Over the past couple of weeks I have written on health in India for The Economist. First I looked at immunisation rates in India–how well different states do at getting children vaccinated against a bunch of preventable diseases, like measles, polio, whooping cough and diphtheria. The government claims it will achieve 95% coverage for this by the end of this decade, which would be an amazing achievement. Having wiped out polio, at last, India could be rid of other scourges too.
The problem with that claim, however, is that new data don’t back up promises of bold action. I recently obtained full results from a huge study, conducted by the government and the United Nations children’s agency, Unicef, in 2013 and 2014. Known as the Rapid Survey on Children (RSOC), it was based on over 210,000 interviews across India. The results were partially released last October by the government, though only for some states. (Disappointing figures on immunisation from Gujarat, for example, were held back). Overall, the report suggests India’s vaccination rate today is 65%, in effect the same level found by a survey done five years earlier. In the words of one person from Unicef, who spoke to me off the record, the vaccination campaign has been “stagnating”.
The RSOC should have been fully published in October last year, but since then the government has been sitting on it. It is not clear why officials or politicians don’t want to make it public–despite my many requests for comment, they would not respond. It might be some problem with the quality of the data, though the UN appears happy with the job done, and anyway it is presumably better to share it now and discuss whatever problems arise. Another explanation is that the data are embarrassing politically. Gujarat did poorly on immunising children despite being a relatively wealthy state, which hardly looks good for its former chief minister, Narendra Modi, given his talk of Gujarat as a model for India.
For those, like the economist Jagdish Bhagwati, who have argued rising incomes in Gujarat would in turn bring rapid social and health gains there, the new data are also disappointing. Gujarat remains worse than the national average on immunising children, despite its relative prosperity. Around 56% of Gujaratis get immunised, whereas next-door Maharashtra is approaching 80%. A telling difference is how vulnerable groups are targeted for help. In Maharashtra over 66% of the adivasi population gets full immunisation. In Gujarat only 44% of the tribal population is covered. That suggests Gujarat’s health system is not reaching the people it should.
If the data on immunisation are sensitive, however, far more touchy are the data on nutrition. It is well understood that India has a terrible record on this score. In China just over 3% of children are reckoned to be under weight. In Africa, where I used to be a correspondent and long wrote about famines and malnutrition, just over a fifth of all children (21%) are underweight. In India what we know officially comes from the last comprehensive, national study in 2005 and 2006, the National Family Health Survey. Data from that suggested nearly 43% of Indian kids are underweight, the worst proportion in the world by a mile. No country has as many malnourished people as India.
Obviously that matters. Children who get insufficient nutrients grow stunted (too short) or wasted (too skinny). Their brains are also less likely to develop to full potential. For Indians to be healthy, bright and productive, its children must consume sufficient nutrients and have bodies healthy enough to absorb and use them. For all that to happen, state governments (and others) need good data to see which policies are having what effect. It helps to know what the rates of open defecation are for different places, for example, and how well they correlate with rates of malnutrition. This week I saw a chart comparing improvement on open defecation in India and improvement on nutrition, built from the RSOC data. The apparent relationship between the two indicators is striking. I suspect it is one reason why India badly lags Africa on nutrition, because open defecation rates are also lower in Africa.
The RSOC report provides all this data. It makes clear which states are making best progress at cutting hunger. It also spells out which states are doing useful things like weighing babies at birth, encouraging mothers to breastfeed quickly and points to trends on the weight of teenage girls. If girls are undernourished they are far more likely (eventually) to produce undernourished children. Crucially, too, the RSOC data breaks down results by state, for rural and urban households, for scheduled caste and scheduled tribe, plus (at a national level) for income.
All this data from 2013 and 2014 is fascinating. RSOC suggests, for example, that even among the wealthiest households (the richest fifth) over a quarter of children are stunted. My guess is that reflects the fact that mothers are often anaemic and undernourished, or that girls are neglected in favour of boys, even among the better off. It makes clear how few children get iron or vitamin A supplements. And the data make clear that a national campaign to give children de-worming medicine is failing to cover more than a quarter of them.
Having obtained RSOC, I wrote about nutrition this week in The Economist. You can read a couple of articles on the website, such as this one. We have also now published the entire RSOC data set on our website, so researchers, policymakers and others more qualified than us can assess the data and what they mean. You can download it all by visiting this page (scroll to the bottom).
Why might the government not want to share the RSOC findings on nutrition? BJP spokesmen asked this question have no answer to give. On the face of it, there is much for India to celebrate. The proportion of children under weight has come down from nearly 43% to just below 30%. Unicef’s chief adivser on nutrition in South Asia calls recent improvements “unprecedented”. National rates on wasting are down from 20% a decade ago to 15% now; the stunting rate has come down from 48% to 39%.
Many states have shown how to cut hunger. Again Maharashtra is worth studying, because household incomes have risen steadily (which means better diets for everyone) and because of its efforts to target the vulnerable, such as the adivasi, but also women. The proportion of underweight children in that state has come down from 37% to 25%, well below the national average. Maharashtra, again, has done better than Gujarat. In Mr Modi’s old state the share of underweight children has also come down substantially, from 44.6% to 33.5%, but it remains worse than the national average on this score and many others, including on stunting and wasting. Similarly, nearly two fifths of Gujaratis continue to practice open defecation.
Could it be that ruling politicians and officials prefer not to discuss the RSOC results because Gujarat’s performance–on nutrition, immunisation, open defecation and more–has been disappointing? It is hard to conclude otherwise if no other explanation is put forward.
There are other examples of data apparently being held back because they are politically inconvenient. It is puzzling to me that, four years after the 2011 census, we have only just had full details of socio-economic assessments, but with all results relating to caste excluded. It would be natural to ask whether the caste details have been left out for political reasons, given a sensitive state election that looms in Bihar, where caste is always a big concern. Similarly, we still don’t have the results from the 2011 census showing religious affiliation.
In a democracy it is hard for politicians to justify prolonged secrecy over data. As Unicef said in a global report on children’s welfare, in June, sharing good data is a means to improving policy and for citizens to hold governments to account. Apparently India’s government is poised to release some more of the RSOC report soon, which is encouraging, though it is unlikely to give information state-by-state. Until it does, the information is at least available for access courtesy of The Economist website.
Adam Roberts is The Economist‘s bureau chief, based in Delhi. He tweets as @Arobertsjourno.