Health and nutrition: the weakest link in India's human capital

Detail

1. What malnutrition means

• Malnutrition means having too little of a nutrient, too much of it, or the wrong balance of nutrients.
• WHO's full definition adds one more case: impaired nutrient utilisation. This means the body cannot use the food it eats, for example because of repeated infections [6].
• It has three forms:
• Undernutrition: the body gets too little food or energy. It shows up as stunting, wasting and underweight.
• Micronutrient deficiency: a lack of vitamins and minerals the body needs in small amounts, such as iron, vitamin A and iodine.
• Overweight and obesity: the body stores too much fat.

2. How child malnutrition is measured

• India measures children against the WHO growth standards. These give the normal (median) height and weight for a healthy child of each age and sex.
• A child counts as affected if they fall below −2 standard deviations (SD) from that median.
• Formula (z-score): z = (child's measurement − median of the reference group) ÷ SD of the reference group
• Worked example (illustrative numbers):
• At a given age, the median height is 87 cm and the SD is 3 cm.
• A child is 80 cm tall. z = (80 − 87) ÷ 3 = −2.33.
• −2.33 is below −2, so the child is stunted.
• A child of 83 cm has z = −1.33, so that child is not stunted.

Measure	Compares	Shows
Stunting	Height for age	Chronic undernutrition and repeated infections
Wasting	Weight for height	Acute undernutrition from recent food shortage or illness
Underweight	Weight for age	Composite measure (chronic plus acute)

• Stunting (low height for age) comes from long-term or repeated undernutrition. WHO links it to poverty, poor health and nutrition of the mother, frequent illness and poor feeding in early life [7].
• Wasting (low weight for height) usually means recent, severe weight loss. It happens when a child has not had enough good food, or has been ill often or for a long time. It can also last a long time [7].
• Underweight mixes both. A low weight for age can come from being short (stunting), from being thin (wasting), or from both.

3. What NFHS-5 (2019-21) shows

NFHS means the National Family Health Survey, a large household survey on health and nutrition.

Indicator (NFHS-5, 2019-21)	Value
Stunting, children under 5	35.5%
Wasting, children under 5	19.3%
Underweight, children under 5	32.1%
Overweight, children under 5	3.4%
Anaemia, children aged 6–59 months	67%
Anaemia, women aged 15–49	57%
Overweight adult women	about one in four

• Anaemia means too little haemoglobin in the blood, most often because of low iron. The blood then carries less oxygen, so the person feels tired and learns and works less well.

• Triple burden of malnutrition: India has all three forms at the same time: 1. undernutrition (stunting, wasting and underweight); 2. micronutrient deficiency (for example, anaemia); 3. overweight and obesity.

• WHO uses a related term, the double burden of malnutrition. It means undernutrition at the same time as overweight, obesity and diet-related non-communicable diseases (long-term illnesses such as diabetes that do not spread from person to person). The "triple burden" adds micronutrient deficiency as a separate third part [7].

• NFHS-6 has been due for some time. Check whether it has been released before quoting newer figures.

4. Why nutrition is a human capital issue

• Human capital means the skills, knowledge and health of people that make them productive. Class 11 NCERT names health, together with education, as a main source of human capital.
• The first 1,000 days (from conception to age 2):
• Poor nutrition in this period harms brain development.
• The child then learns less and misses more school.

• As an adult, that person earns less over their lifetime.

• Much of this damage is hard to undo. Stunting that sets in during early life can last into adulthood.

• Class 8 NCERT link: good health supports cognitive development (growth of thinking, memory and learning) and regular school attendance. A healthy worker is a more productive worker.
• Link to the demographic dividend (the chance for faster growth when a large share of people are of working age):
• A young population raises growth only if those young people are healthy and skilled.
• Stunted, anaemic children grow into less productive workers.
• So malnutrition weakens the demographic dividend.

5. Policy responses on nutrition

• POSHAN Abhiyaan (2018) is the National Nutrition Mission. It brings together the different schemes working on nutrition.
• Mission Saksham Anganwadi and Poshan 2.0 is an umbrella scheme. Three schemes were merged into it [4]:
• Anganwadi services (the old ICDS network);
• POSHAN Abhiyaan;

• the Scheme for Adolescent Girls.

• Its aim is to tackle child and mother malnutrition. It changes what food is given and how it is delivered, and makes departments work together for health and immunity [4].

• Anaemia Mukt Bharat (2018) uses the approach of the health ministry's 6×6×6 strategy: 6 target groups, 6 interventions and 6 institutional mechanisms. Tools include iron-folic acid supplements, deworming and testing.
• PM POSHAN (2021) replaced the Mid-Day Meal scheme. It gives cooked meals in government and aided schools.
• Meals bring children to school.
• At school they get better nutrition.

• Both of these build human capital.

• Rice fortification means adding micronutrients to rice.

• Government-supplied rice is fortified with iron, folic acid and vitamin B12 [5].
• It reaches people through the Targeted Public Distribution System (TPDS), PM POSHAN, ICDS and Other Welfare Schemes, in all States and UTs [5].
• By March 2024, fortified rice had replaced all custom-milled rice in every government scheme [5].

• Fortified rice is also supplied to Anganwadi Centres to fight anaemia in women and children [5].

• Poshan Tracker is a mobile app. It lets officials monitor Anganwadi services in real time, such as child growth and food given out.

6. The health system as an input to human capital

Key terms

• Total Health Expenditure (THE): all money spent on health in the country by the government, households, firms and others.
• Government Health Expenditure (GHE): the health spending done by the Centre, the States and local bodies.
• Out-of-Pocket Expenditure (OOPE): money a family pays directly at the time it gets care, such as doctor fees and medicines, that no insurance or government scheme pays back.
• Formula: OOPE share = (OOPE ÷ THE) × 100
• Worked example:
• Suppose THE is ₹10 lakh crore and OOPE is ₹4.34 lakh crore.
• OOPE share = 4.34 ÷ 10 × 100 = 43.4%.

Target and data

• National Health Policy (NHP) 2017 set a target: public health spending of 2.5% of GDP by 2025.

Indicator	2013-14	2021-22	2022-23 (latest NHA)
GHE as % of GDP	1.15% [2]	about 1.8% (NCERT scaffold)	1.43% [2]
GHE as % of THE	28.6% [2]	48.0% [3]	43.7% [2]
OOPE as % of THE	64.2% [2]	about 39% (NCERT scaffold)	43.4% [2]
Social Security Expenditure as % of THE	6% [2]	—	9.9% [2]

• Updated figure: the latest National Health Accounts (NHA) data are for 2022-23. OOPE is 43.4% of THE, down about 21 percentage points from 64.2% in 2013-14 [2]. (NCERT: about 39% in 2021-22, down from about 64% in 2013-14.)
• Why 2022-23 looks worse than 2021-22: 2021-22 was a COVID year with extra government spending. As that spending ended, the government's share fell and the out-of-pocket share rose. The long-term trend is still clearly downward [2].
• Total health spending in 2021-22: ₹9,04,461 crore. This was 3.8% of GDP, or ₹6,602 per person at current prices [3].
• Government share of THE: rose from 29.0% (2014-15) to 48.0% (2021-22) (Economic Survey 2024-25) [3].
• Social Security Expenditure (SSE) on health includes government-funded insurance such as AB PM-JAY, medical repayments to government employees, and social health insurance. It rose from 6% (2013-14) to 9.9% (2022-23) of THE [2].
• Gap to the target: GHE of 1.43% of GDP (2022-23) is still well below the NHP 2017 target of 2.5% [2].

Why high out-of-pocket costs hurt human capital

• Catastrophic health spending (a large medical bill compared with the family's income) forces families to sell assets or borrow. This can push them into poverty.
• Families that fear the cost skip or delay treatment. Illnesses then get worse and last longer.
• They may also pull children out of school or cut spending on food. This hurts the next generation's human capital too.

Ayushman Bharat (2018): two pillars

1. Ayushman Arogya Mandirs (formerly Health and Wellness Centres) give primary care: first-contact care close to home, screening for non-communicable diseases, and maternal and child health services.
2. PM-JAY (Pradhan Mantri Jan Arogya Yojana) gives hospital insurance cover of ₹5 lakh per family per year for secondary and tertiary care (care at bigger hospitals and specialists). - The regulators (NMC, ICMR) are covered in section 7. Definitions of IMR and life expectancy are in development-and-hdi.

Prelims Hooks

• Stunting = low height for age (chronic). Wasting = low weight for height (acute). Underweight = low weight for age (composite).
• A child is classified as stunted, wasted or underweight if they are below −2 SD of the WHO growth-standard median.
• NFHS-5 (2019-21): stunting 35.5%, wasting 19.3%, underweight 32.1%. Anaemia is 67% in children aged 6–59 months and 57% in women aged 15–49.
• Triple burden = undernutrition + micronutrient deficiency + overweight/obesity. Double burden (WHO) = undernutrition + overweight/obesity and diet-related NCDs.
• Trap: Mission Saksham Anganwadi and Poshan 2.0 merged Anganwadi services, POSHAN Abhiyaan and the Scheme for Adolescent Girls. It did not merge PM POSHAN, which is a Ministry of Education scheme.
• Fortified rice carries iron, folic acid and vitamin B12. It covers TPDS, PM POSHAN, ICDS and OWS, with full coverage from March 2024.
• NHA 2022-23: OOPE is 43.4% of THE, GHE is 43.7% of THE, and GHE is 1.43% of GDP.
• The NHP 2017 target is public health spending of 2.5% of GDP by 2025.
• Ayushman Bharat (2018) has two pillars: Ayushman Arogya Mandirs (primary care) and PM-JAY (₹5 lakh per family per year, for secondary and tertiary care).

Mains Points

• Nutrition decides the demographic dividend. About 35% of children under 5 are stunted (NFHS-5), and much early-life damage is hard to undo. This lowers the productivity of the future workforce, so spending in the first 1,000 days gives the highest return among human capital investments.
• Financial protection is improving but is not yet adequate. OOPE fell from 64.2% to 43.4% of THE between 2013-14 and 2022-23. But GHE is only 1.43% of GDP, far below the NHP target of 2.5%. The rise in OOPE after COVID shows that the gains depend on steady public funding.
• Two approaches to the triple burden: supply-side measures (fortification, supplements) reach people quickly and at scale. Diet diversity, safe water and sanitation, and women's education deal with the deeper causes. Rising overweight also requires policy on diet-related NCDs, not just food volume.
• Primary care versus insurance: PM-JAY protects families from hospital bills. But strong primary care through Ayushman Arogya Mandirs prevents illness at a lower cost. An answer should argue for balancing the two, along with Centre–State coordination, because health is a State subject.