Since the last few decades, childhood malnutrition became one of the major public health concerns in low and middle-income countries. Estimates from the United Nations Children’s Fund (Unicef) suggest that, globally about 165 million children under the age of 5 years were found to be stunted (low height for age), 101 million children were found to be underweight (low weight for age), and 52 million children were found to be wasted (weight for height) [1]. Further, from the estimates from United Nation (UN), about 6.3 million under age-five mortality were occurred in India, of which 45% died due to malnutrition [2].
India alone accounts for more than 61 million stunted children (low height for age), 47 million underweight children (low weight for age) and 25 million wasted children (weight for height). Estimates from the National Family and Health Survey (2015–16) shows that in India, about 38% of the children under the age of five year are stunted (low height for age), 36% of the children are underweight (low weight for age), and 18% children are wasted (weight for height) [3].
Horton (1999) reported that malnutrition is a major concern of development and associated with enormous human and economic causes [4]. Poor health of the children erodes social and economic gains, put countries in a vicious cycle of poor nutritional status, high disease burden and increases poverty. A large number of studies had reported the short-term and long-term impact of early childhood malnutrition in developing countries [5,6,7,8,9,10,11]. The short-term effects include weaker immune system, a higher risk of developing diarrheal disease, acute respiratory infection, and delay in motor skills and cognitive and social development during childhood [5,6,7,8]. The long-term effects include high blood pressure, obesity, diabetes, and heart disease during adulthood.
A number of previous studies had examined the socio-economic gradient of child malnutrition in India, some of the study reported that childhood malnutrition was mainly concentrated among households with low socio-economic status [12,13,14,15,16,17,18,19,20,21]. Majority of these studies were examined the inequalities in childhood malnutrition on the basis of household economic status. Moreover, measuring health inequality on the basis of household economic status may pose limitations in terms of identifying and reaching disadvantaged subpopulations, as the poorest segment of the population may be located throughout different regions of a country [15, 17, 22,23,24,25,26,27,28].
India’s administrative division of 29 states and 7 union territories falls into 640 districts. Therefore, variations in basic demographic and health indicators are prevalent not only in the states but also across the districts. Recent estimates from NFHS-4 (2015–16) suggest that childhood malnutrition varies considerably across Indian districts. The prevalence of stunting among children under age five was lowest in Kollam (13%), a district of Kerala and highest in Bahraich (65%), a district of Uttar Pradesh. Similarly, the prevalence of underweight was lowest in Aizwal (7%), a district of Mizoram and highest in Pashchimi Singhbhum (67%), a district of Jharkhand. Therefore, due to the extensive heterogeneity in childhood malnutrition across Indian districts, the present study aims to determine the socio-economic inequality in childhood malnutrition (stunting and underweight) across districts of India, by taking district as a unit of analysis. The key advantage of doing district level analysis is helpful to give focus on decentralized planning, as the recent interventions to reduce inequities are likely to be implemented at the local administrative level. This may be a useful tool for benchmarking, with implications for resource allocation, planning and evaluation, as the districts are the smallest level of unit to monitor the majority of the ongoing child health intervention program in India. The analysis of the variations across districts is also necessary for development of district level program and interventions in the context of developmental vulnerability and identification of high priority districts to strategized intersectoral co-ordinations involving various impartments like health, social welfare, women and child development. Further, the importance of focusing on district level analysis rather than household level analysis is important, as district-level policies undertaken and implemented by district-level politicians and officials may often be of critical importance in determining these outcomes. Also, the influence of social norms which have been undergoing rapid changes in India in recent years on child mortality, fertility, etc., is probably more adequately captured in district-level than in household-level analysis. Therefore, it has been observed that the district and household-level analyses are not, contradictory even it has been viewed as being complimentary.
Given the lack of study on the topic, using latest round of data from fourth round of National Family Health Survey conducted in 2015–16, the present study intended to examine the socioeconomic inequalities in childhood malnutrition in India. Further, study also examined the causes of socioeconomic inequalities in childhood malnutrition in India.