multi-state stories:insights from the frontrunners of stunting reduction
TRANSCRIPT
Presented by Phuong Hong Nguyen
International Food Policy Research Institute
Multi-state stories:
Insights from the frontrunners of
stunting reduction
2016
38.4%
2006
Significant stunting reduction in all states in India in the last decades
2006
48%
Stunting reduction varies by state
-3.8 -3.8 -3.8
-3.5 -3.5-3.4
-3.1-3.0
-2.9 -2.9 -2.9-2.8 -2.7
-2.6-2.5
-2.4 -2.4 -2.4-2.3 -2.2 -2.2
-2.1 -2.0-1.9
-1.7
-1.4-1.3
-1.1-0.9
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
-20
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
AA
RR
per
cen
tage
po
int
chan
ge
pp change AARR
1,11,20,920
78,64,654
36,51,636
-
20,00,000
40,00,000
60,00,000
80,00,000
1,00,00,000
1,20,00,000
Nu
mb
er o
f st
un
ted
ch
ildre
n
9 states account for ~80% of stunted children
Number of stunted children reduced from ~76 million in 2006 to ~50 million in 2016
In 2016, prevalence stunting is still >30% in 16 states
0
10
20
30
40
50
60St
un
tin
g p
erce
nta
ge
If current trend of AARR continues, only 5 states reach the WHA target in 2025
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%A
vera
ge a
nn
ual
red
uct
ion
rat
e
Required AARR (2016-2025) Current AARR
What can the frontrunners, who have achieved lower rates of stunting, tell us?
48.346.3 45.3
42.039.1
27.125.7
24.3
20.1 19.7
0
10
20
30
40
50
60
% s
tun
tin
g in
20
16
Conceptual framework for examining determinants of stunting
Immediate determinants: Maternal nutrition status, in high versus low stunting states
Low BMI women Anemia in women of reproductive age
25.3 27 28.330.4 31.5
9.711.7
14.6 14.718.9
0
10
20
30
40
50
60
70
%
49.953.1
55.9
67.4 69.5
32.8
38 38
53.2
65.1
0
10
20
30
40
50
60
70
%
Immediate determinants: Infant and young child feeding practices in high versus low stunting states
Early initiation of breastfeeding Adequate diet
25.228.4
33.2 34.5 34.930.7
44.4
54.7
64.3
73.3
0
10
20
30
40
50
60
70
80
%
3.45.3 6.6 7.2 7.5 5.9 5.9
10.4
21.4
30.7
0
10
20
30
40
50
60
70
80
%
Intervention coverage: Antenatal care and IFA consumption, in high versus low stunting states
At least 4 ANC visits Consume 100+ IFA tablets
14.4
26.430.3
35.738.5
64.368.5
81.2
89 90.2
0
20
40
60
80
100
%
9.712.9
15.3 17.3
23.6
13.4
42.6
64.067.1 67.4
0
20
40
60
80
100
%
Intervention coverage: Immunization and vitamin A supplementation for children, in high versus low stunting states
Fully immunized Vitamin A supplementation
51.153.6 54.8
61.7 61.9
54.5
69.7
82.1
88.4 89.1
0
20
40
60
80
100
%
39.5 39.6
52.9
60.4 62.3 62.8
68.370.6
74.4
89.5
0
20
40
60
80
100
%
Underlying determinants: Women’s education and age at marriage, in high versus low stunting states
Women with 10y+ education Married before 18y of age
22.8 23.225.1
28.7
32.9
23.4
50.9
55.158.2
72.2
0
20
40
60
80
%
21.2
30
35.438 39.1
7.6 7.69.8
15.7
32.2
0
20
40
60
80
%
Underlying determinants: Water and sanitation, in high versus low stunting states
Improved drinking water Improved sanitation
24.4 25.2
33.7 35.0
45.0
52.2
61.3
78.381.5
98.1
0
20
40
60
80
100
%
77.8
84.7 85.5
96.4 98.2
87.390.6
94.396.3 99.1
0
20
40
60
80
100
%
Regression analysis comparing very high burden (stunting >40%) and low burden districts (stunting<20%) also provides some insights on important determinants
Asset score13%
Women with 10+ years school
17%
Adequate diet5%
ANC 4+ times4%
Open defecation density
7%
Married at 18+ years5%
Household size8%
ST/SC population3%
Unexplained38%
Differences between high and low stunting states/districts are attributable to factors related to immediate and underlying determinants, and intervention coverage
▪Determinants
o Maternal nutrition
o Infant feeding
o Sanitation
o Women’s education
o Age at marriage
▪ Intervention coverage
o ANC
o IFA
o Others (not shown)
Changing malnutrition outcomes requires an investment
in changing intervention coverage and subsequently in
changing determinants.
The POSHAN Policy Notes for each state can help with
diagnostic assessments
Looking forward: Stories of Change in nutrition for different successful states in India
Initial SoC studies will be done in 5
states: Odisha, Arunachal Pradesh,
Tamil Nadu, Gujarat, Chhattisgarh.
Stories of Change research for Odisha, available in: Menon et al., Nourishing Millions, 2016; Kohli et al., Global Food Security, 2017
Closing thoughts
➢ Malnutrition burden in India remains high despite some progress
➢ Tremendous inter-state and inter-district variability
➢ Inter-district and inter-state differences in stunting are not explained by any single
factor, but rather by a set of maternal, economic, health, hygiene and demographic
factors.
➢ Most importantly, many success stories across India, which are important to learn
from.
➢ POSHAN state Policy Notes help policy community examine state of nutrition
outcomes, immediate and underlying determinants and intervention coverage:
diagnose and identify challenges that need attention.
➢ Analysis of unit-level data, when available, from NFHS-4, and Stories of Change
studies at the state-level will help to support India’s nutrition policy community