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A child being weighed using a Salter scale during a health camp in Netra village in West Bengal, on July 6.CreditMalavika Vyawahare
NEW DELHI- Paharganj is an area populated with decrepit, low-budget hotels, about two miles from the Indian Parliament in central Delhi. Thousands of poor Indians live in a labyrinth of claustrophobic, dirty lanes that veer away from the hotel-lined main street. Kusum Kumar, 37, a day care worker for the Integrated Child Development Scheme, the Indian government’s social welfare program for children under 6, works out of a one-room tenement in an inner lane.
Mrs. Kumar is at the lowest end of a chain of government workers who are also responsible for generating data on children’s health for the country. On a recent afternoon, scores of mothers brought their children, ranging from six months to 6 years, to Mrs. Kumar’s office for their monthly weigh-in.
But Mrs. Kumar’s center has neither a weighing machine for infants nor a salter scale, used for weighing children up to 25 kilograms (55 pounds). For the past three years, Mrs. Kumar has been using a regular weighing machine for children of all ages. First, she weighs the mother with her child and then only the mother. Then she subtracts the weight of the mother to get the weight of the child.
“We make do with what we have,” Mrs. Kumar said.
Being underweight is a common indicator of both short- and long-term malnutrition in children, and government workers can help prevent health problems from worsening by catching the signs of malnutrition early. Yet only 18.3 percent of the over 10,000 government-run child welfare centers in Delhi had weighing instruments for infants, according to a 2011 evaluation study by the country’s Planning Commission.
The government workers are not the only ones who are “making do” when it comes to gauging the nutritional status of children in India. No one, including academics, government officials and journalists, can tell you whether malnutrition in young children in India is improving or worsening, because the government has not collected national-level data for the past eight years. The last National Family Health Survey, in 2005-06, showed that 42.5 percent of children under the age of 5 were underweight.
The lack of clarity on the health of Indian children has proved to be an obstacle for the government as it makes combating malnutrition a priority. In the last five-year plan (2007-2012), the blueprints for the country’s development, goals were set for health and nutrition. But when a Planning Commission committee reviewed the country’s achievements in nutrition in the last five-year-plan, specifically the goal of reducing malnutrition among children under 3, it said that no data was available.
Data from the next round of the national health survey will not be available before 2015, a decade after the last survey. Meanwhile, India’s smaller and poorer neighbor, Bangladesh, has conducted three such health surveys in the past decade.
The International Institute for Population Sciences, a research institute under the Ministry of Health and Family Welfare, has been given the responsibility for conducting the national and district health surveys, which receive both financial and technical assistance from international aid agencies.
The estimated cost of the next round of the National Family Health Survey is less than 2 billion rupees ($32 million), according to Faujdar Ram, director of the institute. “The ideal time frame for the survey would be five to six years,” Mr. Ram said, “and it can be done.”
Private nonprofit organizations have tried to fill in the gaps by coming up with their own data and estimates. One recent attempt by a group of nongovernment organizations, the Hunger and Malnutrition Survey of 2011, covered only 100 districts in India that have historically fared poorly on nutrition indicators and found that almost half of the children surveyed were malnourished. The report cited the lack of national statistics as a reason for undertaking the project.
A study published by the British charity Save the Children in 2012 estimated that 1.83 million Indian children die every year before the age of 5, most of them related to malnutrition.
The Indian government “has failed to monitor national trends in child undernutrition for more than six years,” said the International Food Policy Research Institute, a nonprofit based in Washington that compiles the annual Global Hunger Index. As a result, the 2012 index could not take into account any recent progress in the fight against child undernutrition, the institute said.
Various government agencies conduct their own health surveys, but none on their own provide a complete picture about nutrition in the country.
The National Family Health Survey does not include data at the district level, which is the administrative division at which many government interventions operate. A District Level Health Survey was conducted in 2007-08 by the International Institute for Population Sciences, but that did not collect data on nutrition. The next round of the district survey, currently being conducted, includes nutritional indicators but does not cover nine states, eight of which have historically fared the worst on health and nutrition indicators.
These eight states and the northeastern state of Assam were once covered in the annual health surveys, which began in the 2010-11 fiscal year but have now been discontinued. Surveys carried out by the National Nutrition Monitoring Bureau, established specifically for the purpose of looking at nutrition, have covered only 10 states, which were selected not on any scientific basis but because they have bureau offices.
Dr. A. Laxmaiah, a public health and nutrition specialist at the National Institute of Nutrition, said that because India doesn’t have a central regulatory body to keep track of the research that is conducted by various agencies, data collection efforts are often duplicated.
The data collected by government workers like Mrs. Kumar at the Integrated Child Development Scheme are not suitable for evaluation purposes since the government workers may have incentive to underreport malnutrition, experts say. Some may not even be adequately trained to collect the data.
The Planning Commission evaluation found that official statistics on nutrition generated by the concerned departments “do not represent grassroots reality” and linked the “unreliable and unrepresentative” data to the misuse of available funds in the Integrated Child Development Scheme.
“There are all kinds of problems with routine data,” Dr. Laxmaiah. “Nobody really uses it.”
But the problem with nutrition data collection may represent a larger struggle in India to generate credible health statistics on a regular basis.
“Data quality is poor, and use of available data is low in India’s health sector,” a 2009 World Bank report said. The report listed several factors that hamper effective use of data, among them: the “absence of a work culture that focuses on results, lack of agreement on key indicators of performance, lack of incentives for data utilization, delays in the transmission of data to relevant levels.”
The Indian government is currently making preparations for fourth National Family Health Survey. “This round will provide both district and national level data” because of a revamped format, said Rattan Chand, chief of statistics at the Health Ministry. “The plan is to conduct such a survey every three years.”
Mr. Chand said that he wasn’t aware why the national survey had been delayed but explained that consultations had been under way for a while to come up with a new redesigned survey.
The new data will show how much further India has to go to reach its targets under the first United Nations Millennium Development Goals. The country committed to halving the proportion of people who suffer from hunger, which includes the prevalence of underweight children under 5 years of age, from 1990 to 2015.
The percentage of underweight children has probably come down to about 40 percent, based on findings from a 2012 survey by monitoring bureaus in rural areas, Dr. Laxmaiah said, but more data is needed to confirm that figure on a national level.
The delay in generating quality data has meant a failure to document progress on this front, said Victor Aguayo, chief of child nutrition and development at Unicef India.
“I am convinced there is a positive story,” he said, “but you can only report on the basis of data.”