Assessing inequalities and regional disparities in child nutrition outcomes in India using MANUSH—a more sensitive yardstick
India is strongly committed to reducing the burden of child malnutrition, which has remained a persistent concern. Findings from recent surveys indicate co-existence of child undernutrition, micronutrient de ciency and overweight/obesity, i.e. the triple burden of malnutrition among children below ve years. While considerable efforts are being made to address this challenge, and several composite indices are being explored to inform policy actions, the methodology used for creating such
... eating such indices, i.e., linear averaging, has its limitations. Brie y put, it could mask the uneven improvement across different indicators by discounting the 'lagging' indicators, and hence not incentivising a balanced improvement. signifying negative implications on policy discourse for improved nutrition. To address this gap, we attempt to develop a composite index for estimating the triple burden of malnutrition in India, using a more sensitive measure, MANUSH. Methodology: Data from publicly available nation-wide surveys -National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS), was used for this study. First, we addressed the robustness of MANUSH method of composite indexing over conventional aggregation methods. Second, using MANUSH scores, we assessed the triple burden of malnutrition at the subnational level over different periods NHFS-3(2005-06), NFHS-4 (2015-16) and CNNS (2106-18). Using mapping and spatial analysis tools, we assessed neighbourhood dependency and formation of clusters, within and across states. Result: MANUSH method scores over other aggregation measures that use linear aggregation or geometric mean. It does so by ful lling additional conditions of Shortfall and Hiatus Sensitivity, implicitly penalising cases where the improvement in worst-off dimension is lesser than the improvement in best-off dimension, or where, even with an overall improvement in the composite index, the gap between different dimensions does not reduce. MANUSH scores helped in revealing the gaps in the improvement of nutrition outcomes among different indicators and, the rising inequalities within and across states and districts in India. Signi cant clusters (p<0.05) of high burden and low burden districts were found, revealing geographical heterogeneities and sharp regional disparities. A MANUSH based index is useful in contextspeci c planning and prioritising different interventions, an approach advocated by the newly launched National Nutrition Mission in India. Conclusion: MANUSH based index emphasises balanced development in nutritional outcomes and is hence relevant for diverse and unevenly developing economy like India. Recent surveys [5,6] con rm that India is grappling with the triple burden of malnutrition among children under the age of ve -undernutrition, and micronutrient de ciencies among many and emerging overweight/obesity in some. The coexistence all three forms of malnutrition are often linked to changes in the structure of food systems, economic transitions and income inequalities  . With explicit cognizance of the alarming scenario, nutrition has eventually taken centre stage of development agenda, in recent times, in India. A National Nutrition Strategy was formulated in the year 2017, by NITI Aayog, the think tank body of Government of India, to cater to the problem of child and maternal malnutrition in India through focussed planning and convergent approach  . This eventually led to the launch of National Nutrition Mission (NNM), also known as 'POSHAN Abhiyaan', in March 2018. Targets have been set to reduce the prevalence of under-weight and low birth weight in children below 6 years of age by 6% each (@2% per annum), anaemia among children, adolescent girls and women by 9% (@3% per annum) and to bring down stunting in children below 6 years of age to 25% by the year 2022 . It may be noted that the problem of wasting and overweight/obesity has not been accorded priority even though its emergence needs to be recognised and tackled early  . The Abhiyaan or the campaign, has been adopted to create a nationwide societal movement for improved national outcomes through convergent action at state and district level. The rolling out of NNM in all districts across the country were done in a phased manner within duration of three years (2017-20), i.e. 315 districts in the rst year (2017-18), 235 districts in the second year and remaining districts to be covered in the third year (2019-20)  .