFHS-3 b) NFHS-4 c) CNNS
Next, the nutrition scenario in states surveyed in NFHS-4 (See Figure 1b) was compared with previous round, i.e. NFHS-3 using MANUSH scores. In the NFHS-4 round, none of the states fell in the extremely alarming category (MANUSH score ≥0.65), except Dadra and Nagar Haveli (MANUSH Score 0.67), a Union Territory (UT) penalized on performing poorly on all four dimensions. Three states, Jharkhand (0.64), Madhya Pradesh (0.59) and Bihar (0.58), when compared to NFHS-3, moved from extremely alarming to alarming category on account of reduction in stunting and wasting, although overweight/obesity rose marginally in children below five years in these states with no or minimal reduction in anemia. Sikkim (0.60) and Gujarat (0.57) showed no change in the category on the severity scale between the two rounds and were retained in the alarming category. Karnataka (0.56), on the other hand, deteriorated its position, descending from serious to alarming category between NFHS-3 and NFHS-4. while Meghalaya (0.52) showed a significant upward transition from extremely alarming to serious category between two rounds of the survey. Uttar Pradesh (0.54), Rajasthan (0.54), Haryana (0.53), Chhattisgarh (0.52) and Odisha (0.47) demonstrated one -scale upward shift from alarming to the serious category in NFHS-4 on account of robust decline in stunting, followed by anemia. Except Odisha, wasting was found to increase in all the four states. Goa (0.45) slipped from moderate to serious category, penalized on account of an unprecedented rise in wasting and anemia, despite a small reduction in stunting and children under five years. While, Maharashtra (0.53), Uttarakhand (0.50), Tamil Nadu (0.49), Arunanchal Pradesh (0.49), West Bengal (0.47) and Jammu and Kashmir (0.47), were retained in serious category. Daman and Diu (0.50) and Puducherry (0.45), the union territories, are also found in serious category, with former penalized on account of a high prevalence of wasting and anemia and later due to high prevalence of wasting with respect to other dimensions. Assam (0.44), Delhi (0.44), Andhra Pradesh (0.44), Telangana (0.43), Tripura (0.40), Himachal Pradesh (0.38) and Mizoram (0.35) gradually shifted from serious to moderate category. Punjab (0.40) and Kerala (0.36) held in moderate category, showed no shift on the severity scale between the two rounds. Three UTs, namely, Andaman and Nicobar Island (0.42), Chandigarh (0.40), Lakshadweep (0.38) and Nagaland (0.37) also added to the list of states in the moderate category. Manipur (0.33) demonstrated a positive upward shift from moderate to low category and is the only state to be found in the low category.
Except, Kerala, Jammu and Kashmir, Karnataka and Goa, all the states showed reduction in the MANUSH scores, between NFHS-3 and NFHS-4 (See Figure 2). Meghalaya exhibited maximum improvement between the two rounds, followed by Tripura, Mizoram and Himachal Pradesh accounting to 23% or more reduction in MANUSH scores. Madhya Pradesh and Bihar, the two states accounting to the maximum burden of undernourished children, demonstrated reduction of 17% -18% in MANUSH scores, suggesting that these states are progressing in the right direction in terms of addressing malnutrition, although steadily. Similar is the case of Delhi, Assam, Manipur, Chhattisgarh, Odisha, Andhra Pradesh, Uttar Pradesh and West Bengal that showed 10%-15% reduction in MANUSH scores. States like Jharkhand, Uttarakhand, Punjab, Arunanchal Pradesh, Haryana and Tamil Nadu showed tardy reduction, of about 5-7%, between the two rounds. Gujarat, Maharashtra, Rajasthan and Sikkim showed the minimum decline (less than 5%), suggesting extremely marginal improvement between the two rounds. States like Kerala, Jammu and Kashmir and Karnataka, on the other hand, showed a marginal increase (≤5%) in MANUSH scores between two rounds, suggesting unbalanced development across the dimensions, and hence the penalty. Moreover, Goa showed increment of about 11% in MANUSH scores and has been heavily penalized on account of the unprecedented rise in wasting in children under the age of five.
Figure 2: Percent reduction in MANUSH scores across states in India between NFHS-3 and NFHS-4 rounds of the survey
Further comparison with recently released Comprehensive National Nutrition Survey (2016-18) conducted in 29 states of India and Delhi (Union Territory), a brighter picture of enhanced nutrition scenario across the states in India emerges at the surface (See Figure 1c). No states were found to fall under extremely alarming category (MANUSH score >0.65). Jharkhand continued to retain in alarming category (0.56), although it showed a modest reduction in MANUSH scores between NFHS-4 and CNNS. While Assam (0.50) and Tripura (0.47) fall from moderate to severe category, Nagaland (0.56) descends from moderate to alarming category. On the other hand, Madhya Pradesh (0.49), Gujarat (0.46) and Bihar (0.46) ascend from severe to moderate category. Maharashtra (0.47), Uttar Pradesh (0.47) and Meghalaya (0.46) were retained in a severe category despite decline in their MANUSH scores. A large chunk of states falls under moderate category during CNNS as per MANUSH scores. Sikkim (0.37) and Karnataka (0.42) moved dramatically upwards from alarming to moderate category. Eight states, namely, Chhattisgarh (0.45), Jammu & Kashmir (0.42), West Bengal (0.42), Rajasthan (0.41), Haryana (0.40), Tamil Nadu (0.40), Arunanchal Pradesh (0.39) and Odisha (0.36) showed an upward shift from severe to moderate category. Interestingly, Manipur (0.42), which ranked 1st in NFHS-4 survey dropped to 17th rank in CNNS, falling from low to moderate category, implying heavy penalty imposed by MANUSH indexing method on account of unbalanced development. Andhra Pradesh (0.41), Telangana (0.40), Mizoram (0.39) and Delhi (0.39) continued in moderate category. While Uttarakhand (0.34) and Goa (0.34) ascended from severe to low category, Himachal Pradesh (0.35), Punjab (0.34) and Kerala (0.28) also shifted from moderate to low category.
b) Nutrition scenario across District Boundaries in India:
Next, the nutrition scenario across 640 districts of India was examined, based on MANUSH score and ranking (See Figure 3) computed using district level data of NFHS-4.
Pockets of districts falling under extremely alarming, alarming, serious and moderate range emerge from the central and spread across the posterior end of the country in the said order. Two districts (Pashchimi Singhbhum of Jharkhand and The Dangs of Gujarat) fell in the extremely alarming category (score >0.65), followed by 145 districts in the alarming category, a large proportion belonging to Madhya Pradesh, Uttar Pradesh, Jharkhand, Bihar, Rajasthan and Gujarat. Further, 352 and 140 districts fell in the serious and moderate category and only one district (Mokokchung district of Nagaland) was found in the low category of severity scale.
Of the districts falling in alarming and extremely alarming category (≥0.50 MANUSH score), i.e. a total of 147 districts, 40% were penalized on account of high incidences of wasting, about 30% were penalized due to high incidences of stunting and about 22% have higher prevalence of both stunting and wasting. Interestingly, Erode district in Tamil Nadu was severely penalized on account of high incidence of overweight/obese children under the age of five. Few other districts like Chennai of Tamil Nadu, Ambala in Haryana, Banda of Uttar Pradesh, South District of Sikkim, and Ambala district of Haryana have been penalized on account of overweight/obese children in addition to undernourished children. All the districts in the bottom two category have medium to a high prevalence of anaemic children under the age of five.
Figure 3: Map of India depicting district categorization on the severity scale based on MANUSH scores calculated using CNNS data
Figure 4 provides a snapshot of subnational disparities in triple burden of malnutrition across and within the States/UTs of India covered in NFHS-4 based on MANUSH scores. For each state, this figure shows the mean MANUSH score as well as the highest and lowest MANSUH score obtained by the districts in the state. Though, it is impossible to determine which states have the highest levels of inequality in terms of triple burden of malnutrition based solely on the size of the gaps between the highest and lowest subnational MANUSH scores, yet there are some interesting insights. For instance, in some states, the spread is quite compact, e.g. in Andhra Pradesh and quite large for some, e.g. Odisha and, surprisingly, even Tamil Nadu.
Figure 4: States arranged on the basis of moving average of MANUSH scores of districts. Note: On the y-axis, the value in brackets indicates the number of districts in that particular state.
Interestingly, Odisha's best performing district (Cuttack) with undernutrition score of 0.21, ranks 4th in the country while its worst-performing district, Nabarangpur, with a score of 0.60, ranks 623rd is amongst the worst-performing districts in the country. Similarly, Kanniyakumari of Tamil Nadu with a score of 0.22 ranks 7th in the country, while Chennai in Tamil Nadu ranks 611th and falls in the bottom list of worst-performing districts. Chennai shows higher prevalence in all the four indicators – overweight/obesity, stunting, wasting and anaemia in children under the age of five years. If one takes a closer look at the spread in the case of Odisha, the best and the worst-performing districts appear to form a cluster. A similar pattern is observed in West Bengal. In contrast to the case of Odisha and West Bengal, the states of Bihar and Madhya Pradesh each with 38 and 50 districts, have a low average MANSUH score for their state and a small deviation between the scores of their best performing and worst-performing districts, reflecting the uniformly poor performance across the state. Maharashtra, Karnataka and Rajasthan show a comparable spread. Such inequalities within and across states level reflect spatial heterogeneities that exist in India.
To study the spatial heterogeneity at the district level, Univariate LISA maps were created using MANUSH scores using GeoDa version 1.14.0. As shown in Figure 5a, formation of significant clusters (p<0.05) was observed and the univariate Moran’s I value was found to be 0.619, depicting strong spatial autocorrelation. About 135 districts out of 640 districts, i.e. 20% were surrounded by districts with high MANUSH scores, signifying clusters of high malnutrition, while 108 districts, i.e. around 17% districts were surrounded by districts with low MANUSH scores, signifying better nutrition scenario. The high-high clusters were mostly found in the central belt of India, in the states of Madhya Pradesh, Jharkhand, Maharashtra, Bihar, Rajasthan, Uttar Pradesh, Gujarat and some parts of Chhattisgarh, Odisha, West Bengal and Karnataka. While low-low clusters were found in the peripheral states of India – primarily in the north-eastern states like Nagaland, Manipur, Mizoram, some parts of Assam, Arunanchal Pradesh and Tripura, also in the northern states like Jammu & Kashmir, Himachal Pradesh and Punjab, in the southern coastal belt of Karnataka, Kerala and Tamil Nadu and in eastern coastal belt of Odisha and West Bengal. Interestingly, low-low clusters are also found in few districts of Telangana, bordering Andhra Pradesh. Spatial analysis also brought two groups of outliers, i.e. districts with low MANUSH scores (eight in count) surrounded by districts with high MANUSH scores, that can be grouped under 'positive outliers', and second, districts with high MANUSH score (seven in count) surrounded by districts with low MANUSH scores, that can be grouped under ‘negative outliers’.
Figure 5: Univariate LISA cluster maps of India showing the geographic clustering based on MANUSH scores across districts of India, a) with state boundaries, 2015-16. b) with state and NSS boundaries (as per 68th round of NSS), 2015-16.
Also, when we study the spatial clustering at the National Sample Survey (NSS) region level, the differences within a state become much more evident. NSS regions are the ones used for survey by National Sample Survey Organisation (NSSO) in conducting surveys across India on various socio-economic aspects since 1950. These regions are formed by contiguous grouping districts within a state, in relatively homogenous regions based on geographical features, rural population densities and crop-pattern [32]. As observed in Figure 5b, if one takes a closer look at the spread in the case of Odisha, the best and the worst-performing districts appear to form significant clusters at coastal and southern NSS regions respectively. Similarly, in Karnataka and West Bengal, pockets of low performing and better performing districts appear at the anterior and posterior end, respectively, that are separated by NSS boundaries. Moreover, in states like Chhattisgarh and Bihar, significant clusters of poor-performing districts seem confined to a particular NSS region. A similar scenario is observed in Maharashtra, Gujarat and Rajasthan, where pockets of poor-performing districts seem to grouped together not only in a particular NSS region but also form clusters, across state boundaries, suggesting the spatial dependency of neighbours on malnutrition.
3.3. Implications of MANUSH indexing on nutrition policy:
Scoring and ranking of states and district have become a common phenomenon in recent times, in India, for ease of comparison and prioritization of issues and for development of policies. However, there are two limitations that have been observed in this context. First, if scoring is based on a combination of indicators, linear averaging is the only method of aggregation used, whose limitations have already been discussed in the sections above. Second, if the scoring is done on single parameters, for example, only stunting or wasting or anaemia, and policy is developed based upon it, there is an increased risk of overlooking other indicators.
To understand this, we looked at an actual policy priority measure in the recently launched National Nutrition Mission (NNM) in India. While the Mission objective is to reduce undernutrition in children, adolescent girls and women and achieve targets set for the year 2022 [8], it chose to group districts into three phases, for accelerated intervention, in order of priority. However, the priority was set solely based on the prevalence of stunting. The districts with the highest level of stunting were placed in the list of Phase I districts and so on. If the only objective were to reduce stunting, then this prioritization would have seemed rational. But to reduce undernutrition holistically – stunting, wasting and anaemia, dimensions which are independent and not a substitute for each other, need to be taken together. Not considering other two dimensions, might have led to misallocation of priorities, funds and resources. To comprehend this better, we ranked the same 640 districts according to MANUSH scores and grouped into 3 priority regions – priority 1, 2 and 3. Districts with MANUSH score ≥0.48 were accorded 1st priority, districts with MANUSH score between 0.38 and 0.48 were placed in the 2nd priority list, and districts with MANUSH score less than 0.38 was put in 3rd priority list (see Additional File 1). It is to be noted that MANUSH index discussed in this article, also takes into account wasted and overweight children under the age of five, along with stunted and anaemic children. It needs to highlighted because targets set under the National Nutrition Mission, 2018 do not talk about the reduction in wasting and overweight/obese children, who are on the rise in India.
After grouping the districts into priority 1, 2 and 3 regions, we compared these districts with the priority districts under National Nutrition Mission (NNM), rolled out in three phases, as shown in Figure 6 below. About 8 districts (Dehradun, Ambala, Jamnagar, Chitradurga, Tiruvannamalai, Erode and Dharmapuri) which should have been part of phase 1 of NNM round as per MANUSH ranking, are listed in the 3rd phase of NNM. All the eight districts but Erode have been penalised on account of a high prevalence of wasting. Erode district of Tamil Nadu, on the other hand, is penalised on account of a high prevalence of overweight children, followed by stunted, wasted and anaemic children. If we focussed solely on indicators of undernutrition, then this district would have been neglected, but taking overweight as a measure in MANUSH index, it pinpoints those districts as well who are becoming emerging capital of overnutrition, alongside undernutrition.
Similarly, 37 other districts, that should have been in phase 1 of NNM as per MANUSH ranking are part of the NNM 2nd phase. Majority of these districts too are penalised on the high prevalence of wasting, except South District of Sikkim and Mahe district of Pondicherry, who show a high prevalence of overweight/ obese children under the age of five.
Moving further, 33 districts which should have been part of phase 2 of NNM as per MANUSH ranking are found in the list of districts under NNM 3rd phase. Three districts (Faridabad, Rewari and Kolkata) out of 33 mentioned have been penalised on account of the high prevalence of anaemia while two districts (Tawang of Arunanchal Pradesh and Namakkal of Tamil Nadu) have been penalised on account high incidence of overweight/obese children, while the rest of the districts exhibit high incidences of wasting. Interestingly, Mahamayanagar of Uttar Pradesh, one of the districts among the 33 mentioned above, exhibits a very high burden of stunting, and lower incidence of wasting, anaemia and overweight/obese. It has been penalised by MANUSH on account of unbalanced development across the dimension.
Figure 6: Map of India depicting phase allocation of districts as listed in a) National Nutrition Mission and b) as per MANUSH scores