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(Co-authored with Lekha Chakraborty)

The ‘Statue of Unity’ – world’s tallest iron statue cast in stone (inaugurated on October 31, 2018) has been the most debated public investment priority in India, especially when the nation is burdened with more than one-third of world’s malnourished children.

In the Global Hunger Index 2018, India ranks 103 (with an alarming score of 31.1) out of 119 qualifying countries, which indicates the persistent inequality in access to quality food. This is further accentuated by stark inter-state disparities in nutritional status coupled with poor health infrastructure in most of the states, particularly in Gujarat. The UNICEF’s report, Rapid Survey on Children noted that Gujarat is the only developed state with malnutrition rates worse than national average.

An analysis of anthropometric features (based on data from the fourth round of National Family Health Survey - NFHS-4) reveals that Gujarat has been performing poorly on account of percentage of stunted children (31.7), as against a national average of 31. Protein Energy Malnutrition (PEM) in women of child bearing age (15-44 years) and young children (upto 59 months of age) is one of the underlying reasons for malnourishment. The percentage of wasted children is seen to be increasing from 16.2 (NFHS- 2) to 19.7 (NFHS-3) to 26.4 (NFHS-4) in Gujarat, as compared to a trend in national level figures starting from 15.5 (NFHS-2) to 22.9 (NFHS-3) and finally to 21 (NFHS-4).

About 8.6% of children in the urban region of Gujarat are severely wasted, as against 10.2% in the rural regions, much above the national average of 7.5%. Although Gujarat has progressed over the years in improving the conditions for underweight children, the state needs to progress tremendously as 39.3% of the children are still underweight. As a policy priority, we should aim at reducing the number of anaemic pregnant mothers that results in poor physical health of children.

As we dig deeper into the dismal health conditions in the region, we find that Gujarat has been successful in reducing the IMR (Infant Mortality Rate) from 62.6 (NFHS-2) to 34 (NFHS-4) over a span of 20 years, but still demands better policy priority. For a comparative perspective, in Kerala, the IMR is 10 per 1000 births. In Gujarat, U5MR (Under Five Mortality Rate) has almost a 50% reduction from 85.1 (NFHS-2) to 43 (NFHS-4). However, the progress is not enough.

A detailed analysis of anthropometric indicators across districts in Gujarat

A further district-wise (based on NFHS- 4) analysis of nutrition unveils an alarming picture. Despite ever increasing literacy rates in Ahmedabad, India’s most famous industrial hub, the city has not been a good performer in the anthropometric indicators, namely, stunted (29.4), wasted (27.1), severely wasted (11.5) and underweight (31), as compared to its semi-urban counterparts Vadodara and Anand in Central Gujarat.

The tribal districts in Gujarat - Dohad and Panchmahal - have high numbers of stunted (44.4 in Dohad, and 40.4 in Panchmahal) and underweight children (50.8 in Dohad, and 42.3 in Panchmahal), due to partial immunisation coverage of only 40%.

Gandhinagar, the capital district, has 42.6% underweight and 52.3% stunted children in the rural region. Surat, despite being the eighth largest city in the state, has not been able to perform well on the social indicators, because of about 11% gap in urban and rural figures of anaemia cases. The poor implementation of schemes like “Janani Suraksha Yojana” has added to the problem.

Navsari, the district in South Gujarat has performed relatively better than districts like Surat, Valsad and Baruch, due to success of “Vatsalyadham Project”, under which screening of acute malnourished children are taken care of. The rural districts - Patan, Mehsana and Banaskantha - have on an average 40% stunted children. Another rural district, Sabarkantha, has 53% of stunted children.

On comparing health characteristics of four largest districts of Gujarat such as Vadodara, Ahmedabad, Surat and Rajkot, Ahmedabad continues to fare the worst in number of women with low Body Mass Index (BMI). The anaemia incidence among children, women and men is lowest in Surat and highest in Ahmedabad.

The Dangs continues to be the worst performer amongst all the districts of Gujarat in all the four anthropometric features. Porbandar has the least percent of children under five who are stunted, Rajkot has the least percentage of children under five who are severely wasted (Kachchh and The Dangs are the worst) whereas Junagadh and Jamnagar outperform all other districts with minimum number of underweight children. This dismal variation is seen because of variations in the implementation of different health schemes and probably, because of their geographical locations.

Mehsana, Kachchh and Sabarkantha have the highest percentage of anaemic children. Even though Surat has the least (42.3) percentage of anaemic children, the number does not seem to be low, in absolute terms.

The average percentage holds as high as 63.9 for the same category amongst all the districts of Gujarat, which is alarming. Anaemia amongst women does not seem to be any lower with an average value of 56.4% for all the districts, while for men it is 23%. While urban regions have more of obese women, the rural have more women with anaemia.

The above analysis pinpoints to the fact that there is an urgent need to prioritise state’s investment plans towards nutrition. The ‘Statue of Unity’ may reward India if it turns out to be a well-packaged tourist spot, but an ever increasing GSDP might not translate itself into human development. Hence, there is an urgent need to conduct Public Expenditure Review to reprioritise spending towards nutrition in Gujarat.

Table 1: Percentage figures of all states in India for all anthropometric indicators : Survey Wise

	NFHS-4				NFHS-3			NFHS-2
State	Stunted	Wasted	Severely Wasted	Under weight	Stunted	Wasted	Under weight	Stunted	Wasted	Under weight
Andaman & Nicobar	23.3	18.9	7.5	21.6	38.4	14.9	29.8	29.8	38.6	9.1
Andhra Pradesh	31.4	17.2	4.5	31.9	37	17	29.7	29.7	26.5	7.9
Arunachal Pradesh	29.4	17.3	8	19.5	41.1	16.7	35.8	35.8	50.2	13.3
Assam	36.4	17	6.2	29.8	50.1	32.6	54.9	54.9	53.7	21
Bihar	48.3	20.8	7	43.9	-	-		-	-	-
Chandigarh	28.7	10.9	3.9	24.5	52.6	24.1	47.8	47.8	-	-
Chhattisgarh	37.6	23.1	8.4	37.7	43.2	17.2	24.9	24.9	36.8	12.5
NCT Delhi	32.3	21.2	5	27	-	-		-	-	-
Dadra Nagar Haveli	41.7	27.6	11.4	38.9	25.9	12.8	21.3	21.3	18.1	13.1
Goa	20.1	21.9	23.8	23.8	49.2	19.7	41.1	41.1	43.6	16.2
Gujarat	31.7	26.4	9.5	39.3	43.3	22.4	38.2	38.2	50	5.-3
Haryana	34	21.2	9	29.4	34.3	19.9	31.1	31.1	41.3	16.9
Himachal Pradesh	26.3	13.7	3.9	21.2	33.1	18.1	24	24	38.8	11.8
Jammu & Kashmir	27.4	12.1	5.6	16.6	47.2	35.8	54.6	54.6		-
Jharkhand	45.3	29	11.1	47.8	42.4	18.9	33.3	33.3	36.6	20
Karnataka	36.2	26.1	10.5	35.2	26.5	15.6	21.2	21.2	21.9	11.1
Kerala	19.7	15.7	6.5	16.1	-	-		-	-	-
Lakshadweep	27	13.8	3.3	23.4	46.5	39.5	57.9	57.9	51	19.8
Madhya Pradesh	42	25.8	9.2	42.8	44	17.2	32.7	32.7	39.9	21.2
Maharashtra	34.4	25.6	9.4	36	29	10.8	19.5	19.5	31.3	8.2
Manipur	28.9	6.8	2.2	13.8	47.7	31.8	42.9	42.9	44.9	13.3
Meghalaya	43.8	15.3	6.5	29	35.1	9.7	14.2	14.2	34.6	10.2
Mizoram	28	6.1	2.3	11.9	34.1	15.8	23.7	23.7	33	10.4
Nagaland	28.6	11.2	4.2	16.8	43.9	25.7	39.5	39.5	44	24.3
Odisha	34.1	20.4	6.4	34.4	34.7	10.2	23.9	23.9	39.2	7.1
Punjab	25.7	15.6	5.6	21.6	-	-		-	-	11.7
Puducherry	23.7	23.6	7.8	22	40.1	22.5	36.8	36.8	52	-
Rajasthan	39.1	23	8.6	36.7	31.8	12.8	17.3	17.3	31.7	4.8
Sikkim	29.6	14.2	5.9	14.2	31.1	22.9	25.9	25.9	29.4	19.9
Tamil Nadu	27.1	19.7	7.9	23.8	34.1	24	35.2	35.2	-	-
Telangana	28.1	18	4.8	28.5	-	-		-	-	-
Tripura	24.3	16.8	6.3	24.1	52.4	19.5	41.6	41.6	55.5	11.1
Uttar Pradesh	46.3	17.9	6	39.5	39.6	18.2	31.7	31.7	-	-
Uttarakhand	33.5	19.5	9	26.6	41.8	19.2	37.6	37.6	41.5	13.6
West Bengal	32.5	20.3	6.5	31.6	44.9	22.9	40.4	40.4	45.5	15.5
All India	31	21	7.5	35.7	-	-		-	-	-

Blank columns signify that no corresponding figure was available
Data Source : National Family and Health Survey: State Level Fact Sheet

Table 2: Percentage figures of all states in India for Infant Mortality Rates (IMR) and Under-Five Mortality Rates (U5MR): Survey Wise

	NFHS-4		NFHS-3		NFHS-2
State	IMR	U5MR	IMR	U5MR	IMR	U5MR
Andaman & Nicobar	10	13	-	-	-	-
Andhra Pradesh	35	41	-	-	65.8	85.5
Arunachal Pradesh	23	33	61	88	63.1	98.1
Assam	57	57	66	85	69.5	89.5
Bihar	48	58	62	85	72.9	105.1
Chandigarh	-	-	-	-	-	-
Chattisgarh	54	64	71	90	-	-
NCT Delhi	35	47	40	47	46.8	55.4
Dadra Nagar Haveli	33	-	15	42	-	-
Goa	13	13	50	20	36.7	46.8
Gujarat	34	43	42	61	62.6	85.1
Haryana	33	41	36	52	56.8	76.8
Himachal Pradesh	34	38	45	42	34.4	42.4
Jammu & Kashmir	32	38	69	51	65	80.1
Jharkhand	44	54	43	93	-	-
Karnataka	28	32	15	55	51.5	69.8
Kerala	6	7	-	16	16.3	18.8
Lakshwadeep	19	-	-	-	-	-
Madhya Pradesh	51	65	70	94	86.1	137.6
Maharashtra	24	29	38	47	43.7	58.1
Manipur	22	26	30	42	37	56.1
Megahalya	30	40	45	70	89	122
Mizoram	40	46	34	53	37	54.7
Nagaland	29	37	38	65	42.1	63.8
Odisha	40	49	65	91	81	104.4
Punjab	29	33	42	52	57.1	72.1
Puducherry	16	16	-	-	-	-
Rajasthan	41	51	65	85	80.4	114.9
Sikkim	30	32	34	40	43.9	71
Tamil Nadu	20	27	30	36	48.2	63.3
Telengana	30	34	-	-	-	-
Tripura	27	33	51	59	-	-
Uttar Pradesh	64	78	73	96	86.7	122.5
Uttrakhand	40	47	42	57	-	-
West Bengal	28	32	48	60	48.7	67.6
All India	41	50	57	74	67.6	94.9

Blank columns signify that no corresponding figure was available
Data Source : National Family and Health Survey : State Level Fact Sheet

Table 3: Percentage figures of all districts in Gujarat for anthropometric measures

	Stunted			Wasted			Severely Wasted			Underweight
District	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
Ahmedabad	26.2	-	29.4	26.8	-	27.1	11.1	-	11.5	27.3	-	31
Amreli		38.4	37.8	-	22.8	24.6	-	7.3	6.4		30.4	31.7
Anand	45.8	49	48.2	20.5	22.1	21.7	8.6	7	7.4	37.5	42.6	41.3
Banas kantha	-	39.9	40.7	-	23.6	21.6	-	8.9	8.5	-	44.4	43.1
Baruch	35	45.3	41.5	26.7	31	29.4	8.1	7.4	7.6	33.8	50.5	44.2
Bhavnagar	48.5	48.3	48.4	23.9	27.5	26	9.7	6.6	7.9	43.7	44.9	44.4
Dohad	-	44.9	44.4	-	25.1	24.9	-	8.3	7.8	-	51.7	50.8
Gandhinagar	30.7	42.6	36.5	22.3	36.4	29	7.2	13.5	10.2	33.7	52.3	42.7
Jamnagar	35	19	27.9	19.2	46.8	31.3	6.7	29.6	16.8	26.2	33.2	29.3
Junagadh	30.2	26.7	27.9	20.1	35.6	30.4	12.9	19.9	17.5	24.1	28.8	27.2
Kachchh	37.5	42	40.8	40.6	27.9	31.4	19.6	13.9	15.5	37.6	39.5	39
Kheda	-	44.1	45.5	-	29	27.2	-	7.1	7.1	-	49.4	48.1
Mehsana	-	40.9	40.5	-	26.5	25.3	-	13.4	11.6	-	43.2	41.9
Narmada	-	47.9	47.4	-	37.2	35.8	-	13.5	12.7	-	55.3	53.6
Navsari	32.1	42.2	38.9	11.8	34.3	26.8	4	6.6	5.7	22.4	44.8	37.4
Panchamahal	-	43.1	40.4	-	39.8	36.3	-	15	14.2	-	46.6	42.3
Patan	-	41.8	37.6	-	24.8	24.5	-	9.4	9.2	-	42.3	38.4
Porbandar	19.7	24.2	22.6	16	30.6	25.4	4.9	13.8	10.6	21.6	31.1	27.7
Rajkot	28.7	34.6	30.9	23.4	23.5	23.4	3.3	4.2	3.7	31.3	31.4	31.4
Sabarkantha	-	53.4	50.6		25.7	23.5		8.1	7		47.4	45.5
Surat	24.8		30	25		26.2	8.1		8.1	32.5		36.1
Surendranagar	-	49.6	45.5	-	23.9	27.7	-	6.6	9.5	-	46.4	45.9
Tapi	-	36.4	35.9	-	37.5	35.8	-	10.5	9.6	-	44.7	42.4
The Dangs	-	48.5	48.1	-	43.2	43	-	19.6	18.9	-	60.9	60
Vadodara	38.5	49.1	43.8	15.2	17.5	16.3	7.2	4.5	5.8	34.2	44.1	39.1
Valsad	28.9	51.9	43.3	32.6	29	30.3	16.1	9.4	11.9	31.5	48	41.9

Blank columns signify that no corresponding figure was available
Data Source : National Family and Health Survey 4 : District Level Fact Sheet

Table 4: Percentage figures of all districts in Gujarat for measures of Body Mass Index (BMI)

	Women with Low BMI			Men with Low BMI			Overweight Women			Overweight Men
District	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total	Urban	Rural	Total
Ahmedabad	19.1	-	21.5	22.9	-	25.9	34	-	30.7	29.4	-	26.4
Amreli	-	16.7	17.1	-	12.9	18.1	-	25.7	28.2	-	22.5	23.9
Anand	21.3	42.5	36	14.6	36.4	30.3	35.2	12.5	19.4	38.7	9.6	17.9
Banas kantha	-	36.6	38.4	-	30.9	28.1	-	9	10.6	-	13.2	14
Baruch	18.6	39.2	31.3	20	25.9	23.7	35.6	16.3	23.7	23.2	12.6	16.5
Bhavnagar	18.2	23.6	21.5	14.6	19.8	17.4	34.1	23.9	28	26.1	21.6	23.7
Dohad	-	47.2	44.1	-	48.1	44.9	-	4.4	9.8	-	7.4	8.9
Gandhinagar	27.5	33.2	30.5	31.4	22.6	27.1	30	15.1	22.1	20.9	17.4	19.2
Jamnagar	17	21.8	19.5	12.5	13.2	12.8	37.9	21.3	29.4	14.1	29.6	21.1
Junagadh	11.9	19.3	16.9	12.7	18.1	16.3	34.5	21.4	25.5	23.4	20.2	21.3
Kachchh	20.8	25.1	23.7	14.1	25.2	21.1	20.3	19.8	19.9	19.7	20.1	20.4
Kheda	-	43.6	38.5	-	35.8	31	-	15	18	-	9.3	11.5
Mehsana	-	30	26.8	-	28.1	27.6	-	18.4	22.7	-	13.7	17.9
Narmada	-	47	44.1	-	36.2	31.5	-	8	11.4	-	10.3	16
Navsari	14.9	35.7	29.5	21.4	41.8	35.9	35.7	17.7	23.1	27.7	12.7	17
Panchamahal	-	51.7	46.7	-	46.6	37.2	-	7	10.1	-	10.4	12.8
Patan	-	33.8	30.2	-	32.6	30.6	-	11.2	17	-	10.5	15.3
Porbandar	9.7	18	14	11.5	17.7	14.9	30.5	19.5	24.8	17.1	13.4	15.1
Rajkot	15.8	20	17.4	14.7	18.3	16.3	39.6	30.3	36.1	21.6	23.6	22.3
Sabarkantha	-	38.3	37.1	-	27.9	25.6	-	11	12.9	-	13.7	18.1
Surat	14.9	-	18.4	20	-	22.7	39.8	-	34.5	26.8	-	23.2
Surendranagar	-	31	25.7	-	34	24.3	-	16.3	30.6	-	11	18.2
Tapi	-	45	43.4	-	36.3	33.5	-	7.5	8.8	-	5.2	7
The Dangs	-	45.9	44	-	35.3	35	-	2.3	4	-	3.4	5
Vadodara	19.4	39.7	29.1	20.5	31.7	25.6	29.3	14.1	22	27.3	12.9	20.7
Valsad	17	26.5	22.9	18.2	12.9	15	32.3	20.1	24.8	31.4	17.4	23

Blank columns signify that no corresponding figure was available
Data Source : National Family and Health Survey 4 : District Level Fact Sheet

The authors are a Research Intern, Summer 2018 and an Associate Professor at NIPFP respectively.

The views expressed in the post are those of the authors only. No responsibility for them should be attributed to NIPFP.

Transfixing Public Expenditure Decisions in Gujarat: ‘Statue of Unity’ versus Nutrition