An autonomous research institute under the Ministry of Finance


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(co-authored with Debasri Mukherjee)
The developing world has succeeded in significantly reducing the prevalence of under-nourishment over the last three decades compared to India [See Figure 1]. However, during this time the share of wasted (having low weight-for-height) children in India has remained around 20 percent. The known causes of malnutrition are wide-ranging –access to clean drinking water, access to diverse diets, and the ability to absorb nutrients to name a few – and the effects long-lasting. Malnutrition in childhood causes lifelong disability, lower educational attainment, and reduced lifetime earnings. In extreme cases malnutrition can result in death. Across the developing world, malnutrition continues to be a leading cause of child deaths.
Figure 1: Prevalence of undernutrition rates in India versus the World between 2001 to 2015
Existing studies have evaluated the effects of government programs and socio-economic characteristics on child health outcomes (Kandpal (2011), Jain(2015), Jalan and Ravallion (2003)). These studies pool together cohorts of children under five years of age. However, malnutrition can start as early as only three months of age (Victora et al.(2010)) and some of its health effects can be irreversible. An exclusive focus on infant malnutrition is missing in the literature. Child malnutrition is also crucial indicator of poverty. Factors affecting child malnutrition have long been focal points in research and policy making. Our research focuses on India which bears one-third of the world’s underweight children. In India, the prevalence of malnutrition is disproportionally high in vulnerable communities such as poor households, rural areas and the economically underperforming Empowered Action Group (EAG) States of Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Rajasthan, Orissa and Assam  (Radhakrishna and Ravi (2004), Khan and Mohanty (2018)). We focus on households in these areas as they bear the highest burden of undernutrition. 
Exploring Infant Malnutrition and its Causes
In our recent paper, we look at undernutrition in infants using weight-for-height Z scores (WHZ). We use Indian Human Development Survey-II (2010-2011) data and focus on infants in households below the poverty line. We consider three subgroups of households:
(i) nationally representative sample of rural households;
(ii) households below in the EAG States; and,
(iii) rural households in EAG states. 
Exploring the onset of malnutrition can be challenging as its causes are wide-ranging. Following Mosley and Chen (1984) we include a comprehensive set of 60 covariates covering: 
(i) birth, hereditary, in-utero characteristics of the infants;
(ii) immunizations and micronutrients received;
(iii) incidences and duration of illness;
(iv) household’s demographic and socio-economic characteristics;
(v) mother’s health, fertility, autonomy;
(vi) mother’s correct health beliefs regarding common diseases;
(vii) family dietary practices; and
(viii) receipt of benefits from several government policies. 
Focusing on subsamples of impoverished populations along with many explanatory variables leads to a situation of small sample size with large covariates. This poses a challenge in selecting the appropriate estimation strategy as ordinary least squares technique will lead to high standard errors and poor inference and hypothesis testing. We use a causal Machine Learning technique from Zhang and Zhang (2014) following a debiasing principle to conduct inference. 
Why Water, Sanitation and Hygiene?
Out of all the covariates, household’s access to safe drinking water turns out to be positive and statistically significant across all cohorts. Access to safe drinking water is measured by an indicator for the household’s primary source of drinking water to be piped-supply, tube-well, handpump, tanker-truck or bottled. Safe drinking water protects infants against various water-borne diseases such as diarrhea which cause rapid, significant weight loss. We find other interventions under existing schemes are largely ineffective in improving WHZ (with few exceptions in EAG states). 
Our research reveals that safe drinking water is a crucial factor in curbing the onset of malnutrition and can help serve as a pathway to the SDG goals of reducing malnutrition.  Given the findings, a clear policy directive emerges about the need to provide safe drinking water to impoverished parts of the country. 
Furthermore, the latest Goalkeepers Report reveals that COVID-19 has caused many countries to regress on the SDGs related to health and poverty. Expanding access to clean drinking water through low-cost interventions like chlorine tablets and filters could revert countries to their path towards the SDGs.
Dweepobotee Brahma  is a Fellow at the National Institute of Public Finance and Policy, New Delhi, India and Debasri Mukherjee  is a Professor of Economics at Western Michigan University, USA.  
This post was originally published in Econthatmatters on November 2, 2020.
The views expressed in the post are those of the authors only. No responsibility for them should be attributed to NIPFP.
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