National-‐Level Trends in Outcomes, Determinants and Interventions
Rasmi Avulawith Purnima Menon, Sneha Mani, Neha Kohli, Phuong Nguyen
International Food Policy Research Institute
New Delhi| May 3, 2017
Nutrition in the global agenda
2.2 BY 2030 END ALL FORMS OF MALNUTRITION, INCLUDING ACHIEVING BY 2025 THE INTERNATIONALLY AGREED TARGETS ON STUNTING AND WASTING IN CHILDREN UNDER FIVE YEARS OF AGE, AND ADDRESS THE NUTRITIONAL NEEDS OF ADOLESCENT GIRLS, PREGNANT AND LACTATING WOMEN, AND OLDER PERSONS
Tracking progress: Health and nutrition surveys in India, 1990-‐2015*
1990 1995 2000 2005 2010 2015
NFHS-‐1 NFHS-‐2 NFHS-‐3 NFHS-‐4
DLHS-‐1 DLHS-‐2 DLHS-‐3
AHS AHS AHSRSOCSu
rvey ty
pes
CNNS
*only includes surveys representative at the district level or higherNFHS: National Family Health Survey; DLHS: District Level Household SurveyAHS: Annual Health Survey; RSOC: Rapid Survey on ChildrenCNNS: Comprehensive National Nutrition Survey
POSHAN Report: Trends in nutrition outcomes, determinants, and interventions• Description of national and state trends – WHA targets– Multiple determinants
– Nutrition-‐specific interventions
• Generate a dialogue to support policy decisions for improving nutrition in multiple states
Methods• Data sources:– National Family Health Survey-‐4 (NFHS-‐4, 2015–16) factsheets
– National Family Health Survey-‐3 (2005–06) factsheets/report
– Rapid Survey on Children (RSoC, 2013–2014) for indicators that are currently not available in NFHS-‐4 fact sheets.
• Analysis – trends and levels– Outcome indicators– Immediate and underlying determinants – Coverage of nutrition-‐specific interventions
Indicators based on UNICEF’s conceptual framework and Indian policy frameworkOutcomes (WHA targets+)• Stunting• Wasting• Low birthweight• Exclusive breastfeeding • Underweight• Anemia (women of reproductive age,
pregnant women, children)Immediate determinants• Low body mass index (BMI)• Early initiation of breastfeeding• Timely introduction of foods• Adequate diet • Prevalence of acute respiratory infection
(ARI)• Prevalence of diarrheaUnderlying determinants• Women who are literate • Women with at least 10 years of education• Access to electricity• Married before 18• Improved sanitation • Improved drinking water
Nutrition interventions• Early initiation of breastfeeding• Timely introduction of foods• Adequate diet • Prevalence of acute respiratory infection (ARI)• Prevalence of diarrhea• ANC (first trimester)• ANC 4 or more visits) • ANC-‐neonatal tetanus injections• Consumption of IFA supplements • Food supplementation (pregnancy)• Janani Suraksha Yojana (JSY)• Skilled attendant at birth • Delivery in a health facility• Birth registration• Food supplementation (lactation)• Full immunization• Vitamin A supplementation
Menon et al. 2017. Trends in Nutrition Outcomes, Determinants, and Interventions in India. Page 15
Trends in key global nutrition targets and nutrition outcomes in India, 2005-‐06 to 2015-‐16
48
19.8
55
46.4
21.5
42.5
59
69.4
38.4
21
53 54.9
18.6
37.5
50
58.4
0
10
20
30
40
50
60
70
Stunting Wasting Anemia among women
Exclusive breastfeeding
Low birthweight
Underweight Anemia among pregnant women
Anemia among children
2005-‐06 2015-‐16
32.8
5
61.1
13.7
Source: NFHS-‐3; NFHS-‐4 and RSOC for low birth weightWorld Health Assembly Nutrition Target Level
27.9
Stunting declined – broad improvements, tremendous state-‐level variability in extent of improvement
2005-‐06
Source: NFHS-‐3; NFHS-‐4
2015-‐16
Changes in immediate determinants of nutrition: Limited progress on IYCF and child health
35.5
22.923.4
41.6
52.6
42.7
9 9.2
5.8
2.7
0
10
20
30
40
50
60
70
2006 2016
%
Women with body mass index <18.5
Early initiation of breastfeeding
Timely introduction of foods
Diarrhea in the last two weeks
ARI in the last two weeks
Uttar PradeshUttarakhand
RajasthanNCT of Delhi
PunjabJharkhandChandigarh
Madhya PradeshBihar
TelanganaAndhra Pradesh_New
Himachal PradeshIndia
Andaman & Nicobar IslandHaryanaTripura
Jammu & KashmirChattisgarhWest Bengal
Dadra and nagar haveliGujarat
NagalandLakshadweepTamil Nadu
Daman & DiuKarnataka
MaharashtraArunachal Pradesh
MeghalayaKeralaAssam
PuducherryManipurSikkimOdisha
MizoramGoa
Andhra Pradesh
0 20 40 60 80 100%
2006 2016
TripuraRajasthan
BiharUttar Pradesh
HaryanaMadhya Pradesh
PunjabIndia
MaharashtraNCT of Delhi
Andaman & Nicobar IslandKarnataka
UttarakhandJharkhand
GujaratAssam
Jammu & KashmirWest Bengal
Himachal PradeshArunachal Pradesh
ChattisgarhOdisha
Andhra Pradesh_NewTelangana
SikkimKerala
MeghalayaTamil NaduMizoramNagaland
PuducherryManipur
Andhra PradeshChandigarh
Dadra and nagar haveliDaman & Diu
GoaLakshadweep
0 20 40 60 80 100%
2006 2016
Early initiation of breastfeeding Timely introduction of complementary foods
Coverage of all nutrition-‐specific interventions increased; variable coverage
0
10
20
30
40
50
60
70
80
90
100
2006 2016
%
ANC visit during first trimester
4+ ANC visits for last birth
Consumed IFA during pregnancyFood supplementation during pregnancy Delivery in health facility
Births assisted by a health professional Birth registration
Food supplementation during lactation Fully immunization
Received vitamin A in the last 6 monthsFood supplementation for children ORS during diarrhea
0
10
20
30
40
50
60
70
80
90
100
%Coverage of interventions varies across continuum of care, among states in 2016
Sources: NFHS-4. RSoC data was used for indicators on pregnancy registration, food supplementation during pregnancy, lactating and for children, visits by health worker, pediatric IFA and deworming for children.
Women’s education, age at marriage and infrastructure improved; sanitation improved but still remains a big challenge
0
10
20
30
40
50
60
70
80
90
100
2006 2016
%
Women who are literate
Women with ≥10 years education
Girls married before age of 18
Households with access to improved drinking water
Households with access to improved sanitation facilityHouseholds with electricity
Emerging health problems: Non-‐communicable diseases
13.4
18.6
7.98.8
20.7
5.8
0
10
20
30
40
50
60
70
Hig blood pressure Overweight/Obesity High sugar level
%
Men Women
Summary• Progress on several maternal and child nutrition outcomes in the last decade– Anemia still a public health concern in India– Stunting still a public health concern in some states
• Modest and mixed improvements in the immediate determinants of nutrition– Disease burden unchanged
• Intervention coverage shows positive trends over time for most interventions
• Substantial progress on underlying determinants – Sanitation lags behind
• Interstate variability is masked in national averages– Unpack, investigate, set goals, develop strategies