Progress in child nutrition outcomes: Insights from India’s recent experience

Background: Improvements in child nutrition outcomes have lagged behind India’s recent rapid economic growth, a phenomenon known as the ‘Indian enigma.’ Between 2015-16 and 2019-21, stunting and wasting rates declined only slightly, with some Indian states even experiencing worsening malnutrition. This study investigates the factors driving these trends, focusing on the impact of the COVID-19 pandemic, children’s dietary quality, access to water, sanitation, and hygiene (WASH), and the role of government nutrition programmes. Methods: The study employs a mixed-methods approach, combining a quantitative analysis of data from India’s National Family Health Surveys (NFHS) IV (2015-16) and V (2019-21) with a qualitative comparative case study of Rajasthan and Himachal Pradesh—two states with contrasting malnutrition trends. Individual- and district-level regression models were used to assess the effects of dietary diversity, WASH access, and government programs, whilst interviews with policy makers in Rajasthan and Himachal have provided insights into programme implementation and local responses during the pandemic. Results: Our findings confirm that dietary diversity, particularly consumption of animal-sourced foods, and improved WASH access are key drivers of better nutrition outcomes in India. However, contrary to expectations, our study does not find a consistently negative relationship between the COVID-19 pandemic and child malnutrition. Instead, flexible expansion of some of the welfare programmes during the pandemic along with reductions in children’s disease rates and improvement in some sanitation practices may have mitigated the expected deterioration. Findings from the comparative study of Rajasthan and Himachal further highlighted the importance of tailoring the welfare programmes to specific local conditions, such as the large proportion of migrant labourers in Himachal. Conclusions: Our study challenges assumptions about the pandemic’s uniformly negative effects on child nutrition and highlights the importance of resilient, locally tailored safety nets. The findings underscore the need for policy interventions that enhance dietary diversity, sustain WASH improvements, and strengthen the adaptability of food and nutrition programmes to crises. Clinical trial number: not applicable