The Indian economy has often been likened to an elephant due to its sheer size. The elephant paradigm holds equally true when it comes to the recently released National Family Health Survey on anaemia among women, which has registered an increasing trend.
All Indian states covered in phase I of the National Family Health Survey (NFHS-5) shows an increase in the proportion of women aged 15-49 who are anaemic across the spectrum barring Meghalaya. It’s not just anaemic women, but the proportion of malnourished children and women that have also increased. Also, as India trails behind in the Global Hunger Index, one can connect the dots between rising malnutrition, anaemia, and the changing policy landscape.
In the context of India, due to its sheer population size, a seemingly small increase in anaemia presents a significant reversal of gains in health outcomes. This is not to say that the increase registered has been small. For instance, anaemia among non-pregnant women in states such as Assam and Tripura have registered a jump of 20 per cent and 13 per cent respectively, as compared to NFHS-4. Going back to NFHS-2, the cases of the two major states of Kerala (23 per cent) and Bihar (63 per cent) were among the best and worst performers, respectively We then compare this data to NFHS-5, while acknowledging the methodological differences. Two decades later, anaemia prevalence in Kerala and Bihar in 2020 stands at 37 per cent and 64 per cent among non-pregnant women, respectively, higher than 1999 levels. The reversal in gains is even more distressing in the backdrop of the consistent decline registered in the intervening period (1999-2016).
The prevalence of anaemia indicated by the NFHS-5 state-level figures masks noticeable differences. For instance, the average for anaemia among non-pregnant women in Bihar (around 64 per cent) disguises disparities among its districts such as Araria (68 per cent). In West Bengal, the prevalence of anaemia among non-pregnant women in urban and rural areas is significant at 65 per cent and 75 per cent respectively.
A comparison with NFHS-4 shows the worst-performing states in terms of anaemia among women were Madhya Pradesh, Jharkhand, and Haryana. These states, with their sizeable populations, are the states whose data is yet to be released in Phase II of NFHS-5. Considering the NFHS-5 trend so far, it would not be naive to pre-empt that these states, too, are likely to show a distressing trend. What is worrying is the potential impact that this is likely to have on the population’s health outcomes. Also, data collection in the remaining states will be completed in 2021, and Covid-19 could further contribute to the worsening of nutrition and anaemia among women.
Why this increase is so alarming
Anaemia is a condition where one’s haemoglobin concentration is lower than normal, leading to a range of medical issues. A high proportion of anaemic women often means high malnutrition in the population, and high comorbidities, thereby increasing the burden of disease. Furthermore, maternal anaemia has considerable linkages with the risk of low-birth-weight infants and infant anaemia. Not surprisingly, states have registered an 11 per cent average increase in the proportion of anaemic infants as per NFHS-5. Higher child anaemia then translates into high prevalence of adolescent anaemia. The fertility rate in this age group is very high in India, due to early marriages and unmet need for contraception. This cascades into a high prevalence of anaemia in pregnant women contributing to miscarriage, maternal deaths and premature and low-weight babies.
The cycle of ‘undernutrition-anaemia-at risk pregnant women-low birth weight babies-neonatal illness-undernutrition-anaemia’ continues. An increase in the prevalence of anaemia has grave consequences for not just for women, but also children and overall population health outcomes given its high carry-over costs.
Reasons for high and rising prevalence of anaemia
Nutritional deficiency is the leading cause of anaemia. A high proportion of an anaemic population, to begin with, indicates that the nutrition intake by females in India has been historically inadequate. With investments in healthcare, nutrition intake has tardily improved over the past two decades up until NFHS-4. But the increase captured by NFHS-5 indicates a reversal in these gains. Access to and consumption of nutritious food is linked to various social-economic factors, which closely interact with the policy environment. Among the key determinants of nutritional access and intake are household wealth quartile and income levels. Other factors include deeply entrenched systems (like the caste system) that, in turn, impacts health outcomes.
Another crucial determinant of nutrition for women is female agency. Gendered factors are linked to a complex interaction of restrictive gender roles, educational levels, intra-household power dynamics, etc. As per NFHS-5, while most states have registered an increase in women with schooling, its gains are modest. The average rates of anaemia in 17 states as seen from Phase I study still hovers around 46 per cent. In fact, several states such as Bihar have registered a decline in anaemia among males with a corresponding increase for females. Despite the sex-based differences in the prevalence of anaemia, gendered factors certainly hold some explanatory power.
Linkages between reversal of the trend in anaemia reduction, and the economic growth and policy in India after NFHS-4 do exist. An economic slowdown, cut in budgets of Integrated Child Development Services (ICDS), Mahatma Gandhi Employment Guarantee Act (MNREGA) etc., and centralisation of development policy and its implementation has meant that marginalised populations would receive increasingly lesser policy support and access to food. Both global and domestic economic shocks in this period since NFHS-4, have pushed even more people to face wage losses, disproportionately affecting women.
With rising levels of anaemia, beyond deteriorating health outcomes lurks the wider problem of long-term deterioration of human capital. Given the larger policy and social linkages of problems like anaemia, it is critical for long-term health programmes to broaden their efforts beyond the traditional service delivery packages. The broader development and economic policy also need to consider its linkages with health issues.
Dr Rakesh Parashar is a senior consultant at Oxford Policy Management. Phalasha Nagpal is a policy researcher at Oxford Policy Management. Views expressed are personal.