Making Investments in Maternal Nutrition and Sanitation and Changing Social Norms to Enhance their Effectiveness can help to Exploit India’s Demographic Dividend

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The National Food Security Act and Swachh Bharat are part of the Government’s Policy Agenda to Improve Maternal and Early Life Health

The Economic Survey 2015-16 presented today in the Parliament by the Union Finance Minister Shri Arun Jaitley highlights that relatively low cost maternal and early life health and nutrition programs offer very high returns on investments. Investments in maternal, nutrition and sanitation and enhancing their effectiveness by changing social norms can help India exploit its demographic dividend.

The Survey pointed out that early life conditions affect cognitive development. A healthy mother is more likely to give birth to a healthy baby. Further, returns to human capital investments vary with the age of the child, being highest for programs that target young children and in-utero health. Programs targeting younger children are also relatively cheaper investments. The Survey suggests that early life investments are thus a real opportunity for fiscal and capacity constrained governments.

The Survey notes three things with regards to height for age of children in India –

• There has been a gradual improvement in both rural and urban India. The children surveyed during the RSCO 2013-14 round are on average taller than those surveyed during NFHS 2005-06.

• There is a persistent rural-urban height gap.

• India remains a negative outlier with children being on average two standard deviation shorter than the healthy average.

The Survey identifies neo-natal mortality as an important indicator of in-utero nutrition. Out of all infants to die in India, 70% die in the first month. A leading cause of this is low birth weight. Underweight women at the beginning of pregnancy are far more likely to have low birth weight babies. 42.2% of Indian women are underweight at the beginning of pregnancy in contrast to 35% of non-pregnant women of child bearing age being underweight. The Survey says that thus, pregnant women are more likely to be underweight. Additionally, Indian women do-not gain enough weight during pregnancy. Women in India gain 7 kgs. during pregnancy compared to the WHO recommended figure of 12.5-18 kgs.

Another reason for poor maternal health is that social norms accord young women low status in joint households. This results in stark within-household nutritional differential.

Investing in maternal health could become a top policy priority of the government. The National Food Security Act 2013, legislating a universal cash entitlement for pregnant women of at least Rs. 6000 is a promising opportunity to improve nutrition during pregnancy. The Survey recommended pairing cash transfers with education about pregnancy weight gain.

The Survey identifies open defecation as a source of early life disease in India. According to WHO and UNICEF joint monitoring program, 61% of rural Indians defecated in the open in 2015. The Survey notes that income constraints may not be the main determinants of open defecation. Evidence suggests that open defecation leads to child stunting, diarrhoea and environmental enteropathy. Households who do-not defecate in the open have higher height for age scores.

The Survey notes the vital importance of the Prime Minister’s Swachh Bharat Mission in raising the profile of the problem of open defecation. In the last year alone, the government has built over 80 lakh toilets. The Survey says that the next challenge in rural India is behavioral.

The Survey says that the breast-feeding example illustrates how some investments by the state can lead to tangible changes in social norms in a relatively short period of time. Programs like Janani Suraksha Yojana and other schemes under the Integrated Child Development Scheme delivered via Anganwadi program has increased the proportion of breast feeding mothers to 62%. The Survey says that creating a nudgeunit within government is a useful way of changing norms.