Why are economic growth and reductions in child undernutrition so weakly correlated—and what can public policy do?
Authors: Abhijeet Singh
Journal: The Lancet Global Health (2014)

Child undernutrition in developing countries remains a persistent problem. It contributes importantly to child mortality and carries long-term consequences for malnourished children, including reduced cognitive development, worse economic outcomes, and lower offspring birthweight.1Victora CG de Onis M Hallal PC Blössner M Shrimpton R Worldwide timing of growth faltering: revisiting implications for interventions.Pediatrics. 2010; 125: e473-e480Crossref PubMed Scopus (919) Google Scholar In 2011, an estimated 165 million children in developing countries were stunted and 101 million children were underweight.2UNMillennium Development Goals Report 2013. United Nations, New York2013http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdfCrossref Google Scholar In their analysis in The Lancet Global Health, Sebastian Vollmer and colleagues3Vollmer S Harttgen K Subramanyam MA Finlay J Klasen S Subramanian SV Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countries.Lancet Glob Health. 2014; 2: 226-235Google Scholar assess the (often implicit) claim that economic growth will automatically lead to declines in child undernutrition: if poor nutritional outcomes are a manifestation of the poverty of nations, then surely economic growth would offer a remedy? Marshalling individual-level data from 121 Demographic and Health Surveys, Vollmer and colleagues document at best a weak, and often absent, association between economic growth and reductions in stunting, underweight, or wasting. This latest paper is not the first to cast doubt on the optimistic view that economic growth will necessarily translate into better anthropometric outcomes; indeed, even the current authors have previously presented similar evidence in India and sub-Saharan Africa.4Subramanyam MA Kawachi I Berkman LF Subramanian SV Is economic growth associated with reduction in child undernutrition in India?.PLoS Med. 2011; 8: e1000424Crossref PubMed Scopus (114) Google Scholar, 5Harttgen K Klasen S Vollmer S Economic growth and child undernutrition in sub-Saharan Africa.Popul Dev Rev. 2013; 39: 397-412Crossref Scopus (35) Google Scholar The merit of the present paper rather is in the range of the empirical exercise, specifically the extensiveness of the data and the range of statistical tests implemented. The null to quantitatively weak association between economic growth and child undernutrition documented is not for want of statistical precision or due to model and sample choice: Vollmer and colleagues report narrow confidence bounds of their estimates and robustness to a wide range of data concerns, thus increasing confidence in their results. This disappointing, but perhaps expected, result raises the crucial question: why is it that growth and reductions in child undernutrition are so weakly correlated? Vollmer and colleagues posit three possible channels: (i) perhaps households do not spend incomes in a way that is effectively targeted at improving nutrition; (ii) perhaps unequal distribution of growth within countries leaves poorer households, in which children are most at risk of undernutrition, unaffected; and (iii) rising national incomes might be poorly correlated with the public investments that are necessary to reduce child undernutrition. Each of these channels seems intuitively plausible. From a policy perspective, however, distinguishing between them is essential for the design of effective interventions. In the rest of this Comment, I seek to do this through the lens of India, where high-income growth has been accompanied by a slow decline in undernutrition. Results from India might have broader implications, much as Vollmer and colleagues' latest analysis echoes previous results across Indian states.4Subramanyam MA Kawachi I Berkman LF Subramanian SV Is economic growth associated with reduction in child undernutrition in India?.PLoS Med. 2011; 8: e1000424Crossref PubMed Scopus (114) Google Scholar Rising incomes might indeed not be accompanied by increases in nutritional intake. In 1987, a notable study had reported low nutrient-income elasticities in rural Indian communities;6Behrman JR Deolalikar AB Will developing country nutrition improve with income? A case study for rural South India.J Polit Econ. 1987; 95: 492-507Crossref Scopus (217) Google Scholar in the period since, until 2005, per capita consumption of calories and protein in India declined in absolute terms, despite a manifold increase in incomes and despite a steep decline in the proportion of households reporting a lack of food; although anthropometric indicators have improved, the decline has been slow and absolute levels remain high.7Deaton A Drèze J Food and nutrition in India: facts and interpretations.Econ Polit Wkly. 2009; 44: 42-65Google Scholar Is this perhaps a manifestation of the unequal distribution of growth, reflecting a pattern whereby income increases over the past two decades have benefited only the better-off? The evidence suggests that this is unlikely: across countries, Vollmer and colleagues report similar associations between growth and reductions in undernutrition for the richest and the poorest quintiles of wealth; and the decline in calorie intake noted by Deaton and Dreze7Deaton A Drèze J Food and nutrition in India: facts and interpretations.Econ Polit Wkly. 2009; 44: 42-65Google Scholar for India is evident across income deciles. The contrast in India between high rates of growth, improvement in several other public-health outcomes, and the continued prevalence of high levels of undernutrition (higher than most sub-Saharan African countries, which are much poorer) has led some prominent scholars to question the very premise of globally uniform growth charts to measure child nutrition.8Panagariya A Does India really suffer from worse child malnutrition than sub-Saharan Africa?.Econ Polit Wkly. 2013; 48: 98-111Google Scholar This conclusion is likely to be too pessimistic: as noted in a recent study by Jayachandran and Pande,9Jayachandran S Pande R Choice not genes: probable cause for the India-Africa height gap.Econ Polit Wkly. 2013; 48: 77-79Google Scholar Indian first-borns are taller than African first-borns and the difference in height-for-age Z-scores only appears later in the birth order of children; Jayachandran and Pande relate this lag to environmental influences, especially differential investment in children within the household. What can public policy do if sources of undernutrition stem from household choices that rising incomes do not remedy? Clearly, public health and nutritional interventions can have an important role in reducing child undernutrition. Spears10Spears D how much international variation in child height can sanitation explain? World Bank, Washington, DC2013https://openknowledge.worldbank.org/handle/10986/13163Crossref Google Scholar documents a clear gradient between sanitation and child undernutrition, large enough to statistically explain excess stunting in India compared with sub-Saharan African countries; in another recent study,11Singh A Park A Dercon S School meals as a safety net: an evaluation of the Midday Meal Scheme in India.Econ Dev Cultural Change. 2014; 62: 275-306Crossref Scopus (61) Google Scholar my coauthors and I also document that the Indian Midday Meals programme in schools leads to catch-up growth to compensate for drought-related nutritional deprivation in early childhood. Although economic growth alone might not accomplish an end to child undernutrition, proven interventions targeted at nutrition might. As Vollmer and colleagues remind us, combating child undernutrition in the medium term cannot exclusively rely on policies to promote economic growth. I declare that I have no competing interests. Association between economic growth and early childhood undernutrition: evidence from 121 Demographic and Health Surveys from 36 low-income and middle-income countriesA quantitatively very small to null association was seen between increases in per-head GDP and reductions in early childhood undernutrition, emphasising the need for direct health investments to improve the nutritional status of children in low-income and middle-income countries. Full-Text PDF Open Access