India's unequal battle against undernutrition

Undernutrition in early life remains one of the most pressing public health crises in India. While the national statistics celebrate the decline in child stunting, the averages picture a more unsettling reality — regional and social inequalities that hamper the country's progress.

According to the National Family Health Survey (NFHS-5), nearly 36% of the children under the age of five are stunted. Though this marks an improvement from the previous round of the survey, there are regional disparities that depict a jarring picture. Over time, some regions have successfully reduced the incidence of stunting through interventions, while others continue to remain trapped in the same cycle.

The highest prevalence of child stunting continues to be reported in Bihar (42.94%), Uttar Pradesh (39.71%) and Jharkhand (39.58%) - states where poverty, inadequate healthcare and low maternal education persist as critical barriers. Despite modest improvements since NFHS-4, these states illustrate how economic and social disadvantages converge to impede nutritional outcomes.

In contrast, states such as Kerala (23.41%), Punjab (24.49%) and Tamil Nadu (25.04%) stand out for their relatively low stunting rates. Union territories, including Goa, Puducherry, and the Andaman & Nicobar Islands, also report better outcomes, benefiting from stronger health infrastructure, higher literacy levels and more inclusive social policies. The contrast underscores a fundamental truth - that the geography of stunting is often a reflection of the geography of opportunity.

Encouragingly, regions such as Chandigarh, Daman & Diu, Himachal Pradesh, Manipur, Punjab, Tamil Nadu and Uttarakhand have shown notable reductions in stunting between NFHS-4 and NFHS-5. These successes suggest that sustained public health interventions, improved maternal nutrition and community-based monitoring can yield tangible gains.

The persistence of stunting is not only about genetics; it is also a development issue and a product of inequality. A research study by Magadum, et al, has shown household income, maternal education, access to clean water, food diversity and women's empowerment play decisive roles in causing such disparities. In many high-burden states, low dietary quality and poor sanitation can perpetuate the crisis.

The problem is further compounded by gaps in awareness and behavioural change. Many women are unaware of the nutritional needs of children and the importance of a balanced diet during the first 1,000 days of life. Nutrition programmes often focus on supply - distributing supplements or food - but the demand side, including household awareness and women's agency in decision-making, is equally crucial.

The implications of early-life undernutrition are far-reaching. Stunted children face delayed cognitive development, lower school performance and a higher risk of illness and mortality, which can further harm their physical and mental health. The damage extends into adulthood - reducing productivity and earning potential and perpetuating the cycle of poverty and exclusion. In a country aspiring to harness its demographic dividend, such losses are unaffordable. A report by the World Bank has found that "childhood stunting results in a 1.4% loss in economic productivity for every 1% loss in adult height".

Tackling the region-wise nutritional divide requires more than just scaling up or increasing the expenditures on the existing programmes. It demands state-specific strategies that integrate health, sanitation and education within a community framework. States with high stunting prevalence - such as Bihar, Jharkhand and Uttar Pradesh - must prioritise context-sensitive interventions that address both supply and demand barriers.

For instance, in Uttar Pradesh, factors such as a child's birth order, maternal education, community-level nutrition practices, unsafe stool disposal, inadequate household sanitation facilities and low household wealth have a strong and significant impact. But in Tamil Nadu, individual-level factors play a greater role. This implies that targeting similar variables in different states without considering their present stunting levels can be ineffective.

Policies could be customised as per the state's needs. For instance, Tamil Nadu offers a model for customisation: its Integrated Nutrition Programme (TNIP), merged with the ICDS in 1990, employs a two-worker model to strengthen community engagement - unlike the one-worker model in most states.

To enhance policy effectiveness, introducing co-production - where communities help design and implement nutrition programmes - is vital. This approach enables citizens to co-create and participate in programmes, fostering trust, accountability and better alignment with ground realities. Since community-level sanitation behaviour remains a major driver of inter-state disparity, empowering communities to own these outcomes is key.

India cannot achieve its demographic dividend if vast sections of its children are denied the right to healthy growth. The fight against stunting, therefore, is not just a public health priority - it is a moral and economic imperative.

Views are personal

Manu Prathap is a Research Assistant, IIM Tiruchirappalli  and Dinesh B is a Research Staff at IIM Tiruchirappalli.