Maharashtra’s Child Stunting Declines: What is Driving Them? Findings of a Multidisciplinary of Findings Analysis Them? is Driving What Child Stunting Declines: Maharashtra’s MAHARASHTRA SPECIAL COLLECTION 2014 2014 Maharashtra’s Child Stunting Declines: What is Driving Them? Findings of a Multidisciplinary Analysis Written by Lawrence Haddad, Nick Nisbett, Inka Barnett, Elsa Valli Cover photograph UNICEF/India/Giacomo Pirozzi. Portrait of a married adolescent girl with her one year old child. Copy-editor Judy Hartley at Quincewood Communications - www.quincewood.co.uk Designers Nexus Design & Print - www.nexusdp.co.uk Citation Haddad, L.; Nisbett, N.; Barnett, I. and Valli, E. (2014) Maharashtra’s Child Stunting Declines: What is Driving Them? Findings of a Multidisciplinary Analysis, Brighton: IDS Disclaimer IDS The Institute of Development Studies and Editors cannot be held responsible for errors or any consequences arising from the use of information contained in this report. The views and opinions expressed do not necessarily reflect those of the IDS and Editors. Disclaimer UNICEF The statements contained in this publication do not imply or constitute official opinions or policy positions by UNICEF. Copyright © Institute of Development Studies and UNICEF 2014. ISBN 978-1-78118-179-9 © All rights reserved. Reproduction, copy, transmission, or translation of any part of this publication may be made only under the following conditions: • with the prior permission of the publisher; or • under the terms set out below. This publication is copyright, but may be reproduced by any method without fee for teaching or nonprofit purposes, but not for resale. Formal permission is required for all such uses, but normally will be granted immediately. For copying in any other circumstances, or for re-use in other publications, or for translation or adaptation, prior written permission must be obtained from the publisher and a fee may be payable. Funding The Comprehensive Nutrition Survey of Maharashtra and the analyses included in this report were funded with financial support by Megha and Aditya Mittal and the United Nations Children’s Fund (UNICEF). Institute of Development Studies Brighton BN1 9RE UK www.ids.ac.uk IDS is a charitable company limited by guarantee and registered in England (No 877338). Contents Acknowledgements i List of Abbreviations ii 1 Executive Summary and Overview: Maharashtra’s Child Stunting Declines: What is Driving Them? Findings of a Multidisciplinary Analysis Lawrence Haddad, Nick Nisbett and Inka Barnett 1.1 Introduction 1 1.2 The decline in stunting in Maharashtra in a national and global context 1 1.3 Changes in Maharashtra, 2000–2012 2 1.4 What do the survey data tell us? 3 1.5 What does the stakeholder analysis tell us? 4 1.6 Conclusions 5 2 What is Driving the Stunting Declines in Maharashtra? Clues from Extant Data Lawrence Haddad Executive Summary 6 2.1 Introduction 7 2.2 Trends in pre-schooler anthropometry, 2006 to 2012 7 2.3 Trends in basic determinants 8 2.4 Trends in underlying determinants 18 2.5 Trends in performance of the Integrated Child Development Services Programme (ICDS) 23 2.6 Conclusions 27 3 Maharashtra’s Rapid Decline in Stunting Rates between 2006 and 2012: What do the Survey Data Tell Us? Lawrence Haddad and Elsa Valli Executive summary 28 3.1 Introduction 30 3.2 The surveys and data sets 30 3.3 Comparing the data from 2006 and 2012 32 3.4 Comparing the potential determinants across survey years 33 3.5 Comparing the outcomes by potential determinants across survey years 44 3.6 Econometric analysis 55 3.7 Conclusions 62 4 An Analysis of Maharashtra’s Decline in Childhood Stunting: Stakeholder Perspectives Inka Barnett and Nick Nisbett Executive summary 64 4.1 Introduction 65 4.2 Findings 66 4.3 Conclusions, reflections and implications 78 References 81 Annexes 84 Annex 1: The Case of Maharashtra in the UNICEF 2013 Report 84 Annex 2: How Maharashtra is Tackling Child Malnutrition, Business Today, January 2013 86 Annex 3: Maharashtra’s Malnutrition Miracle, from Jigyasa 87 Annex 4: Background Set of Tables 89 Annex 5: Fully Interacted Model Testing for Differences in Estimated Coefficients across Two Survey Years 109 Annex 6: List of Stakeholders Interviewed 112 Annex 7: Stakeholder Interview Guide 113 Annex 8: Letter to Stakeholders 118 Annex 9: Key Activities, Malnutrition Removal Campaign and Nutrition Mission 119 Acknowledgements This project was funded by UNICEF India. We are extremely grateful to all participants listed in the annexes of this study for giving up their time to be interviewed and in particular to the Chief Minister Mr Prithviraj Chavan, the Minister for Women and Child Development Ms Varsha Gaikwad, Chief Secretary Dr JK Banthia and the current and former Mission Director Generals, Ms Vandana Krishna and Mr V. Ramani for making time in their busy schedules to accommodate our questioning. We are also grateful to IIPS for their assistance in providing data and responding to queries on the Comprehensive Nutrition Survey Maharashtra (CNSM) 2012. UNICEF Maharashtra, India and South Asia offices provided much-appreciated support along the way and we are grateful for their comments on the papers forming this report, particularly to Victor Aguayo, France Begin and Raji Nair. We are also grateful to Alex Cornelius, José Gallegos, Rupinder Kaur, Shilpi Srivastava and for their research assistance, to Leah Plati for project coordination, to Tina Nelis and Alison Norwood for editorial support; and to Shilpa Deshpande, who provided helpful background on nutrition in Maharashtra and the work of the Mission. All errors and omissions remain those of the authors. i List of Abbreviations ACDPO Additional Child Development Project Officer ANC Antenatal Care ANM Auxiliary Nurse Midwife ASHA Auxiliary Social Health Activist AWC Anganwadi Centre AWW Anganwadi Worker CDCs Child Development Centres CDPO Child Development Project Officer CEBs Census Enumeration Blocks CECM Committee to Evaluate Child Mortality CNSM Comprehensive Nutrition Survey of Maharashtra DWCD Department of Women and Child Development FSI Food Security Index GoM Government of Maharashtra GSDP Gross State Domestic Product HAZ Height for Age Z scores HBNBC Home-Based Newborn Care IAP Indian Academy of Paediatrics IAS Indian Administrative Service ICDS Integrated Child Development Services ICRIER Indian Council for Research on International Economic Relations IFPRI International Food Policy Research Institute IGIDR Indira Gandhi Institute of Development Research IIPS International Institute for Population Sciences IMR Infant Mortality Rate IMNCI Integrated Management of Neonatal and Childhood Illnesses MAM Moderate Acute Malnutrition MOHFW Ministry of Health and Family Welfare MoPH Ministry of Public Health MUW Moderate Underweight NCAER National Council of Applied Economic Research (India) NGO Non-Governmental Organisation NFHS National Family Health Survey NIPFP National Institute of Public Finance and Policy, India NREGA National Rural Employment Guarantee Act NRHM National Rural Health Mission ORS Oral Rehydration Salts PCA Principal Components Analysis PDS Public Distribution System PH Public Health PHCs Primary Health Care Centres PHD Public Health Department PSUs Primary Sampling Units RJMCHN Rajmata Jijau Mother–Child Health and Nutrition Mission SAM Severe Acute Malnutrition SNDT Shreemati Nathibai Damodar Thackersey Women’s University SNEHA A Mumbai-based NGO focusing on maternal and child health ST Scheduled Tribe TISS Tata Institute of Social Sciences TPDS Targeted Public Distribution Scheme VCDCs Village Child Development Centres WASH Water, Sanitation and Hygiene WCD (Department of) Women and Child Development ii 1 Executive Summary and Overview: Maharashtra’s Child Stunting Declines: What is Driving Them? Findings of a Multidisciplinary Analysis Lawrence Haddad, Nick Nisbett and Inka Barnett 1.1 Introduction Between 2006 and 2012, Maharashtra’s stunting rate among children under two years of age was reported to decline by 15 percentage points – one of the fastest declines in stunting seen anywhere at any time. This was seemingly more remarkable because it occurred within a context where Indian stunting levels nationally are regularly characterised as stuck or static. Maharashtra, the second largest state in India with a population of over 100 million people, appears to represent a major departure from the norm. This report aims to understand the driving factors behind this rapid decline. The report draws on three source papers written by the authors, which are summarised in this overview paper: one drawing on secondary data (section 2 – Haddad 2014), one drawing on primary survey data (section 3 – Haddad and Valli 2014) and one drawing on primary qualitative data (section 4 – Barnett and Nisbett 2014).1 As will become clear, the three papers, using different methods and written by different combinations of the three principal authors, arrive at very similar conclusions, giving us greater confidence in their validity. This overview first surveys the literature to describe the broad economic, political and social changes occurring within the state in the 2000–2012 period. In what kind of environment did these declines in stunting occur? Second, the paper analyses two child-level surveys undertaken in 2006 and 2012 to describe the distribution of stunting declines, identify factors correlated with the higher stunting (and wasting) rates in both years and to assess whether the relationship between stunting,