Mapping Sustainable Development Goals for Children in India: Progress and Present Challenges (India Studies in Business and Economics) 9819989000, 9789819989003

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India Studies in Business and Economics

Swati Dutta Khanindra Ch. Das

Mapping Sustainable Development Goals for Children in India Progress and Present Challenges

India Studies in Business and Economics

The Indian economy is one of the fastest growing economies of the world with India being an important G-20 member. Ever since the Indian economy made its presence felt on the global platform, the research community is now even more interested in studying and analyzing what India has to offer. This series aims to bring forth the latest studies and research about India from the areas of economics, business, and management science, with strong social science linkages. The titles featured in this series present rigorous empirical research, often accompanied by policy recommendations, evoke and evaluate various aspects of the economy and the business and management landscape in India, with a special focus on India’s relationship with the world in terms of business and trade. The series also tracks research on India’s position on social issues, on health, on politics, on agriculture, on rights, and many such topics which directly or indirectly affect sustainable growth of the country. Review Process The proposal for each volume undergoes at least two double blind peer review where a detailed concept note along with extended chapter abstracts and a sample chapter is peer reviewed by experienced academics. The reviews can be more detailed if recommended by reviewers. Ethical Compliance The series follows the Ethics Statement found in the Springer standard guidelines here. https://www.springer.com/us/authors-editors/journal-author/journal-aut hor-helpdesk/before-you-start/before-you-start/1330#c14214

Swati Dutta · Khanindra Ch. Das

Mapping Sustainable Development Goals for Children in India Progress and Present Challenges

Swati Dutta Institute for Human Development New Delhi, India

Khanindra Ch. Das Birla Institute of Management Technology Greater Noida, India

ISSN 2198-0012 ISSN 2198-0020 (electronic) India Studies in Business and Economics ISBN 978-981-99-8900-3 ISBN 978-981-99-8901-0 (eBook) https://doi.org/10.1007/978-981-99-8901-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Paper in this product is recyclable.

Foreword

Children, as the forefronts of our future, hold the key to a prosperous and thriving society. However, in spite of considerable progress made over the years, a significant number of children in India continue to grapple with deprivation, malnutrition, and lack of access to essential services. Addressing children’s vulnerability and deprivation requires dedicated efforts to secure their rights and promote their well-being which is extremely important for the well-being and development of the country. This book critically examines child development through a multidimensional lens, considering several facets that contribute to their well-being. It weaves together the principles enshrined in the United Nations Convention on the Rights of the Child with the aspirations of the Sustainable Development Goals, providing a comprehensive framework for understanding the complexities of child development in India. The book’s methodology, drawing from a variety of data sources, exemplifies the depth of research that has gone into creating a comprehensive understanding of child development across India’s diverse States and Union Territories. Child development is an important area on which the Institute for Human Development (IHD) has been working and Dr. Swati Dutta has significantly contributed to it. I am very happy that she has taken this work forward with Dr. Khanindra Ch. Das resulting into this important book. The book emphasis on evaluating child well-being against the Sustainable Development Goals provides a benchmark for policymakers, government officials, academics, and researchers. I hope that this book will be useful reference in making informed decisions to addressing deprivations and designing evidence-based interventions for the well-being of India children. I congratulate Dr. Swati Dutta and Dr. Khanindra Ch. Das for bringing this book timely. August 2023

Alakh N. Sharma, Ph.D. Professor and Director Institute for Human Development New Delhi, India

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Preface

Children are the heart of our society, holding within them the promise of a brighter future. The well-being, development, and rights not only are critical for their individual growth but also shape the foundation of a thriving nation. Despite this understanding, the specter of childhood deprivation looms large, casting a shadow on the potential of our youth. Childhood poverty not only denies children of their basic rights but also perpetuates a cycle of disadvantage that spans across generations, impacting the very fabric of our society. Addressing children’s vulnerability and the inequalities they face requires dedicated efforts to secure their rights and promote their well-being in the face of the grand challenges. The United Nations Convention on the Rights of the Child (UNCRC) stands as a testament to the world’s commitment to children’s well-being. Enshrining their rights to survival, growth, protection, and participation, the UNCRC emphasizes the importance of creating an environment where every child can thrive and develop to their fullest potential. Article 2 of the Convention reinforces the principle of nondiscrimination, which aims to ensure that no child is denied these rights based on any characteristics. Articles 13, 19, 28, and 31 highlight the significance of freedom of expression, protection from violence, access to education, and the right to leisure and play. India, as a signatory to the UNCRC, has acknowledged the importance of safeguarding children’s rights. The National Policy for Children and the National Plan of Action for Children are steps toward this commitment. Yet, the ground reality remains a concern. A significant number of Indian children continue to grapple with deprivation, vulnerability, and a lack of access to essential services. India’s rapid economic growth has improved lives, but the benefits have not reached all corners of society equitably. Amid these challenges, our book, provides a clear understanding of child development in India and the associated child-specific SDG targets. It delves into the landscape of child well-being in the context of SDG. Our book involved collaborative efforts at various stages of writing the book. We thank Dr. Alakh N. Sharma, Director- Institute for Human Development, New Delhi, and Dr. Harivansh Chaturvedi, Director-Birla Institute of Management Technology, vii

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Greater Noida for the motivation and support in this endeavour. We also thank several of our colleagues from respective institutions for discussion and comments. We owe a lot to our parents, who encouraged and helped us at every stage of our personal and academic life, and longed to see this achievement come true. We sincerely acknowledge the support of all our near and dear ones whose love and care have been the source of our strength. Everyone has not been mentioned individually, but none is forgotten. We are grateful to our beloved daughter Bhaswati (Hiya) for understanding and generously giving us the time to write this book, even when we couldn’t be there with her. Her support means everything. New Delhi, India Greater Noida, India

Swati Dutta Khanindra Ch. Das

Contents

1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Context and Rational . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Sustainable Development Goals (SDGs) and Children’s Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Methodology and Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4 Structure of the Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 Relevance of the Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1 4 6 7 10 12

2 Child Poverty and Deprivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Different Approaches to Measure Child Poverty . . . . . . . . . . . . . . . . 2.3 Dimensions of Deprivation Relating to Under-Five Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Dimension-Specific Deprivations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.1 Dimension-Specific Deprivation by Place of Residence . . . . 2.4.2 Dimension-Specific Deprivation by Wealth Class . . . . . . . . . 2.5 Multidimensional Deprivation Among Under-Five Children . . . . . . 2.6 Multidimensional Deprivations Among Adolescent Children . . . . . . 2.7 Multidimensional Overlapping Deprivation Analysis . . . . . . . . . . . . 2.8 SDG Targets and Achievements in Key Indicators of Child Wellbeing and Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9 Conclusions and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix: Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 13 14

3 Anthropometric Failure and Undernutrition Among Children . . . . . . 3.1 Different Approaches to Measure Child Undernutrition . . . . . . . . . . 3.2 Nutritional Status and Progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1 Malnutrition Status Among Under-Five Children by Socio-Economic Gradient . . . . . . . . . . . . . . . . . . . . . . . . . .

45 45 48

16 17 20 23 25 30 32 35 37 39 41

48

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3.2.2 Anemia Among Under-Five Children Across Socio-Economic Gradient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.3 State-Wise Status of Malnutrition and Anemia Among Under-Five Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.4 Anemia and BMI Among Adolescent Children in India and Across Socio-Economic Gradient . . . . . . . . . . . . 3.2.5 Status of Anemia and BMI Among Adolescent Children Across Indian States . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Nutrition Status and SDG-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Nutrition Policy in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1 Nutrition Policy Related to Under-Five and Adolescent . . . . 3.4.2 Infant and Young Child Feeding Practices: Main Drivers of Childhood Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 Conclusions and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Child Health Status and Utilization of Healthcare Services . . . . . . . . . 4.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Status of Child Mortality and Morbidity . . . . . . . . . . . . . . . . . . . . . . . 4.2.1 Child Mortality in India and by Socio-economic Gradient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.2 Mortality Status Among Under-Five Children in Indian States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.3 Prevalence of Morbidity Among Under-Five Children . . . . . 4.3 Access to Healthcare Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1 Coverage of Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2 Institutional Birth and Access to Skilled Health Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 Adolescent Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 SDG-3 Targets and Achievements in Key Indicators . . . . . . . . . . . . . 4.5.1 Reduce NMR to 12 Deaths per 1000 Live by 2030 . . . . . . . . 4.5.2 Infant Mortality Rate (IMR) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5.3 Under-Five Mortality Rate (U5MR) to Reduce Under-Five Mortality to 25 Deaths per 1000 Live by 2030 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5.4 Childhood Morbidity and Treatment-Seeking Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5.5 Immunization: To Achieve 100% Coverage of Full Vaccination Among Under-Five Children by 2030 . . . . . . . . 4.5.6 Institutional Delivery and Skilled Health Personnel: To Achieve 100% Institutional Delivery with the Support of Skilled Health Personnel by 2030 . . . . . . . . . . . . . . . . . . . . 4.6 Health Policy in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.7 Conclusions and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

53 56 60 62 63 67 67 71 72 75 79 79 81 81 84 86 93 93 95 101 102 102 102

103 104 104

105 106 110 112

Contents

5 Ensuring Quality Education: Holistic Child Development and the New Education Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Policy Context of Quality Education . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 Foundation of Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2 Increasing Access to Education and Reducing Dropout . . . . 5.2.3 Focus on Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Role of Nutrition and Health in Child Education . . . . . . . . . . . . . . . . 5.4 School Governance and Management . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5 SDG-4: Progress in Ensuring Quality Education and Holistic Child Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6 Foundation for Higher Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.7 Conclusion and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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115 115 116 116 117 119 121 122 123 130 131 132

6 Violence and Gender Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Sex Ratio at Birth and Bias Against Girls . . . . . . . . . . . . . . . . . . . . . . 6.2.1 Different Forms of Violence Against Child and Gender Inequality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.2 Missing Children in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.3 Crime Against Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.4 Child Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3 Child Trafficking and Its Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.4 SDG-5 Targets and Achievement in Key Indicators . . . . . . . . . . . . . . 6.5 Government Policy Addressing Violence and Gender Equity . . . . . . 6.6 Conclusion and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137 137 139

7 Child Well-Being and SDG Status of Indian States . . . . . . . . . . . . . . . . 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 Dimension Specific SDG Status Using Child Well-Being Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.1 Multidimensional Poverty (SDG-1) Status with Reference to Under-Five and Adolescent Children . . . . 7.2.2 Nutrition (SDG-2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.3 Health (SDG-3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.4 Education (SDG-4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.5 Violence and Gender Equality (SDG-5) . . . . . . . . . . . . . . . . . 7.2.6 Access to Cleaned Drinking Water and Improved Sanitation Facility (SDG-6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2.7 Access to Electricity and Cooking Fuel (SDG-7) . . . . . . . . . 7.2.8 Birth Registration of Under-Five Children (SDG-16) . . . . . . 7.3 Child Well-Being Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.1 Nutrition Achievement Index (NAI) . . . . . . . . . . . . . . . . . . . . 7.3.2 Health Achievement Index (HAI) . . . . . . . . . . . . . . . . . . . . . .

161 161

141 142 145 150 151 153 155 156 157

162 162 164 166 169 171 173 175 175 178 178 178

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7.3.3 Education Achievement Index . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.4 Gender Equality Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.5 Basic Amenities Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.6 Child Protection Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.3.7 Child Well-Being Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.4 Conclusion and Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

180 183 188 188 193 193 197

8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.1 SDGs and Children: A Comprehensive Assessment of Child Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.2 Global Importance of Child SDG from Indian Context . . . . . . . . . . . 8.3 Assessing SDGs and Child Well-Being in India: Progress and Spatial Variation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.4 Addressing Critical Concerns for Achieving SDGs . . . . . . . . . . . . . . 8.5 Interventions to Be Made to Achieve Child-Specific SDGs/ Way Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6 Pathway for Achieving SDG Goals for Children–Under-Five and Adolescent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.7 Limitations and Scope for Future Research . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

201 201 202 203 205 206 207 209 209

About the Authors

Dr. Swati Dutta is Fellow at Institute for Human Development, New Delhi. She obtained her Ph.D. from Institute for Financial Management and Research, the University of Madras with IFMR fellowship. Her research interests are child deprivation, multidimensional poverty, human development, financial inclusion, women empowerment, food and nutrition security, and financial inclusion. She has to her credit more than 25 peer-reviewed research papers published in international journals. She is assistant editor of Indian Journal of Human Development. Dr. Khanindra Ch. Das is assistant professor of economics at Birla Institute of Management Technology, Greater Noida (NCR), India. His teaching philosophy is to impart up-to-date knowledge drawn from relevant disciplines that can be applied in business and society. His research aims at generating new insights, through integration of disciplines and ideas, which can shape policy and practice in various spheres for improving economic and societal outcomes. He is editor of BIMTECH Business Perspectives.

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Abbreviations

AARI AARR ARI ASHA AWW BAI BMI CIAF CPI CWI DHS EAI ECCE ECD Edtech FSSAI GEI HAI HCR ICDS ICPS ICT ICU IEC IMR JSY KMC MODA MPI NAI NCRB

Annual average rate of increase Annual average rate of reduction Acute respiratory infections Accredited Social Health Activist Anganwadi workers Basic amenities index Body mass index Composite index of anthropometric failure Child protection index Child well-being index Demographic and Health Survey Education achievement index Early Childhood Care and Education Early Childhood Development Education technology Food Safety and Standards Authority of India Gender equality index Health achievement index Headcount ratio Integrated Child Development Services Integrated Child Protection Scheme Information and communication technology Intensive care unit Information–Education–Communication Infant mortality rate Janani Suraksha Yojana Kangaroo mother care Multidimensional overlapping deprivation approach Multidimensional poverty index Nutrition achievement index National Crime Records Bureau xv

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NEP NER NFHS NGO NHM NMR OBC OECD OSC POCSO QR RBSK REM RRI RRR SAM SC SDGs SNCU SRB ST STEM U5MR UDISE UHC UIP UN UNCRC UNDP UNICEF UNODC UT WHO WIFS

Abbreviations

New Education Policy Net enrollment ratio National Family Health Survey Non-governmental organization National Health Mission Neonatal mortality rate Other Backward Class Organisation for Economic Co-operation and Development One Stop Centers Protection of Children from Sexual Offences Act Quick response Rashtriya Bal Swasthya Karyakram Range equalization method Required rate of increase Required rate of reduction Severely acute malnourished Scheduled Caste Sustainable Development Goals Special newborn care units Sex ratio at birth Scheduled Tribe Science, Technology, Engineering, Mathematics Under-five mortality rate Unified District Information System for Education Universal health coverage Universal Immunization Program United Nations United Nations Convention on the Rights of the Child United Nations Development Programme United Nations International Children’s Emergency Fund United Nations Office on Drugs and Crime Union Territory World Health Organization Weekly iron and folic acid supplementation

List of Figures

Fig. 2.1

Fig. 2.2

Fig. 2.3

Fig. 2.4

Fig. 2.5

Fig. 2.6

Fig. 2.7

Fig. 2.8

Fig. 2.9

Fig. 2.10

Dimension-specific deprivation among under-five children (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimension-specific deprivation among adolescent children (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimension-specific deprivation among under-five children by place of residence 2019–21 (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . Changes in deprivation between 2015–16 and 2019–21 for under-five children. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimension-specific deprivation among adolescent children by place of residence, 2019–21 (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . Reduction in deprivation by place of residence between 2015–16 and 2019–21 for adolescent children. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dimension-specific deprivation among under-five children by wealth class (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . Dimension-specific deprivation among adolescent children by wealth class (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . Multidimensional headcount ratio by Indian states (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intensity of multidimensional poverty by Indian states (percent). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

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Fig. 2.11

Fig. 2.12

Fig. 2.13

Fig. 3.1

Fig. 3.2

Fig. 3.3 Fig. 3.4

Fig. 3.5 Fig. 3.6

Fig. 3.7

Fig. 3.8

Fig. 3.9

Fig. 3.10

Fig. 3.11

List of Figures

Multidimensional poverty headcount and intensity of poverty among adolescent children by Indian states. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multidimensional overlapping deprivations among under-five children (percent): 2019–21. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Multidimensional overlapping deprivations among adolescent children (percent): 2019–21. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in malnutrition among under-five children by place of residence (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in malnutrition among under-five children by age (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anemia among under-five children in India (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . Prevalence of anemia among under-five by place of residence (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anemia among under-five children by age (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . Prevalence of anemia among under-five children by social groups (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of anemia among under-five children by wealth class (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in anthropometric failure among under-five children (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anemia among under-five children in India states (%). Source Authors’ calculation based on NFHS (different rounds). Note - ve sign (of secondary axis) means increase and + ve sign means decrease . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adolescent girl’s anemia in 2019–21 and the gap between NFHS-4 and NFHS-5 (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . Adolescent boy’s anemia in 2019–21 and the gap between NFHS-4 and NFHS-5 (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . .

32

34

35

50

52 53

54 54

55

55

59

60

61

61

List of Figures

Fig. 4.1

Fig. 4.2 Fig. 4.3 Fig. 4.4

Fig. 4.5

Fig. 4.6

Fig. 4.7

Fig. 4.8

Fig. 4.9

Fig. 4.10

Fig. 4.11

Fig. 4.12

Fig. 4.13 Fig. 4.14

Fig. 4.15

Fig. 4.16

Trends in NMR, IMR, and U5MR in India (per 1000). Source Author’s calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in child mortality by place of residence. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . Trends in child mortality by gender. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . Changes in NMR, IMR, and U5MR between 2005–06 and 2019–21 (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of diarrhea and blood dysentery among under-five children (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . Prevalence of diarrhea among under-five children by gender (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proportion of under-five children with fever and ARI (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Proportion of under-five children with fever and ARI by place of residence and wealth class (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . Treatment seeking for fever/cough by gender and place of residence (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Treatment seeking for fever/cough by wealth class (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Any forms of morbidity among under-five children in India by socio-economic character (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . State-wise prevalence of changes in childhood morbidity (%). Source Authors’ calculation based on NFHS (different rounds) Note: positive change means reduction, i.e., NFHS-3–NFHS-5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Coverage of eight types of vaccination (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . Coverage of full vaccination by place of residence and social group (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immunization coverage and change across states (%). Source Author’s calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Place of institutional delivery in India (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . .

xix

81 82 84

85

86

87

88

89

90

91

91

92 94

94

95 96

xx

Fig. 4.17

Fig. 4.18

Fig. 4.19

Fig. 4.20

Fig. 4.21

Fig. 5.1 Fig. 6.1 Fig. 6.2

Fig. 6.3

Fig. 6.4

Fig. 6.5

Fig. 6.6

Fig. 6.7

Fig. 6.8

Fig. 6.9

List of Figures

Changes in institutional delivery by social group and economic status (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . Delivery in public spaces by social group and economic status (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to skilled health personnel by place of residence (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to skilled health personnel by social group and wealth class (%). Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to institutional delivery and skilled health personnel (%), 2019–21. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enrolment in private schools in India in millions (year 2021–22). Source Compilation from Indiastat . . . . . . . . . . . . . . . State-wise sex ratio at birth. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . Changes in SRB between 2015–16 and 2019–21: state-level analysis. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State-wise number and percentage share of missing children. Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . Percentage of missing children by gender (2021). Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Total crime against children in India (per 100,000, and % change). Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . Different forms of violence against children in India—2021 (%). Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Share of victim girls under POSCO in India (in 2021) out of total victim children. Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . State-wise share of girl child victims of kidnaping and abduction in 2021 (out of total victim children). Source Authors’ calculation based on National Crime Records Bureau Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reasons for kidnapping of children (%). Source Authors’ calculation based on National Crime Records Bureau Statistics. Note Other includes ransom, revenge, prostitution, adoption, begging, loan recovery, other motive . . . .

96

97

98

98

100 123 140

141

143

144

146

147

148

149

150

List of Figures

Fig. 6.10

States-wise percentages of women in the age group of 20–24 years married before the age of 18 years (2015–16 and 2019–21). Source Authors’ calculation based on National Family and Health Survey (different rounds) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xxi

151

List of Tables

Table 2.1 Table 2.2 Table 3.1 Table 3.2 Table 3.3 Table 3.4 Table 3.5 Table 3.6 Table 3.7

Table 3.8 Table 4.1 Table 4.2 Table 4.3 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 5.6

Multidimensional headcount ratio for under-five children . . . . . Multidimensional headcount ratio for adolescent children . . . . Indicators of the composite index of anthropometric failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of malnutrition among under-five children in India (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalence of anthropometric failure among under-five children in India (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in malnutrition among under-five children by social groups and wealth class (%) . . . . . . . . . . . . . . . . . . . . . Change in malnutrition indicators in Indian states (%) . . . . . . . Trends in BMI among adolescent children (15–19 years) (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Annual rate of Reduction in Anemia and BMI among adolescent boys and girls between 2015–16 and 2019–21 (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Present status and SDG-2 target 2030 (child-specific indicators) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trends in child mortality by social groups . . . . . . . . . . . . . . . . . Trends in child mortality by wealth class . . . . . . . . . . . . . . . . . . Treatment-seeking behavior among diarrhea-affected children (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comparison of medals in International Mathematics Olympiad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . National indicators used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adjusted net enrolment ratio (2021–22) . . . . . . . . . . . . . . . . . . . Dropout rate at secondary level (2021–22) . . . . . . . . . . . . . . . . . Pupil–teacher ratio (2021–22) . . . . . . . . . . . . . . . . . . . . . . . . . . . Number of beneficiaries and funds released under post-metric scholarship for ST students in India . . . . . . .

25 31 47 49 50 51 57 62

64 65 83 83 88 117 118 125 126 127 128

xxiii

xxiv

Table 7.1 Table 7.2 Table 7.3 Table 7.4 Table 7.5 Table 7.6 Table 7.7 Table 7.8 Table 7.9 Table 7.10 Table 7.11 Table 7.12 Table 7.13 Table 7.14 Table 7.15

List of Tables

SDG status of under-five and adolescent multidimensional poverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SDG achievement in nutrition related indicators for under-five and adolescent children . . . . . . . . . . . . . . . . . . . . SDG achievement status in health related indicators for under-five and adolescent children . . . . . . . . . . . . . . . . . . . . SDG status of education related indicators for children . . . . . . . SDG progress in violence and gender equality related indicators for children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SDG status of drinking water and sanitation related indicators for children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SDG status of electricity and cooking fuel related indicators for children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SDG status of birth registration related indicators for under-five children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nutrition achievement index . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health achievement index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Education achievement index . . . . . . . . . . . . . . . . . . . . . . . . . . . Gender equality index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic amenities index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child protection index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child well-being index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

163 165 167 170 172 174 176 177 179 181 184 186 189 191 194

List of Maps

Map 2.1 Map 2.2 Map 2.3 Map 2.4 Map 7.1 Map 7.2 Map 7.3 Map 7.4 Map 7.5 Map 7.6 Map 7.7

MPI among under-five children-2021. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . MPI among under-five children-2016. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . MPI among adolescent children-2021. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . MPI for adolescent children-2016. Source Authors’ calculation based on NFHS (different rounds) . . . . . . . . . . . . . . . . a Nutrition achievement index 2021, b nutrition achievement index 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a Health achievement index 2021, b health achievement index 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a Education achievement index 2021, b education achievement index 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a Gender equality index 2021, b gender equality index 2016 . . . . a Basic amenities index 2021, b basic amenities index 2016 . . . . a Child protection index 2021, b child protection index 2016 . . . a Child well-being index 2021, b child well-being index 2016 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29 30 33 34 180 182 185 187 190 192 195

xxv

Chapter 1

Background

1.1 Context and Rational Children are the foundation of future societies, directly influencing a nation’s overall progress and sustainability. However, childhood poverty can have profound and longlasting effects, impeding children’s access to basic rights and perpetuating a cycle of disadvantage and poverty across generations (UNICEF, 2007, 2016). Further, children are commonly perceived as inherently vulnerable and lacking autonomy, which results in amplified well-being challenges concerning broader developmental issues, including inequality. Their distinct needs call for focused efforts to safeguard their rights and prioritize their well-being as an integral part of tackling larger developmental complexities. It is essential to ensure that children have the right to thrive, grow, and develop to their full potential, as enshrined in the United Nations Convention on the Rights of the Child (UNCRC, 1989). The UNCRC is a comprehensive treaty comprising 54 articles that recognize and protect the rights of children worldwide. It articulates the entitlements to children to strive, thrive, receive protection, and actively participate in the decision-making process. Article 2 of the Convention highlights the principle of non-discrimination. This implies that every child possesses the right to fully enjoy the provisions outlined in the UNCRC without any discrimination. States Parties are obligated to guarantee that no child is subject to discrimination based on their racial or ethnic background, skin color, gender, language, religious belief, political or ideological views, national, or social origin, economic status, disability, birth, or any other characteristics. Article 13 highlights the paramount importance of child’s entitlement to freedom of expression. Children possess the right to actively pursue, receive, and share information and ideas without any geographical limitations, utilizing whichever media they prefer. This right encompasses the freedom of speech and access to information, empowering children to express their perspectives and actively participate in decisions that directly impact their lives.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_1

1

2

1 Background

Article 31 is centered on safeguarding the child’s right to relaxation, leisure, play, recreational pursuits, and engagement in cultural experiences. States are obliged to acknowledge and encourage the child’s entitlement to participate in age-appropriate play and recreational activities, as well as freely take part in cultural life and artistic expression. Governments are encouraged to create opportunities for leisure, play, and cultural activities that contribute to a child’s physical, mental, and social development. Article 19 highlights the fundamental right of every child to be safeguarded from all forms of physical, psychological, violence, injury or abuse, neglect, or exploitation. States are required to implement necessary legislative, administrative, social, and educational measures to ensure the protection of the child from such harm, with special attention given to instances when the child is under the care of parents, legal guardians, or any other individuals responsible for their well-being. It also acknowledges the right of the child to be protected from abduction, trafficking, and any other form of exploitation. Article 28 focuses on the child’s right to education. States Parties agree to make elementary education free and mandatory for all children. Secondary education should be provided to all children. The objective of education should be focused on nurturing the child’s personality, talents, mental, and physical capabilities to their utmost potential, while also equipping them to lead a responsible life in a society that values freedom and individuality. India, as a signatory to the UNCRC and guided by its Constitutional mandate, has taken steps to prioritize the rights and well-being of children through the establishment of the National Policy for Children in 2013 and the National Plan of Action for Children in 2016. Despite these policy commitments, a significant number of children in India still face deprivation, vulnerability, and limited access to essential services such as healthcare, education, nutrition, and protection. Recognizing the urgent need to address these challenges, this book, “Mapping Sustainable Development Goals for Children in India: Progress and Present Challenges,” examines the progress made and the persisting obstacles in achieving Sustainable Development Goals (SDGs) specifically in the case of children in India. The SDGs, adopted by India at the UN Summit in 2015, provide a comprehensive framework for promoting holistic development, social equity, and environmental sustainability. Within this framework, specific goals and targets directly address the well-being and rights of children, including child poverty, education, health, gender equality, access to clean water, sanitation, electricity, and safe cooking fuel. Understanding the progress and challenges in achieving these goals is crucial for formulating policies, interventions, and strategies that can transform the lives of children and ensure their well-being. On the global front, one of the recent assessments suggests that just 12% of the SDG targets are on track (UN, 2023). In this context, SDG assessment at the national level assumes significance. This book is concerned with SDG progress in the context of children. Studying children and their well-being poses several challenges that make it a complex endeavor. Firstly, defining a child is not universally uniform; while the UNCRC defines children as individuals under 18, “child as a person below the age of 18 years

1.1 Context and Rational

3

unless the laws of a particular nation set the legal age for adulthood younger.” However, different national, cultural, and policy contexts might not align with this definition. In India, child labor is recognized up to the age of 14 albeit the legal age for voting remains 18 years. This lack of a standardized yardstick complicates research on children. Secondly, children, as a dynamic category, undergo a transition from childhood to adulthood. Approaches effective for other groups, like women or caste, may not directly apply to children. Furthermore, children are not isolated; they belong to diverse groups, including ethnic minorities, refugees, and the impoverished, necessitating consideration of their intersecting identities (Morrow, 1998; Punch, 2002). Thirdly, comprehending children’s viewpoints and agency is a challenge. It might be difficult for children to express themselves in ways that adults can understand, making it challenging to collect the direct voice of the children (Milner & Carolin, 1999). Despite these obstacles, conducting research and gathering data on children are essential to formulate evidence-based strategies for enhancing child well-being. This calls for persistent and renewed efforts to address the unique complexities involved in studying and advocating for children’s rights and development. India’s remarkable economic growth in the past two decades has made a phenomenal contribution to global human development. The country’s economic successes have improved the quality of life differently for everyone, especially for children. In 2011, the population of children (0–14 years) in India was 380 million, and in 2020, the total population in the 0–14 age group was 361 million. As a percent of the country’s total population, there is a decrease in the share of children (0–14) from 30.40% in 2011 to 26.16% in 2020 (WDI Databank). In 2022, the 0–14 age group population stands at 358 million, which accounts for 18% of the world’s children population. The number signifies the role India can play in improving global child development indicators. India boasts the world’s largest adolescent population, reaching an impressive 253 million, with one in every five individuals falling in the age range of 10–19 years. The nation has unique opportunity to reap social, political, and economic benefits by ensuring safety, health, education, and empowerment of this large substantial adolescent cohort. Equipping them with information and life skills is crucial for bolstering the country’s overall development and progress. In the rapidly changing economy driven by technology, climate change, demographics, and inequality, there is a need to bring about holistic child development so that their skills and abilities can be useful for the benefit of the country and the world. As the research on child development issues in India is sparse, for holistic development of the children, we need to understand their vulnerabilities be it poverty, malnutrition, health-seeking behavior, child marriages, crime against children, poor learning outcome, and lack of access to basic services and their interlinkages which could have detrimental effects on overall child development. A large proportion of India’s population comprises children, and their well-being is critical for the country’s overall development. However, limited research has focused on comprehensively understanding the multidimensional aspects of child

4

1 Background

well-being in the Indian context. This book fills that vacuum by examining the various dimensions of child well-being and mapping their progress across Indian states. By utilizing data from established sources such as the UDISE, National Family Health Survey (NFHS), the National Crime Records Bureau, this book provides a rigorous analysis of child well-being and development. The COVID-19 pandemic has further exacerbated the challenges faced by children, affecting their access to education, healthcare, nutrition, and protection services. To address the evolving needs and vulnerabilities of children, it is imperative to assess the progress made toward achieving the SDGs and identify areas where interventions are required. This book not only examines the current status of child well-being but also calculates child well-being scores based on the UNDP methodology, enabling a comprehensive evaluation of progress over time and a comparison across states and districts. Furthermore, the book also explores the implications of national policies and programs on child development, and discusses the role of education, health, social protection schemes, and food security initiatives in achieving the SDGs. The findings and insights presented in this book are intended to inform policymakers, government officials, civil society organizations, NGOs, academics, and researchers working in the field of child well-being. By providing a comprehensive understanding of the challenges and opportunities in fulfilling children’s rights and achieving the SDGs, this book aims to guide evidence-based decision-making, policy formulation, and program implementation. Additionally, the research findings and methodologies employed in this book hold relevance for other developing countries, particularly those in South Asia facing similar challenges of child deprivation and limited access to basic services. Through a holistic assessment of child well-being and the mapping of SDG targets, this book contributes to the collective efforts aimed at creating a sustainable and equitable future for children in India. By placing children’s rights and well-being at the forefront of the development agenda, we can pave the way for a society that nurtures, protects, and empowers its youngest members, ensuring their holistic development and enabling them to become active participants and contributors to India’s economic progress and global sustainable development.

1.2 Sustainable Development Goals (SDGs) and Children’s Well-Being Child Rights and the 2030 Agenda for Sustainable Development are closely intertwined, representing a global commitment to securing a prosperous and equitable future for children worldwide. The United Nations Human Rights has been instrumental in advocating for child rights within the 2030 Agenda. Child rights, encompassing the rights to survival, development, protection, and participation, provide the foundational framework for ensuring children’s well-being and shaping their future.

1.2 Sustainable Development Goals (SDGs) and Children’s Well-Being

5

This book aligns with the United Nations Human Rights vision by emphasizing the importance of child rights in achieving SDGs. Among the 17 SDGs, several of these goals are directly linked to improving the well-being and rights of children. In the Indian context too, these goals play a crucial role in shaping policies and interventions aimed at enhancing child welfare and creating a better future for the younger generation. This book deals with eight SDGs that are directly related to well-being and rights of children. These SDGs are explained below. SDG-1: No Poverty Child poverty is a pressing issue in many developing countries including India, with a significant number of children living in impoverished conditions. SDG-1 aims to eradicate extreme poverty and reduce multidimensional poverty. Child poverty is a multidimensional problem, encompassing access to education, healthcare, nutrition, sanitation, and social protection measures. SDG-2: Zero Hunger Child malnutrition remains a significant challenge in developing countries, affecting millions of children. SDG-2 aims to end hunger, achieve food security, improve nutrition, and promote sustainable agriculture. Ensuring access to nutritious food and implementing effective nutrition programs are crucial for improving child well-being. SDG-3: Good Health and Well-Being SDG-3 focuses on ensuring healthy lives and promoting well-being at all ages. It encompasses targets related to reducing child mortality, improving maternal health, combating communicable and non-communicable diseases, and providing universal access to healthcare. Enhancing child health, immunization coverage, and reducing child mortality are critical for child well-being. SDG-4: Quality Education Access to quality education is vital for children’s all round development and prospects. SDG-4 aims to ensure inclusive and equitable quality education for all. In the Indian context, achieving this goal involves addressing challenges such as inadequate infrastructure, teacher shortages, high dropout rates especially at the secondary level, learning shortfall, and gender disparities in education. SDG-5: Gender Equality Promoting gender equality and empowering girls are crucial for child well-being. SDG-5 addresses gender disparities and discrimination, aiming to eliminate all forms of violence, discrimination, and harmful practices against children in general and women and girls in particular. Empowerment of girls through education and healthcare, and protection measures contribute to improved child well-being. SDG-6: Clean Water and Sanitation Access to clean water and sanitation facilities is essential for children’s health and well-being. SDG-6 seeks to ensure the availability and sustainable management of

6

1 Background

water and sanitation for all. Addressing issues such as open defecation, water scarcity, and lack of proper sanitation facilities is crucial for improving child health outcomes. SDG-7: Affordable and Clean Energy (Electricity and Cooking Fuel) Access to affordable and clean energy, specifically electricity and clean cooking fuel, is critical for child well-being. SDG-7 focuses on ensuring access to reliable, sustainable, and modern energy for all. Improving energy infrastructure, promoting renewable energy sources, and reducing reliance on traditional biomass for cooking can significantly impact children’s lives, improving their health, education, and overall well-being. SDG-16: Peace, Justice, and Strong Institutions Creating a safe and inclusive environment for children is a key to their well-being. SDG-16 focuses on promoting peaceful and inclusive societies, ensuring access to justice, and building effective, accountable, and inclusive institutions. Protecting children from violence, exploitation, and abuse and providing them with a secure and supportive environment are vital for making progress in SDG-16. The interlinkages among these SDGs are also evident, as progress in one goal often influences the achievement of others. For instance, improving education (SDG-4) can positively impact child health and well-being (SDG-3), reduce poverty (SDG-1), and promote gender equality (SDG-5). Similarly, addressing gender disparities (SDG-5) can contribute to reducing child mortality (SDG-3) and promote inclusive societies (SDG-16). In the Indian context, addressing these interlinkages requires a coordinated and integrated approach that involves government agencies, civil society organizations, academia, local communities, and the private sector. It necessitates policy coherence, resource mobilization, and effective implementation strategies. Furthermore, it is essential to prioritize marginalized and vulnerable groups to ensure that no child is left behind in the pursuit of sustainable development.

1.3 Methodology and Data Sources This book examines six dimensions of child well-being, i.e., nutrition, health, education, gender equality, basic amenities, and protection from violence. Further, it reviews the SDG targets across eight SDGs encompassing child-specific indicators at the national and states levels from the perspective of children. Children and their well-being play an important role in Indian development policy goal. This research assumes importance in developing the actionable steps necessary to address SDG bottlenecks in the Indian context, particularly with reference to children. The research provides valuable insights into what can be and should be done to ensure the well-being, and advancement, of children within the framework of SDGs. We use unit level data from the National Family Health Survey (NFHS), Unified District Information System for Education Plus (UDISE Plus), and other government data

1.4 Structure of the Book

7

sources like the National Crime Records Bureau statistics. Child well-being index (CWI) is calculated based on UNDP methodology, and the states are categorized in terms of achievement of child development between 2015–16 and 2019–21. CWI consists the of nutrition achievement index (NAI), health achievement index (HAI), education achievement index (EAI), gender equality index (GEI), basic amenities index (BAI), and child protection index (CPI). The child well-being index provides specific information on all the dimensions important for the holistic development of children. It provides a framework based on which policies can be formulated by respective governments for effective implementation to achieve Vision 2030 of SDGs. In addition to the child well-being index, we have also developed specific multidimensional poverty indices (MPIs) tailored for two crucial age groups: under-five children and adolescents aged 15–19 years. The annual average rate of reduction/increase in child-specific indicators is calculated to understand the current growth rate. The book also provides an estimate of the required growth rate of child-specific indicators to achieve the SDG targets by 2030. In addition to rich quantitative analysis, implications of National Education Policy, National Health Policy, social protection schemes, Poshan Abhiyan, among others, on child development and its role in achieving SDG targets are also discussed. The book compares the performance of the Indian states in terms of achieving SDG targets using child-specific indicators. The uniqueness of the book lies in the use of multidimensional indicators to analyze the well-being of children and the quantification of gap from SDG targets based on NFHS-4 (2015–16) and NFHS-5 (2019–21). More than 30 child-related indicators have been used that spans across the eight child-specific SDGs identified for analysis. Child well-being achievement score pertaining to 2015–16 has been considered as a baseline for assessing the achievement of SDGs. The indicators used in this book could be useful for tracking the SDG indicators and sustainable monitoring of child well-being at the state levels. Overall, the book provides details on the depth and the experience of deprivations. Child well-being achievement score provides a layout for region-wise priority areas, and it suggests to child centric policy interventions.

1.4 Structure of the Book This chapter lays the foundation for the book’s exploration of the SDGs for children. By combining insights from global literature and national perspectives, the chapter highlights the significance of addressing children’s well-being as an integral part of the broader sustainable development agenda. With a clear context established, the subsequent chapters will delve into specific dimensions of child development and propose actionable strategies to create a brighter and more sustainable future for children in the country.

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Chapter 2 delves into the critical issue of deprivation and multidimensional poverty among children in India by adopting a life-cycle approach to comprehensively examine the problem. Using data from the National Family and Health Survey (NFHS-4 and NFHS-5), the analysis focuses on children across different age groups to understand how deprivation impacts them differently. Two approaches are utilized to measure child poverty among under-five and adolescent (15–19 years) age groups, namely the multidimensional poverty approach and the multidimensional overlapping deprivation approach (MODA). The multidimensional poverty index (MPI) categorizes states into high, moderate, and low poverty levels, employing the equal range method. To effectively capture multidimensional child poverty, the chapter identifies indicators that signify deprivation. The MODA approach incorporates a comprehensive set of tools, including deprivation headcount rates, overlap analysis, and multidimensional deprivation ratios by indicator and dimension. Recognizing the diversity of children’s needs based on age, the MODA approach adopts a child-centered perspective, focusing on appropriate age group analysis rather than treating all children as a homogeneous group. A core set of dimensions and corresponding indicators are identified, derived from the child rights framework and the Convention on the Rights of the Child, to assess children’s well-being comprehensively. By adopting a life-cycle approach and utilizing robust methodologies, this chapter provides valuable insights into the multidimensional poverty faced by children in India. It sheds light on the specific challenges each age group encounters and offers a foundation for evidence-based policies and interventions to address this pressing issue. Chapter 3 deals with anthropometric failure and undernutrition. Malnutrition remains a pressing concern in India, with undernutrition resulting in low birth weight and susceptibility to childhood illnesses and diseases. The challenge is exacerbated by inadequate maternal and childcare practices and feeding habits, which are further compounded by gender discrimination and exclusion. This chapter uses three major indicators: stunting, wasting and underweight along with composite index of anthropometric failure (CIAF) to reflect the status of malnutrition among under-five children across the states of India. Further, anemia among under-five children is also considered to understand their nutrition intake and poor health status. The chapter also discusses various age-specific feeding practices, and other household -specific indicators to explore the pattern of malnutrition among under-five children across socio-economic classes. The chapter also delves into the nutrition deficiency among adolescents aged 15–19 years by calculating age-appropriate body mass index (BMI) and anemia rates. In addition to presenting data and analysis, the chapter evaluates different government policies aimed at reducing malnutrition among children and assesses the efficacy and potential impact on combating this persistent issue. Chapter 4 sheds light on health and utilization of healthcare services. One of the most fundamental rights that every child deserves is the right to survival. Across the globe, a staggering 5.3 million children face untimely deaths before even reaching their fifth birthday, and India, unfortunately, bears a significant burden of this heartwrenching statistic. This chapter delves into the critical issue of childhood mortality,

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focusing on its prevalence in Indian states and among various socio-economic classes. Childhood mortality is not only a humanitarian crisis but also an important indicator of the overall well-being and development of a nation. Understanding the current trends and factors influencing this issue is of paramount importance to policymakers, healthcare professionals, and society as a whole. In addition to exploring childhood mortality rates, this chapter also examines childhood morbidity and the health-seeking behaviors prevalent among children from diverse socio-economic backgrounds. Access to healthcare facilities, immunization, institutional delivery, and skilled birth attendants play pivotal roles in determining the well-being of children, and understanding their utilization is vital for improving healthcare access and outcomes. Moreover, this chapter delves into adolescent pregnancy and mental health problems among teenagers, emphasizing the need for targeted interventions and support systems to safeguard their well-being. As we look ahead, the achievement of SDG-3 becomes a central theme in this discourse. With focus on child-related indicators, and targets set for 2030, the urgency of policy interventions by Indian states to ensure progress toward these goals cannot be overstated. The chapter highlights the significance of aligning national health policies with the specific needs and challenges faced by children. Chapter 5 presents a discussion on SDG-4 achievement that concerns with ensuring quality education. Apart from presenting achievement and gaps in education related targets, the case of holistic child development is discussed through the lens of new education policy and related measures. In the light of prevailing child health status, implementation of the new education policy along with nutrition and health policies could bring about holistic child development. Chapter 6 deals with violence against children and gender equity. Child protection is a crucial policy commitment in India as it recognizes the vulnerability of children, particularly those from marginalized communities, to various forms of exploitation and harassment. Every child has the inherent right to be safeguarded from neglect, discrimination, violence, abuse, as well as economic and sexual exploitation. Exposure to violence in childhood often begins as early as the age of one, with children being subjected to direct abuse from primary caregivers and other family members. Domestic violence also has detrimental effects on children. This chapter examines several important aspects, including the sex ratio at birth (SRB), the prevalence of child marriage, and the various other forms of violence experienced by children. Additionally, the chapter explores the factors that contribute to child trafficking and suggests necessary policy implications to address the issue effectively. Chapter 7 examines the status of child well-being in Indian states, using several child-specific target indicators, and their progress toward achieving the SDGs. The analysis provides the present and required growth rates to meet SDG target levels of various indicators. The analysis helps in identifying whether states are on track or have weak and insufficient growth rates in achieving the SDGs. Furthermore, an overall child well-being index has been developed for the period 2015–16 and 2019–21. To standardize the indicators and bring those to a common scale, the max–min method has been utilized. This method converts the indicators

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into a standardized range between 0 and 1, where the lowest achievement corresponds to zero and the highest achievement corresponds to 1. The range equalization method (REM), as adopted by the United Nations Development Programme (UNDP), has been applied to construct this index. States with higher scores on the child well-being index are considered to have a better level of well-being compared to states with lower index values. Based on the child well-being index, states are categorized as leading, moderate, or lagging in terms of progress made toward achieving the SDG using the equal range method. Chapter 8 provides a brief summary of the book, major highlights, and some of the areas of concerns. It also discusses way forward to achieve child-specific SDG targets by 2030 and to bring about holistic child development through targeted and timely interventions. Some of the limitations are also discussed.

1.5 Relevance of the Book Our book contributes to a comprehensive understanding of child-focused SDG indicators. Such measurement and assessment of indicators in high-income countries are already available (Richardson et al., 2017). The same study highlights the importance of developing child-specific indicators to track progress and assess the impact of the SDGs on children’s well-being. It emphasizes the need for a multidimensional approach, encompassing various dimensions of child well-being, including health, education, protection, and participation. These insights are relevant for India, where a similar approach is necessary to ensure comprehensive monitoring and evaluation of child-focused SDGs. Our book recognizes the significance of disaggregated data and explores its implications for understanding child well-being in the country. It delves into the complexities of intersecting factors and highlights the need to address the prevailing child development disparities through policy formulation and implementation. By examining the intersections of state, gender, caste, and economic status, our book provides a comprehensive analysis of the challenges and potential solutions to achieve equitable outcomes for all her children. Childhood is often acknowledged as a critical period for disrupting the cycle of intergenerational poverty (Camfield et al., 2008). Child-related indicators have a visible presence in global development agendas. The Sustainable Development Goals (SDGs) comprise 44 child-related indicators spread across 17 goals. These indicators in the SDGs are organized into five dimensions of child rights, which include the rights to survival and well-being, education, protection from violence, access to a safe and clean environment, and equal opportunities for success (UNICEF, 2018). Comprehensive exploration of policy and program reforms in early childhood development emphasizes the critical role of such initiatives in ensuring holistic human development in India (Shreeranjan, 2019). It delves into the challenges faced in addressing childhood underdevelopment and undernutrition, offering valuable perspectives on areas needing improvement and greater attention. The work

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offers a unique glimpse into the strategic planning processes in the social development arena, focusing on India’s nutrition challenges and the formation of the Prime Minister’s Nutrition Council. It advocates for inclusive and equitable opportunities for optimal child development at the national level while outlining key priorities and pathways for enhancing early childhood development including nutrition efforts. Given the paramount importance of attaining the Sustainable Development Goals (SDGs), the book advocates for renewed momentum and collaboration endeavors across the missions of Nutrition, Integrated Child Development Services (ICDS), and Early Childhood Care and Education (ECCE) to ensure holistic child development in India. This book on mapping SDGs for children in India would serve as comprehensive guide for policymakers and practitioners dedicated to enhance the well-being of children in the nation. Further, The Indian Child Well-being Report published by IFMR and World Vision (2019) has been a significant contribution to understanding the status of children’s well-being in India. The report provides valuable insights into various dimensions of child well-being, including education, health, nutrition, child protection, and participation. This book aims to address certain gaps and enhance the understanding of child well-being in the Indian context. One of the gaps it addresses is the need for a comprehensive analysis of the Sustainable Development Goals (SDGs) in relation to child well-being. While the IFMR and World Vision report touches upon the SDGs, this book takes a more focused approach by mapping the SDGs specifically for children in India. We delve into the interlinkages between the SDGs and their implications for children, providing a more detailed and nuanced understanding of how the goals impact their well-being, and assess achievements and shortfalls in child-specific SDG targets with reference to SDG1, SDG-2, SDG-3, SDG-4, SDG-5, SDG-6, SDG-7, and SDG-16. In the Indian context, monitoring and assessing the progress toward achieving the SDGs has been a crucial undertaking. NITI Aayog, the premier policy think tank of the Government of India, has been instrumental in this regard. NITI Aayog regularly publishes the SDG India Index, which evaluates India’s performance across various SDGs and provides insights into the country’s progress (Government of India, 2019, 2021). While the NITI Aayog’s reports offer valuable insights and a comprehensive assessment of India’s progress, our book aims to delve deeper into the nuances and intricacies of the SDGs concerning children, as children are at greater risk of (relative) income poverty, which is an aspect of SDG Goal 1, than the overall population (Marguerit et al., 2018). By conducting an in-depth mapping exercise and examining the progress and present challenges of achieving the SDGs for children in India, our book provides a timely analysis and complements the existing reports. It goes beyond the aggregate indicators and explores the specific implications for children’s well-being, drawing attention to the gaps and areas requiring focused attention. The book provides potential interventions and strategies that can bridge the gaps and accelerate progress toward the targets, taking into account the unique socio-cultural and economic dynamics of the country.

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References Camfield, L., Streuli, N., & Woodhead, M. (2008). Children’s-well-being in contexts of povertyapproaches to research monitoring-and-participation. Government of India. (2019). SDG India Index and dash board 2019–20. NITI Aayog Government of India. Government of India. (2020–21). SDG India Index & dashboard 2020–21. Partnerships in the Decade of Action, NITI Aayog Government of India and United Nations. IFMR and World Vision. (2019). India child wellbeing report. IFMR and World Vision. Marguerit, D., Cohen, G., & Exton, C. (2018). Child well-being and the sustainable development goals: How far are OECD countries from reaching the targets for children and young people? OECD Statistics Working Papers, No. 2018/05. OECD Publishing. https://doi.org/10.1787/5e5 3b12f-en Milner, P., & Carolin, B. (Eds.). (1999). Time to listen to children: Personal and professional communication. Routledge. Morrow, V. (1998). Understanding families: Children’s perspectives. National Children’s Bureau. Punch, S. (2002). Research with children: The same or different from research with adults? Childhood, 9, 321–341. Richardson, D., Brukauf, Z., Toczydlowska, E., & Chzhen, Y. (2017). Comparing child-focused sustainable development goals (SDGs) in high-income countries: Indicator development and overview. Innocenti Working Paper 2017–08, UNICEF Office of Research, Florenc. Shreeranjan. (2019). Child development and nutrition: The Indian Experience Academic Foundation. UN. (2023). Secretary-general’s remark to launch the special edition of sustainable development goals progress report. https://www.un.org/sg/en/content/sg/statement/2023-04-25/secretarygenerals-remarks-launch-the-special-edition-of-the-sustainable-development-goals-progressreport-delivered UNCRC. (1989). Convention on the rights of the child. https://www.ohchr.org/sites/default/files/ Documents/ProfessionalInterest/crc.pdf UNICEF. (2007). Child poverty in perspective: An overview of child well-being in rich countries (Rep. No. 7). UNICEF. (2016). The state of the world’s children 2016: A fair chance for every child. United Nations Children’s Fund (UNICEF). UNICEF. (2018). Progress for every child in the SDG era. UNICEF.

Chapter 2

Child Poverty and Deprivation

2.1 Background Child poverty continues to be a pressing concern on a global scale, with developing countries including India facing significant challenges. According to estimates, nearly one-fourth of children under the age of 18 live on $1.9 per day, in contrast to 9.2% of adults aged 18 and above globally (Newhouse et al., 2016). Furthermore, COVID-19 greatly increased child poverty globally since 2020, a situation unprecedented in recent times. Children account for 41% of the world’s 83.9 million forcibly displaced persons, and a quarter of their childhood was spent in poverty, with uncertain futures (ILO & UNICEF, 2023). Moreover, the COVID-19 pandemic has exacerbated the situation, plunging an additional 100 million children worldwide into extreme poverty, as reported by UNICEF in 2020 (UNICEF, 2021a, 2021b). Some years back, India was home to approximately 30% of the world’s extreme child poverty cases (UNICEF & World Bank, 2016). In this context, this equates to approximately 30 million more children falling into extreme poverty due to the devastating impact of the COVID-19 outbreak. Further, every year, 1.4 million children in India don’t make it past their fifth birthday. At the same time, malnutrition continues to be a serious problem for more than one-third of children in the country. These children suffer from stunted growth and other health issues. Children living in rural areas, urban slums, scheduled castes, and tribal communities face multiple challenges. They often struggle with malnutrition, limited access to quality healthcare, lack of clean sanitation facilities, poor hygiene conditions, limited access to clean water, and the harmful practice of child marriage (UNICEF, 2023; World Bank, 2022). Children are usually at a greater risk of poverty than the adult population (Marguerit et al., 2018). In fact, children are still twice as likely as adults to experience poverty. More than 800 million children live on less than $3.20 per day globally, while 1.3 billion live on less than $5.50 per day. Additionally, over a billion children live in multidimensional poverty (ILO & UNICEF, 2023). As India is home to 358 million children in the age group 0–14 accounting for 18% of children in this

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_2

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age group, the issue of child poverty in the country holds significant importance in addressing this global problem. The consequences of child poverty are profound and far-reaching, impacting children in both immediate and longer-term. In the short-term, poverty exacerbates child rights violations, which could lead to child labor and child marriages. Children are often forced into laborious work at a young age, denying them the right to education and robbing them of their childhood. Additionally, poverty can expose children, particularly girls, to the risk of early marriages, eroding their rights, well-being, and prospects. Neglecting the untapped human potential can have adverse effects on community, society, and the economy. Hence, study of deprivations among underfive and adolescent children is of utmost value as it would highlight the nature and extent of vulnerabilities they face and the potential solutions to improve long-term prospects. The Sustainable Development Goals (SDGs), adopted by the United Nations in 2015, provide a comprehensive framework to address poverty in general. Within this context, addressing child poverty in particular is of utmost importance to achieve the broader goals of sustainable development. SDG-1.2 aims to reduce poverty rates among children, while SDG-1.3 aims to establish nationally appropriate social protection systems to safeguard the well-being of individuals. Additionally, SDG2 emphasizes adequate nutrition, SDG-3 underscores access to healthcare, SDG-4 highlights quality education, SDG-5 addresses violence against children and women, SDG-6 focuses on access to clean drinking water and sanitation, SDG-7 emphasizes access to electricity and safe cooking fuel, and SDG-16 highlights peace, justice, and strong institutions. All these goals are essential for comprehensively addressing child deprivation and poverty.

2.2 Different Approaches to Measure Child Poverty Approaches to measure child poverty include a child-centric approach, which considers indicators such as child mortality, malnutrition, basic needs, education, and protection from abuse (UNICEF, 2017). Interhousehold and intrahousehold measures provide valuable insights into resource distribution and well-being among households and within households, respectively (Cockburn et al., 2009; Main, 2019; Najman et al., 2018). Interhousehold measures compare poverty levels and resources across different households, revealing disparities in living standards and economic conditions. Intrahousehold measures examine resource allocation within a single household, recognizing its impact on children’s experiences of poverty. These measures identify inequalities within families, shedding light on gender dynamics, generational differences, and power imbalances influencing child well-being. Child deprivation encompasses various dimensions and can be assessed using three distinct methodologies: (a) the Bristol approach, (b) the Multidimensional Poverty Index (MPI), and (c) the Multidimensional Overlapping Deprivation

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Approach (MODA). The identification of a comprehensive set of indicators holds significance in capturing the multidimensional nature of child poverty. The Bristol approach focuses on fundamental human needs instead of the purely economic definition of poverty (Gordon et al., 2003). It evaluates child poverty based on seven basic requirements: access to clean water, sanitation, shelter, education, information, food, and health. By assessing whether households have access to these needs, the approach identifies those deprived of one or more as “deprived” and those lacking two or more as suffering from “absolute poverty.” The Bristol approach is significant because it provides a careful and scientifically reliable measurement of child deprivation (Gordon et al., 2003; Minujin & Nandy, 2012). The MODA, developed by the United Nations Children’s Emergency Fund (UNICEF), offers a multidimensional perspective on child poverty. It recognizes that children may experience multiple deprivations simultaneously, and these deprivations often intersect and reinforce one another. The MODA involves identifying various dimensions of child well-being, such as health, education, and standard of living, and determining the degree to which children are lacking in each dimension (Alkire & Foster, 2011; Chzhen & Ferrone, 2017; Dickerson & Popli, 2018; Dutta, 2021; Hjelm et al., 2016). MODA also includes the overlapping nature of deprivations by considering the cumulative impact of multiple deprivations on children’s lives. By analyzing multiple dimensions and their interactions, the MODA provides a comprehensive understanding of child poverty and guides targeted interventions that address the specific deprivations faced by children (de Neubourg et al., 2012a, 2012b; Dutta, 2021; Gordon et al., 2003; Roche, 2013). Nevertheless, only a limited number of studies have endeavored to analyze and draw attention to the issue of child deprivation from a multidimensional perspective (Chaurasia, 2010, 2016; Dutta, 2021). This chapter uses the multidimensional poverty index as well as MODA to analyze child poverty in India, as illustrated in Dutta (2021), for the period 2015–16 and 2019–21. Details of the methodology is given in Appendix. This chapter explores the issue of child poverty in India within the context of SDG-1. It delves into the multidimensional nature of child poverty, considering factors such as education, health, nutrition, housing quality, water, sanitation, information, indoor air quality, and child protection. By examining the current status of child poverty in India, we seek to identify key challenges, and policy interventions that could effectively address this pressing issue. We also highlight the efforts undertaken by government and civil society organizations to address child poverty, including policy initiatives, social protection programs, and grassroots interventions. The effectiveness and the impact of these interventions are analyzed to identify areas for further improvement.

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2.3 Dimensions of Deprivation Relating to Under-Five Children and Adolescents Nutrition Deprivation: Proper nutrition is essential for the healthy growth and development of children. Malnutrition can arise from various factors, including inadequate dietary diversity, feeding practices, morbidity, insufficient care, and disparities in the allocation of food baskets within the household. Assessing nutrition deprivation involves measuring indicators such as stunting, wasting, underweight, exclusive breastfeeding up to 6 months, and the dietary diversity during 6–23 months of a child. Failure to meet these criteria indicates deprivation in the nutrition dimension (Murarkar et al., 2020; Striessnig & Bora, 2020). In the case of adolescents (15–19 years), BMI is used to assess their nutritional deficiencies. Healthcare Deprivation: Access to healthcare services is important for the wellbeing of children under-five and adolescents. Healthcare deprivation occurs when children do not receive essential healthcare interventions. This includes indicators such as incomplete immunization against major diseases recommended by the World Health Organization (e.g., BCG, DPT, polio, measles), lack of skilled attendantassisted births, and inadequate postnatal care. Without proper healthcare, children are at risk of preventable diseases and face challenges in their overall development (Waters, 2021; Wendt et al., 2022). Education Deprivation: Education plays a fundamental role in the development of individual qualities and future prospects of children and adolescents. Education deprivation occurs when children are unable to access or continue their formal education. It includes indicators such as school enrolment, dropout, lack of school attendance and learning, availability of qualified teachers, and failure to complete primary education. Ensuring enrolment and providing continuous educational opportunities for children are crucial for their overall development (Denny et al., 2016). Information Deprivation: Access to information is vital for the holistic development of children and adolescents. Information deprivation occurs when children have limited exposure to various forms of media and are not adequately connected to the outside world. This deprivation can hinder their knowledge acquisition, awareness of societal developments, and understanding of important programs and opportunities (Jihyun, 2023). The indicator for information deprivation among children aged 15– 19 years is the infrequent usage of any form of media, while for children aged 0–5 years, it is derived from the level of information available to their mothers. Housing Deprivation: The living conditions of under-five and adolescents have a significant impact on their well-being. Inadequate housing quality can have severe health implications for children, including issues such as respiratory problems, developmental delays, and behavioral difficulties (Desmong & Kimbro, 2015; Gaitan, 2019; Green et al., 2021; Solari & Mare, 2012). Overcrowded living spaces and poor floor materials could contribute to increased stress, mental health issues, and a higher risk of accidents and injuries among both children and adults (D’Souza, 2019;

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Lim & Kim, 2020). To assess housing deprivation, the extent of overcrowding and the quality of floor materials have been considered. Sanitation Deprivation: Sanitation deprivation refers to the lack of access to improved toilet facilities, particularly in rural areas where open defecation is still not extinct. Access to improved sanitation facilities is essential to prevent the spread of diseases and maintain good hygiene practices among children (Fuller et al., 2014; UNICEF & WHO, 2018). Water Deprivation: Ensuring access to clean and sufficient water is crucial for the well-being of children under-five and adolescents. Lack of access to safe water sources not only affects their health but also places a burden on children who often assist in obtaining water for their families (Fonta et al., 2020; Geere et al., 2010; Milliaona & Plavgo, 2018). Both the quality and quantity of water are important factors to consider. Adequate water availability promotes hygienic behaviors such as handwashing, bathing, and maintaining cleanliness. Indoor Air Quality Deprivation: Indoor air quality can significantly impact the health and safety of children. Indoor air pollution, in particular, poses a threat to their well-being. Lack of access to clean cooking fuel and the absence of a separate kitchen room contribute to indoor air pollution, which can lead to respiratory issues and other health problems (Emmelin & Wall, 2007; Mathiarasan & Hüls, 2021). Children are considered deprived in terms of indoor air quality if their household lacks safe cooking fuel and dedicated kitchen space. Child Protection Gaps: Protecting the rights and safety of children is of utmost importance. Deprivation in child protection occurs when children face vulnerabilities or lack necessary safeguards. In this context, the absence of a birth certificate for children under-five signifies deprivation in establishing their legal identity (Bhatia et al., 2019). Additionally, early marriage poses a significant risk to adolescents, as it can lead to early pregnancies and adverse health consequences (UNICEF, 2021a, 2021b; Women Alliance, 2021). Furthermore, different forms of violence against children can reveal gaps in child protection (see Chap. 6 on violence).

2.4 Dimension-Specific Deprivations The analysis of child poverty data highlights both progresses and persistent challenges in various dimensions of deprivation among under-five children. We examine the period from 2015–16 to 2019–21. Among the eight domains studied, the greatest deprivation among children under-five in 2015–16 was observed in housing (76%), indoor air pollution (75%), and sanitation facilities (55%). However, in 2019–21, the highest deprivation for under-five children shifted to indoor air pollution (54.5%), followed by housing (51.3%), and access to information (52.2%). Notably, except for the information dimension, deprivation decreased in the other seven dimensions during the two time periods (Fig. 2.1).

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-24.9 51.3

Indoor air pollution

-20.7

Sanitation

-20.0

54.5

-10.0

Child Protection

-9.4

Drinking water

-8.7

35.3 25.21 10.9

20.3

23.2 14.5

-1.8

Nutrition

48.3 46.5 2.4

Information -40

-20

75.2

54.5

34.5

Health

76.2

0

Reduction

49.8 52.2 20

2015-16

40

60

80

100

2019-21

Fig. 2.1 Dimension-specific deprivation among under-five children (percent). Source Authors’ calculation based on NFHS (different rounds)

Significant improvements have been made in reducing deprivation in several dimensions. Housing witnessed the most significant improvement, with a 25% point reduction in deprivation. This is quite an encouraging trend, indicating efforts to address inadequate housing conditions and improve living standards for the children. Indoor air pollution has also shown substantial progress, with a 21% point decrease in deprivation. This suggests that measures have been taken at various levels to mitigate the harmful effects of indoor pollution on children’s health. Additionally, there was a noteworthy 20% point reduction in the deprivation related to sanitation, reflecting improvements in access to safe and hygienic sanitation facilities. However, challenges persist in the areas of nutrition, health, and access to clean drinking water. In 2019–21, over 47% of under-five children were still experiencing malnutrition, indicating the need for enhancing efforts to address nutritional deficiencies and promoting adequate food intake. One-fourth of children were deprived in terms of health, highlighting the importance of improving healthcare access and its quality. Similarly, 15% of children faced deprivation in the access to clean drinking water, which indicates the need for urgency to ensure safe and reliable water sources. It is worth noting that child protection dimension has demonstrated positive progress, as the lowest levels of deprivation was observed in this domain. In 2019–21, 11% of under-five children were deprived of child protection, a notable improvement from 20% in 2015–16. The initiatives aimed at safeguarding children’s rights and ensuring their safety and well-being must have worked thereby yielded positive outcomes. On the other hand, the proportion of deprivation in the access to information has slightly increased from 50% in 2015–16 to 52% in 2019–21. This highlights the importance of addressing barriers to information access, such as limited access

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80 60 40 20 0 -20 -40

2019-21

2015-16

Change

Fig. 2.2 Dimension-specific deprivation among adolescent children (percent). Source Authors’ calculation based on NFHS (different rounds)

to educational resources or lack of technology, to ensure that children have equal opportunities for learning and development. Overall, while progress has been made in reducing deprivation in several dimensions related to child poverty, the persistence of challenges in nutrition, health, clean drinking water, and access to information necessitates continued efforts and targeted interventions. By aligning with the SDGs, which include specific targets for child well-being and poverty eradication, policymakers and implementing agencies can prioritize these areas and work toward ensuring a better future for all children. When it comes to poverty among adolescents (aged 15–19 years), positive progress has been observed in reducing deprivation across all dimensions during this period. However, it becomes evident that certain dimensions have consistently exhibited high levels of deprivation (Fig. 2.2). Both in 2015–16 and 2019–21, deprivations were most pronounced in the domains of indoor air pollution, housing, and access to sanitation facilities. Between 2015–16 and 2019–21, each dimension experienced a decrease in deprivation. In particular, information and indoor air pollution saw a significant 20% point reduction in deprivation. This indicates that efforts to improve access to information and reduce exposure to harmful indoor pollution have yielded desired results. Additionally, deprivation related to drinking water and sanitation witnessed a notable 13% point reduction, indicating better access to clean water sources and sanitation facilities. However, despite these positive developments, challenges persist in specific areas. Housing remains a significant concern, with nearly half of adolescent children experiencing deprivation in this domain. Adequate housing is essential for ensuring a safe and conducive environment for adolescent development. Furthermore, 52% of adolescent children were found to have experienced deprivation in indoor air pollution. There is a need for strategies to address this issue, as exposure to pollutants has adverse health effects.

20

2 Child Poverty and Deprivation

Adolescent nutrition is another key area of concern. In 2019–21, more than onefourth of adolescent children were found to be nutritionally deficient, which is down from 35% in 2015–16. While progress has been made, the prevalence of nutrition deficiencies remains relatively high. To reduce it further continuous efforts are needed to improve access to nutritious food as well as address underlying factors contributing to malnutrition. Focus should also be given on the above-mentioned areas of concern to alleviate adolescent poverty. To address issues related to housing, indoor air pollution, and nutrition, targeted interventions can be implemented to improve the well-being and opportunities for adolescents. Additionally, concerted efforts are required to further reduce deprivation in dimensions such as access to information, drinking water, and sanitation. Such efforts need to empower the adolescents through necessary resources and support for their overall development.

2.4.1 Dimension-Specific Deprivation by Place of Residence The disparity in child deprivation between rural and urban areas among under-five children is evident across all domains. In 2019–21, rural areas experienced higher levels of deprivation compared to urban areas. The largest gap in deprivation was observed in the domain of indoor air pollution, with a difference of 50% points between rural and urban areas. This was followed by housing, with a deprivation gap of 39% points, and information, with a gap of 27% points. Moreover, the deprivation gap in the sanitation domain was 16% points higher in rural areas than in urban areas for the under-five children (Fig. 2.3). There have been improvements in narrowing the deprivation gap between rural and urban areas in some of the domains (Fig. 2.4). In 2019–21, the disparity between rural and urban areas in child safety, drinking water, nutrition, and health was substantially Nutrition

48

40

Information

58

31

Sanitation

22

Housing

21

Health

20

Indoor air pollution

38 59 29 65

15

Drinking water

15

12

Child protection

13

7 60

40

20 Rural

0

20

40

60

80

Urban

Fig. 2.3 Dimension-specific deprivation among under-five children by place of residence 2019–21 (percent). Source Authors’ calculation based on NFHS (different rounds)

2.4 Dimension-Specific Deprivations

21

60 50

49.6

50.7

40 30

27.7 27

25

20

18 12 10

10 0

5.3 3 Nutrition

-10

14

11.6

12

7.9 4.3

Health

Drinking water

Sanitation

Rural

Housing

-4 Indoor air Information Child pollution protection

Urban

Fig. 2.4 Changes in deprivation between 2015–16 and 2019–21 for under-five children. Source Authors’ calculation based on NFHS (different rounds)

reduced. This indicates progress in addressing disparity in these dimensions of child deprivation, resulting in more equitable conditions for children across rural and urban India. Between 2015–16 and 2019–21, rural areas experiences the greatest reduction in deprivation among under-five children in the sanitation dimension, with a 27% point decrease. This was followed by housing, with a 25% point reduction, and indoor air pollution, with an 18% point reduction. However, it is worth noting that the information dimension experienced a 4% point increase in deprivation in rural areas for under-five children. In comparison, urban areas demonstrated a significant reduction in deprivation, with a 50% point decrease in both indoor air pollution and housing dimensions. Additionally, sanitation and information deprivation among children under-five decreased by 28% point and 12% point, respectively, in urban regions. These findings highlight the persistent rural–urban divide in child deprivation, with rural areas generally experiencing higher levels of deprivation in several dimensions. Efforts should be made to implement targeted interventions to address the specific challenges faced by rural communities, particularly in domains such as indoor air pollution, housing, and information access. By addressing these disparities, policymakers can work toward creating more equitable living conditions for all children, regardless of their geographical location. There is a noticeable disparity in dimension-specific deprivation between adolescent children of rural and urban areas, similar to the patterns observed among underfive children (Fig. 2.5). In the majority of dimensions, there is a significant difference in deprivation levels between rural and urban locations. Specifically, for adolescent children, the deprivation gap is most pronounced in the domains of indoor air pollution and household conditions, with rural areas experiencing a disadvantage of 51% and 37% points, respectively, compared to urban areas.

22

2 Child Poverty and Deprivation

Child protection Information Indoor air pollution Housing Sanitation Drinking water Education Nutrition

3

7.8

8

23.7

14

64.5 57.9

21 20

33 11

14.4 6

9.1

21 40

29.1 20

0 Rural

20

40

60

80

Urban

Fig. 2.5 Dimension-specific deprivation among adolescent children by place of residence, 2019–21 (percent). Source Authors’ calculation based on NFHS (different rounds)

Although the difference in nutrition deficiency between rural and urban areas is relatively smaller, with only an 8% point gap, it is important to note that almost one-third of adolescent children in rural regions and more than one-fifth in urban areas are still found to be deprived in nutrition dimension. When considering education, approximately 9% of adolescent children in rural areas have faced deprivation, which is 3% points higher than those in urban areas. Similarly, access to drinking water presents a challenge with 14% of adolescent children in rural areas lacking access to it compared to 11% in urban areas. Additionally, approximately 8% of teenage children in rural areas have experienced disadvantages in the child protection dimension, a figure that is 5% points higher than that of the urban areas. When we examined the changes between 2015–16 and 2019–21, it became evident that urban areas witnessed greater reductions in deprivation in dimensions such as indoor air pollution, housing conditions, and access to information for adolescent children. On the other hand, rural areas have made greater progress in reducing deprivation in education, access to drinking water, and child protection (Fig. 2.6). These findings highlight some of the ongoing disparities between rural and urban areas in terms of dimension-specific deprivation among adolescent children, particularly for indicators such as indoor air pollution, housing conditions, and education. Efforts should be redirected toward implementing targeted interventions that address the specific challenges faced by adolescent children in rural areas, including improving living conditions, access to education, clean drinking water, and child protection measures. By bridging the rural–urban divide and promoting equal opportunities and resources for adolescent children across geographies, policymakers can work toward creating a more inclusive and equitable society in line with the SDGs.

2.4 Dimension-Specific Deprivations

23

60 54.5

50 40 30.4

30 20 10

16 11.6

9.5 9.8 Nutrition

Education

12.9

15.4 12.2

6.6

5.2 2.8

0

24.7 18.6

20.1 19.9

Drinking water

Sanitation

Rural

Housing

Indoor air Information Child pollution protection

Urban

Fig. 2.6 Reduction in deprivation by place of residence between 2015–16 and 2019–21 for adolescent children. Source Authors’ calculation based on NFHS (different rounds)

2.4.2 Dimension-Specific Deprivation by Wealth Class It is evident that the most deprived under-five children are from the poorest wealth class, both in 2015–16 and 2019–21. The dimensions of deprivation are information, housing conditions, and indoor air pollution. These dimensions consistently exhibited higher levels of deprivation for children in the poorest wealth class (Fig. 2.7). As of 2019–21, there is a noticeable disparity in the deprivation between the poorest and richest wealth classes across multiple dimensions. The largest gap in deprivation between these wealth classes is observed in the dimensions of information, housing conditions, indoor air pollution, and sanitation. These dimensions 100 90 80 70 60 50 40 30 20 10 0 Poorest

Richest

Poorest

2019-21

Richest 2015-16

Nutrition

Health

Drinking water

Sanitation

Housing

Indoor air pollution

Information

Child protection

Fig. 2.7 Dimension-specific deprivation among under-five children by wealth class (percent). Source Authors’ calculation based on NFHS (different rounds)

24

2 Child Poverty and Deprivation

highlight the significant differences in living conditions and access to resources between the poorest and richest segments of the population. On the other hand, the least deprivation gap between the poorest and richest wealth classes was noticed in the drinking water dimension. This suggests that access to clean drinking water is more equitable across different wealth classes. Furthermore, the available data highlights substantial deprivation gaps in health, nutrition, and child protection dimensions between the poorest and richest wealth classes. There is a 17% point gap in health deprivation, a 15% point gap for nutrition deprivation, and a 14% point gap for child protection. These findings underscore the challenges faced by the poorest wealth class in accessing adequate healthcare, proper nutrition, and basic child protection services for their children. Overall, the assessment underscores the need for targeted interventions and policies aimed at reducing deprivation in dimensions such as information, housing conditions, indoor air pollution, sanitation, health, and nutrition for under-five children belonging to the poorest wealth class. By addressing these disparities, policymakers can work toward promoting more equitable opportunities and improving the well-being of children across different economic backgrounds. We also find that indoor air pollution and housing conditions are two dimensions with highest levels of deprivation among adolescent children belonging to the poorest wealth class, both in 2015–16 and 2019–21. These two dimensions consistently emerged as areas of significant concern for adolescents in the poorest wealth class (Fig. 2.8). Between 2015–16 and 2019–21, the richest wealth class experienced the most substantial reduction in deprivation in the information dimension, which is assisted by digital policy push, with a reduction of 20% points. Additionally, there was a 14% point reduction in housing deprivation among the richest wealth class during 100 80 60 40 20 0 Poorest

Richest 2019-21

Poorest

Richest 2015-16

Nutrition

Education

Drinking water

Sanitation

Housing

Indoor air pollution

Information

Child protection

Fig. 2.8 Dimension-specific deprivation among adolescent children by wealth class (percent). Source Authors’ calculation based on NFHS (different rounds)

2.5 Multidimensional Deprivation Among Under-Five Children

25

this period. These findings suggest improvements in access to information and better housing conditions for adolescents in the wealthiest segment of the population. Conversely, the poorest wealth class exhibited the greatest reduction in deprivation in dimensions such as drinking water, child protection, and nutrition for adolescent children. Specifically, there was a 19% point reduction in drinking water deprivation, a 15% point in child protection, and a 12% point in nutrition among the poorest wealth class. These reductions highlight success in the efforts to improve access to clean drinking water, enhance child protection measures, and address nutrition deficiencies among adolescent children in the most disadvantaged socio-economic group. Overall, our findings emphasize the persistent challenges faced by adolescent children in the poorest wealth class involving indoor air pollution and housing conditions. It also underscores the importance of targeted interventions aimed at reducing deprivation in these dimensions for vulnerable adolescents. Furthermore, the improvements seen in the richest wealth class in terms of information access and housing conditions demonstrate the substantial change which need to be realized even in the poorest wealth class. Continued efforts to address deprivation in drinking water, child protection, and nutrition for the poorest wealth class will contribute to the overall well-being and development of adolescent children in the country.

2.5 Multidimensional Deprivation Among Under-Five Children We present an overview of the multidimensional poverty indicators for under-five children (Table 2.1). These indicators include the multidimensional headcount ratio, intensity of poverty, and the multidimensional poverty index (MPI) for the two periods. Table 2.1 Multidimensional headcount ratio for under-five children 2019–21

2015–16

HCR (%)

Intensity (%)

MPI

HCR (%)

Intensity (%)

MPI

Total

30.7

44

0.135

35

49

0.172

Rural

35.5

44

0.156

41.9

52

0.218

Urban

11.8

42

0.050

22.7

40

0.091

Poorest

53.5

45

0.241

64.6

51

0.329

Richest

8.9

39

0.035

13.6

44

0.060

SC

35.1

44

0.154

44.2

51

0.225

ST

41.5

45

0.187

49.5

53

0.262

OBC

28.8

43

0.124

35.7

45

0.161

Others

16.3

42

0.068

24.7

43

0.106

Source Authors’ calculation based on NFHS (different rounds)

26

2 Child Poverty and Deprivation

In 2015–16, the multidimensional headcount ratio stood at 35%. It decreased to 31% in 2019–21, indicating some progress in reducing multidimensional poverty in this age group. However, rural areas exhibited significantly higher multidimensional headcount ratios compared to urban areas. Rural areas had a headcount ratio that is 19% points higher than urban areas in 2015–16, and the difference increased further to 24% points in 2019–21. The disparities between the poorest and richest wealth classes were stark. In 2015–16, the headcount ratio for under-five children in the poorest wealth class was five times higher than that of the richest wealth class. This gap grew to six times in 2019–21, indicating the significant persistence of poverty among the most vulnerable populations. Additionally, children belonging to scheduled tribe communities experienced higher multidimensional poverty rates, followed by scheduled caste communities. In 2019–21, over 40% of scheduled tribe children and 35% of scheduled caste children were identified as multidimensionally poor. The intensity of poverty among under-five children decreased from 49% in 2015– 16 to 44% in 2019–21 at the national level. Rural areas consistently exhibited higher poverty intensities than urban areas. Similarly, the intensity of poverty was higher in the poorest wealth class in comparison to the richest wealth class. Children from scheduled tribe communities faced greater poverty intensity compared to other social groups. The MPI score, which considers multiple dimensions of poverty, decreased from 0.172 in 2015–16 to 0.135 in 2019–21 for the under-five children. The rural–urban disparity in MPI was notable, with rural areas having an MPI score of 0.218 in 2015–16, which decreased to 0.156 in 2019–21, whereas urban areas experienced a decline from 0.091 to 0.050 during the same period. However, in 2019–21, rural areas still had an MPI more than three times higher than the urban areas, indicating the persistence of rural poverty. The MPI disparity between the poorest and richest wealth classes also remained significant, with the poorest class witnessing an MPI score that is seven times higher than the richest wealth class in 2019–21, an upward rise from 5.5 times in 2015–16. Among various social groups, the MPI ranged from 0.187 in the scheduled tribe community to 0.068 in the other caste in 2019–21, compared to 0.262 in the scheduled tribe community to 0.106 in the other caste in 2015–16. The analysis highlights the continued prevalence of multidimensional poverty among under-five children, particularly in rural areas and among the vulnerable social groups. Efforts to reduce poverty should address the dimensions and disparities identified, and focus on improving access to basic services, housing conditions, nutrition, and child protection. Additionally, policies should aim to bridge the gap between rural and urban areas and promote equitable opportunities for all children, irrespective of their socio-economic background. Our analysis also reveals significant variation in the HCR among under-five children across different states in India (Fig. 2.9). In 2019–21, Bihar had the highest HCR at 54.4%, followed by Jharkhand at 48.3%, Meghalaya at 47.2%, Madhya Pradesh at 40%, and Uttar Pradesh at 37.2%. On the other hand, states like Goa, Kerala, Tamil

2.5 Multidimensional Deprivation Among Under-Five Children 60

27 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

50 40 30 20 10 Bihar Jharkhand Meghalaya Madhya Pradesh Uttar Pradesh Nagaland Odisha Chhattisgarh Tripura Assam West Bengal Rajasthan Gujarat Manipur Arunachal Pradesh Maharashtra Karnataka Telangana Andhra Pradesh Mizoram Jammu & Kashmir Haryana Uttarakhand Himachal Pradesh Punjab Sikkim Delhi Tamil Nadu Kerala Goa

0

2019-21

2015-16

Relative change

Fig. 2.9 Multidimensional headcount ratio by Indian states (percent). Source Authors’ calculation based on NFHS (different rounds)

Nadu, Delhi, and Sikkim experienced the lowest poverty rates among under-five children. Furthermore, when examining the reduction in child poverty, there is notable variation across regions. Bihar witnessed a marginal reduction of 1.1%, indicating very slow progress in poverty alleviation efforts. Similarly, Gujarat showed a modest reduction of 1.4%. In contrast, Meghalaya demonstrated a more significant reduction of 4.6%, while Jharkhand displayed a slightly higher reduction of 5.3% (Fig. 2.9). The standout performers in poverty reduction efforts were Tamil Nadu and Kerala, with Tamil Nadu experiencing an impressive reduction of 81% in child poverty among under-five children, followed closely by Kerala with an 80% reduction in the same. These states have shown remarkable progress in addressing child poverty. Additionally, Goa exhibited a substantial reduction of 78% (Fig. 2.9). We also measure the intensity of poverty among children under-five in various states of India, for the years 2019–21 and 2015–16, along with the corresponding change (Fig. 2.10). Intensity is a measure that reflects the severity of deprivation experienced by individuals living in poverty. In 2019–21, Bihar had the highest intensity of poverty among under-five children, with a value of 47%. This suggests a relatively higher severity of deprivation in this state. Meghalaya, Chhattisgarh, Jharkhand, Mizoram, Madhya Pradesh, and Odisha also exhibited relatively highintensity levels, ranging from 44 to 47%. When analyzing the change in intensity from 2015–16 to 2019–21, it is evident that most states witnessed a decrease in the severity of poverty. Bihar experienced a notable reduction in intensity, with a relative change of 11.3%. This indicates significant progress in reducing the severity of poverty among under-five children in the state. Other states that demonstrated substantial reductions in intensity include Telangana (9.1%), Goa (8.3%), Chhattisgarh (8.2%), Uttarakhand (7%), Jharkhand (4.3%), Mizoram (4.3%), Madhya Pradesh (4.3%), Odisha (4.3%), and Uttar Pradesh (6.4%).

28

2 Child Poverty and Deprivation

2019-21

Goa

Kerala

Tamil Nadu

Uttarakhand

Sikkim

Telangana

Delhi

Himachal Pradesh

Punjab

Manipur

Karnataka

Andhra Pradesh

Jammu & Kashmir

Nagaland

2015-16

West Bengal

Maharashtra

Tripura

Gujarat

Rajasthan

Assam

Haryana

Arunachal Pradesh

Odisha

0.0 Uttar Pradesh

2.0

0 Mizoram

4.0

10 Madhya Pradesh

6.0

20

Jharkhand

8.0

30

Chhattisgarh

10.0

40

Bihar

12.0

50

Meghalaya

60

Relative change

Fig. 2.10 Intensity of multidimensional poverty by Indian states (percent). Source Authors’ calculation based on NFHS (different rounds)

It is encouraging to see that several states have made strides in reducing the severity of poverty among under-five children. The reduction in intensity signifies an improvement in addressing the multidimensional aspects of poverty and a potential enhancement in the overall well-being of children. However, it is important to continue these efforts and ensure sustained progress to lift more children out of poverty. On the other hand, some states exhibited smaller reductions in intensity, indicating a relatively slower pace of progress. These states must focus on targeted interventions and policies to accelerate reduction in the severity of poverty among under-five children. The MPI score for under-five children in different states of India for the years 2019–21 and 2015–16, along with the relative change, is depicted in Maps 2.1 and 2.2 respectively. In 2019–21, Bihar had the highest MPI among under-five children, with a value of 0.26. This indicates a significant level of multidimensional poverty in the state. Other states such as Meghalaya, Jharkhand, Madhya Pradesh, Uttar Pradesh, and Chhattisgarh are also found to have relatively high MPI values ranging from 0.15 to 0.22. When examining the relative change in MPI between 2019–21 and 2015–16, it is evident that some states have made remarkable progress in reducing multidimensional poverty. Bihar exhibited a relative reduction of 12.3%, suggesting substantial improvements in addressing various dimensions of poverty among underfive children. Other states that showed significant relative reductions in MPI include Karnataka (41.1%), Andhra Pradesh (47.1%), Haryana (50.5%), Himachal Pradesh (20.4%), Punjab (32.3%), Sikkim (39.2%), and Tamil Nadu (81.6%). Our findings also indicate that states such as Odisha and Chhattisgarh, which were classified as high-poverty states in 2015–16, transitioned to the moderate category in 2019–21. On the other hand, Maharashtra, Karnataka, Haryana, and Andhra Pradesh have moved from the moderate category to the low-category states in terms of the prevalence of MPI. These findings highlight the efforts made by several states in addressing multidimensional poverty and improving the overall well-being of under-five children.

2.5 Multidimensional Deprivation Among Under-Five Children

29

Map 2.1 MPI among under-five children-2021. Source Authors’ calculation based on NFHS (different rounds)

The substantial reductions in MPI score indicate advancements in areas such as education, healthcare, housing, and standard of living, contributing to an enhanced quality of life for children. However, it is important to note that some states experienced relatively smaller reductions in MPI, indicating a slower pace of progress. These states should focus on targeted interventions and policy measures to accelerate the reduction in multidimensional poverty and address the specific needs and vulnerabilities of under-five children. The overall MPI reduction of 21.24% across all states reflects the collective efforts made to alleviate multidimensional poverty among under-five children in India. However, regional disparities persist, emphasizing the importance of targeted strategies through equitable resource allocation to ensure that comprehensive poverty reduction is achieved, regardless of geographical location.

30

2 Child Poverty and Deprivation

Map 2.2 MPI among under-five children-2016. Source Authors’ calculation based on NFHS (different rounds)

2.6 Multidimensional Deprivations Among Adolescent Children Multidimensional poverty among adolescent children was 25% in 2015–16, which declined to 13% in 2019–21 (Table 2.2). Such poverty is more prevalent among adolescent children in rural areas and the poorest wealth class. In 2019–21, rural poverty among adolescent was 3.7 times higher compared to the urban areas, which was 2.3 times in 2015–16. Similarly, poverty in the poorest wealth class was 9.6 times higher than in the richest wealth class, which was 4.2 times higher in 2015–16. These indicate an increasing disparity between rural and urban areas, as well as between the poorest and richest wealth classes. Multidimensional poverty varied across social groups, with rates ranging from 30.4% in the Scheduled Tribe community to 11.3% in the other caste in 2015–16, which reduced to 19.3% in the scheduled tribe community to 6.4% in the other caste in 2019–21. At the national level, the intensity of poverty among adolescent children was 44% in 2015–16, which has reduced to 41% in 2019–21. Furthermore, the intensity of poverty was below the national average in urban areas, the richest wealth class, the Other Backward Class (OBC), and other caste communities. In the poorest wealth

2.6 Multidimensional Deprivations Among Adolescent Children

31

Table 2.2 Multidimensional headcount ratio for adolescent children 2019–21

2015–16

HCR (%)

Intensity (%)

MPI

HCR (%)

Intensity (%)

MPI

Total

13.1

41

0.054

24.9

44

0.110

Rural

15.7

41

0.064

27.9

49

0.137

Urban

4.3

40

0.017

12.3

40

0.049

Poorest

25.1

41

0.103

36.7

51

0.187

Richest

2.6

38

0.010

8.8

40

0.035

SC

14.9

41

0.061

28.7

48

0.138

ST

19.3

42

0.081

30.4

49

0.149

OBC

12.3

40

0.049

27.4

43

0.118

6.4

39

0.025

11.3

40

0.045

Others

Source Authors’ calculation based on NFHS (different rounds)

class, the intensity of poverty was 51% in 2015–16, which has reduced to 41% in 2019–21. The MPI score for adolescent children was 0.110 in 2015–16, which decreased to 0.054 in 2019–21. Between 2015–16 and 2019–21, there was a reduction of 0.072 points in MPI in rural areas, compared to 0.032 points in urban areas. Although there was a 10% point reduction in the intensity of poverty in the poorest wealth class, the MPI score remained relatively high at 0.103 in 2019–21, compared to 0.010 in richest class. The reduction in MPI was highest among the Scheduled Caste community, followed by the OBC community. These findings demonstrate the progress made in reducing multidimensional poverty among adolescent children, but significant challenges still remain. Efforts should focus on addressing the higher poverty rates among adolescent children in rural areas and the poorest wealth class. Targeted interventions, such as improving access to education, healthcare, and basic services, are crucial to reduce poverty and inequality among the vulnerable population. Additionally, policies could aim to bridge the rural–urban divide and promote inclusive development across social groups. Similar to under-five children, the multidimensional headcount ratio among adolescent children ranged from 0.57% in Kerala to 23.5% in Bihar in 2019– 21 (Fig. 2.11). The states of Bihar, Jharkhand, Meghalaya, Madhya Pradesh, and Odisha had the highest proportion of poverty among adolescent children. Conversely, Kerala, Goa, Tamil Nadu, and Delhi had the lowest poverty rates. There have been significant relative reductions in adolescent poverty rates in several states. Notably, Himachal Pradesh, Punjab, Goa, and Kerala achieved remarkable reduction rates of 75.3%, 80.1%, 77.6%, and 83.7%, respectively. These states have made substantial progress in reducing poverty among adolescents. Other states, including Karnataka, Maharashtra, Mizoram, Uttarakhand, Arunachal Pradesh, Jammu & Kashmir, and Haryana, also demonstrated notable relative reductions ranging from 54 to 75%.

32

2 Child Poverty and Deprivation

50 45 40 35 30 25 20 15 10 5 0

2019-21 HCR

2019-21 Intensity

2015-16 HCR

2015-16 Intensity

Fig. 2.11 Multidimensional poverty headcount and intensity of poverty among adolescent children by Indian states. Source Authors’ calculation based on NFHS (different rounds)

Even the states with the highest levels of poverty experienced significant reductions, ranging from 34.5% in Odisha to 47% in Bihar. However, the northeastern states showed relatively lower poverty reduction compared to other states. Furthermore, in 2019–21, the intensity of poverty varied from 44.7% in Meghalaya to 32% in Gujarat. Among the states, 10 states had poverty intensity levels exceeding 40% during this period. However, in 2015–16, there were 25 states with poverty intensity rates exceeding 40%. Overall, in 2015–16, Bihar, Jharkhand, Madhya Pradesh, Uttar Pradesh, Chhattisgarh, Odisha, and Meghalaya were having the highest burden of multidimensional poverty, going by MPI score, among adolescent children (Map 2.4). In 2019–21, these states continued to experience high MPI albeit the order varied. Among the states, Kerala achieved the highest relative reduction in MPI, followed by Punjab, while Nagaland and Meghalaya had the lowest reductions (Map 2.3). However, there are a few states, namely Uttar Pradesh, Odisha, and Meghalaya, that have shifted from the moderate MPI to the high incidence category between 2015–16 and 2019–21. In contrast, Karnataka has transitioned from the moderate MPI in 2015–16 to the low incidence category states in 2019–21.

2.7 Multidimensional Overlapping Deprivation Analysis An examination of the overlap of deprivations is essential in comprehending the nature and extent of child deprivation. It could help us understand the various combinations of deprivations that children experience simultaneously. This approach can greatly contribute to policy intervention by effectively addressing the diverse needs of children. By studying deprivation overlap, we can determine whether specific

2.7 Multidimensional Overlapping Deprivation Analysis

33

Map 2.3 MPI among adolescent children-2021. Source Authors’ calculation based on NFHS (different rounds)

deprivations are unique or if certain dimensions of deprivation are interconnected with other forms of deprivations. Identifying whether specific deprivations are standalone concerns or interconnected with each other can pinpoint potential gaps in extant strategy and actions. Among the under-five children, only 6% faced nutrition deficiency as a standalone problem. Approximately 27% of nutrition-deficient children also experienced deprivation in one additional dimension, while more than one-third of nutrition-deficient children suffered from deprivation in two other dimensions (Figs. 2.12 and 2.13). Additionally, 32% of nutrition-deprived children faced overlapping deprivation in three to seven dimensions. Similarly, only 12% of children faced health deprivation on standalone basis, while 35% of health-deprived children also experienced deprivation in one more dimension. Another 36% of children suffered from deprivation in two other dimensions, followed by 17% children experiencing deprivation in three to seven dimensions. Likewise, in the adolescent age group, only 17% of children faced education deprivation as a standalone problem. One-fourth of education-deprived children also experienced deprivation in one more dimension along with the education dimension. Furthermore, 34% of education-deprived children suffered from deprivation in two other dimensions, and this is followed by 24% children who experienced deprivation in three to seven dimensions. Similarly, 11% of children solely experienced deprivation in the nutrition dimension, while nearly one-third of nutrition-deprived children also experienced deprivation in one more dimension, and another 35% experienced

34

2 Child Poverty and Deprivation

Map 2.4 MPI for adolescent children-2016. Source Authors’ calculation based on NFHS (different rounds) Child protection Health Information Indoor air pollution Housing Sanitation Drinking water Nutrition 0

20

40

60

80

Deprived only in Specified Dimension

Deprived in 1 other dimension

Deprived in 2 other dimensions

Deprived in 3 -7 other dimensions

100

Fig. 2.12 Multidimensional overlapping deprivations among under-five children (percent): 2019– 21. Source Authors’ calculation based on NFHS (different rounds)

2.8 SDG Targets and Achievements in Key Indicators of Child Wellbeing …

35

Child Protection Information Indoor air pollution Housing Sanitation Drinking water Education Nutrition 0

20

40

60

80

Deprived only in Specified Dimension

Deprived in 1 other dimension

Deprived in 2 other dimensions

Deprived in 3 -6 other dimensions

100

Fig. 2.13 Multidimensional overlapping deprivations among adolescent children (percent): 2019– 21. Source Authors’ calculation based on NFHS (different rounds)

deprivation in two more dimensions. The dimensions of drinking water, sanitation, housing, indoor air pollution, information, and child protection cannot be considered as standalone deprivation issues and need to be analyzed in the context of overlapping deprivation to understand their severity. The analysis of deprivation overlap provides critical insights into the interconnected nature of deprivations experienced by children. It underscores the importance of addressing multiple dimensions of deprivation simultaneously to ensure comprehensive and effective poverty reduction. By considering deprivation overlap, targeted strategies can be developed that would address the complex and interconnected needs of children, leading to more impactful and sustainable outcomes.

2.8 SDG Targets and Achievements in Key Indicators of Child Wellbeing and Poverty Our analysis of Indian states’ progress reveals several advancements and a few persistent challenges in achieving SDG-1 (No Poverty), SDG-6 (Drinking water and sanitation), and SDG-7 (Safe cooking fuel) targets in relation to under-five children and adolescents. SDG targets that have high relevance for child well-being and poverty eradication include the following: • SDG-1.2 Target: By 2030, reduce poverty level by half from the baseline. • SDG-6.1 Target: By 2030, achieve universal and equitable access to safe and affordable drinking water for all. • SDG-6.2 Target: By 2030, achieve access to adequate and equitable sanitation for all and end open defecation.

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• SDG-7.1.1 Target: By 2030 ensure universal access to electricity. • SDG-7.1.2 Target: By 2030 ensure universal access to affordable, reliable, and clean energy services. Additional aspects of SDG relevant for children and their well-being are provided in Chaps. 3, 4, 5, and 6, which contain discussion on SDG-2, SDG-3, SDG-4, and SDG-5 respectively. Chapter 7 provides a detailed analysis of the progress made by states and UTs in achieving the children-related goals and SDG targets by 2030. For children under the age of five, significant improvements have been made in reducing deprivation across a number of dimensions. Housing witnessed the most substantial improvement, with a 25% point reduction in deprivation between 2015– 16 and 2019–21, followed by indoor air pollution and sanitation with 21 and 20% point reductions, respectively. However, challenges persist in nutrition, health, and access to clean drinking water, sanitation facility, and safe cooking fuel. Over 47% of under-five children are deprived in nutrition dimension, highlighting the need for enhanced efforts. Similarly, a quarter of children are found to have deprivation in health, 15% lacked access to clean drinking water, and more than half of the children were deprived in terms of access to safe sanitation facility and cooking fuel. Regarding adolescent (aged 15–19), with reductions in deprivation, positive progress has been observed across all dimensions. However, deprivation remains high in dimensions such as indoor air pollution, housing conditions, and access to sanitation facilities. Nutrition deficiencies and housing conditions continue to be areas of concern for adolescents. Disparities between rural and urban areas are also evident across all dimensions for both under-five children and adolescents. Rural areas experience higher levels of deprivation, particularly in domains such as indoor air pollution, housing conditions, and access to information. Improvements have been made in reducing the rural–urban deprivation gap in some dimensions, such as child safety, drinking water, nutrition, and health. Undoubtedly, the poorest wealth class faces the highest levels of deprivation in various dimensions for both under-five children and adolescents. Dimensions such as information, housing conditions, indoor air pollution, and sanitation exhibit significant disparities between the poorest and richest wealth classes. Challenges in health and nutrition dimensions are more pronounced for the poorest wealth class. In 2015–16, the 35% of the under-five children were multidimensionally poor. However, by 2019–21, the HCR decreased to 30%, suggesting an improvement. The SDG 2030 target aims to further reduce the HCR to 17.5%, i.e., reduction by half from the baseline. This requires emphasis and commitment to alleviate under-five child poverty. While progress has been made, continued efforts are required to ensure the achievement of the SDG targets and improve the well-being of under-five children. Furthermore, HCR for adolescent children decreased from 24.9% in 2015–16 to 13.1% in 2019–21, indicating progress in reducing poverty among adolescents. This achievement is not very far from the SDG 2030 target of 12.5%, which can very well be achieved before 2030.

2.9 Conclusions and Way Forward

37

The poverty indicators for under-five children and adolescent in India demonstrate progress in reducing multidimensional poverty. However, rural areas continue to exhibit higher poverty rates compared to urban areas. Disparities between the poorest and richest wealth classes and among social groups persist. The intensity of poverty has decreased, but challenges remain, particularly with respect to children from scheduled tribe communities and a few states like Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Rajasthan, Meghalaya, among others. To fully achieve SDG-1 target of reducing poverty, it is crucial to address the multidimensional aspects of poverty in dimensions such as access to education, healthcare, nutrition, adequate housing, safe drinking water, and sanitation facility. By doing so, the overall well-being and development of children and adolescents can be improved, thereby contributing to ending poverty in all its forms.

2.9 Conclusions and Way Forward Our analysis of child poverty and deprivation among under-five and adolescent children reveals both progress and persistent challenges in various dimensions related to the SDGs. Compared to children aged 15–19, the age group of 0–5 have experienced higher levels of multidimensional deprivation due to various risk factors such as poverty, inadequate housing, lack of healthcare facilities, malnutrition, and insufficient child protection. Additionally, poverty is more intense among under-five children compared to adolescent, indicating a greater risk of experiencing deprivation across multiple dimensions simultaneously. One possible explanation for the higher levels of multidimensional poverty among the younger age group is that certain indicators included in the multidimensional poverty index (MPI) for 0–5 years specifically capture issues related to malnutrition and health deprivation, which are significant drivers of deprivation in this age group. It is worth noting that the available data from the Demographic and Health Survey (DHS) for children aged 15–19 is limited in terms of having similar information pertaining to multidimensional deprivation. In the context of child poverty, it is encouraging to observe significant reductions in deprivation in dimensions such as housing, indoor air pollution, and sanitation. These improvements indicate efforts that address inadequate living conditions and promote healthier environments for children. Additionally, positive progress has been observed in child protection, reflecting the success of initiatives aimed at safeguarding children’s rights and ensuring their safety. However, challenges persist in ensuring adequate nutrition, healthcare, and access to clean drinking water for children. The prevalence of malnutrition and health deprivation among under-five children highlights the need for enhanced efforts in these areas. Similarly, access to clean drinking water remains a concern, emphasizing the urgency to provide safe and reliable water sources. To address these challenges and to promote child well-being, initiatives could prioritize the provision of nutrition, health, and clean drinking water in policy

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agendas. Targeted interventions can be implemented to improve access to nutritious food, healthcare services, and safe water sources for children and households. These interventions should be aligned with the SDGs, which will have specific targets for poverty eradicating and improving child well-being. Way Forward The existence of higher multidimensional deprivation among under-five children compared to those aged 15–19 has important policy implications. To address these issues and ensure the well-being of young children, we emphasize the importance of the following measures: 1. Child-Centric Approach in National Programs: Policy measures could focus on addressing the specific risk factors contributing to multidimensional deprivation among under-five as well as teenage children. This includes interventions to alleviate poverty, improve housing conditions, expand access to healthcare facilities, increase coverage of basic immunization, combat malnutrition, provide ages-specific complementary feeding, and strengthen child protection mechanisms. 2. Early Childhood Development (ECD) Programs: Investing in comprehensive ECD programs is crucial. These programs could encompass health services, nutrition support, early childhood education, stimulation, cognitive development, and psychosocial support. By adopting a holistic approach to early childhood development, policies and programs can mitigate the drivers of deprivation and enhance children’s overall well-being. 3. Strengthening Data Collection: Efforts should be made to improve the availability and quality of data for children of all ages. This will enable a more comprehensive assessment of multidimensional deprivation among both younger and older children that can inform targeted policy interventions. In 2013, the Government of India conducted the Rapid Survey of Children (RSoC) across 29 states to strengthen the data system on children and women (Government of India, 2015). The United Nations Children’s Fund (UNICEF) provided technical and financial support for this survey. However, no follow-up survey has been conducted to monitor the indicators thereafter. 4. Monitoring and Evaluation: Monitoring child-specific indicators through regular surveys is crucial for understanding the progress made, identifying areas that require attention, and formulating evidence-based policies and interventions. Follow-up surveys would help capture changes, trends, and challenges faced by children, enabling governments and stakeholders to make informed decisions and allocate resources effectively. This will help identify gaps and ensure continuous improvement in addressing multidimensional deprivation among children of different age groups. 5. Multisectoral Convergence Approaches: It is essential to adopt a multisectoral convergence approach that brings together multiple sectors such as health, education, social welfare, and housing. Collaboration among different government

Appendix: Methodology

39

departments and agencies can ensure a coordinated effort in addressing the multidimensional needs of children and promoting their overall development. 6. Awareness and Capacity Building: To reduce social stigma and discrimination, increasing awareness among parents, caregivers, and communities is crucial about the importance of child well-being and the availability of support services irrespective of gender, caste, and place of residence. Additionally, capacitybuilding programs for healthcare providers, teachers, and social workers can enhance their ability to identify the root causes and address the multidimensional needs of children effectively. 7. Child-Sensitive Social Protection: Child-sensitive social protection systems, which include social transfers, social insurance, child care support, and teenage employability, must be structured to alleviate child poverty and deprivation, with a particular emphasis on those who are economically and socially vulnerable. Studies have shown that the Mid Day Meal scheme has led to an increase in primary school enrolment and improved the nutrition status of children (Afridi, 2007). Similarly, state-specific intervention such as Bihar’s Cycle Program has been found to significantly enhance class 9 completion rates among female students in rural areas, with an increase of 30% (Muralidharan & Prakash, 2013). By implementing measures in line with the above, policymakers could work toward reducing multidimensional deprivation among under-five children and adolescent, promoting their holistic development, and creating a supportive environment for their well-being and ultimately achieving the SDGs targets related to child wellbeing. It is essential to prioritize the most vulnerable populations, such as those in the poorest wealth classes and rural areas, to ensure equitable outcomes for all children.

Appendix: Methodology Multidimensional Poverty Index The multidimensional deprivation headcount (H) refers to the count of deprived children, which varies depending on the chosen cut-off point for deprivation as defined by Alkire and Foster (2011). A child, denoted as “i”, is considered deprived if the count of dimensions in which they experience deprivation (Di ) is equal to or exceeds the specified cut-off point, denoted as “K”. yk = 1 if Di ≥ K yk = 0 if Di < K . The calculation of the multidimensional child deprivation headcount ratio is as follows:

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2 Child Poverty and Deprivation

∑ qk , with qk = yk , n i=1 n

H= where

qk The number of children experiencing at least K deprivations; n The total count of children considered in the analysis; yk The deprivation status of a child “i” is determined based on the cut-off point “K”. If the number of dimensions in which the child is deprived (Di ) is equal to or greater than K, the child is considered deprived; otherwise, they are not classified as deprived; Di The number of deprivations experienced by each child “i”; K Deprivation threshold level. The intensity of poverty (A) or the breadth of deprivation represents the average weighted number of deprivations experienced by those who are considered multidimensionally poor. The Intensity of Poverty (A) =

∑qk

1 ck with ck = Di ∗ yk , qk × d

where d The total number of dimensions taken into account for each child; ck The count of deprivations experienced by each child “i” who is multidimensionally deprived. Adjusted Multidimensional Poverty Index (MPI) MPI = H × A Based on MPI score, states are categorized into three categories, i.e., high (red), moderate (green), and low (blue) using the equal range method. The equal range method involves dividing the range of MPI scores into equal intervals and assigning each interval a specific color category to represent in the Map. MODA MODA has been utilized as a comprehensive approach for the multidimensional assessment of child deprivation (de Milliano & Plavgo, 2014, 2018). In accordance with MODA, our analysis is centered on the child as the primary unit of examination, incorporating a life-cycle approach to recognize the diversity of children’s needs. This approach acknowledges that deprivations may vary based on the child’s age.

References

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Tropical Medicine and Hygiene, 91(1), 173–80. https://doi.org/10.4269/ajtmh.13-0503. Epub 27 May 2014. PMID: 24865679; PMCID: PMC4080558. Gaitan, V. (2019). How housing affects children’s outcomes. How Housing Matters. https://howhou singmatters.org/articles/housing-affects-childrens-outcomes/ Geere, J. A., Hunter, P. R., & Jagals, P. (2010). Domestic water carrying and its implications for health: A review and mixed methods pilot study in Limpopo Province, South Africa. Environmental Health, 9, 52. https://doi.org/10.1186/1476-069X-9-52. PMID: 20796292; PMCID: PMC2939590. Gordon, D., Nandy, S., Pantazis, C., Pemberton, S., & Townsend, P. (2003). Child poverty in the developing world. The Policy Press. Government of India. (2015). Rapid survey of children 2013–2014. India Fact Sheet. Ministry of Women and Child Development, New Delhi. Green, K. A., Bovell, A. A., & Sandel, M. (2021). Housing and neighborhoods as root causes of child poverty. Academic Paediatrics, 21(8), S194–S199. https://doi.org/10.1016/j.acap.2021. 08.018. ISSN: 1876-2859. Hjelm, L., Ferrone, L., Handa, S., & Chzhen, Y. (2016). Comparing approaches to the measurement of multidimensional child poverty. Innocenti Working Paper 2016–29, UNICEF Office of Research, Florence. ILO & UNICEF. (2023). More than a billion reasons: The urgent need to build universal social protection for children. Second ILO–UNICEF Joint Report on Social Protection for Children, Geneva and New York. Lim, S. H., & Kim, H. J. (2020). Housing experiences of families with children living in poor and overcrowded housing in Korea. Children and Youth Services Review, 118(2020), 105437. https://doi.org/10.1016/j.childyouth.2020.105437. ISSN: 0190-7409. Main, G. (2019). Child poverty and subjective well-being: The impact of children’s perceptions of fairness and involvement in intra-household sharing. Children and Youth Services Review, 97(2019), 49–58. https://doi.org/10.1016/j.childyouth.2017.06.031. ISSN: 0190-7409. Marguerit, D., Cohen, G., & Exton, C. (2018). Child well-being and the sustainable development goals: How, far are OECD countries from reaching the targets for children and young people? OECD Statistics Working Papers 2018/05-92. Mathiarasan, S., & Hüls, A. (2021). Impact of environmental injustice on children’s healthinteraction between air pollution and socioeconomic status. International Journal of Environmental Research Public Health, 18(2), 795. Minujin, A., & Nandy, S. (2012). Global child poverty and well-being: Measurement. Concepts, Policy and Action. https://doi.org/10.1332/policypress/9781847424822.003.0001 Muralidharan, K., & Prakash, N. (2013). Cycling to school: Increasing secondary school enrollment for girls in India. IZA Discussion Paper No. 7585, Forschungsinstitut zur Zukunft der Arbeit, Institute for the Study of Labor, Bonne. Murarkar, S., Gothankar, J., Doke, P., et al. (2020). Prevalence and determinants of undernutrition among under-five children residing in urban slums and rural area, Maharashtra, India: A community-based cross-sectional study. BMC Public Health, 20, 1559. https://doi.org/10.1186/ s12889-020-09642-0 Najman, J. M., Bor, W., Ahmadabadi, Z., Williams, G. M., Alati, R., Mamun, A. A., Scott, J. G., & Clavarino, A. M. (2018). The inter- and intra-generational transmission of family poverty and hardship (adversity): A prospective 30 year study. PLoS One, 13(1), e0190504. https://doi.org/ 10.1371/journal.pone.0190504. PMID: 29360828; PMCID: PMC5779648. Newhouse, D., Suarez-Becerra, P., & Evans, M. C. (2016). New estimates of extreme poverty for children. Policy Research Working Papers. https://doi.org/10.1596/1813-9450-7845 Oh, J. (2023). Prevalence and factors associated with multidimensional child deprivation: Findings from the future of families and child well-being study. Children and Youth Services Review, 148(2023), 106890. https://doi.org/10.1016/j.childyouth.2023.106890. ISSN: 0190-7409. Roche, J. M. (2013). Monitoring progress in child poverty reduction: Methodological insights and illustration to the case study of Bangladesh. OPHI Working Paper No. 57, University of Oxford.

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Chapter 3

Anthropometric Failure and Undernutrition Among Children

3.1 Different Approaches to Measure Child Undernutrition Nutrition has far-reaching effects on child development, and it is a crucial component of the SDG-2. The problem of undernutrition among infant, under-five children as well as adolescents is a critical concern. The number of underweight children under the age of five is one of the highest in India. Globally, a staggering 149.2 million children under-five suffered from stunted growth of which with 36.2 million (24%) of them were from India (UNICEF/WHO/World Bank Group, 2021). The high prevalence is concerning as undernutrition is responsible for almost 45% of all deaths among children under-five worldwide (Lopez et al., 2006; Bitew et al., 2021; Perin, 2022). Further, malnutrition in all its forms was found to be associated with 68% of child mortality in India (Lancet, 2019; Osendarp et al., 2020). The impact of undernutrition in infants and young children is profound, encompassing growth delays, heightened morbidity rates, elevated survival risks, compromised cognitive development, diminished academic performance, and reduced productivity in adulthood. These detrimental effects ultimately hamper a nation’s economic growth (UNICEF, 2019). Moreover, there exists considerable spatial variation in child undernutrition across different districts of India (Menon et al., 2018; Sing et al., 2019). The first 1000 days (from conception to age two years) of a child’s life, encompassing both the prenatal and postnatal periods, play a vital role in determining their physical and cognitive development (Schwarzenberg et al., 2018; Crookston et al., 2014). Therefore, the initial 1000 days are regarded as the critical period for intervention to mitigate the lifelong consequences induced by malnutrition (Rahman & Hossain, 2020). Undernutrition in the first two years is driven by lack of exclusive breastfeeding, complementary feeding as well as the optimal frequency of meal consumption. Further, breastfeeding within the first hour of birth is widely recognized as the most crucial intervention for infant survival. When combined with ageappropriate complementary feeding, exclusive breastfeeding can potentially reduce

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_3

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under-five mortality by 20% (UNICEF, 2019; Lamberti et al., 2011). Therefore, it is vital to exclusively breastfeed children during the first six months of their lives, followed by the gradual addition of complementary and diverse food items to meet their nutritional needs. Child undernutrition encompasses both undernutrition and overnutrition. It encompasses insufficiencies, excesses, or imbalances in the consumption of energy, protein, and other vital nutrients. Childhood malnutrition is shaped by diverse factors, as underscored in past studies by UNICEF (1990) and the Lancet nutrition series (Bhutta et al., 2013). These factors can be classified into three primary groups: immediate causes, underlying causes, and fundamental causes. Immediate causes of childhood malnutrition include inadequate diet and disease. Insufficient food intake and the presence of illnesses directly contribute to undernutrition among children (Bentley, 2015; Gibson, 2009). Underlying causes encompass broader set of factors that influence the immediate causes. These include household food insecurity, poverty, limited access to healthcare, and inadequate water, sanitation, and hygiene services (Siddiqui et al., 2020; Cuesta & Bank, 2007; HenryUnaeze & Ibe, 2013; Abuya et al., 2012; Roy et al., 2005; Harpham et al., 2005). These underlying factors create a challenging environment for children’s nutritional wellbeing. Fundamental causes refer to socio-economic and political factors that shape the underlying causes. Issues such as social inequality, gender imbalances, geographical location, and social groups can play a role in determining a child’s nutritional status (Singh et al., 2020; Ulahannan et al., 2022; Vart et al., 2015; Porter & Goyal, 2016). Several other factors also contribute to childhood malnutrition, such as agricultural practices, cultural beliefs, and governance policies. These factors complement the causes mentioned earlier and therefore need to be considered in formulating comprehensive strategies to combat childhood malnutrition (WHO, 2010; Barros et al., 2010; UNICEF, 2019; Dewary & Vitta, 2013; Bhutta et al., 2013). Addressing these causes is crucial for effective interventions to combat child undernutrition and improve child health outcomes. It is necessary to tackle immediate causes by providing adequate nutrition and healthcare access to children. Additionally, efforts should focus on addressing the underlying causes by alleviating poverty, enhancing access to healthcare and essential services, and improving food security. To tackle the fundamental causes, socio-economic and political factors need to be improved through measures that reduce poverty, promote social equality, and improve inclusive governance. Monitoring undernutrition plays a crucial role in improving child health status. Weight-for-age, height-for-age, and weight-for-height are key indicators used to assess undernutrition in children. Among these indicators, low height-for-age (stunting) reflects the long-term effects of undernutrition and infections, which can occur even before birth. Low weight-for-age (underweight) may indicate acute weight loss (wasting), stunting, or a combination of both. However, it is suggested that while these individual indicators provide valuable insights into specific biological processes, they alone cannot offer a comprehensive understanding of the overall burden of malnutrition among children in a population (Svedberg, 2000). To address this limitation, Svedberg (2000) proposed the construction of a Composite Index of Anthropometric Failure (CIAF) that incorporates all undernourishment indicators.

3.1 Different Approaches to Measure Child Undernutrition

47

The CIAF identifies six groups of children. It includes those with height and weight appropriate for their age (No Failure), as well as children whose height and weight fall below the norm, indicating various types of anthropometric failure (Table 3.1). The CIAF measures were utilized in the context of India to assess the burden of malnutrition based on NFHS-2 data (Nandy & Svedberg, 2014). Subsequent studies have also employed a composite index of anthropometric failure for Indian states based on NFHS-4 data and found an association between malnutrition and mortality (Khan & Das, 2020). Their research revealed that children experiencing anthropometric failure are at a higher risk of childhood morbidity and mortality. Different forms of anthropometric failure were utilized to identify districts with a high burden of anthropometric failure (Kochupurackal et al., 2021). In the case of adolescent undernutrition, it is crucial to understand the specific challenges faced by adolescents as their nutritional status can have intergenerational effects. Undernutrition can significantly impact the achievement of nutrition and health-related SDG targets. Adolescents (10–19 years) constitute one-fifth of India’s total population (UNICEF country page), and the health and nutritional status of adolescent girls are particularly vital as they influence fetal growth and newborn health. Adequate nutrition for adolescent girls is crucial as it contributes to a better quality of life and yields benefits across generations (Salam et al., 2016; Chaparro et al., 2014). Adolescence is a transitional phase characterized by physical, physiological, and psychological changes from puberty to adulthood. Ensuring the health and well-being of this population group is paramount in achieving the SDGs. Adolescents play a key role in breaking the cycle of intergenerational malnutrition. Two key indicators for measuring adolescent malnutrition are anemia and body mass index (BMI). Anemia in adolescence is caused by factors such as iron deficiency or micronutrient deficiencies, and it accounts for a significant proportion of disability-adjusted life years among adolescent girls (Deshmukh et al., 2008; Bellizzi et al., 2020; Akseer et al., 2017). Anemia is also associated with household and individual-level factors such as age, education, age at marriage, age at childbirth, number of children, and access to improved sanitation and drinking water facilities (Nguyen et al., 2018; Varghese & Table 3.1 Indicators of the composite index of anthropometric failure Stunting

Underweight

Wasting

No failure (A)

No

No

No

Wasting only (B)

No

No

Yes

Stunting only (C)

Yes

No

No

Underweight only (D)

No

Yes

No

Wasting and underweight (E)

No

Yes

Yes

Stunting and underweight (F)

Yes

Yes

No

Wasting, stunting and underweight (G)

Yes

Yes

Yes

Total CIAF = B + C + D + E + F + G Source Adapted from Svedberg (2000)

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3 Anthropometric Failure and Undernutrition Among Children

Stein, 2019; Scott et al., 2022; Chakrabarti et al., 2018). Previous studies have also shown a strong association between BMI and anemia (Kamruzzaman et al., 2021). To address child and adolescent undernutrition effectively, it is essential to utilize various measurement tools and adopt comprehensive approaches. Measuring child and adolescent undernutrition requires adopting a multidimensional approach and utilizing a range of indicators. Identifying the underlying causes of undernutrition and implementing appropriate interventions at both the individual and community levels are crucial for combating the problem and improving child and adolescent health outcomes. Adequate attention to the health and nutritional needs of adolescents is paramount, as they play a vital role in breaking the cycle of intergenerational malnutrition. By addressing undernutrition comprehensively, states can strive toward achieving the SDG-2 and promoting the well-being and development of children and adolescents.

3.2 Nutritional Status and Progression 3.2.1 Malnutrition Status Among Under-Five Children by Socio-Economic Gradient Box 3.1: Definition of Undernourishment Three anthropometric indicators of child undernutrition are Stunting (low height for age), Wasting (low weight for height), and Underweight (low weight for age). A child is considered undernourished if he/she is found to have abnormally low height for his/her age, or weight for height, or weight for age. It is measured by Z-score which is a standardized indicator. A child is undernourished if the Z-score is below − 2 and severely undernourished if the score is below − 3. We present the prevalence of malnutrition among under-five children in India from different survey rounds (Table 3.2). In 2005–06, almost half of under-five children were stunted. There has been a decline in stunting from 48% in 2005–06 to 38.4 in 2015–16, and to 35.5% in 2019–21. Despite this improvement, the estimates still remain high. Additionally, the estimates suggest that 15% of children under-five were severely stunted, albeit there was a decrease in the prevalence from 23.7% in 2005–06 to 15.1% in 2019–21. Stunting among children is influenced by various factors such as poverty, lack of access to drinking water and sanitation facility, inadequate maternal and child nutrition, frequent illnesses, adolescent pregnancy, and poor access to nutritious foods (UNICEF, 1990). Wasting, another form of malnutrition, affected approximately one-fifth of children in 2005–06. While there has been a decrease in wasting from 21 to 19.2%

3.2 Nutritional Status and Progression Table 3.2 Prevalence of malnutrition among under-five children in India (%)

49

NFHS-5

NFHS-4

NFHS-3

Stunted

35.5

38.4

48.0

Underweight

32.1

35.7

42.5

Wasted

19.2

21.0

19.8

Severely stunted

15.1

16.2

23.7

Severely Underweight

10.6

10.9

6.4

Severely wasted

7.7

7.4

6.1

Overweight

2.9

1.7

1.2

Source Authors’ calculation based on NFHS (different rounds)

between 2015–16 and 2019–21, the prevalence of severe wasting increased from 6% in 2005–06 to 7.7% in 2019–21. In 2005–06, around 42.5% of under-five children were underweight, which decreased to 35.7% in 2015–16 to 32.1% in 2019–21. However, the estimates suggest that prevalence of severely underweight children increased from 6.4% in 2005–06 to 10.6% in 2019–21. Further, the prevalence of overweight among under-five children has increased from 1.2% in 2005–06 to 2.9% in 2019–21. No significant gender gap was observed in terms of these malnutrition-related indicators. Inadequate access to sanitation, hygiene practices, and clean water has a profound impact on the nutritional status of children. Insufficient sanitation facilities contribute to a heightened risk of infections, particularly diarrhea, which is responsible for up to 50% of all cases of child malnutrition. Each episode of diarrhea results in the loss of essential nutrients from the body. Moreover, in regions where a significant portion of the population practices open defecation due to the lack of proper sanitation facilities, the risk of bacterial infections and childhood illnesses is found to be significantly high (Bhutta et al., 2013; UNICEF, 1990). Improving sanitation infrastructure, promoting hygiene practices, and ensuring access to clean water are critical interventions required to address child malnutrition and to reduce the burden of preventable infections. By addressing these fundamental factors, the nutritional status and overall health of children can be significantly improved. The prevalence of composite anthropometric failures among children is presented in Table 3.3. In 2019–21, 55.9% of children showed no anthropometric failure, indicating a 5.3 percentage point improvement over 2005–06. Stunting remains a significant issue, with 12.8% of children have experienced the anthropometric failure. Further, the percentage of only wasted children has registered an increase by 2 percentage points during the same period. The encouraging trend is that the percentage of children suffering from all three anthropometric indicators has reduced throughout from 7% in 2005–06 to 4% in 2091–21 (Table 3.3). Overall, the CIAF reduced marginally from 47.7 to 44.1% between 2015–16 and 2019–21, which is still over 40%. This suggests to the persistent challenges in reducing undernutrition among children.

50

3 Anthropometric Failure and Undernutrition Among Children

Table 3.3 Prevalence of anthropometric failure among under-five children in India (%)

NFHS-5 NFHS-4 NFHS-3 No failure

55.9

52.3

50.6

Stunted only

12.8

11.5

11.8

Wasted only

5.4

5.3

3.4

Underweight only

1.9

2.2

1.9

Stunted_underweight

13.2

15.8

19.8

Wasted_underweight

6.4

7.1

5.5

Stunted_wasted_underweight

4.4

5.7

7.0

CIAF

44.1

47.7

49.4

259,627

51,555

Total children (NFHS sample) 232,920

Source Authors’ calculation based on NFHS (different rounds)

Results of disaggregated analysis by place of residence, social groups, wealth quintiles, age groups are presented below. By Place of Residence: The prevalence of malnutrition is significantly higher in rural areas compared to urban areas. In 2019–21, rural areas exhibited approximately 7 percentage points higher rates of stunting, underweight, and composite anthropometric failure than urban areas. While stunting and underweight declined in both rural and urban areas between 2005–06 and 2019–21, the prevalence of wasting and severe wasting increased in rural areas by 2.7 and 1 percentage point, respectively. Similarly, in urban areas, severely wasted children increased by 2 percentage points to 7.6% in 2019–21. On the other end of the spectrum, the occurrence of overweight children even in rural areas tripled compared to 2005–06. The encouraging development has been the reduction in composite anthropometric failure by 6 percentage points in rural areas and 2.5 percentage points in urban areas (Fig. 3.1).

60.0 50.0 40.0 30.0 20.0 10.0 0.0 Rural

Urban

Rural

2019-21

Urban 2015-16

Rural

Urban 2005-06

stunted

underweight

wasted

severely stunted

severely underweight

severely wasted

over weight

composite failure

Fig. 3.1 Trends in malnutrition among under-five children by place of residence (%). Source Authors’ calculation based on NFHS (different rounds)

3.2 Nutritional Status and Progression

51

By Social groups: Malnutrition rates are found to be significantly higher among scheduled tribe children compared to other social groups. In 2019–21, the percentage of stunted and underweight children was 11 and 14 percentage points higher respectively among tribal children compared to those from general caste households. Also, the prevalence of multiple anthropometric failures was 12 percentage points higher among tribal children than in general caste households, i.e., 37.3% versus 49.4%. Despite the overall decline in stunting, wasting, and underweight among all social groups between 2005–06 and 2019–21, the percentage of severely wasted children increased for Scheduled Castes (SCs), Other Backward Classes (OBCs), and general castes, while overweight children increased across all social groups (Table 3.4). By Wealth Quintiles: Between 2005–06 and 2019–21, there was a decline in the percentage of stunted and underweight children across all wealth quintiles (Table 3.4). As expected, the occurrence of malnutrition decreased with increasing levels of Table 3.4 Trends in malnutrition among under-five children by social groups and wealth class (%) Social group SC NFHS-5 Stunted

ST

Wealth class

OBC General Poorest Poorest Middle Richer Richest

39.4 40.2 35.0

29.1

46.1

39.7

34.4

28.2

22.9

Underweight 35.0 39.4 31.5

25.5

43.1

35.7

30.3

25.4

20.0

Wasted

19.6 23.1 19.0

16.8

22.5

19.9

18.3

17.6

16.1

Severely Stunted

17.1 18.2 14.6

12.1

21.8

16.8

13.8

10.7

9.1

Severely 11.4 14.5 10.3 Underweight

8.1

15.4

11.7

9.6

7.5

6.6

Severely Wasted

7.0

8.6

7.9

7.3

7.1

7.0

Overweight Composite Failure NFHS-3 Stunted

7.7

9.2

7.5

2.7

2.8

2.7

3.8

2.3

2.5

3.0

3.3

4.1

47.5 49.4 43.6

37.3

53.6

48.4

43.1

38.1

31.4

53.9 54.2 48.8

40.4

59.9

54.4

48.8

40.8

25.6

Underweight 47.9 55.0 43.1

33.8

56.7

49.4

41.5

33.6

19.7

Wasted

21.0 27.8 20.0

16.4

25.1

22.1

18.9

16.5

12.7

Severely Stunted

27.8 29.5 24.7

17.8

34.4

28.1

23.2

16.5

8.3

Severely 18.4 25.4 15.8 Underweight

11.3

24.5

19.5

14.1

9.5

4.9

5.3

8.6

6.8

6.3

4.9

4.2

Severely Wasted Overweight Composite Failure

6.6

9.4

6.6

1.0

1.2

1.1

1.7

0.8

0.9

1.1

1.7

2.1

53.5 55.3 50.7

42.3

58.8

54.2

50.6

44.4

29.6

Source Authors’ calculation based on NFHS (different rounds)

52

3 Anthropometric Failure and Undernutrition Among Children

wealth, from the poorest to the richest households. However, nearly half of the children from the poorest households were stunted and underweight, which underscores the long-term implications for their growth and development. The high levels of malnutrition among children belonging to the poorest households are likely stem from intergenerational poverty and limited access to food sources. By Age Groups: Disaggregated analysis by age of the child reveals that the percentage of underweight children is relatively higher among those above 36 months, while the percentage of stunted children is higher among those aged 12 to 47 months. On the other hand, the percentage of wasted, severely wasted, and overweight children is higher among those below 12 months. Overall, composite anthropometric failure is more prevalent among children aged 12 to 35 months. Except for severely wasted and overweight children, malnutrition percentages have declined in all age groups between 2005–06 and 2019–21. Notably, the prevalence of overweight children has doubled in the age group of 0–11 months (Fig. 3.2). It is important to recognize that all three anthropometric measures of malnutrition (stunting, wasting, and underweight) share common underlying causes. Program interventions targeting these causes are likely to have an impact on all three conditions. Underweight may also reflect wasting and/or stunting, with wasting presenting a higher risk of mortality compared to stunting. Recurrent infections, low birth weight, inadequate food supplementation during the weaning period, diarrheal and respiratory tract morbidity are associated with wasting among children (World Health Organization, 2010; Derso et al., 2017). 60 50 40 30 20 10

NFHS-5 0-11 months

12-23 months

composite failure

over weight

severely wasted

severely underweight

severely stunted

wasted

underweight

stunted

composite failure

over weight

severely wasted

severely underweight

severely stunted

wasted

underweight

stunted

0

NFHS-3 24-35 months

36-47 months

48-59 months

Fig. 3.2 Trends in malnutrition among under-five children by age (%). Source Authors’ calculation based on NFHS (different rounds)

3.2 Nutritional Status and Progression

53

3.2.2 Anemia Among Under-Five Children Across Socio-Economic Gradient India continues to face a significant challenge in reducing anemia among children under-five. The prevalence of anemia in this age group is substantially high, with as many as 68% of children affected by it in 2019–21. Moreover, there has been a 9.4 percentage point increase in the prevalence of anemia between 2015–16 and 2019–21 (Fig. 3.3). Interestingly, there is no significant gender gap in the prevalence of anemia across different years. The disparity in anemia prevalence is more pronounced between rural and urban areas. Rural areas continue to face a more severe burden than urban areas, although there has been a slight improvement over the years. Between 2005–06 and 2019–21, anemia among under-five children in rural areas decreased by 2.3 percentage points. Conversely, urban areas witnessed an increase of 1.8 percentage points during the same period. In 2005–06, rural areas had an 8.5 percentage point higher prevalence of anemia compared to urban areas, which has reduced to 4.4 percentage points in 2019– 21 (Fig. 3.4). Efforts are needed to combat anemia and reduce its prevalence across the country for ensuring improved child health outcomes. Program interventions and strategies need to be designed and implemented by targeting affected groups and areas. The prevalence of anemia varies across age groups, with the highest rates observed among children below two years of age, and the lowest among those aged 48– 60 months. Infants and young children below two years are more susceptible to anemia compared to older children (Fig. 3.5). This can be attributed to factors such as the depletion of existing iron stores, increased iron requirements during rapid growth (6–23 months), and inadequate dietary intake of iron (Kotecha, 2011). Insufficient breastfeeding practices and a lack of iron-rich food supplements are commonly cited

Fig. 3.3 Anemia among under-five children in India (%). Source Authors’ calculation based on NFHS (different rounds)

54

3 Anthropometric Failure and Undernutrition Among Children

80 70 60 50 40 30 20 10 0 NFHS-5

NFHS-4 Rural

NFHS-3 Urban

Fig. 3.4 Prevalence of anemia among under-five by place of residence (%). Source Authors’ calculation based on NFHS (different rounds)

as the main causes of anemia in children. While breast milk contains low levels of iron, its consumption by infants helps prevent infections that could lead to anemia. Anemia prevalence across social groups suggests that under-five children belonging to Scheduled Tribes (ST) and Scheduled Castes (SC) were more likely to be affected by it (73.9% and 70.4% respectively). Between 2005–06 and 2019–21, there has been a decrease in anemia prevalence among all social groups, except for the general category where the percentage has gone up to 65.8% (Fig. 3.6). Furthermore, anemia prevalence is significantly higher in the two poorest wealth classes, and its prevalence decreases as wealth increases. A decline in anemia prevalence has been observed across all wealth classes, except for the richest, between 90 80 70 60 50 40 30 20 10 0 0-11 months

12-23 months NFHS-5

24-35 months NFHS-4

36-47 months

48-60 months

NFHS-3

Fig. 3.5 Anemia among under-five children by age (%). Source Authors’ calculation based on NFHS (different rounds)

3.2 Nutritional Status and Progression

55

80 60 40 20 0 SC

ST NFHS-5

OBC NFHS-4

General

NFHS-3

Fig. 3.6 Prevalence of anemia among under-five children by social groups (%). Source Authors’ calculation based on NFHS (different rounds)

2005–06 and 2019–21 (Fig. 3.7). However, compared to 2015–16, anemia prevalence has increased across all wealth classes. These findings highlight the need for large-scale targeted interventions to address anemia among specific age groups, social groups, and economic classes. Emphasis should be made to improve breastfeeding practices, ensure access to iron-rich food supplements, and implement interventions that address the underlying causes of anemia in different population subgroups.

80 70 60 50 40 30 20 10 0 Poorest

Poor

Middle NFHS-5

NFHS-4

Richer

Richest

NFHS-3

Fig. 3.7 Prevalence of anemia among under-five children by wealth class (%). Source Authors’ calculation based on NFHS (different rounds)

56

3 Anthropometric Failure and Undernutrition Among Children

3.2.3 State-Wise Status of Malnutrition and Anemia Among Under-Five Children The prevalence of stunting widely varied across states. In 2019–21, it ranges from 52% in Bihar to 24% in Sikkim. There are 18 states with more than 40% stunting prevalence rate with the highest prevalence in Bihar. Further, 23 states have stunting prevalence above all India average of 35.5%. Between 2005–06 and 2019–21, all the states have experienced reduction in stunting. However, from 2015–16 to 2019–21, nine states experienced an increase in stunted children. These states include Goa, Gujarat, Himachal Pradesh, Kerala, Maharashtra, Meghalaya, Nagaland, Tripura, and West Bengal (Table 3.5). Similar to stunting, in 2019–21, the prevalence of underweight children also varied from 12% in Mizoram to 41% in Bihar. There were 12 states with more that 30% prevalence of underweight with the highest prevalence in Bihar (41%) and the lowest prevalence in Chhattisgarh (31%). Except for Nagaland rest of the states have a reduction in underweight children between 2005–06 and 2019–21. On the other hand, 11 states have experienced an increase in underweight children between 2015–16 and 2019–21. The rate of increase was highest in Nagaland, Jammu & Kashmir, Kerala, and Himachal Pradesh (Table 3.5). The prevalence of wasted children varied from 9% in Chandigarh to 26% in Maharashtra in 2019–21. There are six states with more than one-fourth of underfive children suffering from wasting, that is, West Bengal, Assam. Jharkhand, Bihar, Gujarat, and Maharashtra. Between 2005–06 and 2019–21, 13 states have experienced an increase in wasted children among under-five children. Also, 10 states have experienced an increase in wasted children between 2015–16 and 2019–21 and the highest increase was experienced by Nagaland and Mizoram (Table 3.5). Despite majority of states experiencing a reduction in stunted children over the past 15 years, there was an increase in severely stunted children between 2015–16 and 2019–21 in 14 out of 29 states. Additionally, 16 out of 29 states witnessed an increase in severely underweight children during the same period. When it comes to overweight among under-five children, the 2019–21 figures are significantly higher than that of 2015–16 in the majority of the states. Himachal Pradesh, Kerala, Delhi, Tripura, Meghalaya, Andhra Pradesh, Madhya Pradesh, Arunachal Pradesh, and Assam observed the highest increases in this parameter. In 2005–06, the percentage of children experiencing multiple anthropometric failures ranged from 29.13% in Goa to 61.17% in Madhya Pradesh (Fig. 3.8). Seven states, namely Madhya Pradesh, Bihar, Chhattisgarh, Himachal Pradesh, Jammu & Kashmir, Gujarat, and Odisha, had more than 50% of children experiencing multiple anthropometric failures in 2005–06. In 2015–16, the range of anthropometric failure varied from 29% in Mizoram to 57% in Jharkhand, with more than half of the children still experiencing multiple anthropometric failures in seven states. The pattern of multiple failures in 2019–21, captured by CIAF scores at the state level, shows wide variation across states. Three states, namely Bihar, Gujarat, and Meghalaya, had more than half of their children experiencing multiple

2.2

3.0

1.9

1.8

3.1

2.3

0.1

2.0

3.5

1.5

2.0

1.6

1.5

0.4

2.4

1.9

Arunachal Pradesh

Assam

Bihar

Chhattisgarh

Delhi

Goa

Gujarat

Haryana

Himachal Pradesh

Jammu & Kashmir

Jharkhand

Karnataka

Kerala

Madhya Pradesh

Maharashtra

4.2 0.1

− 0.9

1.0

− 4.0

4.0

1.0

2.6

1.4

0.6

3.4

0.7

2.5

− 4.0

0.8

− 0.5 4.3

0.2

− 6.5

5.2

1.5

2.9

2.2

0.7

5.1

0.7

1.0

2.1

2.9

0.7

1.1

0.3

NFHS-3 to NFHS-5

Andhra Pradesh

Underweight

NFHS-3 to NFHS-5

NFHS-4 to NFHS-5

Stunted

− 0.1

6.4

− 4.8

− 3.2

4.4

0.0

7.5

− 0.1

6.8

− 0.6 0.0

6.2

− 3.1

1.6

4.7

− 11.6

3.8

− 5.8

− 5.8

14.1

1.4

3.3

7.9

4.9

− 3.3

6.9

− 0.7

2.8

3.4

0.5

− 15.3

8.2

− 2.6

− 0.7

1.7

2.3

3.5

0.8

3.6

− 2.1

− 2.2

2.6

0.4

− 2.7

− 4.8

6.9

− 5.9

2.0

4.8

− 14.8

− 14.5

7.7

− 4.1

− 5.5

1.6

3.2

2.3

− 9.4

− 1.3

− 0.8

− 2.3

− 5.6

Severely underweight

− 1.4

Severely stunted

NFHS-4 to NFHS-5

− 6.3

6.3

1.9

NFHS-4 to NFHS-5

− 4.3

7.6

− 0.2

− 0.4

5.6

4.5

1.2

− 3.4

− 2.5 1.7

1.0

− 1.9

NFHS-3 to NFHS-5

Wasting

5.6

2.1

NFHS-4 to NFHS-5

Table 3.5 Change in malnutrition indicators in Indian states (%)

− 3.6

8.5

2.9

5.0

5.2

− 14.7

− 14.2

16.7

− 2.2

5.5

(continued)

− 18.8

− 24.2

− 38.1

− 15.1

− 18.9

15.8

− 51.3

− 17.2

− 15.9

− 0.9

− 7.6 − 36.8

2.5

− 19.1

− 21.7

− 22.6

− 28.0

Overweight

− 0.8

− 6.1

− 10.0

3.9

− 7.1

Severely wasted

3.2 Nutritional Status and Progression 57

1.2

2.3

1.3

2.6

2.8

2.3

3.7

1.6

0.8

2.5

3.5

1.9

2.1

Meghalaya

Mizoram

Nagaland

Odisha

Punjab

Rajasthan

Sikkim

Tamil Nadu

Tripura

Uttar Pradesh

Uttarakhand

West Bengal

All India

3.3 − 0.4

− 0.8

− 3.5

2.0

1.2

− 0.9

1.9

4.9

5.5

1.2

3.0

− 7.7

3.8

2.2

3.0

2.7

2.7

2.0

6.7

5.1

1.3

2.3

4.3

− 1.5

2.4

3.6

5.1

2.6

− 0.6

5.9

5.1

− 1.7

2.0

1.8

6.8

6.0

3.6

− 12.4

− 1.1

2.0

0.8

NFHS-4 to NFHS-5

Source Authors’ calculation based on NFHS (different rounds) Note − ve sign means increase and + ve sign means decrease

2.9

NFHS-3 to NFHS-5

Manipur

Underweight

NFHS-3 to NFHS-5

NFHS-4 to NFHS-5

Stunted

Table 3.5 (continued)

0.2

− 1.4

0.9

0.6

2.3

2.2

− 0.3

9.2

0.9

− 2.0

7.1

1.1

− 2.3 2.8

7.5

9.6

1.4

3.0

0.6

− 13.9

− 13.1

5.3

− 9.4

NFHS-4 to NFHS-5

− 1.2

− 2.6

− 0.8

6.5

− 0.7

NFHS-3 to NFHS-5

Wasting

1.7

− 8.2

6.9

4.4

− 18.2

3.9

2.1

7.3

− 2.5

1.8

− 9.6

− 7.6

− 3.7

4.3

Severely stunted

0.7

− 3.9

2.6

2.5

− 13.8

1.2

− 16.5

6.3

7.1

2.5

− 16.9

− 3.6

− 2.1

− 8.6

Severely underweight

NFHS-4 to NFHS-5

− 19.5 − 14.3

− 3.0 − 1.0

− 3.1

− 18.1

− 4.6 14.7

− 29.3

3.0

3.6

− 12.0

− 13.0

− 8.0

− 2.0

− 4.4

− 27.1

− 6.2

Overweight

− 4.5

8.5

− 2.6

3.0

10.3

1.4

− 16.7

− 22.3

7.2

− 11.5

Severely wasted

58 3 Anthropometric Failure and Undernutrition Among Children

3.2 Nutritional Status and Progression

59

70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

2019-21

2015-16

2005-06

Fig. 3.8 Trends in anthropometric failure among under-five children (%). Source Authors’ calculation based on NFHS (different rounds)

anthropometric failures. Additionally, 13 other states, including Jharkhand, Assam, Maharashtra, West Bengal, Uttar Pradesh, Nagaland, Chhattisgarh, Tripura, Madhya Pradesh, Karnataka, Odisha, Himachal Pradesh, and Rajasthan, had over 40% of children with multiple anthropometric failures. Most states witnessed a reduction in multiple anthropometric failures between NFHS-3 and NFHS-5. However, eight states, namely Assam, Delhi, Goa, Jharkhand, Karnataka, Maharashtra, Meghalaya, and Nagaland, experienced an increase in anthropometric failures during NFHS-3 and NFHS-5 (2005–06 and 2019–21). Furthermore, 11 states, including Assam, Delhi, Gujarat, Himachal Pradesh, Jammu and Kashmir, Kerala, Maharashtra, Mizoram, Nagaland, Tripura and West Bengal, have seen an increase in multiple anthropometric failures between 2015–16 (NFHS-4) and 2019–21 (NFHS-5). The continued prevalence of anthropometric failure emphasizes the need for targeted interventions to reduce the burden of malnutrition in the identified states (Fig. 3.8). In 2019–21, Gujarat, Madhya Pradesh, Jammu and Kashmir, Punjab, Rajasthan, Haryana, and Bihar recorded the highest level of anemia among under-five children. An increase in anemia among under-five children, between 2015–16 and 2019–21, was observed by 27 states and UTs (Fig. 3.9). Significant Increase: Mizoram, Manipur, Nagaland, Assam, and Chhattisgarh have recorded a notable increase in anemia prevalence. Mizoram experienced the highest increase of 25.3% annually, followed by Assam (18%), Manipur (15.7%), Nagaland (12.7%), and Chhattisgarh (13%). Moderate Increase: Odisha, Gujarat, Maharashtra, Punjab, and Rajasthan have shown moderate increase in anemia prevalence. Odisha witnessed an annual increase of 10.0%, followed by Gujarat (6.7%), Maharashtra (6.7%), West Bengal (6.1%), Punjab (6.0%), and Rajasthan (4.3%). Minor Increase: Some states had a minor increase in anemia prevalence. For example, Bihar (2.6%), Delhi (3.8%), Telangana (3.7%), Kerala (2.3%), Karnataka

60

3 Anthropometric Failure and Undernutrition Among Children 5.0

90 80 70 60 50 40 30 20 10 0

0.0 -5.0 -10.0 -15.0 -20.0 -25.0 Gujarat Madhya Pradesh Jammu & Kashmir Punjab Rajasthan Haryana Bihar Assam Telangana Maharashtra Delhi Jharkhand West Bengal Chhattisgarh Uttar Pradesh Karnataka Odisha Tripura Andhra Pradesh Puducherry Uttarakhand Tamil Nadu Arunachal Pradesh Sikkim Himachal Pradesh Goa Mizoram Meghalaya Manipur Nagaland Kerala

-30.0

2019-21

2015-16

Annual rate of reduction

Fig. 3.9 Anemia among under-five children in India states (%). Source Authors’ calculation based on NFHS (different rounds). Note − ve sign (of secondary axis) means increase and + ve sign means decrease

(2.0%), Tamil Nadu (3.2%), and Andhra Pradesh (2.4%) experienced a relatively smaller increase. No Significant Change: Haryana, Jharkhand, Uttar Pradesh, Uttarakhand, Himachal Pradesh, Arunachal Pradesh, Sikkim, and Himachal Pradesh did not experience any significant change in anemia prevalence. These state-level findings highlight the diverse landscape of anemia prevalence in the country. Addressing the issue requires tailored approaches and targeted interventions to in the identified regions. Localized strategies focusing on nutritional interventions, healthcare access, and awareness programs can play a vital role in reducing anemia prevalence and improving the health outcomes of children across the states.

3.2.4 Anemia and BMI Among Adolescent Children in India and Across Socio-Economic Gradient Anemia, with multiple contributing factors, remains a leading cause of morbidity among adolescents (Kassebaum et al. 2014; Mokdad et al. 2016). In 2019–21, anemia prevalence was 60% among adolescent girls and 31% among boys aged 15–19 (Figs. 3.10 and 3.11). Anemia was prevalent in 56% of adolescent girls (15– 19 years of age) in 2005–06, which decreased to 55% in 2015–16, and increased again to 60% in 2019–21. On the other hand, prevalence of anemia among adolescent boys has increased from 29% in 2005–06 to 31% in 2019–21. Rural areas, ST and SC communities, and poorer wealth classes exhibit higher anemia prevalence among adolescents. Between 2015–16 and 2019–21, anemia among adolescent boys

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have increased in various demographic groups. In rural areas, the increase was 2.2 percentage points, while for boys belonging to the ST community the increase was eight percentage points. Boys from general castes experienced a five percentage point increase, and those from the poorest wealth class witnessed 1.1 percentage point increase. The middle wealth class had 3 percentage point increase, and the richer and richest wealth classes experienced an increases of 1 percentage point and 2 percentage points, respectively. Similarly, there has been an increase in anemia rates among adolescent girls, except in urban areas. Richest Richer Middle Poorest Poorest General OBC ST SC Urban Rural Total -20

-10

0

10

20

30

NFHS4-NFHS5

40

50

60

70

80

NFHS-5

Fig. 3.10 Adolescent girl’s anemia in 2019–21 and the gap between NFHS-4 and NFHS-5 (%). Source Authors’ calculation based on NFHS (different rounds) Richest Richer Middle Poorest Poorest General OBC ST SC Urban Rural Total -20

-10

0

10

NFHS-4 & NFHS-5

20

30

40

50

NFHS-5

Fig. 3.11 Adolescent boy’s anemia in 2019–21 and the gap between NFHS-4 and NFHS-5 (%). Source Authors’ calculation based on NFHS (different rounds)

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Table 3.6 Trends in BMI among adolescent children (15–19 years) (%) NFHS-5

NFHS-4

Adolescent boys

Adolescent girls

Adolescent boys

Adolescent girls

Total

40.3

39

44.8

41

Rural

35.8

39.8

47.7

42.4

Urban

42.3

37

39.2

37.3

SC

44.3

40.5

42.6

42.7

ST

39.6

40.9

43.4

41.4

OBC

41.3

39.9

46.7

42

General

36.7

35.7

41

37.4

Poorest

42.3

41

51.9

44.8

Poorest

44.1

40.8

49.3

43.2

Middle

43.6

39.3

45.6

41.8

Richer

38.2

37.5

43.2

38.9

Richest

30.6

34.1

33.9

33.8

Source Authors’ calculation based on NFHS (different rounds)

Similar to anemia, low BMI among adolescent children is a growing public health concern. BMI is an important indicator of nutritional status, and it provides insights into the overall health and well-being of the population. Between 2015–16 and 2019– 21, the prevalence of low BMI among adolescent boys declined by 4.5 percentage points (Table 3.6). However, it is important to note that while there was a decline of 11 percentage points in rural areas, urban areas witnessed an increase of 3 percentage points in low BMI prevalence among adolescent boys. Similarly, the prevalence of low BMI among adolescent girls decreased by 2 percentage points, with a higher rate of reduction observed among girls belonging to the poorest wealth class (4 percentage points). In 2019–21, the adolescent boys had a higher BMI than girls, except in rural areas, Scheduled Tribes (ST) communities, and the richest wealth class.

3.2.5 Status of Anemia and BMI Among Adolescent Children Across Indian States A state-level analysis of adolescent anemia and BMI reveals significant patterns (Table 3.7). In 2015–16, states like Manipur, Goa, Kerala, and Mizoram had the lowest prevalence of anemia among adolescent boys. Conversely, Jharkhand, Bihar, Gujarat, Madhya Pradesh, West Bengal, Punjab, Odisha, Jammu and Kashmir, Himachal Pradesh, Andhra Pradesh, and Delhi had more than one-third of adolescent boys suffering from anemia. In 2019–21, Manipur had a prevalence of anemia among adolescent boys below 8 percentage points, while Jammu and Kashmir, Assam, and Jharkhand experienced prevalence rates above 40%. Out of the 32 states and UTs

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63

analyzed, an increase in anemia among adolescent boys was observed in 19 of them between 2015–16 and 2019–21. Kerala, Assam, Jammu and Kashmir, and Mizoram experienced the highest increase, while Delhi witnessed 10.6% reduction in anemia prevalence among adolescent boys. In 2015–16, more than 60% of adolescent girls suffered from anemia in Bihar, West Bengal, Andhra Pradesh, Haryana, and Jharkhand. By 2019–21, the number of states with over 60% prevalence of anemia among adolescent girls increased to 14, which include Andhra Pradesh, Punjab, Haryana, Telangana, Bihar, Odisha, Jharkhand, Assam, Tripura, Gujarat, West Bengal, and Jammu and Kashmir. Out of the 32 states and UTs analyzed, 23 of them recorded an increase in anemia prevalence among adolescent girls in 2019–21 compared to 2015–16. The state-level comparison of BMI among adolescent boys in 2019–21 shows that Goa (51%), Karnataka (47%) Madhya Pradesh (?), and Telangana (47%) showed the highest proportion of adolescent boys with low BMI. On the other extreme, the states with the lowest proportion of adolescent boys having low BMI were Arunachal Pradesh (14%) Jammu and Kashmir (16%) and Mizoram (19%). In the case of adolescent girls, the prevalence low BMI varied from 12% in Mizoram to 52% in Gujarat in 2019–21. Between 2015–16 and 2019–21, out of 32 states and UTs analyzed, 11 have experienced an increase in low BMI among adolescent boys as well as girls. The magnitude of the average annual rate of increase in low BMI among adolescent boys varied from 56.7% in Sikkim followed by 14.7% in Goa. On the other hand, the rate of increase in low BMI among girls was highest in Nagaland (10.7%). Overall, these findings highlight the need for targeted interventions to address the prevalence of low BMI and high incidence of anemia among adolescent children in India. Strategies need to be tailor-made to address the specific challenges faced by different regions and population groups, focusing on improving nutrition and health outcomes among adolescents.

3.3 Nutrition Status and SDG-2 SDG-2 aims to achieve zero hunger, improve nutrition, promote sustainable agriculture, and ensure food security for all. India has made significant efforts to address malnutrition and improve food security. However, some of the challenges persist, particularly at the state level, where disparities in nutritional outcomes are evident. Analyzing key indicators can provide insights into India’s progress in achieving SDG-2 and help identify areas that require targeted interventions (Table 3.8). Detailed discussion about nutrition achievement can be found in Chapter 7. Stunting Target: By 2030, prevalence of stunting among children under-five should be reduced below 21%. In terms of stunting, India has made significant progress in reducing the proportion of children under-five who are affected by chronic malnutrition. The decline in stunting rates from 48% in 2005–06, to 38.4% in 2015–16, to

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Table 3.7 Annual rate of Reduction in Anemia and BMI among adolescent boys and girls between 2015–16 and 2019–21 (%) Adolescent boy (Anemia) Andhra Pradesh Arunachal Pradesh Assam

Adolescent girl (Anemia)

Adolescent boy (BMI)

Adolescent girl (BMI)

11.6

0.8

− 0.2

− 0.3

− 4.4

0.0

1.1

4.3

− 16.1

− 11.9

4.5

4.3

2.0

− 1.8

2.5

1.2

− 4.1

− 7.8

4.7

− 0.4

Delhi

10.6

2.0

4.4

6.6

Goa

− 4.9

− 10.3

− 14.7

− 1.7

1.0

− 5.1

2.9

− 1.5

− 1.1

0.3

− 5.6

− 2.8

Himachal Pradesh

8.0

− 0.1

6.3

1.6

Jammu & Kashmir

− 14.8

− 11.0

12.2

9.2

Jharkhand

− 0.9

− 0.3

2.9

0.2

Bihar Chhattisgarh

Gujarat Haryana

− 1.0

− 2.3

− 2.3

0.6

− 17.1

3.5

− 7.2

− 3.4

23.8

15.1

1.3

5.3

4.8

− 2.4

4.2

0.8

− 0.6

− 3.5

4.3

− 2.1

5.9

− 7.6

− 3.5

0.3

− 1.3

− 0.1

0.4

− 7.8

Mizoram

− 11.6

− 13.9

− 5.5

2.7

Nagaland

− 2.6

− 6.5

4.3

− 10.7

0.9

− 6.5

5.6

2.1

Puducherry

− 2.1

− 1.3

0.0

9.8

Punjab

− 0.7

− 0.9

− 2.1

− 1.6

Rajasthan

− 7.5

− 5.0

6.2

2.7

Sikkim

6.4

− 0.2

− 56.7

2.0

Tamil Nadu

2.4

0.7

1.9

2.8

Telangana

− 8.1

− 2.0

4.0

2.2

Tripura

− 3.2

− 6.7

− 5.3

− 4.5

0.1

0.4

3.8

2.6

Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya

Odisha

Uttar Pradesh

(continued)

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Table 3.7 (continued) Adolescent boy (Anemia)

Adolescent girl (Anemia)

Uttarakhand

− 3.6

3.1

West Bengal

− 3.9

− 3.4

Adolescent boy (BMI)

Adolescent girl (BMI)

− 0.1

1.3

5.4

4.0

Source Authors’ calculation based on NFHS (different rounds) Note − ve sign means increase and + ve sign means decrease

Table 3.8 Present status and SDG-2 target 2030 (child-specific indicators) Target 2030

NFHS-5

NFHS-4

Stunted among under-five children

21

35.5

38.4

Wasted among under-five children

5

19.2

21.0

Overweight among under-five children

5

2.9

1.7

Anemia among adolescents and women

Halved (27.7)

59.6

55.4

Source Authors’ compilation from NFHS, NITI Aayog and UN

35.5% in 2019–21 is a notable improvement. This indicates that efforts to improve child nutrition and overall well-being have yielded results. However, the current prevalence is still higher than the targeted level of 21% required to achieve SDG-2. The present annual rate of reduction of stunting is 2.2%, which leaves the required rate of reduction at 4.7% to achieve the target by 2030. This calls for sustained efforts to address the underlying causes of stunting, such as inadequate dietary intake, poor sanitation and hygiene practices, and limited access to healthcare and nutrition services. Disparities among states are a major concern, with certain states reporting higher prevalence of stunting. Bihar, Uttar Pradesh, and Madhya Pradesh continue to face significant challenges, requiring focused interventions to address chronic malnutrition effectively. Successful models implemented in states like Kerala and Tamil Nadu could be customized and replicated to improve outcomes in poor performing states. Wasting Target: By 2030, achieve a significant reduction in wasting among children under-five and it should be reduced below 5%. Wasting, which reflects acute malnutrition, has shown improvement but there remains a concern. The wasting rates of 19.8% in 2005–06, which increased to 21% in 2015–16, reduced to 19.2% in 2019–21 demonstrates some progress, but it is not sufficient to meet the SDG-2 target of brining it down to less than 5%. At present, annual rate of reduction of wasting is 1.8% which is far less than the required rate of 13.9%. Immediate measures are needed to prevent and treat wasting, including improved access to nutritious food, timely healthcare interventions, and effective management of acute malnutrition cases. Wasting remains a concern, particularly in states like Jharkhand, Bihar, and Uttar Pradesh, where interventions should be prioritized. The Integrated Child Development Services (ICDS) and the National

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Nutrition Mission (POSHAN Abhiyaan) should be strengthened to provide better nutrition and healthcare services, especially in vulnerable areas. Underweight Target: By 2030, achieve a significant reduction in underweight among children under-five. The prevalence of underweight in India decreased from 35.7% (NFHS-4) to 32.7% (NFHS-5) between the two survey periods, indicating progress in reducing underweight children. However, the decline of three percentage points falls short of the targeted reduction. At the state level, while some states have achieved notable improvements, others continue to struggle. States like Madhya Pradesh, Jharkhand, and Bihar require focused attention and targeted interventions to address the persistent challenge of underweight among children. Access to nutritious food, healthcare, and sanitation should be improved in these states to tackle the underlying causes effectively. Overweight Target: Target: By 2030, the prevalence of overweight among children under-five should be reduced below 5%. The prevalence of overweight children has risen from 1% in 2005–06 to, 1.7% in 2015–16, 2.9% in 2019–21. The trend of increasing overweight prevalence in this age group is another concern. Overweight cases are the other extreme of the nutrition indicator which is not desirable either. Overweight prevalence was found to have increased the most in states such as Himachal Pradesh, Kerala, Goa, Meghalaya, Andhra Pradesh, and Madhya Pradesh. These states should implement interventions and strategies to combat childhood overweight. Anemia Target: By 2030, the prevalence of anemia among under-five children should be reduced significantly. The prevalence of anemia among children under-five in India remains high with 68% of them affected by it in 2019–21. Additionally, there has been an increase of 9.4 percentage points between 2015–16 and 2019–21. The findings indicate that the progress in reducing anemia has been limited and that the current interventions may not be sufficient to meet the SDG-2 target. Targeted interventions are needed to address anemia, such as iron and folic acid supplementation, dietary diversification, and improved access to clean water and sanitation facilities. Efforts should focus on raising awareness among caregivers, strengthening health systems, and implementing comprehensive anemia prevention and control programs. While there has been a slight improvement in rural areas, with a 2.3 percentage point decrease in anemia prevalence between 2005–06 and 2019–21, urban areas witnessed an increase of 1.8 percentage points during the same period. This disparity highlights the need for targeted interventions in rural areas where the burden of anemia is more severe. Efforts should be made to bridge the gap between rural and urban areas to ensure equitable progress across the country. The state-level findings reveal a diverse landscape of anemia prevalence. States like Rajasthan, Bihar, and Uttar Pradesh reported high prevalence, indicating the need for targeted interventions in these regions. Efforts should be made to identify and

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replicate successful interventions from states that have achieved significant reductions. It is crucial to address the rural–urban disparity, focus on the most vulnerable age groups, and target interventions toward marginalized social groups. Furthermore, a comprehensive and coordinated approach at the national and state levels is necessary to combat anemia effectively and ensure improved child health outcomes. Adolescent Anemia Target: By 2030, halve anemia among adolescent girls. Many adolescent girls in India are suffering from anemia, with 60% being affected during 2019–21. There has been an increase of 4.2 percentage points between 2015– 16 and 2019–21. It reveals that efforts to reduce anemia among these girls have not been successful, and current interventions may not be enough to meet the SDG-2 target. Moreover, out of the 32 states and UTs studied, 23 witnessed an increase in anemia prevalence among adolescent girls in 2019–21 compared to 2015–16, which is a significant roadblock in achieving SDG-2 by 2030. BMI Target: By 2030, ensure a significant reduction in low BMI prevalence among adolescents. The prevalence of low BMI among adolescent boys and girls in India varies between rural and urban areas, wealth classes, and states. The analysis of BMI trends among adolescents reveals a mixed picture. While there have been reductions in some segments, disparities exist in low BMI prevalence among different groups and states. Urban areas have shown an increase in low BMI among adolescent boys, highlighting the challenges of urbanization and lifestyle changes. States like Goa, and Karnataka, reported high proportions of adolescent boys with low BMI, indicating the need for targeted interventions in these regions. Furthermore, the prevalence of low BMI among adolescent girls is higher in certain states, such as Gujarat, suggesting the need for tailored strategies. State-specific programs should address these variations and focus on improving the overall nutritional status of adolescents. In conclusion, while India has made progress in several SDG-2 indicators, including stunting, wasting, underweight, anemia, and adolescent BMI, the pace of change needs to be accelerated. Bridging the gaps requires targeted interventions, state-specific strategies, and a multisectoral approach. By addressing the underlying causes of malnutrition, improving access to nutritious food, healthcare services, education, and promoting awareness, India can move closer to achieving the SDG-2 targets and ensure a healthier and food-secure future for her children.

3.4 Nutrition Policy in India 3.4.1 Nutrition Policy Related to Under-Five and Adolescent India faces significant challenges in several policies exist to address the challenge of malnutrition among children under the age of five and adolescents. Malnutrition not only affects the physical and cognitive development of individuals but also

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hampers the overall socio-economic progress of the nation. To combat this issue, the Government of India has implemented various policies and initiatives focusing on nutrition for these vulnerable age groups. Some of the key nutrition programs related to under-five and adolescent malnutrition are discussed below. 1. Integrated Child Development Services (ICDS): The ICDS is a flagship program aimed at providing holistic care and support to children under six years of age and pregnant women. It includes supplementary nutrition, immunization, health check-ups, referral services, and early childhood education. The program seeks to address undernutrition, promote optimal growth, and prevent micronutrient deficiencies. 2. Mid-Day Meal Scheme: The Mid-Day Meal Scheme provides cooked meals in primary and upper primary schools to enhance enrollment, retention, and attendance, while also addressing the issue of malnutrition. The meals aim to provide a balanced diet, including proteins, carbohydrates, and essential micronutrients, to school-going children. 3. Food Fortification: The Food Safety and Standards Authority of India (FSSAI) has initiated efforts to fortify staple foods like rice, wheat, oil, and salt with essential micronutrients. This approach helps to improve the nutrient content of commonly consumed foods and bridge the nutrient gap, especially for vulnerable populations. 4. National Iron + Initiative: This initiative focuses on preventing and controlling iron deficiency and anemia among children, adolescents, and women. It includes the provision of iron and folic acid supplementation, promotion of iron-rich diets, and behavior change communication to increase awareness about anemia and its prevention. 5. Adolescent Nutrition: Recognizing the unique nutritional needs of adolescents, the government has implemented programs like the WIFS program to address deficiencies, promote good nutrition, and improve the overall health and wellbeing of adolescents. 6. National Health Mission (NHM): The NHM aims to provide accessible, affordable, and quality healthcare to underprivileged populations, including children and adolescents. It integrates nutrition interventions into maternal and child health services, promotes breastfeeding, provides counseling on infant and young child-feeding practices, and offers support for early detection and management of malnutrition. 7. National Nutrition Mission (Poshan Abhiyaan): Multisectoral Nutrition Program, renamed as POSHAN Abhiyaan was initiated by the Government of India in 2018, followed by an integrated nutrition strategy through POSHAN 2.0 in 2022 to provide a platform at all levels (macro, meso, micro, national/ state, district, block) to facilitate accountable convergence of all key activities/ services and associated stakeholders for holistically addressing the underlying factors, including social determinants, that contribute to maternal and child health. Several activities are carried out under the Poshan Abhiyan.

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i. Awareness and Outreach: Poshan Abhiyan has made significant progress in creating awareness about the importance of nutrition and health among the target population. The program has implemented various community-based initiatives, including the use of Anganwadi centers, health camps, and mobile technology to reach out to pregnant women, lactating mothers, and children. ii. Malnutrition Reduction: Poshan Abhiyan focuses on reducing malnutrition, and it has highlighted the need for a multisectoral approach. The program aims to address the underlying causes of malnutrition by emphasizing the importance of proper nutrition, sanitation, and access to clean drinking water. It also focuses on the timely identification and management of malnourished children. iii. Convergence of Services: Poshan Abhiyan recognizes the need for collaboration between various government departments, such as Health, Women and Child Development, Education, and Drinking Water and Sanitation, to achieve its objectives. The program promotes convergence of services and adopts a holistic approach to nutrition. iv. Monitoring and Evaluation: Poshan Abhiyan has emphasized the importance of monitoring and evaluation to measure the effectiveness of its interventions. The program has implemented various monitoring mechanisms to track progress, including the use of technology for real-time data collection and reporting. An analysis of the success of Poshan Abhiyan in the context of SDG-2 reveals both positive progress and areas that require further attention. Some of the positive aspects are as under. • Decline in stunting: The reduction in stunting prevalence from 38.4 to 35.5% between NFHS-4 and NFHS-5 rounds indicates progress in combating chronic malnutrition among children under-five. This decline suggests that efforts to improve nutrition by addressing the underlying causes of stunting have been successful to some extent. It signifies the effectiveness of interventions implemented through Poshan Abhiyan in improving the nutritional status of children. However, the progress needs to be accelerated to reach SDG-2 targets by 2030. • Reduction in wasting: The decrease in wasting prevalence from 21.0 to 18.9% is another positive change. Although the progress is modest, any reduction in acute malnutrition is significant. The Integrated Child Development Services (ICDS) and Poshan Abhiyan have played crucial roles in providing nutrition and health services to vulnerable populations, contributing to this reduction. These initiatives have helped in identifying and addressing the immediate nutritional needs of children. • Decrease in underweight prevalence: The decline in underweight prevalence from 35.7 to 32.7% demonstrates progress in addressing overall malnutrition. This reduction indicates that efforts to improve access to nutritious food, healthcare, and sanitation have yielded a positive impact. Programs and interventions implemented under Poshan Abhiyan must have contributed to improving the nutritional status of children, leading to a decrease in underweight prevalence.

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However, there are certain concerns as regards the effectiveness of Poshan Abhiyan. Some of these concerns are as Under • Disparities among states: While progress has been made at the national level, significant disparities exist among states. Some states, such as Bihar, Uttar Pradesh, and Madhya Pradesh, continue to face higher prevalence of malnutrition. These states would require focused attention and targeted interventions to address the persistent challenges. Efforts should be made to understand and address the specific factors contributing to these disparities and implement strategies tailored to the needs of each state. • Modest progress in wasting and low BMI: Although there have been slight reductions in wasting and low BMI prevalence, the pace of change falls short of the required rate to achieve SDG-2 targets. States like Jharkhand, Bihar, and Uttar Pradesh still struggle with higher prevalence of acute malnutrition and low BMI. This highlights the need for intensified efforts and targeted interventions in these regions to effectively address wasting and low BMI. • Persistence of anemia: Anemia remains a significant concern, both among adolescent girls and children (6–59 months). The progress in reducing anemia prevalence varies, with some states experiencing stagnation or even an increase. This necessitates comprehensive strategies and targeted interventions to address the underlying causes of anemia effectively. Efforts should focus on improving access to nutritious food, promoting iron-rich diets, enhancing antenatal care, and strengthening iron and folic acid supplementation programs. Nonetheless, Poshan Abhiyan has made significant strides in addressing malnutrition and improving nutritional outcomes in India, which is aligned with the SDG-2 objectives. The decline in stunting, wasting, and underweight prevalence signifies progress in combating chronic and acute malnutrition among children under-five. Initiatives such as the Integrated Child Development Services (ICDS) and Poshan Abhiyan have played pivotal roles in providing nutrition and healthcare services to vulnerable populations during the reference period. However, there are concerns that need to be addressed to ensure sustained progress. Disparities among states highlight the need for targeted interventions in regions with higher prevalence and persistent challenges. States such as Bihar, Uttar Pradesh, and Madhya Pradesh require focused attention and tailor-made strategies to overcome these hurdles effectively. Additionally, the modest progress made in reducing wasting, low BMI prevalence, and the persistence of anemia warrants intensification of efforts using comprehensive approaches. To overcome these challenges, collaborative efforts involving governments, civil society organizations, and national and international stakeholders are crucial. Evidence-based interventions and best practices should be shared among states to drive sustainable change and accelerate progress. Strengthening healthcare infrastructure, improving access to nutritious food, promoting awareness, and addressing social determinants of malnutrition, such as poverty and gender inequality, are vital components of a comprehensive strategy.

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By addressing these concerns and building on the strengths of Poshan Abhiyan, India can continue its journey toward achieving SDG-2 targets. Continued investments, innovation, and policy commitments are essential to ensure that no child is left behind and that the vision of zero hunger, improved nutrition, and food security for all becomes a reality in the country. These policies and initiatives in turn reflect the commitment of the Indian government to address the issue of malnutrition among children under-five and adolescents. While progress has been made, sustained efforts and effective implementation are crucial to achieve the desired outcomes. It is essential to strengthen monitoring and evaluation mechanisms, improve intersectoral coordination, enhance community participation, and increase investments in nutrition-specific and nutrition-sensitive programs. By prioritizing nutrition and adopting a multidimensional approach, India can significantly improve the nutritional status and overall well-being of its children population, leading to a healthier and productive upcoming generations.

3.4.2 Infant and Young Child Feeding Practices: Main Drivers of Childhood Nutrition Breastfeeding practices play a crucial role in addressing malnutrition among young children. The findings regarding breastfeeding practices among under-five children highlight both progress and areas of concern. While there has been an increase in the proportion of children being breastfed within the first hour of birth and exclusive breastfeeding during the first six months, the rates are still below the SDG-2 targeted levels (Dutta et al., 2022; Dutta, 2022). Early initiation of breastfeeding is crucial for providing newborns with colostrum, which is rich in nutrients and antibodies. The increase in the proportion of children breastfed within one hour of birth from 23% in 2005–06 to 41% in 2019–21 is an encouraging development. However, the fact that around 60% of newborns are still not initiated with breastfeeding within the recommended timeframe indicates the need for further improvement. Efforts should be on to ensure that healthcare facilities promote and support the early initiation of breastfeeding as a standard practice. Furthermore, exclusive breastfeeding during the first six months is essential for optimal growth and development of infants. The increase in exclusive breastfeeding rates by 11 percentage points between 2015–16 and 2019–21 is quite encouraging. However, the overall prevalence of exclusive breastfeeding remains below the targeted levels. It is also concerning that the rates are lower in urban areas compared to rural areas. This could be due to factors such as the availability of formula milk, the influence of formula milk marketing practices, and participation in labor force. Policies should prioritize creating a supportive environment for exclusive breastfeeding, regulation of formula milk marketing, and strengthening breastfeeding support systems in urban areas. Priority should be given for creating an enabling environment that supports and promotes breastfeeding both at home and workplace,

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improving healthcare practices, regulating of formula milk marketing, educating parents and caregivers about nutrition. Strengthening breastfeeding support systems and addressing barriers to exclusive breastfeeding, particularly in urban areas, is crucial for improving child nutrition outcomes. Dietary diversity and frequency also play crucial role in meeting the nutrient requirements of children. Our analysis indicates that only 25% of children between 6 and 23 months met the minimum dietary diversity requirement in 2019–21, with a marginal increase since 2015–16. Similarly, there has been a reduction in the percentage of children receiving minimum meal frequency. These findings suggest the need to improve access to diverse and nutritious foods for younger children. Policies should focus on promoting the consumption of a variety of foods from different food groups and ensuring regular and adequate meals for children, especially in the vulnerable population groups. A multisectoral approach involving healthcare, nutrition, and social welfare sectors is the need of the hour to effectively address malnutrition among underfive children. The policy measures should aim to create an enabling environment that promotes and supports breastfeeding practices, improves dietary diversity, and ensures regular and adequate meals for younger children, with a particular focus on vulnerable sections.

3.5 Conclusions and Way Forward The high prevalence of malnutrition among children suggests the need to urgently address the issue within the framework of SDG-2 (i.e., Zero Hunger). While progress has been made in reducing stunting, underweight, and wasting, these rates still remain high, particularly among vulnerable populations. Furthermore, the persistence of anemia poses an additional challenge to child health and well-being. There are significant disparities in child malnutrition indicators across states, with states like Madhya Pradesh, Jharkhand, and Chhattisgarh consistently reporting high prevalence of stunting, underweight, and wasting. States with high tribal populations, such as Jharkhand, Odisha, and Rajasthan, often face greater challenges in combating child malnutrition due to limited access to healthcare and nutritious food. In conclusion, addressing child malnutrition requires multifaceted and targeted approaches that would prioritize the needs of the most vulnerable children. By reducing disparities and focusing on the marginalized, poorest, and adolescent populations, states can achieve significant strides in combatting this pressing issue. Investing in comprehensive nutrition programs especially targeted at the initial 1000 days of a child’s life, from conception to age 2, is vital for ensuring optimal growth and development of children. Empowering caregivers and communities with required knowledge and support, strengthening healthcare systems, and implementing social safety nets are additional key components of a comprehensive strategy.

3.5 Conclusions and Way Forward

73

To make substantial advancement toward achieving SDG-2 and ensuring adequate nutrition for all children, multidimensional and holistic approaches are required. We highlight below some of the key steps that can be taken in the direction. Holistic Care for Vulnerable Infants and Children: To ensure the well-being and healthy development of most vulnerable population, it is imperative to implement a comprehensive strategy that addresses the specific needs of low birth-weight infants, severely acute malnourished (SAM) children, and those who are wasted below six months of age. Special attention should be given to designing personalized nutrition plans for low birth-weight infants, SAM, and wasted children under six months. A robust system of screening vulnerable infants and children for early detection of growth failure need to be established. Regular health check-ups and growth monitoring can help identify and address nutritional deficiencies or health issues promptly. Primary healthcare system should to be tailored-made to this need. Promoting Breastfeeding and Complementary Feeding Practices: Enhancing awareness about the benefits of exclusive breastfeeding during the first six months and appropriate complementary feeding practices thereafter can contribute to improving nutritional outcomes. Health departments in each state should create awareness among parents and care-givers about the benefits of breastfeeding through campaigns. The rise in the marketing of formula milk for infant and children under-five can mislead parents due to their less attention to details. Further, Formula milk market needs to be kept under check, which has grown with the rise of private healthcare facilities, disposable income and lifestyle changes. Awareness creation can help prevent the unnecessary introduction of formula milk and promote exclusive breastfeeding during the first six months. Promoting Behavioral Change and Nutrition Education: Awareness campaigns and nutrition education programs at the community level can empower families to make informed choices about proper nutrition, hygiene practices, and promote optimal feeding behaviors. Policies should prioritize improving the quality of healthcare services and ensuring that all healthcare facilities promote and support early initiation of breastfeeding. This can be achieved through training healthcare professionals, ASHA workers, AWWs, NGOs, for implementing breastfeeding-friendly practices and creating awareness among parents and caregivers about the importance of early breastfeeding. A Comprehensive Approach to Address Anemia: A multisectoral approach involving nutrition programs, health services, and awareness campaigns should be adopted to address anemia among adolescent children. Improving access to nutritious food, provision of anemia-preventing services, including promotion of iron-rich diets, and strengthening iron and folic acid supplementation programs are crucial components of the strategy. Enhancing Food Diversification: Emphasize should be given to improve nutritious, safe, affordable, and sustainable diets. The Millet Mission and the promotion of kitchen gardens have emerged as effective strategies for reducing child and adolescent

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malnutrition. These initiatives focus on improving dietary diversity and enhancing access to nutritious food at the household level. By popularizing millet as a dietary staple, especially among vulnerable populations, such as children and adolescents, the mission could address malnutrition challenges. On the other hand, Nutri gardens enable families to grow nutritious foods, including leafy greens, vegetables, and herbs, providing a readily available source of fresh and diverse produce. Nutri gardens not only improve dietary diversity but also empower households to have greater control over their food supply, particularly in areas with limited access to markets or where nutritious food is expensive. Strengthening Food Safety Measures: Implementing targeted nutrition programs, such as integrated child development services, maternal and child health programs, and school feeding initiatives, can help provide access to nutritious meals, healthcare, and essential micronutrients. To improve dietary diversity and frequency, states should prioritize strengthening food security and nutrition programs, especially for vulnerable populations. This can include initiatives such as promoting local food production, ensuring access to diverse and nutritious foods, and implementing targeted nutrition interventions for children in low-income households. Improving Access to Clean Water and Sanitation: Investments in water supply, sanitation infrastructure, and hygiene promotion campaigns are crucial to reduce the burden of preventable infections and improving overall child health. Strengthening Data and Monitoring Systems: Developing robust data collection and monitoring systems can provide accurate and timely information on the nutritional status of children, enabling evidence-based decision-making and targeted interventions. Regular monitoring and evaluation of breastfeeding and complementary feeding practices should be carried out to assess progress and identify gaps. Such data and monitoring systems can inform evidence-based decisions and help in designing targeted interventions to address the specific needs of different regions and population groups. Ensuring Multistakeholder Collaboration: Collaboration among different government departments, and stakeholders is crucial in ensuring holistic change. Multisectoral government platforms and systems, which includes food, health, sanitation, hygiene, education, and social protection need make coordinated efforts to deliver nutritious diets, essential nutrition services, healthcare services, and other best practices needed for improving child health outcomes. By prioritizing these strategies and aligning them with the SDG-2 agenda, India can make significant progress in reducing child malnutrition, ensuring food security, and improving the overall well-being of her children. It requires a sustained commitment from all stakeholders to create an enabling environment where every child has access to nutritious food, adequate healthcare, and a nurturing environment for their holistic development.

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Harpham, T., Huttly, S., De Silva, M. J., & Abramsky, T. (2005). Maternal mental health and child nutritional status in four developing countries. Journal of Epidemiology & Community Health, 59(12), 1060–1064. Henry-Unaeze, H., & Ibe, L. (2013). Effect of family structure on nutritional status of preschool children (2–5 years) in a rural Nigerian population. Journal of Biology Agriculture and Healthcare, 3(18), 37–48. Kamruzzaman, M. (2021). Is BMI associated with anemia and hemoglobin level of women and children in Bangladesh: A study with multiple statistical approaches. PLoS One, 16(10), e0259116. https://doi.org/10.1371/journal.pone.0259116 Kassebaum, N.J., Jasrasaria, R., Naghavi, M., Wulf, S.K., Johns, N., Lozano, R., Regan, M., Weatherall, D., Chou, DP., Eisele, T.P, Flaxman, S.R., Pullan R.L, Brooker S.J, Murray C.J (2014). A systematic analysis of global anemia burden from 1990 to 2010. Blood. 2014 Jan 30;123(5):615–24. https://doi.org/10.1182/blood-2013-06-508325. Epub 2013 Dec 2. PMID: 24297872; PMCID: PMC3907750. Khan, J., & Das, S. K. (2020). The burden of anthropometric failure and child mortality in India. Scientific Reports, 10, 20991. https://doi.org/10.1038/s41598-020-76884-8 Kochupurackal, S. U., Channa Basappa, Y., Vazhamplackal, S. J., & Srinivas, P. N. (2021). An intersectional analysis of the composite index of anthropometric failures in India. International Journal of Equity Health, 20, 155. https://doi.org/10.1186/s12939-021-01499-y Kotecha, P. V. (2011). Nutritional anemia in young children with focus on Asia and India. Indian Journal of Community Medicines, 36(1), 8–16. https://doi.org/10.4103/0970-0218.80786 Lamberti, L. M., Fischer Walker, C. L., Noiman, A., Victora, C., & Black, R. E. (2011). Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health, 11(Suppl 3), S15. https:// doi.org/10.1186/1471-2458-11-S3-S15 Lancet. (2019). The double burden of malnutrition. https://www.thelancet.com/series/double-bur den-malnutrition Lopez, A. D., Mathers, C. D., Ezzati, M., Jamison, D. T., & Murray, C. J. (2006). Global and regional burden of disease and risk factors, 2001: Systematic analysis of population health data. The Lancet, 367(9524), 1747–1757. Menon, P., Headey, D., Avula, R., & Nguyen, P. H. (2018). Understanding the geographical burden of stunting in India: A regression-decomposition analysis of district-level data from the 2015–16. Maternal and Child Nutrition. https://doi.org/10.1111/mcn.12620 Mokdad, A.H., Marielle, C., Gagnier, K., Ellicott, C., Paola, Z-B., Diego, R.Z., Annie, H., Erin, B. P., Brent, W., Anderson, Sima, S. D., Catherine, W. G., Tasha, M. , Paria, N., Jennifer, N., Dharani, D., Alexandra, S., Gulnoza, U , Shelley, W., Bernardo, H., Rafael, L., and Emma, I., (2016). Health and wealth in Mesoamerica: findings from Salud Mesomérica 2015. BMC Medicine 13:164 , https://doi.org/10.1186/s12916-0150393-5https://bmcmedicine.biomedcentral.com/counter/pdf/10.1186/s12916-015-0393-5.pdf Nandy, S., & Svedberg, P. (2014). The composite index of anthropometric failure (CIAF): An alternative indicator for malnutrition in young children (Handbook of Anthropometry, pp. 127– 137). Springer. Nguyen, P. H., Scott, S., Avula, R., Tran, L. M., & Menon, P. (2018). Trends and drivers of change in the prevalence of anaemia among 1 million women and children in India, 2006 to 2016. BMJ Global Health, 3(5), e001010. https://doi.org/10.1136/bmjgh-2018-001010 Osendarp, S., Brown, K., Neufield, L. M., Udomkesmalee, E., & Moore, S. E. (2020). The double burden of malnutrition-further perceptive. Lancet. https://www.thelancet.com/journals/lan cet/article/PIIS0140-6736(20)31364-7/fulltext#:~:text=In%20December%2C%202019%2C% 20The%20Lancet,because%20of%20insufficient%20prevalence%20data Perin, J., Mulik, A., Yeung, D., Villavicencio, F., Lopez, G., Strong, K. L., Merino, D. P., Cousens, S., Black, R., & Liu, L. (2022). Global, regional, and national causes of under-5 mortality in 2000–19: An updated systematic analysis with implications for the sustainable development goals. The Lancet Child & Adolescent Health, 6/2, 106–115.https://doi.org/10.1016/s2352-464 2(21)00311-4

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Porter, C., & Goyal, R. (2016). Social protection for all ages? Impacts of Ethiopia’s productive safety net program on child nutrition. Social Science & Medicine, 159, 92–99. Rahman, A., & Hossain, M. M. (2020). Quantile regression approach to estimating prevalence and determinants of child malnutrition. Journal of Public Health: from Theory to Practice, 30(2), 323–339. Roy, S. K., Fuchs, G. J., Mahmud, Z., Ara, G., Islam, S., Shafique, S., Sharmin Akter, S., & Chakraborty, B. (2005). Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh. Journal of Health Population and Nutrition, 23(4), 320–330. Salam, R. A., Hooda, M., Das, J. K., Arshad, A., Lassi, Z. S., Middleton, P., & Bhutta, Z. A. (2016). Interventions to improve adolescent nutrition: A systematic review and meta-analysis. Journal of Adolescent Health, 59(4S), S29–S39. https://doi.org/10.1016/j.jadohealth.2016.06.022 Schwarzenberg, S. J., Georgieff, M. K., & Committee on Nutrition. (2018). Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health. Pediatrics, 141(2), e20173716. https://doi.org/10.1542/peds.2017-3716 Scott, S., Lahiri, A., Sethi, V., de Wagt, A., Menon, P., Yadav, K., Varghese, M., Joe, W., Vir, S. C., & Nguyen, P. H. (2022). Anaemia in Indians aged 10–19 years: Prevalence, burden and associated factors at national and regional levels. Maternal Child Nutrition, 18(4), e13391. https://doi.org/ 10.1111/mcn.13391 Siddiqui, F., Salam, R. A., Lassi, Z. S., & Das, J. K. (2020). The intertwined relationship between malnutrition and poverty. Frontiers in Public Health, 8, 453. https://doi.org/10.3389/fpubh.2020. 00453 Singh, S., Srivastava, S., & Upadhyay, A. K. (2019). Socio-economic inequality in malnutrition among children in India: An analysis of 640 districts from national family health survey (2015– 16). International Journal of Equity Health, 18(1), 203. https://doi.org/10.1186/s12939-0191093-0 Singh, S. K., Srivastava, S., & Chauhan, S. (2020). Inequality in child undernutrition among urban population in India: A decomposition analysis. BMC Public Health, 20(1), 1852. https://doi. org/10.1186/s12889-020-09864-2 Svedberg, P. (2000). Poverty and under nutrition: Theory, measurement and policy. Oxford India Paperbacks. Ulahannan, S. K., Wilson, A., Chhetri, D., Soman, B., & Prashanth, N. S. (2022). Alarming level of severe acute malnutrition in Indian districts. BMJ Glob Health, 7(4), e007798. https://doi.org/ 10.1136/bmjgh-2021-007798 UNICEF. (1990). Strategy for improved nutrition of children and women in developing countries. UNICEF policy review 1990-1 (E/ICEF/1990/L.6). UNICEF. UNICEF. (2019). The state of the world’s children, 2019: Children, food and nutrition growing well in a changing world. UNICEF. UNICEF. https://www.unicef.org/india/what-we-do/adolescent-development-participation. Accessed on August 6, 2023. UNICEF/WHO/World Bank Group. (2021). Levels and trends in child malnutrition. https://www. who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb Varghese, J. S., & Stein, A. D. (2019). Malnutrition among women and children in India: Limited evidence of clustering of underweight, anemia, overweight, and stunting within individuals and households at both state and district levels. The American Journal of Clinical Nutrition, 109(4), 1207–1215. Vart, P., Jaglan, A., & Shafique, K. (2015). Caste-based social inequalities and childhood anemia in India: Results from the national family health survey (NFHS) 2005–2006 chronic disease epidemiology. BMC Public Health, 15(537). https://doi.org/10.1186/s12889-015-1881-4 World Health Organization. (2010). Assessing infant and young child feeding practices. Part 2: Measurement. WHO Press

Chapter 4

Child Health Status and Utilization of Healthcare Services

4.1 Background Ensuring the survival and well-being of children is a fundamental goal that every society should strive to achieve. However, the challenge of child mortality remains a significant concern. Despite notable progress being made in recent years, India continues to face high levels of child mortality, which poses a significant obstacle in the attainment of SDG-3, that is, “Ensure healthy lives and promote well-being for all at all ages.” Globally, 5.3 million children die before reaching their fifth birthday in which India bears a substantial burden. In 2022, India accounted for 14.1% of global underfive deaths and 15.6% of global infant deaths (UN Interagency Group for Child Mortality Estimation, 2022). Furthermore, neonatal deaths, which account for 62% of under-five deaths in India, remain a critical issue (UN Interagency Group for Child Mortality Estimation, 2019). In this backdrop, the global community has recognized the urgent need to address child mortality. SDG-3 aims to end preventable deaths of newborns and children under-five. It sets specific targets for reducing neonatal mortality to 12 deaths per 1000 live births and under-five mortality not exceeding 25 deaths per 1000 live births by 2030. Concerted efforts based on a comprehensive understanding of the underlying factors would be required to achieve SDG-3 targets. Several studies have examined cross-country trends and patterns of child mortality, revealing the need for tailored interventions (Gianino et al., 2019; Sartorius & Sartorius, 2014). These studies emphasize the importance of adopting context-specific approaches to effectively address child mortality. Socio-economic and spatial disparities have been identified as key determinants of child mortality in India (Dandona, 2020). In particular, poverty, education, and healthcare access are found to have impact on child survival rates (Bhatia et al., 2019; Brinda et al., 2015; Kravdal, 2004; Mehta & Pratap, 2018; Mishra et al., 2021;

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_4

79

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Mohanty, 2011; Pappachan & Choonara, 2017; Po & Subramanian, 2011; Saikia et al., 2013; Singh-Manoux et al., 2008; WHO, 2018). Furthermore, gender disparities play a significant role in child mortality. The excess female under-five mortality rate in India can be attributed to factors such as gender inequity, economic development, and high fertility rates (Guilmoto et al., 2018). It is crucial to eliminate gender-based discrimination and ensure equal access to healthcare and resources for all children for reducing child mortality and achieving SDG-3. Efforts to address the high burden of newborn and under-five child mortality in India have also focused on specific regions and communities with persistently high mortality rates. Studies have highlighted the challenges faced by districts in Chhattisgarh and Uttar Pradesh, where child mortality rates remain disproportionately high (Bora & Saikia, 2018; Bora et al., 2019). These studies emphasize the importance of targeted interventions, resource allocation, and community engagement to address the unique challenges faced by these regions and underscore the importance of targeted interventions and resource allocation to address the specific challenges faced by these regions and communities. The primary healthcare assumes importance in advancing SDG-3. Various studies have argued that strengthening primary healthcare systems is essential for improving access to quality healthcare services, especially in low-income countries (Guerra et al, 2019; Kumar, 2016; Okonofua et al., 2022; UN News, 2023). The emphasis is on robust infrastructure, trained healthcare professionals, and efficient health information systems to deliver equitable and affordable care to all. Furthermore, community engagement and empowerment also have a significant role in achieving SDG-3. The significance of community-led initiatives in addressing health inequities and fostering sustainable health practices is evident from studies (Popay et al., 2020). These studies advocate for participatory approaches that involve local communities in decision-making processes, as this promotes ownership and ensures the relevance and effectiveness of interventions. Additionally, it is important to note the impact of environmental factors on health outcomes and the achievement of SDG-3. Addressing environmental determinants of health, including air pollution, water contamination, and inadequate sanitation has been underscored in studies (Hollin et al., 2022). It is argued that investing in environmental sustainability and creating resilient health systems are crucial for reducing the burden of communicable and non-communicable diseases. In this chapter, we examine the progress and achievement of SDG-3 in the Indian context and analyze the multifaceted challenges and opportunities with respect to the child-related SDG indicators. Our findings suggest that there is still a high prevalence of child mortality (both neonatal and under-five). Besides there is considerable variation in the health status of children and in the utilization of healthcare services such as immunization, institutional delivery, and having skilled birth attendants during delivery. We observe that achieving SDG-3 would require a holistic approach that addresses socio-economic disparities, strengthens healthcare systems, promotes gender equality, and targets interventions in high-burden regions, thereby ensuring the survival and well-being of every child in the country.

4.2 Status of Child Mortality and Morbidity

81

4.2 Status of Child Mortality and Morbidity 4.2.1 Child Mortality in India and by Socio-economic Gradient The neonatal mortality rate (NMR) is a critical indicator that reflects the underlying factors influencing pregnancy, delivery, the health of newborns, as well as the quality of services provided during the prenatal, intrapartum, and neonatal periods. Over the years, there has been a notable reduction in NMR. The NMR decreased from 39 per 1000 live births in 2005–06 (NFHS-3) to 29 per 1000 live births in 2015–16 (NFHS-4) and further declined to 25 per 1000 live births in the most recent survey of 2019–21 (NFHS-5). In addition to the decline in neonatal mortality, there has been significant progress in reducing infant mortality rate (IMR) and under-five mortality rate (U5MR). In the 2019–21 survey, the IMR in India stood at 35 per 1000 live births, a decrease from 57 per 1000 live births recorded in 2005–06. Similarly, the U5MR dropped from 74 per 1000 live births in 2005–06 to 42 per 1000 live births in 2019–21 (Fig. 4.1). Several factors have contributed to the reduction in IMR and U5MR rates, with the household environment, mother’s education, age at birth, maternal health, and access to institutional delivery being major determinants (Bango & Ghosh, 2023; Bhatia et al., 2019; Sankar et al., 2016; Singh & Tripathi, 2013). These factors play a crucial role in shaping child survival outcomes. To reduce child mortality further so as to meet the SDG-3 target levels, targeted interventions and policy measures are required. Child mortality rates in India vary significantly based on the place of residence and social groups. Children living in rural areas experience higher mortality rates compared to those in urban areas. In 2019–21, the NMR in rural areas was 9.5% points higher than in urban areas. Similarly, the IMR in rural areas was 12% points higher, and the U5MR was 14% points higher than their urban counterparts in the same period. The silver lining is that the rate of decline in NMR, IMR, and U5MR 74.3 80

56.9

60 40

38.9 24.9 29.4

41.9

35.2 40.7

49.7

20 0 NMR

IMR NFHS-5

NFHS-4

U5MR NFHS-3

Fig. 4.1 Trends in NMR, IMR, and U5MR in India (per 1000). Source Author’s calculation based on NFHS (different rounds)

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4 Child Health Status and Utilization of Healthcare Services

100 81.9 80 62.2 60

45.5

42.5 40 20

27.5 18

33.1

38.5

28.5

26.6

20.1

55.7

51.7

45.7

41.5

31.5

28.5

34.4

0 -10.5 -15

-20

-14.9 -23.7

-20.2

-40

-36.2

-60 NFHS-5 NFHS-4 NFHS-3 NFHS 3 NFHS-5 NFHS-4 NFHS-3 NFHS 3 NFHS-5 NFHS-4 NFHS-3 NFHS 3 & NFHS & NFHS & NFHS 5 5 5 NMR

IMR Rural

U5MR

Urban

Fig. 4.2 Trends in child mortality by place of residence. Source Authors’ calculation based on NFHS (different rounds)

between 2005–06 and 2019–21 was much higher in rural areas than in urban areas (Fig. 4.2). In terms of social groups, Scheduled Tribe (ST) children face higher U5MR and IMR compared to other social groups (Dutta, 2022). Although the NMR for tribal children decreased from 42 per 1000 live births in 2005–06 to 29 per 1000 live births in 2019–21, the gap between ST and general caste children in terms of NMR increased from 20 to 44%. Similarly, the IMR for ST children dropped from 65 per 1000 live births in 2005–06 to 42 per 1000 live births in 2019–21, but the gap between ST and general caste children increased from 29 to 46%. During the same period, the U5MR of ST children decreased from 97 per 1000 live births to 50 per 1000 live births, and the gap between ST and general caste children in terms of U5MR decreased from 63 to 50% (Table 4.1). Examination of child mortality rates across different wealth quintiles reveals a consistent pattern of declining mortality with higher levels of wealth. Between 2005–06 and 2019–21, NMR, IMR, and U5MR declined across all wealth quintiles. However, disparities persist. In 2005–06, NMR in the poorest class was 2.2 times higher than in the richest class, and by 2019–21, this gap increased to 2.8 times. Similarly, the IMR was 2.4 times higher in the poorest class in 2005–06, and it increased to 2.8 times in 2019–21. The gap in U5MR between richest and poorest remained more or less same in both 2005–06 and 2019–21 (Table 4.2). The findings highlight the urgent need for targeted interventions to address child mortality disparities based on the place of residence and social groups. Efforts should focus on improving access to quality healthcare services, maternal education, and addressing socio-economic inequalities to reduce child mortality rates across

4.2 Status of Child Mortality and Morbidity

83

Table 4.1 Trends in child mortality by social groups NMR

IMR

U5MR

SC

ST

OBC

General

Gap ST and general caste %

NFHS-5

29.2

28.8

24.3

20

44

NFHS-4

33

31.3

30.4

23.8

32

NFHS-3

43.8

42.2

38.3

35.1

20

NFHS-5

40.7

41.6

34.1

28.5

46

NFHS-4

45.2

44.4

42.1

32.7

36

NFHS-3

64.5

64.6

56.1

50

29

NFHS-5

48.9

50.3

40.5

33.2

52

NFHS-4

55.8

57.2

50.8

39.3

46

NFHS-3

86.2

97.4

72.5

59.6

63

Source Authors’ calculation based on NFHS (different rounds)

Table 4.2 Trends in child mortality by wealth class NMR

IMR

U5MR

Poorest

Poorest

Middle

Richer

Richest

Poorest/Richest

NFHS-5

33.8

29.8

23.2

19.9

12.2

2.8

NFHS-4

40.7

34.2

28

21.6

14.6

2.8

NFHS-3

48.4

44.5

39.3

31.9

22

2.2

NFHS-5

48

40.9

33.7

28.5

17

2.8

NFHS-4

56.3

47.2

39.1

30

19.8

2.8

NFHS-3

70.4

68.5

58.4

44

29.2

2.4

NFHS-5

59

48

39.1

32.7

20.1

2.9

NFHS-4

71.7

57.3

46.1

34.9

22.6

3.2

NFHS-3

100

89.6

71.9

51.2

33.8

3.0

Source Authors’ calculation based on NFHS (different rounds)

all segments of society. Achieving SDG-3 requires comprehensive and inclusive approaches that prioritize the most vulnerable populations and strive for equitable health outcomes for all children. Globally, a higher mortality rate can be observed among male infants compared to female. Research has shown that boys are approximately 0.4% more likely to die during infancy (Li et al., 2015). However, in the context of India, an interesting trend emerges. Girls in India have experienced lower NMR than boys, with a difference of 4% points, both in 2005–06 and in 2019–21 mainly due to biological factors. In terms of IMR, a different pattern emerges. In 2005–06, girls had a slightly higher IMR, with a difference of 1.4% points, compared to boys. Similarly, in the U5MR category, girls had a higher rate of mortality with a difference of 9.5% points. However, in subsequent periods, there has been a notable shift. In both 2015–16 and 2019–21, girls have exhibited lower IMR and U5MR than boys, indicating a change in line with the global trend (Fig. 4.3).

84 90 80 70 60 50 40 30 20 10 0 -10 -20

4 Child Health Status and Utilization of Healthcare Services 79.2 69.7 57.7 56.3

26.9 22.7 4.2

32.8 25.8 7

40.9 36.8

37.4 32.8

5.4

4.6

4.1

43.6 40

43.3 37.9

51.5 47.8

3.6

3.7

NFHS-5

NFHS-4

-1.4 -9.5 NFHS-5

NFHS-4

NFHS-3

NFHS-5

NMR

NFHS-4

NFHS-3

IMR Male

Female

NFHS-3

U5MR Gender Gap

Fig. 4.3 Trends in child mortality by gender. Source Authors’ calculation based on NFHS (different rounds)

Understanding the dynamics of gender-based child mortality disparities is crucial for designing effective strategies and policies that address the underlying causes. It is essential to continue monitoring and evaluation of these trends to ensure that efforts aimed at reducing child mortality are equitable and inclusive, benefiting all children, regardless of their gender. By addressing the underlying factors contributing to higher child mortality rates among certain socio-economic groups, India can strive toward achieving SDG-3, which aims to ensure healthy lives and promote well-being for all, irrespective of gender or social background.

4.2.2 Mortality Status Among Under-Five Children in Indian States State-level analysis reveals significant variations in NMR, IMR, and U5MR across states. In 2005–06, Bihar, Andhra Pradesh, Rajasthan, Madhya Pradesh, Odisha, Assam, Uttar Pradesh, Jharkhand, and Chhattisgarh were identified as the worst performers as the NMR exceeded 40 per 1000 live births in each state. By 2015–16, Uttar Pradesh, Chhattisgarh, Madhya Pradesh, and Bihar had the highest NMR, while Goa and Kerala demonstrated the lowest rates. Similarly, in 2019–21, Uttar Pradesh, Bihar, and Chhattisgarh remained the worst-performing states in terms of NMR. Notably, the NMR declined in all states between 2005–06 and 2019–21, except for Uttarakhand. Arunachal Pradesh, Rajasthan, Assam, West Bengal, Jharkhand, Andhra Pradesh, and Jammu and Kashmir achieved the largest reductions in NMR during this period (Fig. 4.4). In 2005–06, IMR ranged from 73 per 1000 live births in Uttar Pradesh to 15 per 1000 live births in Goa. Nine states, including Arunachal Pradesh, Bihar, Odisha, Rajasthan, Assam, Jharkhand, Madhya Pradesh, Chhattisgarh, and Uttar Pradesh,

NMR

Goa

Kerala

Uttar Pradesh

Haryana

Manipur

Tamil Nadu

Himachal Pradesh

Delhi

Tripura

Punjab

Maharashtra

Gujarat

Karnataka

Bihar IMR

Andhra Pradesh

Sikkim

85

Mizoram

Nagaland

Meghalaya

Jharkhand

West Bengal

Uttarakhand

Chhattisgarh

Assam

Madhya Pradesh

Jammu & Kashmir

Odisha

Rajasthan

80 70 60 50 40 30 20 10 0 -10

Arunachal Pradesh

4.2 Status of Child Mortality and Morbidity

U5MR

Fig. 4.4 Changes in NMR, IMR, and U5MR between 2005–06 and 2019–21 (%). Source Authors’ calculation based on NFHS (different rounds)

exhibited IMR rates exceeding 60 per 1000 live births. In 2015–16, IMR varied from 64 per 1000 live births in Uttar Pradesh, 54 per 1000 live births in Chhattisgarh, 51 per 1000 live births in Madhya Pradesh, to 7 per 1000 live births in Kerala, and 1 per 1000 live births in Goa. In 2019–21, Uttar Pradesh, Bihar, Chhattisgarh, and Madhya Pradesh continued to have IMR rates exceeding 40 per 1000 live births, while Puducherry (3 per 1000 live births), Kerala (4 per 1000 live births), and Goa (6 per 1000 live births) demonstrated the lowest IMR rates. Arunachal Pradesh, Rajasthan, Assam, and Jharkhand demonstrated the highest reduction rates in IMR between 2005–06 and 2019–21 (Fig. 4.4). In 2005–06, nine states, namely Bihar, Assam, Rajasthan, Arunachal Pradesh, Chhattisgarh, Odisha, Jharkhand, Madhya Pradesh, and Uttar Pradesh, had U5MR rates exceeding 80 per 1000 live births. Kerala (6 per 1000 live births) and Goa (20 per 1000 live births) showcased the lowest U5MR rates during the same period. By 2015–16, seven states, including Rajasthan, Jharkhand, Assam, Bihar, Chhattisgarh, Madhya Pradesh, and Uttar Pradesh, reported U5MR rates exceeding 50 per 1000 live births. Kerala and Goa remained top performer with the lowest U5MR rates in 2015– 16 as well. In 2019–21, only three states—Chhattisgarh, Bihar, and Uttar Pradesh— experienced U5MR rates exceeding 50 per 1000 live births, while Puducherry, Kerala, and Goa showcased the lowest U5MR rates. The states that demonstrated the highest reductions in U5MR between 2005–06 and 2019–21 are Arunachal Pradesh, Odisha, Rajasthan, among others (Fig. 4.4). The state-level analysis of child mortality rates reveals significant disparities. While progress has been made in reducing neonatal mortality, infant mortality, and under-five mortality rates nationwide, some of the states continue to face considerable challenges. The findings indicate that in 2019–21, Uttar Pradesh, Bihar, Chhattisgarh, and Madhya Pradesh emerged as the worst performers in terms of neonatal mortality, infant mortality, and under-five mortality. These states require focused attention and targeted interventions to improve the health outcomes of children. However, some states have shown commendable progress in reducing child mortality rates. Arunachal Pradesh, Rajasthan, Assam, Jharkhand, and a few other

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states have successfully achieved significant reductions in neonatal mortality, infant mortality, and under-five mortality over the years. Some of these states can serve as role models for others in implementing effective strategies and interventions to further bring down child mortality rates. To effectively address the challenges associated with child mortality, it is imperative to adopt a multidimensional approach. Such approach should encompass improving healthcare infrastructure, enhancing access to quality maternal and child healthcare services, promoting education and awareness, addressing socio-economic disparities, and empowering marginalized communities.

4.2.3 Prevalence of Morbidity Among Under-Five Children 4.2.3.1

Prevalence of Diarrhea and Treatment-Seeking Behavior by Socio-economic Gradient

We find that the prevalence of diarrhea among children aged 0–5 years has decreased over the years in India. In 2005–06 and 2015–16, the proportion of children suffering from diarrhea was 9.4%, which decreased to 7.4% in 2019–21. On the other hand, the proportion of children suffering from blood dysentery has remained around 10% since 2005–06 (Fig. 4.5). When examining the data by gender, it is observed that the prevalence of diarrhea was slightly higher among boys than girls in all the years. Conversely, the proportion of boys suffering from blood dysentery increased from 8.7% in 2005–06 to 9.3% in 2019–21, while the proportion of girls suffering from the same decreased from 11.5% in 2005–06 to 8.6% in 2019–21 (Fig. 4.6). Furthermore, the prevalence of diarrhea is relatively higher in rural areas compared to urban areas regardless of the period of survey. Moreover, there has been an increase in the proportion of children suffering from blood dysentery in urban areas between 2005–06 and 2019–21 (Fig. 4.6). There are no significant differences observed across 12 10 8 6 4 2 0 NFHS-5

NFHS-4 Diarrhoea

NFHS-3

Blood dysentery

Fig. 4.5 Prevalence of diarrhea and blood dysentery among under-five children (%). Source Authors’ calculation based on NFHS (different rounds)

4.2 Status of Child Mortality and Morbidity

87

14 12 10 8 6 4 2 0 NFHS-5

NFHS-4

NFHS-3

NFHS-5

Diarrhoea

NFHS-4

NFHS-3

Blood Dysentery Male

Female

Rural

Urban

Fig. 4.6 Prevalence of diarrhea among under-five children by gender (%). Source Authors’ calculation based on NFHS (different rounds)

different caste groups in terms of children suffering from diarrhea. Additionally, the proportion of children suffering from diarrhea and blood dysentery is higher in the poorest wealth class compared to the richest wealth class. Regarding treatment seeking for diarrhea, there has been a positive trend over the years (Table 4.3). The percentage of children seeking treatment for diarrhea increased from 63% in 2005–06 to 68% in 2015–16 and further to 71% in 2019– 21. Among the children affected by diarrhea, treatment seeking was higher among boys compared to girls in all the years studied. Between 2005–06 and 2019–21, treatment seeking for boys increased by 7% points, while for girls it increased by 10% points. Furthermore, the percentage of children receiving oral treatment for dehydration has shown improvement. Only 26.1% of children received oral treatment in 2005–06, which increased to 50.6% in 2015–16 and further to 60.8% in 2019–21. Irrespective of the child’s gender, 26.1% of children affected by diarrhea received oral treatment, while in 2019–21, oral treatment was 2.6% points higher for boys than girls. Treatment-seeking behavior for diarrhea was higher in urban areas and the richest wealth class across all the years analyzed. These findings heighten the importance of continued efforts to reduce the prevalence of diarrhea and improve treatment-seeking behaviors among children. It is crucial to focus on both prevention strategies, such as hygiene and sanitation practices, as well as ensuring access to appropriate healthcare services and treatments of children affected by diarrhea. Additionally, targeted interventions are needed to address the disparities observed in treatment-seeking behaviors based on gender, urban–rural divide, and wealth status, for ensuring equitable access to healthcare services for all children.

4.2.3.2

Prevalence of Fever, ARI, and Treatment-Seeking Behavior by Socio-economic Gradient

The analysis reveals important insights regarding the prevalence of fever and acute respiratory infections (ARIs) among children under the age of five. Over time, there has been a reduction in the prevalence of fever and ARI, with fever decreasing from 15

88

4 Child Health Status and Utilization of Healthcare Services

Table 4.3 Treatment-seeking behavior among diarrhea-affected children (%) Medical NFHS-5

Oral treatment NFHS-4

NFHS-3

NFHS-5

NFHS-4

NFHS-3

Male

71.8

69.4

64.6

62.0

51.4

26.2

Female

70

66.2

60.3

59.4

49.6

25.9

Rural

70.2

65.8

61.3

60.2

47.9

23.8

Urban

73.4

74.1

66.6

62.5

58.5

32.7

SC

71.3

69.6

63.8

58.6

51.1

26.1

ST

70.9

64.6

59.4

65.8

55.3

28.7

OBC

71.3

67.4

59.7

58.2

48.1

22.1

General

71.3

70.6

67.8

65.2

53.5

32.1

Poorest

67.5

59.4

53

59.5

43.9

19.1

Poorest

68.9

65

60.8

59.6

47.8

19.5

Middle

71.7

71.1

63.1

60.8

51

25.5

Richer

76.2

73.4

67.4

62.6

56.8

31.1

Richest

76.4

79.1

75.8

64.2

61.1

43.2

Total

71

68.0

63.0

60.8

50.6

26.1

Source Authors’ calculation based on NFHS (different rounds)

to 13% and ARI decreasing from 5.4 to 2% between 2005–06 and 2019–21 (Fig. 4.7). It is noteworthy that the gender gap in both fever and ARI is minimal though it is in favor of girls. 18 16 14 12 10 8 6 4 2 0 NFHS-5

NFHS-4 Fever

NFHS-3

ARI

Fig. 4.7 Proportion of under-five children with fever and ARI (%). Source Authors’ calculation based on NFHS (different rounds)

4.2 Status of Child Mortality and Morbidity

89

18 16 14 12 10 8 6 4 2 0 Rural

Urban

Poorest

Poorest

Middle

Richer

Fever NFHS-5

Fever NFHS-4

Fever NFHS-3

ARI NFHS-5

ARI NFHS-4

ARI NFHS-3

Richest

Fig. 4.8 Proportion of under-five children with fever and ARI by place of residence and wealth class (%). Source Authors’ calculation based on NFHS (different rounds)

Furthermore, the prevalence of fever and ARI is higher among children residing in rural areas compared to urban areas (Fig. 4.8). This highlights the need for targeted interventions and improved access to healthcare services in rural regions to address these health concerns effectively. Additionally, the analysis suggests that the prevalence of fever is significantly higher among children from the poorest wealth class compared to the richest wealth class. It is crucial to prioritize interventions and healthcare provisions for children in economically disadvantaged households to bridge this gap. Further, there has been a concerning increase in the proportion of children suffering from fever in the poorest wealth class during 2015–16 and 2019–21. On the other hand, the proportion of children suffering from ARI has decreased by 2% points in rural areas and by 4% points in urban areas between 2005–06 and 2019–21. Also, there has been a decrease of 3% points in the proportion of children suffering from ARI in the poorest wealth class from 2005–06 to 2019–21. These findings emphasize the importance of health monitoring and addressing health issues among vulnerable populations, especially in cases of fever and ARI. Regarding treatment-seeking behavior, there has been a decline in the percentage of children seeking treatment for fever or cough over time. Treatment seeking for fever/cough decreased from 69% in 2005–06 to 61% in 2019–21. It is notable that treatment seeking for fever/cough has been consistently higher among boys compared to girls. The gender gap in treatment seeking for fever/cough has reduced from 4% points in 2005–06 to 0.9% points in 2019–21. Treatment seeking for fever/cough is also higher in urban areas compared to rural areas (Fig. 4.9).

90

4 Child Health Status and Utilization of Healthcare Services

90 80 70 60 50 40 30 20 10 0 Male

Female NFHS-5

Rural NFHS-4

Urban

Total

NFHS-3

Fig. 4.9 Treatment seeking for fever/cough by gender and place of residence (%). Source Authors’ calculation based on NFHS (different rounds)

As expected, the proportion of children receiving treatment for fever/cough is higher among children from the general caste, while it is the lowest among children belonging to ST category. Additionally, the proportion of children suffering from fever/cough who receive treatment is the lowest in the poorest wealth class and the highest in the richest wealth class. Irrespective of the wealth class, treatment seeking for fever and cough has decreased and reduction was the highest in the richest wealth class and the lowest in the poorest wealth class (Fig. 4.10). It is crucial to address the barriers and challenges faced by economically disadvantaged households in accessing healthcare services and ensure equitable access to treatment for all children. Overall, these findings underscore the need for targeted interventions, improved healthcare infrastructure, and increased awareness regarding fever and ARI prevention and treatment, particularly in rural areas and among vulnerable populations. Efforts should focus on reducing the prevalence of fever and ARI, closing the gender gap in treatment seeking, and addressing the disparities based on wealth and social groups to promote better health outcomes for children in the country.

4.2.3.3

Prevalence of Any Morbidity Among Under-Five Children in India by Socio-economic Gradient

The analysis reveals the prevalence of any morbidity among children under the age of five. The prevalence of any morbidity was 56% in 2005–06, slightly decreased to 54% in 2015–16, and then marginally increased to 55% in 2019–21. Although the changes

4.2 Status of Child Mortality and Morbidity

91

100 80 60 40 20 0 Poorest

Poor

Middle

Richer

Richest

-20 -40 NFHS-5

NFHS-4

NFHS-3

Changes_NFHS-3 & NFHS-5

Fig. 4.10 Treatment seeking for fever/cough by wealth class (%). Source Authors’ calculation based on NFHS (different rounds)

are relatively small, it highlights the ongoing burden of morbidity among young children (Fig. 4.11). When comparing rural and urban areas, it is evident that the prevalence of morbidity is significantly higher in rural areas. In 2019–21, the proportion of under-five children suffering from any morbidity was 5.5 times higher in rural areas compared to urban areas. This disparity highlights the challenges faced by children residing in rural regions, such as limited access to healthcare services, sanitation, and nutrition. Efforts should be directed toward improving healthcare infrastructure and implementing targeted interventions to address the higher prevalence of morbidity in rural areas. The analysis also reveals the extant disparities based on wealth status. Children from the poorest wealth class experience a higher prevalence of morbidity compared to those from the richest wealth class. This emphasizes the impact of socio-economic 65 60 55 50 45 40 Male Female Rural Urban

SC

ST NFHS-5

OBC General Poorest Poorest Middle Richer Richest Total NFHS-4

NFHS-3

Fig. 4.11 Any forms of morbidity among under-five children in India by socio-economic character (%). Source Authors’ calculation based on NFHS (different rounds)

92

4 Child Health Status and Utilization of Healthcare Services

factors on child health outcomes. Interventions should focus on addressing the underlying determinants of health, such as poverty, inadequate nutrition, and limited access to healthcare, to reduce the burden of morbidity among children from economically disadvantaged backgrounds. Furthermore, examination of the data across different demographic groups provides additional insights. In terms of gender, the prevalence of morbidity is similar between males and females, with slight fluctuations over the years. However, it is important to note that gender disparities may exist within specific types of morbidities, which require further investigation. When considering social categories, the prevalence of morbidity demonstrates relatively consistent pattern among different castes. Analysis by wealth class highlights the disparities in the burden of morbidity. The poorest wealth class consistently experienced a higher prevalence of morbidity compared to other wealth classes. This disparity emphasizes the need for economic upliftment, targeted interventions, and social protection measures to improve the long-term health outcomes of children from economically vulnerable backgrounds.

4.2.3.4

Prevalence of Any Morbidity Among Under-Five Children by Indian States

The state-level analysis provides insights into the prevalence of morbidity among children under-five across different states. In 2019–21, the proportion of under-five children suffering from any type of morbidity varied significantly, ranging from 38% in Sikkim to 76% in Tamil Nadu (Fig. 4.12). In the examination of the changes in prevalence between 2005–06 and 2019–21, it is noted that several states experienced an increase in the prevalence of morbidity indicating a significant burden of morbidity among children. These states include 100 80 60 40 20 0 -20 -40

NFHS-5

Changes_NFHS-3 & NFHS-5

Fig. 4.12 State-wise prevalence of changes in childhood morbidity (%). Source Authors’ calculation based on NFHS (different rounds) Note: positive change means reduction, i.e., NFHS-3– NFHS-5

4.3 Access to Healthcare Facility

93

Arunachal Pradesh, Goa, Gujarat, Jharkhand, Kerala, Odisha, Punjab, Rajasthan, Tamil Nadu, Tripura, Uttar Pradesh, Uttarakhand, and West Bengal. This high burden of morbidity is concerning, thereby worsening the health conditions among children in these states over the past decade and a half. On the other hand, Andhra Pradesh, Himachal Pradesh, Meghalaya, Sikkim, and Haryana witnessed a substantial decrease in childhood morbidity, suggesting potential improvements in child health conditions (Fig. 4.12). The state-level findings indicate significant variations in the prevalence of morbidity among children under-five across states. The increase in morbidity prevalence in some of the states raises concerns regarding the overall health conditions of children as well as progress in SDG-3 is concerned.

4.3 Access to Healthcare Facility 4.3.1 Coverage of Vaccination 4.3.1.1

Coverage of Vaccination by Socio-economic Gradient

Immunization coverage plays a crucial role in protecting children from serious diseases. To be considered fully immunized, a child between 12 and 23 months should receive a total of eight basic vaccinations, including three polio vaccinations, three DPT vaccinations, one BCG vaccination, and one measles vaccination. These vaccines are administered at regular intervals, which serve as a proxy for assessing the availability and accessibility of healthcare services. Failing to complete the full course of immunization exposes children to the risk of contracting dangerous diseases such as polio, tetanus, pneumonia, and diphtheria. It is the right of every child to receive full immunization. Between 2005–06 and 2019–21, there has been a notable improvement in immunization coverage, with a 33% point increase in the proportion of children who received full immunization. The coverage rates for BCG, DPT-1, DPT-2, and Polio1 were above 90% albeit some gaps still persist in vaccination rates. In particular, 19% of children did not receive the Polio-3 vaccine, 12% did not receive the measles vaccine, and 13% did not receive DPT-3 in 2019–21 (Fig. 4.13). Disaggregated analysis based on the place of residence shows that the proportion of children receiving full vaccination increased by 15% points in rural areas and 11% points in urban areas between 2015–16 and 2019–21. Furthermore, there was a significant increase in full vaccination coverage among specific communities during the same period, with a 20% point increase among ST communities, 15% points among OBC communities, and 13% points among SC communities (Fig. 4.14). Further analysis indicates that a substantial percentage of children received the initial round of polio drops or DPT, but failed to complete the subsequent vaccinations. This dropout trend needs to be addressed urgently. It is imperative to identify the children who have been left behind during the immunization process and take

94

4 Child Health Status and Utilization of Healthcare Services

100 80 60 40 20 0

NFHS-5

NFHS-4

NFHS-3

Fig. 4.13 Coverage of eight types of vaccination (%). Source Authors’ calculation based on NFHS (different rounds)

100 80 60 40 20 0 Rural

Urban

SC NFHS-5

ST NFHS-4

OBC

Others

NFHS-3

Fig. 4.14 Coverage of full vaccination by place of residence and social group (%). Source Authors’ calculation based on NFHS (different rounds)

measures to bridge the gaps in coverage. Raising awareness about the importance of immunization within the local community is crucial. This can be achieved through the effective mobilization of children during vaccination campaigns, involving Panchayat representatives, community leaders, ASHA workers, AWWs and helpers in the process. Utilizing Information–Education–Communication (IEC) and Interpersonal Communication (IPC) strategies can help educate the population about the significance of immunization and the potential consequences of not receiving or completing the required vaccinations.

4.3.1.2

Coverage of Vaccination by State

At the state level, we observe significant variations in the proportion of children receiving full vaccination in 2019–21, ranging from 57% in Nagaland to 91% in Odisha. Odisha stands out as the only state with more than 90% coverage of full

4.3 Access to Healthcare Facility

95

100 80 60 40 20 Odisha Himachal Pradesh Tamil Nadu West Bengal Jammu & Kashmir Lakshadweep Karnataka Puducherry Uttarakhand Goa Chandigarh Rajasthan Chhattisgarh Sikkim Telangana Andaman & Nicobar Island Kerala Haryana Madhya Pradesh Gujarat Delhi Punjab Maharashtra Jharkhand Mizoram Andhra Pradesh Bihar Manipur Uttar Pradesh Tripura Assam Arunachal Pradesh Meghalaya Nagaland

0 -20

NFHS-5

NFHS4

Change

Fig. 4.15 Immunization coverage and change across states (%). Source Author’s calculation based on NFHS (different rounds)

vaccination (Fig. 4.15). Between 2015–16 and 2019–21, there has been a substantial increase in the coverage of full immunization in most of the states and UTs, except for Goa, Kerala, Puducherry, Punjab, Lakshadweep, and Sikkim. States with more than a 20% points increase in full vaccination coverage include Arunachal Pradesh, Gujarat, Karnataka, Madhya Pradesh, Mizoram, Nagaland, Rajasthan, and Uttarakhand. These states have made significant progress in improving immunization coverage during the given period. On the contrary, Punjab experienced a 14% points reduction in coverage, followed by a 9% points decrease in Puducherry, a 7% points decline in Goa, and a 4% points drop in Kerala. These states require attention and targeted interventions to address the decline in immunization coverage.

4.3.2 Institutional Birth and Access to Skilled Health Personnel 4.3.2.1

Institutional Birth and Access to Skilled Health Personnel by Socio-economic Gradient

In relation to SDG-3, the National Health Mission targets improving coverage of institutional delivery and ensuring equitable access to healthcare for all women and children. The incidence of institutional births in India has increased from 79% in 2015–16 to 89% in 2019–21. Moreover, the incidence of institutional births in public facilities has risen from 52% in 2015–16 to 62% in 2019–21. However, there are disparities in terms of institutional delivery that need to be addressed (Fig. 4.16). One significant disparity observed is between rural and urban areas. In 2019–21, institutional delivery rates were 7% points higher in urban areas compared to rural

96

4 Child Health Status and Utilization of Healthcare Services

100 80 60 40 20 0 Public Sector

Private Sector NFHS-5

Home NFHS-4

Other

Institutional

NFHS-3

Fig. 4.16 Place of institutional delivery in India (%). Source Authors’ calculation based on NFHS (different rounds)

areas (Fig. 4.17). This suggests the need for targeted interventions and improved access to healthcare services to bridge this gap and ensure equitable access to institutional delivery in rural regions. Another disparity exists among social groups. Institutional delivery rates are the lowest among the ST community and the highest among the general caste community. There has been a handsome 14% points increase in institutional delivery among the ST community between 2015–16 and 2019–21. This suggests the success of targeted interventions aimed at improving institutional delivery in marginalized communities. Socio-economic factors also contribute to disparities in institutional delivery rates. The poorest wealth class has lower institutional delivery rates compared to the richest wealth class. Nevertheless, there has been a significant improvement of 20% points in institutional delivery among the poorest wealth class between 2015–16 and 2019– 21. This highlights the effectiveness of past efforts to improve access to institutional delivery for economically disadvantaged populations. 80 70 60 50 40 30 20 10 0

NFHS-5

NFHS-4

Changes

Fig. 4.17 Changes in institutional delivery by social group and economic status (%). Source Authors’ calculation based on NFHS (different rounds)

4.3 Access to Healthcare Facility

97

80 60 40 20 0

NFHS-5

NFHS-4

Changes

Fig. 4.18 Delivery in public spaces by social group and economic status (%). Source Authors’ calculation based on NFHS (different rounds)

Furthermore, there has been a noteworthy increase in institutional delivery in public spaces (Fig. 4.18). In rural areas, institutional delivery in public hospitals increased by 11% points, followed by a 6% points increase in urban areas between 2015–16 and 2019–21. This indicates that past efforts to strengthen public healthcare facilities and improve access to institutional delivery services have shown positive results. Among specific social groups, the ST community experienced a 14% point increase in public institutional delivery, followed by a 9% point increase in the OBC community. This demonstrates the effectiveness of targeted interventions to address disparities and ensure equitable access to institutional delivery for all social groups. The increase in institutional delivery in public hospitals among the poorest wealth class is notable, which registered a 19% point rise between 2015–16 and 2019–21. It signifies progress in providing accessible and affordable healthcare services to economically vulnerable populations. To address disparities in institutional delivery, it is essential to continue strengthening healthcare infrastructure in rural areas, prioritize outreach programs and awareness campaigns, and enhance the capacity of both healthcare system and professionals. Additionally, interventions should focus on marginalized communities, providing targeted support, and ensuring financial protection for all women seeking institutional delivery services. By addressing these disparities, promoting equitable access to institutional delivery, and improving the quality of care, India can make significant progress in achieving SDG-3 targets related to maternal and child health and ensuring the well-being of all women and newborns. In the context of SDG-3, increasing access to skilled health personnel during childbirth is a vital indicator for reducing child and maternal mortality rates. In India, there has been a significant improvement in access to skilled health personnel between 2005–06 and 2019–21, with a 44% points increase. Additionally, between 2015–16 and 2019–21, there has been an 8% points increase in access to skilled health personnel during childbirth (Fig. 4.19). The period between 2005–06 and 2015–16 witnessed a drastic improvement in access to skilled health personnel (Figs. 4.19 and 4.20). In rural areas, the access increased from 36 to 90%, indicating the success of initiatives aimed at bridging

98

4 Child Health Status and Utilization of Healthcare Services

100 90 80 70 60 50 40 30 20 10 0 NFHS-5

NFHS-4 Rural

Urban

NFHS-3 Total

Fig. 4.19 Access to skilled health personnel by place of residence (%). Source Authors’ calculation based on NFHS (different rounds)

the urban–rural divide. Among tribal communities, access rose from 24 to 72%, reflecting the success of past efforts to address healthcare disparities in marginalized populations. In the SC community, access increased by 40–81%, which is a positive change toward achieving equity in healthcare access. 100 90

88.5

80 70

66.5

60

58.9

50

47.8

45.4 40

39.5 30.4

30 24.5

20

18.1

10 0 SC

ST

OBC

General Poorest Poorest Middle

NFHS-5

NFHS-4

Richer

Richest

NFHS-3

Fig. 4.20 Access to skilled health personnel by social group and wealth class (%). Source Authors’ calculation based on NFHS (different rounds)

4.3 Access to Healthcare Facility

99

Furthermore, access to skilled health personnel significantly improved in the poorest wealth class, rising from 18 to 64% between 2005–06 and 2019–21. This demonstrates progress in ensuring access to healthcare services during delivery among the economically disadvantaged population. Access to trained healthcare professionals during childbirth contributed significantly to reduction in maternal and child mortality rates. These improvements in the access to skilled health personnel signify notable advancements toward achieving SDG-3 and addressing inequality in healthcare. At the same time, despite the progress made, there are gaps that need to be addressed, particularly in reaching out to remote and underserved areas and vulnerable populations. To further improve access to skilled health personnel, it is crucial to continue strengthening the healthcare workforce, particularly in rural and tribal areas. Initiatives such as deploying more skilled birth attendants, improving infrastructure and equipment, and enhancing training and capacity-building programs for healthcare professionals can help bridge the reminder of the gaps. Additionally, promoting awareness among communities about the importance of skilled birth attendance and encouraging the use of healthcare facilities for childbirth can play a significant role in reducing inequalities. By ensuring equitable access to skilled health personnel during childbirth, India can make substantial progress in reducing maternal and child mortality rates, improving the overall health and well-being of its population, and advancing toward meeting the targets outlined in SDG-3.

4.3.2.2

Institutional Birth and Access to Skilled Health Personnel Across Indian States

The analysis of institutional delivery and access to skilled birth attendants across states reveals regional variations. Further, it highlights some important implications for maternal and child healthcare. In 2019–21, states such as Kerala, Goa, Tamil Nadu, Lakshadweep, Puducherry, and Andaman and Nicobar Islands exhibited the highest proportions of institutional delivery, with nearly 100% of deliveries taking place in healthcare facilities. Conversely, Nagaland (46%), Meghalaya (59%), Jharkhand (75.86%), and Bihar (76.34%) performed poorly in terms of institutional delivery. Jharkhand and Bihar too have institutional delivery rates below 80% (Fig. 4.21). Furthermore, there is a correlation between states with high rates of institutional delivery and access to skilled health personnel. States with high institutional delivery rates also demonstrated high proportion of births attended by skilled attendants. This indicates that the presence of skilled healthcare professionals is crucial in promoting and facilitating institutional deliveries, ensuring safer childbirth practices, and reducing maternal and neonatal mortality. The variations in institutional delivery rates across states have implications for maternal and child health outcomes. States with low institutional delivery rates, such as Nagaland, Meghalaya, Jharkhand, and Bihar seem to have challenges related to access to healthcare facilities, lack of awareness about the importance of institutional deliveries, and availability of skilled

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Kerala Goa Tamil Nadu Lakshadweep Puducherry Andaman & Nicobar Island Telangana Karnataka Chandigarh Andhra Pradesh Dadra & Nagar Haveli Haryana Ladakh Rajasthan Maharashtra Sikkim Punjab Gujarat Odisha Jammu & Kashmir 124.9004 West Bengal Delhi Madhya Pradesh Tripura Himachal Pradesh Chhattisgarh Mizoram Assam Uttar Pradesh Uttarakhand Manipur Arunachal Pradesh Bihar Jharkhand Meghalaya Nagaland

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Fig. 4.21 Access to institutional delivery and skilled health personnel (%), 2019–21. Source Authors’ calculation based on NFHS (different rounds)

health personnel. These factors contribute to higher risks during childbirth and may result in increased maternal and neonatal mortality rates. On the other hand, states with high institutional delivery rates have strengthened their healthcare systems, including infrastructure, training, and capacity building of healthcare professionals. Investment in maternal and child healthcare facilities leads to better health outcomes for mothers and infants, including reduced maternal and neonatal mortality rates. To address the disparities in institutional delivery rates and access to skilled birth attendants, it is crucial to focus on regions and communities with lower achievements. This will involve improving the availability and accessibility of healthcare facilities, especially in remote and marginalized areas. Increasing awareness about the benefits of institutional deliveries and skilled birth attendance through community outreach and education programs can also play a vital role in promoting safer childbirth practices. Additionally, targeted interventions are needed to address the specific challenges faced by states with lower institutional delivery rates. These interventions may include improving connectivity and transportation infrastructure, enhancing the quality of healthcare services, strengthening health systems, creating awareness among communities, and providing adequate training and incentives for skilled birth attendance. By focusing on reducing regional disparities in institutional delivery and ensuring access to skilled health personnel during childbirth, India can make significant progress in achieving SDG-3 targets related to maternal and child health, improving overall healthcare outcomes, and fostering growth of an equitable healthcare system.

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4.4 Adolescent Health Adolescent health is a pivotal aspect of SDG-3, that is, “Good Health and WellBeing,” which requires adequate attention due to its profound impact on individuals and societies. This critical phase of life, encompassing ages from 10 to 19, is marked by rapid physical, emotional, and social changes, making it a crucial period for healthcare interventions that can shape lifelong health outcomes. By addressing major aspects such as adolescent pregnancy, universal access to sexual and reproductive health services, and mental well-being, governments and communities can promote healthier and more resilient future generations. One of the primary concerns with adolescent health is the high prevalence of adolescent pregnancies. Adolescent pregnancy poses significant risks to the health and well-being of young mothers and their children. Due to the physical immaturity of adolescent mothers, complications during childbirth are more common, leading to increased maternal morbidity and mortality rates. Moreover, babies born to adolescent mothers are at higher risk of being born prematurely or with low birth weight, leading to potential long-term health issues. Addressing this issue requires comprehensive sex education in both schools and communities, emphasis on the importance of family planning, reproductive health, and responsible sexual conduct. Additionally, governments should initiate universal access to affordable and confidential reproductive health services, including contraception and prenatal care, to reduce the incidence of unintended pregnancies and support young mothers throughout their journey into motherhood. Furthermore, ensuring universal access to sexual and reproductive health services is a critical component of SDG-3. Target 3.7 under SDG-3 specifically aims to achieve universal access to sexual and reproductive healthcare, information, and education. By providing young individuals with comprehensive information about their reproductive health rights, family planning options, and sexually transmitted infections, societies can empower adolescents to make informed decisions about their physical relationships. This access to sexual and reproductive health services could also foster gender equality and empower young girls to continue their education, pursue their aspirations, and break the cycle of intergenerational poverty. Governments should work toward removing barriers to accessing reproductive health services, including stigma, cost, and geographical constraints, to ensure that no adolescent is left behind. Chapter 7 provides a detailed discussion on adolescent pregnancy and state-wise progress toward SDG-3. Mental well-being is another major aspect of adolescent health that must not be overlooked. Adolescence can be a vulnerable period from mental health standpoint, as young individuals face increased stress, academic pressures, peer pressure, and hormonal changes. Depression, anxiety, and eating disorders are among the most common mental health issues affecting adolescents. The stigma surrounding mental health often prevents young individuals from seeking help, thereby exacerbating the impact of these conditions on their lives. To address this, governments and communities should prioritize mental health education, raise awareness about mental health

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issues, and promote a supportive and stigma-free environment for adolescents to seek help. School-based mental health initiatives, helplines, volunteering, and community support services could be crucial components of the efforts in this area. By investing in mental health infrastructure and providing accessible and affordable mental health services, societies can ensure that adolescents receive the support they need to thrive emotionally and mentally during this critical phase of life.

4.5 SDG-3 Targets and Achievements in Key Indicators Childhood mortality and morbidity are critical indicators of the overall health and well-being of a population. These two indicators are closely linked to SDG-3, which aims to ensure healthy lives and promote well-being for all at all ages. In this section, and in the context of SDG-3, we assess the position of Indian states in terms of targets and achievements related to childhood mortality and morbidity. Further discussion on the status of states in achieving SDG-3 targets is presented in Chap. 7.

4.5.1 Reduce NMR to 12 Deaths per 1000 Live by 2030 The neonatal mortality rate (NMR) figures suggest progress toward the SDG target albeit at a slower pace. It may be noted that one of the SDG-3 targets is to reduce NMR to 12 deaths per 1000 live births by 2030. NMR in India has reduced over the years from 39 per 1000 live births to 25 per 1000 live births between 2005–06 and 2019–21. This indicates that efforts and interventions aimed at reducing neonatal mortality have had some success. However, the goal still looks ambitious as the NMR rate has to be reduced by another 50% by 2030. In addition, certain challenges and regional disparities persist. The identification of the worst-performing states in terms of NMR in different periods highlights the presence of regional disparities. States like Bihar, Andhra Pradesh, Rajasthan, Madhya Pradesh, Odisha, Assam, Uttar Pradesh, Jharkhand, and Chhattisgarh consistently had higher NMR rates, indicating the need for focused interventions in these regions. The analysis also suggests that the states like Goa, Kerala, Arunachal Pradesh, Rajasthan, Assam, West Bengal, Jharkhand, Andhra Pradesh, and Jammu and Kashmir achieved significant reductions in NMR during this period.

4.5.2 Infant Mortality Rate (IMR) There has been overall reduction in IMR. Some states, including Arunachal Pradesh, Rajasthan, Assam, and Jharkhand, have made substantial progress in reducing IMR.

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However, several states still have high IMR rates. For instance, states like Uttar Pradesh, Bihar, Chhattisgarh, and Madhya Pradesh continue to have high IMR. States with high NMR and IMR need to prioritize investments in healthcare infrastructure, skilled birth attendance, and expand maternal and child healthcare services including Kangaroo Mother Care (KMC) and Special Newborn Care Units (SNCUs). Sharing experiences and replicating successful interventions can facilitate progress in reducing IMR. Achieving the SDG target of reducing IMR requires sustained efforts to improve healthcare infrastructure and access to quality healthcare. Addressing social determinants of health will be equally important.

4.5.3 Under-Five Mortality Rate (U5MR) to Reduce Under-Five Mortality to 25 Deaths per 1000 Live by 2030 Under-five mortality rate (U5MR) has seen a significant reduction over the years. However, regional disparities persist, and there is still work to be done to achieve the SDG target of reducing U5MR to below 25 per 1000 live births. To achieve the U5MR target by 2030, there needs to be a reduction of at least 40% from 2019– 21 levels. It may be noted that there is a substantial decline in U5MR from 74 per 1000 live births in 2005–06 to 42 per 1000 live births in 2019–21. This reduction reflects the fruits of interventions implemented to address child mortality in India. The progress made is commendable and indicates that various initiatives, such as immunization programs, improved healthcare services, and nutrition interventions, have had a positive impact. While the overall U5MR has decreased, some states, such as Rajasthan, Jharkhand, Assam, Bihar, Chhattisgarh, Madhya Pradesh, and Uttar Pradesh, were found to have U5MR rates exceeding 50 per 1000 live births in 2015–16. This indicates the persistence of challenges and the need for sustained efforts to ensure equitable progress across all regions. Improvements are made by some of these states over the years. In 2019–21, only three states—Chhattisgarh, Bihar, and Uttar Pradesh— experienced U5MR rates exceeding 50 per 1000 live births, while Puducherry, Kerala, and Goa showcased the lowest U5MR rates. This indicates that some of the states have made significant progress in reducing child mortality, which can serve as examples for other states to emulate. While the progress in reducing U5MR is commendable, India needs to accelerate efforts to achieve the SDG target of reducing U5MR to below 25 per 1000 live births. This requires a comprehensive approach that addresses the specific challenges faced by different regions, ensures equitable access to healthcare, strengthens preventive and curative interventions, and focuses on improving maternal and child health services.

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4.5.4 Childhood Morbidity and Treatment-Seeking Behavior The varying prevalence of childhood morbidity across states highlights the need for targeted interventions and expansion of healthcare services. The SDG target of reducing childhood morbidity requires investments in preventive healthcare, quality primary care, and access to essential health services. There are significant disparities in morbidity prevalence among states, with some states experiencing an increase in morbidity over time. This calls for a deeper understanding of the underlying causes followed by tailored interventions to address specific health conditions and risk factors in each state. The findings indicate variations in treatment-seeking behavior, which differs based on gender, urban–rural divide, and wealth status. Addressing these disparities requires improved accessibility, affordability, and quality of healthcare services, along with awareness campaigns to promote timely and appropriate treatment-seeking behavior. To effectively address childhood mortality and morbidity in line with SDG-3, Indian states must prioritize investments in healthcare infrastructure, strengthen primary healthcare systems, enhance access to essential health services, and implement evidence-based interventions targeting the specific health needs of children. Collaboration between the government, healthcare providers, civil society, private sector providers, and communities is essential to achieve the SDG targets and ensure every child’s right to health and well-being across the country.

4.5.5 Immunization: To Achieve 100% Coverage of Full Vaccination Among Under-Five Children by 2030 Immunization coverage plays a crucial role in achieving SDG-3. The target under SDG-3.8 specifically focuses on achieving universal health coverage, including access to quality essential healthcare services, and the achievement of the target can be assessed, in part, through immunization coverage. When analyzing the immunization coverage across states, there are notable variations that bear implications for SDG-3 progress. While some states have made significant progress in improving immunization coverage, others face challenges that need to be addressed. States such as Odisha, Himachal Pradesh, Jammu and Kashmir, and Tamil Nadu have achieved high immunization coverage rates, with more than 80% of the children receiving full immunization. These states demonstrate progress toward the SDG3.8 target and serve as best cases of successful immunization coverage. However, there are states with lower coverage rates, such as Nagaland, Arunachal Pradesh, and Bihar, where less than 70% of children have received full immunization. These states face significant challenges in achieving SDG-3.8 and require focused efforts to improve immunization coverage and ensure equitable access. The variations in immunization coverage across states indicate the need for targeted interventions and resource allocations to address the gaps. States with low coverage rates require

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enhanced support in terms of infrastructure and resources, capacity expansion of healthcare delivery systems, community engagement, and awareness campaigns to improve immunization uptake. Furthermore, the decline in coverage observed in some states, such as Punjab, Puducherry, Goa, and Kerala, is concerning, and such trend demands urgent attention. Understanding the reasons behind the decline is crucial to develop strategies for revitalizing immunization programs in these areas and avoiding further setbacks in achieving SDG-3.8 target. To effectively achieve universal immunization coverage, it is essential to strengthen health systems at the state level, enhance training and capacity-building efforts for healthcare workers, improve supply chain management, and prioritize community engagement and awareness programs. Collaboration among government bodies, healthcare providers, community volunteers and leaders, and development partners is vital to ensure the availability, accessibility, and affordability of vaccines and immunization services. Focus should also be on addressing socio-economic disparities, reaching marginalized communities, and addressing barriers such as vaccine hesitancy, misinformation, and logistical challenges. Additionally, monitoring and evaluation systems need to be strengthened to track progress, identify gaps, and facilitate evidence-based decision-making to improve immunization coverage across all states. Overall, achieving immunization coverage targets in line with SDG3 is a complex and multifaceted task. It requires sustained commitment, resources, and a comprehensive approach that addresses challenges at the national, state, and community levels. By prioritizing immunization, and implementing targeted strategies, it is possible to improve coverage, reduce the burden of vaccine-preventable diseases, and contribute to the broader goal of ensuring healthy lives for all.

4.5.6 Institutional Delivery and Skilled Health Personnel: To Achieve 100% Institutional Delivery with the Support of Skilled Health Personnel by 2030 The analysis of institutional delivery and access to skilled health personnel across Indian states and by socio-economic groups reveals both positives and the existence of disparities. Firstly, there has been an overall increase in institutional delivery rates and access to skilled health personnel between the reference periods. This indicates progress in improving maternal and child health outcomes aligned with the SDG3 targets. Significant increase in access to skilled health personnel in rural areas, tribal communities, Scheduled Caste communities, and the poorest wealth class demonstrates serious efforts to address healthcare disparities and improve access to quality healthcare services. However, despite the positives, some notable disparities and challenges persist. There is regional variation across states, with some states achieving near-universal institutional delivery rates and access to skilled health personnel, while others lag behind significantly. States such as Kerala, Goa, Tamil Nadu, and Puducherry demonstrate higher rates of institutional delivery and access

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to skilled health personnel, indicating the presence of effective healthcare systems and infrastructure. On the other hand, states like Nagaland, Meghalaya, Jharkhand, and Bihar have lower achievement, highlighting the need to have improvements in healthcare infrastructure and delivery to services. Socio-economic disparities also persist, as evidenced by variations in institutional delivery rates and access to skilled health personnel across different wealth classes. The analysis shows that the poorest wealth class experiences lower rates of institutional delivery and access to skilled health personnel compared to the richest wealth class. This suggests the presence of barriers related to affordability, awareness, and equitable distribution of healthcare resources. To achieve the SDG-3 targets, it is essential to address these disparities and ensure that all socio-economic groups have equitable access to quality healthcare services. It is evident that while progress has been made in improving institutional delivery rates and access to skilled health personnel, more efforts are needed to bridge the gaps across states and socio-economic groups. This requires a multifaceted approach, including strengthening healthcare infrastructure, expanding and upgrading healthcare facilities, enhancing the training and deployment of skilled health personnel, and implementing targeted interventions in regions and communities with lower rates. Furthermore, addressing socio-economic disparities requires a focus on equity and inclusivity in healthcare service delivery. This entails providing financial support and incentives to ensure affordability, raising awareness about the importance of institutional deliveries and skilled birth attendance, and promoting community engagement and participation in healthcare decision-making. Overall, while there are positives in institutional delivery rates and access to skilled health personnel, it is crucial to address the existing disparities across states and socioeconomic groups. By implementing comprehensive strategies that prioritize equity, accessibility, and quality of healthcare services, India can make significant strides toward achieving the SDG-3 targets, thereby improving overall maternal and child health outcomes.

4.6 Health Policy in India The importance of ensuring the health and well-being of children is well recognized, particularly those under the age of five, as they are in a critical stage of physical and cognitive development. To address the unique healthcare needs of this age group, the Indian government has implemented several policies and programs aimed at promoting child health. These initiatives focus on multiple aspects, including nutrition, immunization, early detection of diseases, and access to healthcare services. Some key constituents of the government’s child health program include: 1. Integrated Child Development Services (ICDS): The ICDS is a flagship program that provides a comprehensive package of services to children under six years of age, which includes health and nutrition. It focuses on improving

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the nutritional status of children, promoting early learning, and enhancing the overall development of the child. Universal Immunization Program (UIP): The UIP aims to protect children against vaccine-preventable diseases by providing free immunization services. Vaccines for diseases such as polio, measles, diphtheria, pertussis, and tetanus are administered to under-five children to ensure health protection and prevent outbreaks. The Government of India implemented the Mission Indradhanush initiative in 2014 as part of its UIP. Mission Indradhanush has played a pivotal role in expanding immunization coverage, particularly in remote and underserved areas, which is enhancing the overall health and well-being of the children. National Nutrition Mission (Poshan Abhiyaan): Launched in 2018, Poshan Abhiyaan aims to reduce malnutrition among children under five years of age. It focuses on improving the nutritional status of pregnant women, lactating mothers, and young children through the provision of balanced diets, nutritional supplements, and behavior change communication. Janani Suraksha Yojana (JSY): The JSY is a maternal healthcare program that provides financial assistance to pregnant women for institutional delivery and postnatal care. It encourages pregnant women to seek professional healthcare services, thereby reducing maternal and neonatal mortality rates. Rashtriya Bal Swasthya Karyakram (RBSK): RBSK is a health screening initiative that aims to detect and manage health conditions in children from birth to 18 years of age. Under this program, children are screened for common health disorders, including developmental delays, birth defects, and deficiencies, ensuring early intervention and treatment. National Health Mission (NHM): The NHM focuses on improving healthcare infrastructure, including primary health centers and hospitals, to provide accessible and quality healthcare services to children under five years of age. It supports initiatives for child health, including the establishment of special newborn care units and pediatric ICUs. Information, Education, and Communication (IEC) Campaigns: The government conducts various IEC campaigns to create awareness among parents and caregivers regarding child health, nutrition, hygiene, and preventive measures against diseases. These campaigns emphasize the importance of exclusive breastfeeding, appropriate complementary feeding, and good hygiene practices.

The government’s policy on child health for under-five children signifies a multipronged approach, encompassing nutrition, immunization, early diagnosis, and comprehensive healthcare services. By focusing on these aspects, the government aims to improve the overall health and well-being of children, thereby laying a foundation for their healthy growth and development. An analysis the National Health Policy in the context of SDG-3 reveals several pertinent aspects. These are discussed below. 1. Emphasis on Universal Health Coverage: The National Health Policy recognizes the importance of achieving universal health coverage (UHC), which aligns with the SDG-3, that is, ensuring healthy lives and promoting well-being for all.

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By aiming to provide equitable and accessible healthcare services, the policy strives to address the health needs of every child in the country. Focus on Primary Healthcare: The policy emphasizes strengthening primary healthcare as a foundational component of the health system. This is crucial for child health as it promotes preventive healthcare services, early detection of illnesses, and timely interventions. By prioritizing primary healthcare, the policy aligns with SDG-3 target of reducing child mortality and improving overall child health outcomes. Integrated Child Health Services: The National Health Policy recognizes the need for integrated child health services, including immunization, nutrition, Early Childhood Development, and preventive interventions. By addressing the multiple needs of children, the policy acknowledges the multidimensional nature of child health and aligns with SDG-3 to bring about comprehensive child well-being. Strengthening Health Infrastructure: The policy highlights the importance of strengthening health infrastructure, including the expansion of healthcare facilities and ensuring the availability of essential services. This is crucial for child health as it improves access to quality care and reduces barriers that hinder timely interventions. It is aligned with SDG-3 with respect to providing quality healthcare services to all, including children. Multisectoral Approach: The National Health Policy recognizes the need for a multisectoral approach to address the social determinants of health that impact child well-being. It acknowledges that factors such as education, nutrition, sanitation, and social protection play a crucial role in promoting child health and development. This also aligns with SDG-3 by focusing on intersectoral collaboration to achieve child health targets.

National Health Policy in India provides a framework for addressing child health in alignment with SDG-3. By emphasizing universal health coverage, primary healthcare, integrated child health services, and health infrastructure, the policy lays a foundation for improving child health outcomes. However, to fully achieve the objectives in line with the SDG-3 targets, there is a need for effective implementation, targeted interventions to address health inequalities, delivery of comprehensive child health services, and evidence-based decision-making. Regular monitoring and evaluation of the impact of intervention on child health outcomes will be crucial to ensure progress toward SDG-3 targets. The analysis of National Health Policy in the context of SDG-3 revels both improvements and concerns in a few areas that require further attention. These improvements and concerns are given below in reference to mortality indicators, immunization coverage, institutional delivery, and availability of skilled health personnel.

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Mortality Indicators: Improvements: States demonstrating significant progress in reducing child mortality rates can benefit from the policy’s emphasis on strengthening healthcare infrastructure and services. These states can build upon their success and further invest in interventions to sustain, or course correct, the declining trend in child mortality. Critical Concerns: States with high child mortality rates need to prioritize implementation of the policy’s interventions aimed at improving healthcare access, quality, and outreach. These states may require additional resources, targeted interventions, and strengthened health systems to address the underlying causes of child mortality. Immunization Coverage: Improvements: States that have achieved high immunization coverage can leverage the policy’s focus like the success of Mission Indradhanush, a Central Government Program, on maintaining and further expanding immunization services. These states can further strengthen their immunization programs, ensure vaccine availability, and enhance community engagement to sustain high coverage rates. Critical Concerns: States with low immunization coverage need to prioritize the policy’s strategies to improve access, awareness, and uptake of immunization services. These states may require healthcare capacity building, targeted campaigns, improved cold chain systems, and community mobilization efforts to overcome barriers to increase immunization rates. Institutional Delivery: Improvements: States with high institutional delivery rates can align their efforts with the policy’s emphasis on quality maternal and child healthcare. These states can further enhance the infrastructure, skilled birth attendance, and referral systems to ensure safe and comprehensive institutional deliveries. Critical Concerns: States with low institutional delivery rates need to focus on implementing the policy’s strategies to increase access, awareness, and utilization of institutional delivery services. These states may require improved facility, add capacity, increase skilled birth attendants, and carry out community-level interventions to overcome barriers to promote safe institutional deliveries. Availability of Skilled Health Personnel: Improvements: States with high availability and utilization of skilled health personnel during delivery can capitalize on the policy’s emphasis on strengthening the workforce. These states can invest in training programs, retention strategies, quality of services, and supportive policies to enhance the presence of skilled health personnel. Critical Concerns: States with limited access to skilled health personnel during delivery need to prioritize the policy’s interventions to bridge the gap. These states

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may require targeted recruitment, training programs, and policy measures to ensure adequate availability and utilization of skilled health personnel.

4.7 Conclusions and Way Forward Conclusions In this chapter, we discuss child mortality, morbidity, immunization, and institutional delivery. We provide several insights into the progress made in respect of child health and identify areas that require further attention. Decline in the NMR, along with IMR and U5MR can be seen over the years. However, significant disparities persist based on the place of residence, social groups, wealth quintiles, and gender. The findings underscore the need for targeted interventions to address these disparities and achieve equitable health outcomes for all children. While there have been positive developmental outcomes in terms of increase in coverage of immunization, and increasing institutional delivery rates, some challenges and disparities persist. To build on the progress made, it is crucial to continue efforts aimed at reducing the prevalence of specific health conditions such as diarrhea and blood dysentery. The efforts include implementing preventive strategies, promoting hygiene and sanitation practices, and ensuring equitable access to healthcare services for all children, regardless of their gender, location, or socio-economic status. Furthermore, addressing disparities in immunization coverage is another crucial aspect. While the overall vaccination rates have improved, there are still underachievements across different states and social groups. To bridge these gaps, it is crucial to enhance access to vaccination services, raise awareness about the importance of immunization, and address vaccine hesitancy or other barriers that hinder optimal vaccine uptake. Furthermore, institutional delivery rates have shown improvement, indicating progress in ensuring safe childbirth and thereby reducing maternal and neonatal mortality. However, regional disparities as well as cultural barriers persist. To further enhance institutional delivery rates, particularly in underserved areas, it is necessary to strengthen maternal healthcare services, improve infrastructure, and provide skilled birth attendants to ensure that women have access to the necessary care during childbirth. Adolescent health is another vital component of SDG-3. Addressing adolescent pregnancy, universal access to sexual and reproductive health services, and mental well-being are essential for creating healthier and more productive societies. By implementing targeted initiatives, comprehensive sex education, accessible mental health services, and empowering adolescents with the knowledge and resources they need, states can enable the development of healthier, more resilient, and empowered future generations. Investing in the health and well-being of adolescents is not only a moral imperative but also a strategic action for achieving the broader goals of sustainable development and ensuring a healthier society at all levels. Way Forward

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• Improve Access to Quality Healthcare Services: Concerted efforts should be made to enhance healthcare infrastructure and ensure access to quality maternal and child healthcare services, especially in rural areas. This will entail strengthening primary healthcare centers, increasing the availability of skilled healthcare professionals, and promoting mobile healthcare services for remote areas. • Address Socio-economic Inequalities: Socio-economic disparities contribute to higher prevalence of child mortality rates. Addressing poverty, improving education, and promoting income-generating opportunities can help alleviate these disparities. Targeted interventions should be designed to uplift marginalized communities and provide them with opportunities for better health outcomes. • Enhance Maternal Education and Awareness: Maternal education plays a crucial role in improving child health. Promoting education and awareness about proper nutrition, hygiene practices, immunizations, and early detection of health issues can significantly reduce child mortality rates. Community-based programs and health education initiatives should be intensified to empower mothers with knowledge and skills. • Strengthen Monitoring and Evaluation: Continuous monitoring and evaluation of child mortality rates, healthcare utilization, and treatment-seeking behaviors are essential to track progress and identify gaps. Regular data collection and analysis will help in assessing the effectiveness of interventions and informing evidence-based decision-making. • Promote Gender Equality: Gender-based disparities in child mortality rates need to be addressed. Focus should be on empowering girls and women, promoting gender equality, and ensuring equal access to healthcare services. Policies and programs should be designed to address the specific needs and challenges faced by both boys and girls. • Learn from Successful Cases: States that have achieved significant reductions in child mortality rates can serve as role models. Sharing best practices, replicating and customizing successful interventions, and fostering interstate collaboration can accelerate progress in reducing child mortality across the country. • Emphasize Preventive Measures: Along with improving healthcare services, preventive measures such as hygiene and sanitation practices, clean drinking water, and immunizations should be prioritized. Public health campaigns and community engagements can play a vital role in the uptake these preventive measures. • Strengthen Collaboration and Partnerships: Addressing child mortality requires a multisectoral approach involving government agencies, nongovernmental organizations, healthcare providers, communities, private sectors, and international partners. Collaboration and partnerships can leverage resources, expertise, and knowledge for implementing comprehensive strategies and initiatives. By implementing evidence-based interventions, promoting collaboration among stakeholders, and prioritizing the SDG-3 targets, India can make substantial progress in reducing child mortality and morbidity and ensuring a healthier future for her

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children. It is a collective responsibility that requires concerted efforts from the government agencies, civil society, healthcare professionals, development partners, and communities to create a healthy society where every child gets the opportunity to thrive and reach their full potential.

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Kumar, P. (2016). How to strengthen primary health care. Journal of Family Medicine and Primary Care, 5(3), 543–546. https://doi.org/10.4103/2249-4863.197263. PMID: 28217580; PMCID: PMC5290757. Li, L., Oza, S., Hogan, D., Perin, J., Rudan, I., Lawn, J. E., Cousens, S., Mathers, C., & Black, R. E. (2015). Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet, 385, 430–440. Mehta, A. K., & Pratap, S. (2018). Ill health and poverty: Policy imperatives for achieving SDG3. In A. K. Mehta, et al. (Eds.), Poverty, chronic poverty and poverty dynamics: Policy imperatives. Springer International. Mishra, P. S., Veerapandian, K., & Choudhary, P. K. (2021). Impact of socio-economic inequity in access to maternal health benefits in India: Evidence from Janani Suraksha Yojana using NFHS data. PLoS One, 16(3), e0247935. https://doi.org/10.1371/journal.pone.0247935. PMID: 33705451; PMCID: PMC7951864. Mohanty, S. K. (2011). Multidimensional poverty and child survival in India. PLoS ONE, 6(10), e26857. Okonofua, F. E., Ntoimo, L. F. C., Adejumo, O. A., Imongan, W., Ogu, R. N., & Anjorin, S. O. (2022). Assessment of interventions in primary health care for improved maternal, new-born and child health in Sub-Saharan Africa: A systematic review. SAGE Open, 12(4). https://doi. org/10.1177/21582440221134222 Pappachan, B., & Choonara, I. (2017). Inequalities in child health in India. BMJ Pediatric Open, 1(1), e000054. https://doi.org/10.1136/bmjpo-2017-000054. PMID: 29637107; PMCID: PMC5862182. Po, J. Y., & Subramanian, S. V. (2011). Mortality burden and economic status in India. PLoS One, 6(2), e16844. PMID: 21347373. Popay, J., Whitehead, M., Ponsford, R., Egan, M., & Mead, R. (2020). Power, control, communities and health inequalities I: Theories, concepts and analytical frameworks. Health Promotion International, 36(5), 1253–1263. https://doi.org/10.1093/heapro/daaa133 Saikia, N., Singh, A., Jasillionis, D., & Ram, F. (2013). Explaining the rural—Urban gap in infant mortality in India. Demographic Research, 29, 473–506. Sankar, M. J., Neogi, S. B., Sharma, J., Chauhan, M., Srivastava, R., Prabhakar, P. K., Khera, A., Kumar, R., Zodpey, S., & Paul, V. K. (2016). State of newborn health in India. Journal of Perinatology, 36(s3), S3–S8. https://doi.org/10.1038/jp.2016.183. PMID: 27924104; PMCID: PMC5144119. Sartorius, B. K., & Sartorius, K. (2014). Global infant mortality trends and attributable determinants—An ecological study using data from 192 countries for the period 1990–2011. Population Health Metrics, 12, 29. https://doi.org/10.1186/s12963-014-0029-6 Singh, R., & Tripathi, V. (2013). Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: A comprehensive multivariate study. Springer Plus, 2, 284. https://doi.org/10. 1186/2193-1801-2-284. PMID: 23961385; PMCID: PMC3724980. Singh-Manoux, A., Dugravot, A., Smith, G. D., Subramanyam, M., & Subramanian, S. V. (2008). Adult education and child mortality in India: The influence of caste, household wealth, and urbanization. Epidemiology, 19(2), 294–301. https://doi.org/10.1097/EDE.0b013e3181632c75. PMID: 18300716; PMCID: PMC3056118. UN Interagency Group of Child Mortality Estimation. (2019). Levels and trends of child mortality. UNICEF, New York. UN Interagency Group of Child Mortality Estimation. (2022). Levels and trends of child mortality. UNICEF, New York. UN News. (2023). Improve healthcare access to end preventable tragedy of child mortality, United Nations. https://news.un.org/en/story/2023/01/1132187 WHO. (2018). Health inequalities and their causes. https://www.who.int/news-room/facts-in-pic tures/detail/health-inequities-and-their-causes

Chapter 5

Ensuring Quality Education: Holistic Child Development and the New Education Policy

5.1 Introduction Education policy has evolved globally with the initiatives such as education for all and millennium development goals in the 1990s (Mukherjee et al., 2023). The 2030 SDG-4 (quality education) focuses on education and aims to “ensure inclusive and equitable quality education and promoting lifelong learning opportunities for all” as envisaged by United Nations. The SDG-4 goal has seven outcome targets and three means of implementation. These outcome targets include universal primary and secondary education, Early Childhood Development and universal preprimary education, equal access to technical/vocational and higher education, relevant skills for decent work, gender equity and inclusion, universal youth policy, and education for sustainable development and global citizenship. In this chapter, we deal with those outcome targets that are related to primary and secondary education as they relate to child development. The issue of access, equity, and quality especially in early childhood education still remains an issue (Rao et al., 2021). Further, the three means of SDG-4 implementation include effective learning environments, scholarships, and teachers and educators. We discuss these means of implementation in the context of New Education Policy in India. Besides global attention to education for all through SDGs, India has its own set of policies aimed at increasing enrolment and learning of various knowledge and skills. Several direct and indirect policy initiatives took shape in the past decades, e.g., Sarva Shiksha Abhiyan, Right to Education, Mid-Day Meal Scheme, and various statesspecific initiatives such as Iron Folic Acid Supplementation (Berry et al., 2021), Nutritional Support to Primary Education, among others. The New Education Policy (NEP) 2020 is the latest development which aims to overhaul the entire education system from elementary to higher education levels by bringing an orientation toward Indian Knowledge System and focusing on learning of varied skills with greater disciplinary flexibility.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_5

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The rise of private sector as partners in the development journey of India has gained momentum. Education sector has seen increasing participation of private sector be it at the primary or secondary education. However, education being a merit good, the role of government ought to remain significant in ensuring access and quality of education. The chapter contains a discussion on the SDG-4 progress in bringing about holistic child development. While there is notable progress made by the country in some of the SDG-4 indicators, the distance from target is visibly high in a few others. There is also the presence of significant spatial variation. The COVID-19 may also have worsened the progress, which needs to be reckoned in quick time. The chapter is organized as follows. Section 5.2 deals with the policy context and prevailing background of the primary and secondary education from multiple vantage points. The foundation, the issue of dropout, and learning as envisaged in the New Education Policy are discussed. We discuss the role of nutrition and health in child education in Sect. 5.3. Governance and management structure of schools are dealt with in Sect. 5.4. SDG-4 progress and issues pertaining to quality of school education for holistic child development are assessed in Sect. 5.5. School education and its pathways to higher education have been covered in Sect. 5.6. The final section concludes.

5.2 Policy Context of Quality Education 5.2.1 Foundation of Learning The National Education Policy 2020 envisages to strengthen foundation of learning through strong investment in Early Childhood Care and Education (ECCE). Existing 10 + 2 school system is being replaced by 5 + 3 + 3 + 4 academic structure. The foundation building is proposed in the first five years. It modifies the pedagogy and curriculum in school education and early childhood care education. Schooling is made mandatory during 3–18 years from 6 to 14 years earlier. Pre-schooling from 3 to 6 years is recognized under school curriculum. The age groups corresponding to 5 + 3 + 3 + 4 are 3–8, 8–11, 11–14, and 14–18, respectively. The emphasis on indigenous knowledge is another pertinent feature of the NEP 2020. It encourages Indian Knowledge System to be made part of curriculum. Prevalent education systems, such as the Anglo-Saxon, German, France, Norwegian, Swedish, American, and Finnish education system, are recognized as successful systems. For example, Finland has been able to upgrade human capital by transforming its education system from mediocrity to one of the best international performers in a relatively short period of time despite (WEF, 2018). Success of countries in international Olympiads has often been used as a proxy of the quality of national education systems (Sahlberg, 2011). Table 5.1 illustrates the position of India among selected nations in Mathematical Olympiad since 1959. India participated in

5.2 Policy Context of Quality Education

117

Table 5.1 Comparison of medals in International Mathematics Olympiad Country

Year of first participation

Participants (cumulative)

Gold

Silver

Bronze

2022 rank#

India

1989

198

14

71

77

24

Brazil

1979

255

13

53

86

19

China

1985

218

174

36

6

1

Russia

1992

180

106

62

12

2*

USA

1974

300

141

118

30

3

UK

1967

356

52

119

128

13

Sweden

1967

355

7

33

85

60

France

1967

337

26

68

123

32

Germany

1977

276

54

109

84

7

Norway

1984

226

3

15

38

61

Finland

1965

308

1

10

55

62

Bulgaria

1959

420

56

126

115

16

Source International Mathematics Olympiad (https://www.imo-official.org/results_country.aspx) as of March 2023 #shows the position of each country in the unofficial mark ordering *2021 rank

these games since 1989. Indian students’ performance was at the best modest by international standards. This requires understanding the best practices of different education systems which can help improve Indian education system. The Indian education system has a significant influence of Anglo-Saxon system. The promotion of Indian Knowledge System will require benchmarking with other systems, and the implementation needs to be based on both scientificity and context.

5.2.2 Increasing Access to Education and Reducing Dropout The NEP 2020 talks about curtailing dropout rates and enduring universal access to education at all levels. It recognizes that through the initiatives such as the Samagra Shiksha (erstwhile Sarva Shiksha Abhiyan) and the Right to Education Act 2009, India has achieved significant progress in attaining near-universal enrolment in elementary education. The Right to Education Act 2009 states that education is a fundamental right of every child. Under the Act, private schools are required to keep 25% of seats reserved for children belonging to weaker sections of society. The Act intended to provide free and compulsory elementary education to kids between 6 and 14 years and break the vicious circle of the education system and poor learning outcomes. The Act also offers provisions for kids who dropped out of school. The NEP gives priority to prevent students from dropping out with a goal to achieve 100% gross enrolment ratio in preschool to secondary level by 2030, which is in line

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with SDG-4 target (Table 5.2). The NEP observes that the drop in enrolment for the latter grades (grade 6 onward) is a serious issue. The gross enrolment was 90.9% for grades 6–8, which further declined to 79.3% for grades 9–10, which indicates that significant portion of enrolled students’ dropout. The dropout is even higher for grades 11–12 which stood at 56.5% (MHRD, 2020). The NEP aims to address the issue of dropout through a two pronged approach, i.e., (a) by providing effective and sufficient infrastructure and (b) by carefully tracking students, as well as their learning levels. Understanding the reasons for dropout might provide further insights to the problem. Extant studies show that the reason for dropout varies across districts, males and females, rural areas, and among social groups (Goel & Husain, 2018; Hoque et al., 2022; Prakash et al., 2017). Empirical evidence suggests to a positive role of free education in reducing school dropout albeit the effect varies across districts with different levels of development (Hoque et al., 2022). Literary skills and local job opportunities have long-lasting and positive effect on subsequent school progression in India (Nakajima et al., 2018). Economic and social factors and schoolrelated factors such as poor learning environment and bullying at school are found to increase the odds of school dropout and absenteeism among adolescent girls (Prakash et al., 2017). Additional challenge persists with respect to children with disability and those coming from marginalized community (Prakash et al., 2017; Takeda & Lamichhane, 2018). Education outcome spans beyond enrolment and dropout. These include performance in school and test score, performance in STEM, and other educational outcomes. The NEP talks about multiple pathways to learning involving both formal Table 5.2 National indicators used SDG global target

Indicators selected for SDG India index

National target value for 2030

Status

4.1

1. Adjusted net enrolment ratio at elementary (class 1–8) and secondary (class 9–10) school

100

See Table 5.3

2. Percentage of correct responses on learning outcomes in language, mathematics and EVS for class 5 students

67.89

3. Percentage of correct responses on learning outcomes in language, mathematics, science, and social science for class 8 students

57.17

See Sect. 5.5 (Discussion)

4. Percentage of children in the age group of 6–13 0.28 who are out of school 4.c

5. Average annual dropout rate at secondary level

10

6. Percentage of school teachers professionally qualified

100

7. Percentage of elementary and secondary school 100 with pupil–teacher ratio less than/equal to 30 Source Aayog (2018, p.53)

See Table 5.4

See Table 5.5

5.2 Policy Context of Quality Education

119

and non-formal modes. There is an emphasis on open and distance learning programs for meeting the learning needs of young people in the country who are not able to attend the physical school. Monitoring performance of both online and physical mode students would be interesting endeavor, and the ways to mitigate any difference in learning would assume significance. The ambit of learning beyond the boundaries of the school seems to be an interesting experiment. Evidence from other developing countries suggest that dropout is affected by cognitive and non-cognitive skills (Tran, 2022), transportation cost especially in remote areas (Sharma & Levinson, 2019), educational factors such as academic performance (Yi et al., 2015), inadequate teaching and untested methods of evaluation (Dahal et al., 2019), and maternal education (Yi et al., 2015). Chapters 3 and 4 provide detailed discussion on child health issues in India and its likely impact on education. It thus suggests that cognitive skills, learning environment, socioeconomic, and gender-related factors have an impact on dropout across developing countries. To reduce dropout, all these factors need to be addressed which falls under the realm of child health, mother’s education, gender, household income, distance, teacher training, and school infrastructure-related aspects. Some evidence suggests that technology adoption in school is found to have no effect on repetition, dropout, and initial enrolment (Cristia et al., 2014). However, this might change with increase in penetration of digital technologies. A strong supply-side mechanism is found to be in place in low- and middleincome countries which ensure functional services at schools (and health centers), which are instrumental in economic shock to recipient households (Das & Sethi, 2023). In the Indian scenario, the supply side remains significantly robust with the growth of private schools albeit the role of demand side would rise with the increase in income levels.

5.2.3 Focus on Learning Effective learning environment is one of the means of implementation of SDG-4. Following NEP, a draft National Curriculum Framework was released in April 2023. The framework brings more diversity, and it blurs the distinction among science, arts, commerce by allowing choices to students. It aims to break the straitjacket of streams by enlarging the bouquet of curricular areas for class 9–10 and 11–12. These curricular areas include humanities, social science, science, mathematics and computing, arts, vocational education, sports, and interdisciplinary. The framework proposes greater flexibility as students in the class 11–12 are permitted to opt for choice based courses from the eight curricular areas. Similarly, in class 9–10, it is proposed that students will complete two essential courses from each of the eight curricular areas over the two years. This lays foundation in curricular areas which needs to be pursued in higher education. However, in exercising choices, attention must be given to depth along with diversity of courses opted so that there is strong connect among disciplines chosen along with flexibility. While this is likely to provide

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new horizons, the ability of educational institutions to invest in physical and human capital to offer more choices to learners would assume significance. Exploring digital skills in schools is going to increase manifold although technology adoption in school is found to have no effect on repetition, dropout, and initial enrolment (Cristia et al., 2014). However, with the growth of internet penetration, the role of digital infrastructure in schools will increase manifold. The tech savvy generation will pose additional challenges for educators especially in rural areas. Seeing the opportunity, many education technology (edtech) startups have sprawled in the country which have encroached upon the business of erstwhile tutors, extra-curricular instructors, and coaching institutes. When it comes to digital learning, the edtech startups surface as one of the major players. How far will the edtech startups will contribute to the holistic development will be questionable as these business models are going to have high cost for average population and lack universal coverage. However, the expansion of edtech startups to various tire-1 and tier-2 cities has attracted children from middle class and from families with financial firepower. Edtech business builds on existing public education problems to combine profit and humanitariasm (Peruzzo et al., 2022). Despite various controversies, edtech is going to remain an important element of the evolving school education ecosystem in the country. The education regulators will need to ensure that there is no overt or covert nexus between school administration and edtech companies. Startups will need to remain a choice rather than compulsion as in the latter case there will be additional burden on students and parents that can increase cost and affect learning continuity and effectiveness. NEP also recognizes the role of language in the learning process. The NEP envisages to promote multilingualism in teaching and learning and encouraging use of mother tongue and local language in schools. Teachers with familiarity of local languages, books for students at all levels in all local and Indian languages, home/ mother/local/regional language as the medium of instruction at least until grade 5 and beyond, and three-language formula in the respective states of which two languages are native to India are some of the salient features of NEP involving use of language. It argues that so many developed countries around the world have amply demonstrated the educational, social, and technological benefits as they are well educated in one’s language, culture, and traditions (MHRD, 2020). Thus, the NEP aims at promotion of Indian languages, arts, and culture. This is proposed for the purposes of cultural enrichment as well as national integration. It has been observed that neoliberalism interwoven with ethnic nationalism could lead to dilemmas in the practice of transformative curriculum planning (Um & Cho, 2022). The constraints of implementing metalinguistic curriculum need to be recognized and addressed. Multicultural curriculum could show ambivalence as it contains competing discourses, conflicting views, and approaches, and yet the discourse can coexist (Kang, 2021). The NEP also says “the curriculum must include basic arts, crafts, humanities, games, sports and fitness, languages, literature, culture, and values, in addition to science and mathematics, to develop all aspects of capabilities of learners; and make education more well-rounded, useful, and fulfilling to the learner.” While this is ambitious in its face, the fine balance among different goals will have to be achieved

5.3 Role of Nutrition and Health in Child Education

121

through calibrated practices at the state, district, and school levels. In the short-run, the availability of translated books will be an issue. In the long-run, the proposition of students with command over Indian language could increase without compromising international languages that are essential in globalized economy. The gap between rural and urban might grow as the latter are more exposed to multilingual skills even outside school setting. Therefore, implementing will hold key so that gaps do not widen. Furthermore, the availability of trained teachers will play crucial role in this direction. Teacher quality plays an important role on student outcomes. However, the teacher quality is found to vary in the country in spite of national policies related to teacher quality (Wiseman & Kumar, 2021). Teachers and educators are recognized as important means of implementation of SDG-4. The teacher training system will require drastic change in view of the inefficiency and ineffectiveness (Chand et al., 2021). Training establishments will need to develop new technical and academic capabilities by investing more resources through collaboration. Sardana (2020) argue that middle-of-the-road policy could be adopted with pedagogical awareness and multilingual resources.

5.3 Role of Nutrition and Health in Child Education While we discussed child health status in India in Chaps. 3 and 4, its link with children’s education needs to be emphasized. Extant evidence suggests that for better educational outcomes, improvement in child health status and supporting institutions is crucial. School enrolment and learning could get affected by nutrition and household poverty. The school meal programs across countries have been tried and tested to address nutrition deficiency among children (Kaur, 2021; Wang & Cheng, 2022; Wang et al., 2023). Nutrition status improvement due to salt iodization or mid-day meal can have impact on test score (Chakraborty & Jayaraman, 2019; Tafesse, 2022). The “National Program for Mid-day Meal in Schools” scheme in India is world’s largest free school lunch program. The scheme has been found to increase children’s enrolment in primary school and learning. Further, the program has heterogeneous responses by socio-economic status and larger effects on socially disadvantaged groups and on girls (Chakraborty & Jayaraman, 2019; Kaur, 2021). As per the Ministry of Education, the program covers about 118 million children studying in 1.12 million government and government-aided schools across the country. Apart from Mid-day Meal, the Rajiv Gandhi Scheme for Adolescent Girls aged 11–18 was introduced in 2010. The scheme dealt with nutritional provision at a later stage of childhood. Evaluation of the program suggests that early childhood nutrition may assume greater significance compared to at the later stage. There was significant improvement in health status and school enrolment due to the program, but improvement in learning outcome was found to be at the basic level (Mishra & Mukhopadhyay, 2022).

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5 Ensuring Quality Education: Holistic Child Development and the New …

On the reverse, education can have a positive impact on health outcomes though it takes longer time to manifest the impact. Schooling is found to have impact on sanitation (Banerjee et al., 2017) and health choices. Therefore, education outcome could affect and be affected by health outcome. Education and poverty are also found to affect the prevalence of girl child marriage (Binu et al., 2022; Chauhan et al., 2020; Kumari & Shekhar, 2023; Paul, 2019). Child marriage remains a deep-rooted problem in several states.

5.4 School Governance and Management The governance of school education is vested with both central and state boards. These boards govern the examination and quality of education in school. The schools are both in the government and private sectors. Over the years, the private sector schools have grown in number as well as student intake. Total student enrolment from primary to higher secondary levels stood at 255.7 million in 2021–22 (Unified District Information System for Education). The enrolment in private schools (primary to higher secondary) stood at 82.45 million in the same year (Fig. 5.1), which amounts to about one-third of total enrolments. The private school system in India has become the third largest school system is the world, which is just behind the India’s government school system and the China’s school system (Raina, 2021). This is an interesting development which poses important question about the state versus market provisioning. Market-based solutions have its deficiencies, and it has been ineffective even in developed countries (Rabitch, 2013). Public sector schools are important as it helps in absorbing household’s economic shocks such as the loss of jobs. Across systems, across all countries and economies, school systems with larger share of students in private-independent schools tended to show lower mean performance in reading (OECD, 2020). The COVID-19 pandemic opened new forms of education governance. Digital and remote education became one of the recognizable modes of delivery. Edtech startups and private sector were found to lead the transformation in the digital modes of teaching and learning especially during pandemic. This has important lesson for schools both in the public and private sectors in terms of investment in digital education technology even within the physical classroom setting. Although the access and equity gap remain in digital education (van Cappelle et al., 2021), measures to ensure better utilization of technologies at the grassroot level would assume significance. The state of readiness for digital education is important to impact competencies of future workforce. However, the deployment of digital education in the country is found to be lower due to reasons such as poor school infrastructure, pedagogical capacity and students’ skills, socio-demographic difference, and digital divide in rural and urban areas (Martin & Ramos, 2022). Digital divide in learning measured by access to smartphone was found to be worst in poorer states and government schools (ASER, 2021). The proportion of rural households with smartphone was found to be 74.8% in 2022 from 36% in 2018 (ASER, 2023). This could pave way

5.5 SDG-4: Progress in Ensuring Quality Education and Holistic Child …

123

70.00 60.00

58.95

50.00 40.00 30.00 20.00

12.85

10.65

10.00 0.00 Elementary (I-VIII)

Secondary (IX-X)

HS (XI-XII)

Fig. 5.1 Enrolment in private schools in India in millions (year 2021–22). Source Compilation from Indiastat

for use of digital technology to improve school education in rural areas though it is lacking thus far. Global evidence suggests to positive income effect on educational expenditure (Naoi et al., 2021). In India, parents have critical consideration to expenses while sending children to public schools (Lahoti & Mukhopadhyay, 2019). With economic growth, the role of private education sector is expected to rise further. Bagde et al. (2022) observe that stratification and choice of private schools by not only well-todo strata but also by high-performing students might undermine public schools. The governance and management of educational institutions both in the public and private sectors will thus play an important role in inclusive and holistic child development.

5.5 SDG-4: Progress in Ensuring Quality Education and Holistic Child Development The seven outcome targets and three means of implementation are reproduced in the Box. Furthermore, national indicators and targets used to track progress in SDG-4 in India are provided in Table 5.2. We track progress of SDG-4 in the country and its states using available indicators. The adjusted net enrolment ratio target is 100% by 2030. The achievement in this parameter is presented in Table 5.3. At the national level, the enrolment stands at 96.5 at elementary stage and 64.71 at the secondary level in 2021–22. The elementary stage enrolment is closer to the target. However, the secondary enrolment will need to

124

5 Ensuring Quality Education: Holistic Child Development and the New …

improve drastically. State-wise, there is significant variation in secondary enrolment. Some of the states have less than 50% secondary enrolment (Nagaland, Jammu and Kashmir), whereas a few others have it in the north of 80% (Delhi, Tamil Nadu, Kerala, Himachal Pradesh). Overall dropout rate at secondary level stands at 12.61 (Table 5.4) against the SDG4 target of 10%. This could be achieved with focused interventions to reduce dropout. However, at the state level, the dropout rate at the secondary level stood above 20 percent in 2021–22 in Assam, Bihar, Meghalaya, and Odisha and between 15 and 20% in Andhra Pradesh, Gujarat, Nagaland, Punjab, and West Bengal. Substantial reduction in secondary school dropout is needed in these states to meet this SDG-4 target. In relation with the SDG target for 2030, the achievement in dropout reduction at the secondary level is an area of concern (see Table 5.4). The percentage of elementary and secondary school with pupil–teacher ratio less than/equal to 30 should be 100%. At the national level, the pupil–teacher ratio is already below 30 indicating achievement of this target at both elementary and secondary levels (Table 5.5). At the state level, there are a few states requiring improvement as the pupil ratio is found to be above 30. These states are Bihar, Jharkhand, and Delhi. While Delhi and Jharkhand are not very far from the target ratio at the elementary and secondary levels, Bihar will require substantial improvement to meet this target. Scholarship is one of the means of SDG-4 implementation. Scholarships (financial support) in India are given to students from socially disadvantaged students. Close to 20 lakh ST and 77 lakh OBC students received post-metric scholarship in 2020– 21, which translated to spending of Rupees 1829 and 115,925 lakhs, respectively (Table 5.6). Public provisioning is important in ensuring access and equity. Meritbased scholarships are also available at the higher education levels. Box: SDG 4 Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Target 4.1 By 2030, ensure that all girls and boys complete free, equitable and quality primary and secondary education leading to relevant and effective learning outcomes. Target 4.2 by 2030, ensure that all girls and boys have access to quality early childhood development, care and primary education so that they are ready for primary education Target 4.3 by 2030, ensure equal access for all women and men to affordable and quality technical, vocational and tertiary education, including university. Target 4.4 by 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship

5.5 SDG-4: Progress in Ensuring Quality Education and Holistic Child …

125

Table 5.3 Adjusted net enrolment ratio (2021–22) Elementary (I–VIII)

Secondary (IX–X)

Girls

Boys

Overall

Girls

Boys

Overall

All India

97.52

95.58

96.5

64.73

64.68

64.71

Andhra Pradesh

96.71

97.14

96.93

67.73

69.64

68.71

Arunachal Pradesh

100

98.39

100

53.58

50.05

51.8

Assam

100

100

100

63.02

52.57

57.71

Bihar

98.42

95.59

96.96

51.8

49.52

50.63

Chhattisgarh

91.13

90.38

90.75

70.02

63.67

66.79

Delhi

100

100

100

88.92

92.57

90.88

Goa

88.56

85.36

86.88

71.38

62.92

66.86

Gujarat

90.6

87.62

89

61.26

64.61

63.05

Haryana

98.21

97.28

97.7

78.12

78.35

78.24

Himachal Pradesh

100

100

100

89.06

87.77

88.38

Jammu and Kashmir

85.91

82.86

84.29

46.69

45.25

45.92

Jharkhand

95.29

93.65

94.44

54.98

52.21

53.57

Karnataka

100

100

100

76.25

75.3

75.76

Kerala

100

100

100

87.83

85.65

86.72

Madhya Pradesh

81.39

81.67

81.54

53.79

55.09

54.46

Maharashtra

100

100

100

73.86

74.33

74.11

Manipur

100

100

100

69.63

67.51

68.55

Meghalaya

100

100

100

58.8

46.27

52.45

Mizoram

100

100

100

67.52

60.38

63.87

Nagaland

83.33

77.52

80.29

45.29

38.25

41.62

Odisha

93.03

93.06

93.05

65.56

63.8

64.66

Punjab

100

98.3

99.21

67.82

61.92

64.59

Rajasthan

93.6

93.75

93.68

62.88

69.52

66.35

Sikkim

85.02

85.33

85.18

61.99

53.35

57.63

Tamil Nadu

100

98.78

99.49

92.05

88.78

90.37

Telangana

100

100

100

79.35

75.26

77.25

Tripura

100

100

100

75.11

69.46

72.21

Uttarakhand

100

100

100

78.94

76.65

77.72

Uttar Pradesh

95.54

92.7

94.04

53.09

58.65

56.01

West Bengal

100

100

100

76.43

69.13

72.71

Source UDISE + https://dashboard.udiseplus.gov.in/#/reportDashboard/sReport

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5 Ensuring Quality Education: Holistic Child Development and the New …

Table 5.4 Dropout rate at secondary level (2021–22)

Girls

Boys

Overall

All India

12.25

12.96

12.61

Andhra Pradesh

14.97

17.52

16.29

Arunachal Pradesh

12.25

11.20

11.74

Assam

20.66

19.78

20.25

Bihar

21.42

19.48

20.46

Chhattisgarh

8.05

11.50

9.73

Delhi

3.71

5.85

4.84

Goa

5.45

12.05

8.98

Gujarat

15.89

19.39

17.85

Haryana

4.94

6.68

5.91

Himachal Pradesh

0.90

1.96

1.46

Jammu and Kashmir

6.34

5.63

5.96

Jharkhand

8.94

9.68

9.31

Karnataka

14.65

13.02

16.16

Kerala

4.06

6.85

5.49

Madhya Pradesh

9.67

10.55

10.14

10.61

10.81

10.72

1.21

1.35

1.27

Meghalaya

20.37

23.28

21.68

Mizoram

10.83

13.06

11.90

Nagaland

16.19

18.92

17.52

Odisha

25.24

29.22

27.29

Punjab

17.24

Maharashtra Manipur

15.96

18.27

Rajasthan

7.49

7.78

7.65

Sikkim

9.48

14.55

11.93

Tamil Nadu

2.52

6.31

4.47

12.94

14.49

13.74

8.15

8.53

8.34

Uttarakhand

4.63

5.37

5.02

Uttar Pradesh

10.01

9.45

9.70

West Bengal

17.66

18.37

17.98

Telangana Tripura

Source UDISE + https://dashboard.udiseplus.gov.in/#/reportDas hboard/sReport

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127

Table 5.5 Pupil–teacher ratio (2021–22) Primary (I–V)

Upper primary (VI–VIII)

Secondary (IX–X)

Higher secondary (XI–XII)

All India

26

19

17

27

Andhra Pradesh

25

15

10

31

Arunachal Pradesh

11

8

10

19

Assam

21

14

11

20

Bihar

53

23

54

62

Chhattisgarh

20

18

14

16

Delhi

33

32

27

21

Goa

26

15

9

18

Gujarat

30

24

29

28

Haryana

25

19

12

14

Himachal Pradesh

15

8

6

10

Jammu and Kashmir

14

9

12

27

Jharkhand

29

25

34

57

Karnataka

22

17

17

28

Kerala

27

21

14

21

Madhya Pradesh

24

17

22

30

Maharashtra

25

26

20

38

Manipur

13

10

9

15

Meghalaya

20

13

11

19

Mizoram

15

7

9

14

Nagaland

11

7

10

17

Odisha

17

15

18

35

Punjab

25

19

10

17

Rajasthan

25

13

10

18

Sikkim

6

8

8

11

Tamil Nadu

19

14

12

21

Telangana

20

13

9

28

Tripura

18

19

13

15

Uttarakhand

18

16

11

16

Uttar Pradesh

28

25

26

38

West Bengal

26

28

16

27

Source UDISE + https://dashboard.udiseplus.gov.in/#/reportDashboard/sReport

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5 Ensuring Quality Education: Holistic Child Development and the New …

Table 5.6 Number of beneficiaries and funds released under post-metric scholarship for ST students in India Year

Number of beneficiaries (in lakh)

Fund release (Rs. in lakh)

ST

OBC

ST

OBC

2016–2017

18.70731

39.79

1555.67

87,587.83

2017–2018

19.32627

39.68

1463.87

82,962.35

2018–2019

17.46905

43.12

1646.98

100,046.39

2019–2020

20.66667

40.94

1862.65

129,932.88

2020–2021

19.54109

76.59*

1829.08

115,924.91

Source Indiastat, * up to Dec. 2020

Target 4.5 by 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations. Target 4.6 by 2030 ensure that all youth and a substantial portion of adults, both men and women, achieve literacy and numeracy Target 4.7 by 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and of culture’s contribution to sustainable development. Target 4.a Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environment for all Target 4.b by 2020, substantially expand globally the number of scholarships available to developing countries, in particular least developed countries, small island developing States and African countries, for enrolment in higher education, including vocational training and information and communications technology, technical, engineering and scientific programmes, in developed countries and other developing countries. Target 4.c by 2030, substantially increase the supply of qualified teachers, including through international cooperation for teacher training in developing countries, especially least developed countries and small island developing States Source: https://sdgs.un.org/goals/goal4 (see for indicators)

5.5 SDG-4: Progress in Ensuring Quality Education and Holistic Child …

129

Discussion There is large variation in the access to early childhood education across countries based on family wealth. Nevertheless, the measurement of quality early childhood education has remained a concern. Extant measurements of quality of early childhood education typically consider structural and process dimensions. The structural dimensions require equal attention as the process dimension. The structural dimension includes teacher education and training, adult–child ratios, group size, physical setting, facilities, and books and materials. Critical parameters of educational quality such as teachers’ capacity, especially in low-fee private schools, are found to get inadequate attention due to information asymmetry between school realities and parental perceptions due to emphasis on non-educational parameters (Lahoti & Mukhopadhyay, 2019). The issue of deteriorating quality of government school teachers has also been noted (Kundu, 2019). There is an effort to increase cost-effectiveness and accountability in government school system, and there has been a push to link teachers’ salaries to student outcome (Aayog, 2017). However, this is easier said than done as the learning outcome is influenced by several other factors including availability of professionally qualified teachers, socio-economic factors, curriculum, condition of teaching, and gender bias (Kundu, 2019; Rakshit & Sahoo, 2023). Globally, more than one-half of children and adolescents are found to have poor learning outcome in terms of minimum proficiency levels in reading and mathematics at the end of lower secondary education, thereby impacting the achievement of SDG-4 (UNESCO, 2017). On the other hand, the process dimensions encompass teacher–child interactions, educational activities, implementation of the curriculum, and language of instruction (Rao et al., 2021). In India, the NEP 2020 emphasizes on providing quality education system to all students irrespective of the place of residence of students. Previously, the standards of quality included a national policy and curriculum framework and quality standards for early childhood care education (Ministry of Women & Child Development, 2013), a teacher education program framework and guidelines (NCTE, 2014), and a national early childhood care education council (Chandra et al., 2017). However, there is considerable variation in quality of early childhood education services which have been set up in response to market needs. As the states have the responsibility of monitoring and assessing quality of school programs, such variation is quite natural. Foundational skills for STEM include arithmetic. The performance of children in basic arithmetic is more varied. One survey finds that the proportion of standard VIII children in rural area who can do division has increased slightly from 44.1% in 2018 to 44.7% in 2022 (ASER, 2023). However, children in government schools were found to show poor performance in arithmetic as only 41.8% of them could do division compared to 53.8% of children in private schools in the same standard. This is still below the national target value of 57.17% corresponding to SDG India index (Table 5.2), that is, percentage of correct responses on learning outcomes in language, mathematics, science, and social science for class 8 students.

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5 Ensuring Quality Education: Holistic Child Development and the New …

Schools in India are found to utilize traditional teacher-centered approaches focusing on procedures and drill practices. Compared to developed counterparts, STEM in India is mostly conceptualized as a fragmented concept, which is limited to science and technology (Tawbush et al., 2020). Although there is lack of implementation of uniform standards across countries, science, technology, engineering, mathematics, and ICT are crucial components of STEM education. STEM streams are costly for parents who cannot afford school fee and additional expenses on teaching–learning resources. The availability of qualified school teacher along with quality infrastructure at an affordable cost for parents is necessary to instill confidence in students who come from heterogeneous section of society to choose STEM as a study domain. With technology boom, such learning opportunity will help in broadening participation of school graduates in the science and technology sector to pursue higher education that will have an impact on inclusive economic growth in the decades to come. Foundation in STEM opens up opportunities not only in science and engineering, but also in medical and other emerging technologies. The importance of test score is high for secondary school students as they seek admission in better institutions for higher studies. However, quality measured by math score is found to be impacted by teacher’s gender bias (Rakshit & Sahoo, 2023). Furthermore, foundation for social sciences, business management, and entrepreneurship requires cross-connections among disciplines. There are attempts albeit at smaller scale to develop such skills but more needs to be done. Above all, the skills to navigate life and work including collaborative problem-solving skills need to be recognized and given more important. The demand for skills such as critical thinking, creativity, problem-solving, use of technology, interpersonal, and socio-emotional has also risen. This necessitates a holistic learning approach. Such an approach to the teaching and learning of the set of abilities, skills, attitudes, and values has been termed as Education 4.0 (WEF, 2023).

5.6 Foundation for Higher Education Childhood education is the foundation for higher education. Both and primary and secondary education should be supported with resources and infrastructure. With the adoption of NEP, there is a pressing need to address resource constraints at all levels in implementing the policy (Maniar, 2022). The growth of private sector especially in higher education is also contributed by financial loans provided by commercial banks to aspiring students. A fair balance between public and private and public provisioning should also be maintained so that public resource requirement for education is not overly demanding on exchequer for a developing country of its size. This can be done without marginalizing the public provisioning. Ensuring both equity and quality should be the key. As the future holds in an innovative and skilled workforce that will leverage technology, educational reform from primary and secondary level will assume importance in developing robust higher education system that will produce skilled and innovative

5.7 Conclusion and Way Forward

131

workforce. The system need has research-based and practical learning as a choice to drive an innovative and knowledge-based economy. The growth of digital education during COVID-19 was unprecedented (Martin & Ramos, 2022). India was not an exception which experienced many disruptive delivery modes (e.g., online education, QR scan innovation for textbook distribution). The existence of digital divide in both rural and urban areas calls for efforts to ensure that vulnerable children are not lag behind in the digital economy. Innovation in education system will also play a role in ensuring the robust foundation for higher education. Every state needs to spend at least six percent of state domestic product on education and health so that quality education is imparted. States that fail to grow state domestic product will face constraints in doing so due to borrowing limit imposed by federal legislation. State economic health is therefore crucial in meeting education-related SDG targets. Therefore, resource needs for education are crucial, and it needs to be addressed. Although comparative educationalists have warned from time to time about uncritical transfer of education policy (Chung, 2010), the Indian education system can project its strength (Khushnam, 2022) and integrate Indian Knowledge System with global best practices. The understanding of contexts, i.e., those related to historical, socio-cultural, and political features can help in harnessing best of both Indian and global knowledge systems. In the context of demographic dividend, hard infrastructure development, software for practice-based teaching and learning, hassle-free academic administration, and teacher training need parallel emphasis. There is a debate on adopting foreign models in Indian schools (e.g., Finland model). Policy enablement will hold key.

5.7 Conclusion and Way Forward Given the prevalence of child malnutrition, anthropometric failures, low per capita income, and regional development disparities in the country, the New Education Policy (NEP) needs to be implemented keeping in mind development disparities across states. For instance, combining the New Education Policy with nutrition and health policy could bring about holistic child development across the breadth of the country. Further, education being a state subject, it will require proactive role of the state governments in facilitating quality education not only by way of educational policy changes but also through implementation of related policies in the health, infrastructure, and social support domains so that children from every corner of a state get the benefit of New Education Policy. Concern for government support in education will grow as economic inequality and low per capita income hinder access to private sector education. Even in the OECD countries, not more that 10% of their children are in private schools (Raina, 2021). This calls a fine balance between private and public provisioning of school education to avoid unintended long-run economic and social consequences.

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Addressing the issue of dropout at the secondary level will require a multipronged approach encompassing fundamental socio-economic issues and school-level factors. Developing predictive models for dropout followed by intervention may help in reducing dropout required to meet SDG-4 target. For this to happen, every state will need to gather data from the school ecosystem. Performance of government school in imparting foundational skills (e.g., arithmetic) needs to improve. Disparities in learning facilities suggest that interventions required to meet the shortfalls in learning will have to be made effectively so that demographic dividend does not become a demographic burden. Role of online school is to be taken with a pinch of salt. While the edtech startups have sprawled across the country, it fails to address inclusivity as it is not affordable for the low-income strata. Edtech companies are significant addition to startup ecosystem. Startups are able to revolutionize pedagogy and delivery. However, equity is still a far cry. Investment in public education system is needed to ensure that quality education is provided at affordable cost across states. While private sector will continue to be a significant provider, state governments have a major role to play in shaping the effective delivery of educational services keeping in mind inclusivity and quality education.

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Chapter 6

Violence and Gender Equity

6.1 Background Violence against children and adolescents is a pervasive global issue that impacts societies worldwide. In the Indian context, diverse forms of violence against children, encompassing physical and sexual abuse, neglect, emotional harm, and exploitation could be observed. These violations of child rights have far-reaching and enduring consequences, impeding their development and reducing their future prospects. Specifically, violence against children under-five and adolescents has multiple manifestations such as physical abuse, sexual exploitation, child labor, child marriage, and neglect. Gender equity, on the other hand, is an essential aspect of societal progress and sustainable development. It encompasses equal access to opportunities, resources, and rights for individuals of all gender. However, gender-based discrimination and inequity persist in many spheres of society, perpetuating a cycle of violence against children. The SDGs adopted by the United Nations in 2015 provide a comprehensive framework for countries worldwide to address social, economic, and environmental challenges. SDG-5 specifically focuses on achieving gender equality, empowering all women, and ending violence of all forms. India has made significant strides in the past years to address violence against children and to advance gender equity. Legislative measures, such as the Protection of Children from Sexual Offences Act (POCSO) and the Prohibition of Child Marriage Act, have been enacted to provide legal protections and deterrence against these violations. Furthermore, initiatives like Beti Bachao Beti Padhao (Save the Daughter, Educate the Daughter) have aimed to raise awareness and promote girls’ education. However, despite these efforts, several challenges remain. Socio-cultural norms, deeply rooted gender stereotypes, and inadequate implementation and enforcement of laws pose barriers to achieving gender equity and eradicating violence against children. Furthermore, poverty and economic disparities, lack of access to education,

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_6

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and limited healthcare facilities further exacerbate the vulnerability of under-five and adolescent children. This chapter delves into the complexities of violence and gender equity, specifically focusing on the under-five and adolescent age groups. We explore the underlying factors contributing to violence against children, the systemic barriers hindering gender equity, and the implications for achieving the SDG-5 targets. Additionally, we highlight successful interventions and best practices, along with recommendations for policy and practice to foster the development of a safer and more equitable environment for children. By addressing the interplay between violence, gender equity, and the SDGs, this chapter seeks to contribute to a broader understanding of the challenges and opportunities in India’s journey toward a more inclusive and equitable society for the children. Numerous research endeavors have delved into the correlation between violence, gender equality, and child well-being in India. The exposure to violence commences even before birth, particularly affecting girls. In their early stages of life, children endure direct abuse from primary caregivers and other family members (Know Violence in Childhood, 2017). Furthermore, domestic violence leaves a deleterious impact on children globally. Approximately one in five homicide victims among children is under the age of four. A staggering 78% of these homicides are perpetrated by parents in children under the age of one. Additionally, it is disheartening to observe that three out of every four children aged 1–14 years experienced corporal punishment (Nandakumar et al., 2017). The prevalence and determinants of violence against children in India were examined by several researchers (Daral et al., 2016; Malhotra, 2010; Patel et al., 2021; Vinay et al., 2022). Their findings revealed that children from marginalized communities, particularly girls, faced higher risks of violence due to factors such as poverty, low education levels, early marriage, and sexual and discriminatory practices. These studies emphasized the need for targeted interventions to address the disparities and protect children’s rights. These studies also underscored the need for gender-responsive policies, social norms changes, and empowerment programs to address violence and promote gender equity among children and adolescents. Further research explored the intersections of gender-based violence and child marriage in India (Girls Not Bride, 2022; Guedes et al., 2016; Ribas, 2020). The extant studies emphasized the cyclical nature of violence, demonstrating how child marriage perpetuates gender inequality and increases the risk of violence against girls. It also underscored the need for comprehensive strategies that address child marriage as both a cause and consequence of violence. Other studies explored prevalence, risk factors, and challenges associated with child sexual abuse in India (Kumar et al., 2017; Tyagi & Karande, 2021). Their studies emphasized on the importance of awareness, education, and multisectoral collaboration to protect children from sexual violence. Analysis of the prevalence, causes, and consequences of child labor in India highlights the need for comprehensive legislative measures, social protection policies, and education programs to eliminate child labor and promote the well-being of children (Kaur & Byard, 2016). The analysis of socio-economic factors influencing

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gender inequality in education in India highlighted the significant gender disparities in school enrollment and retention, attributing them to social norms, economic constraints, and cultural beliefs (Rammohan & Vu, 2018). It underscored the importance of addressing these factors to ensure equal access to education for all children, irrespective of their gender. In terms of interventions, the effectiveness of government initiatives and policies in promoting gender equity and reducing violence against girls has also been evaluated (Sharma, 2015). The research highlighted the positive impact of awareness campaigns and community mobilization in challenging gender stereotypes and empowering girls. However, it also emphasized the need for sustained efforts and multisectoral collaboration to address deeply ingrained social norms. These above studies collectively demonstrate the complex relationship between violence, gender equity, and the well-being of under-five and adolescent children. They provide valuable insights into the underlying causes, contributing factors, and potential strategies for intervention. By integrating these findings with our analysis, we contribute to the understanding of the challenges and opportunities in achieving SDG targets related to various facets of violence against children and gender equity in India. The remaining chapter is structured as follows. Section 6.2 examines the issue of sex ratio at birth and gender bias against girls. In Sect. 6.3, we shed light on child trafficking and its underlying drivers. Section 6.4 delves into the targets and achievements pertaining to key SDG-5 indicators. Government policies concerned with violence and gender equity are the main focus of discussion in Sect. 6.5. Section 6.6 provides conclusions based on the findings.

6.2 Sex Ratio at Birth and Bias Against Girls Sex ratio at birth (SRB) is a crucial indicator that reflects the balance between male and female births within a population. Internationally, SRB is typically measured as the number of male live births per 100 female births. The “natural” sex ratio at birth is considered to be around 105 boys per 100 girls. However, in the Indian context, SRB is measured as the number of female live births per 1000 male births. The SRB in India remains a matter of concern as it indicates the presence of gender bias and discrimination against the girl child. The SRB has shown some improvement over the years, which has increased from 919 in 2016 to 929 in 2021, but still suggests the existence of bias. The “natural” level of SRB would require 954 girls to be born per 1000 boys. One way to understand the impact of biased sex ratios is through the concept of “missing girls.” It refers to the number of girls who should have been born based on the natural sex ratio but are missing due to prenatal sex selection or other factors. In 2021, an estimated 2.5% [(954 − 929)/1000] of girls were missing which amounts to approximately 25 out of 954 girls. We analyze the SRB across major states in India. It becomes evident that some regions exhibit significant bias against the girl child (Fig. 6.1). In 2019–21, the states

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India Uttarakhand Karnataka Jammu & Kashmir West Bengal Assam Chhattisgarh Madhya Pradesh Gujarat Kerala Uttar Pradesh Andhra Pradesh Maharashtra Bihar Punjab Jharkhand Telangana Odisha Haryana Rajasthan Tamil Nadu Himachal Pradesh 750

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Fig. 6.1 State-wise sex ratio at birth. Source Authors’ calculation based on NFHS (different rounds)

with the lowest estimates of sex ratio at birth were Himachal Pradesh (875), Tamil Nadu (878), Rajasthan (891), and Haryana (893). These figures below 900 indicate that approximately 8% of girls were missing in Himachal Pradesh, while Tamil Nadu, Rajasthan, and Haryana had missing girls to the extent of 7.7%, 6.4%, and 6.2%, respectively (further discussed in Sect. 6.2.2). On the other hand, some states have showed more favorable SRB. Uttarakhand (984), Karnataka (978), and Jammu and Kashmir (976) had the highest SRB estimates in 2019–21. These states demonstrate desired gender balance among the newborns. Changes in SRB between 2015–16 and 2019–21 suggest that eight states experienced a deterioration in sex ratios (Fig. 6.2). The most significant improvements were observed in Uttarakhand (96 points) and Karnataka (68 points). Conversely, Kerala (− 96), Tamil Nadu (− 76 points), and Himachal Pradesh (− 62 points) witnessed the largest deteriorations in SRB. These numbers highlight the persistence of gender bias and discrimination against girls in several states, despite some progress in improving the sex ratio at birth at the national level. Addressing this issue requires comprehensive efforts that challenge deep-rooted societal norms, promote gender equality, and enforce strict measures to prevent prenatal sex selection and discrimination against the girl child.

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Uttarakhand Karnataka Haryana Jammu & Kashmir Gujarat Punjab Uttar Pradesh Assam Madhya Pradesh Telangana Andhra Pradesh West Bengal Rajasthan Maharashtra Chhattisgarh Jharkhand Bihar Odisha Himachal Pradesh Tamil Nadu Kerala

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Fig. 6.2 Changes in SRB between 2015–16 and 2019–21: state-level analysis. Source Authors’ calculation based on NFHS (different rounds)

6.2.1 Different Forms of Violence Against Child and Gender Inequality Ensuring the safety and well-being of every child is a core principle of the SDGs. However, in reality, many girls and boys around the world continue to suffer from various forms of gender-based violence, which not only robs them of their childhood but also jeopardizes their future prospects. Gender-based violence knows no boundaries and affects individuals across all socio-economic strata. Gender-based violence against children and adolescents takes various distressing forms, perpetuating cycles of discrimination, inequality, and harm. Child marriage remains a prevalent issue, denying children, especially girls, their right to education, health, and personal development. Sexual abuse and exploitation, including child sexual abuse, trafficking, and forced prostitution, expose children and adolescents to severe physical, emotional, and psychological consequences. Physical abuse, such as corporal punishment, inhibits children’s well-being and growth. Moreover, the prevalence of child labor subjects many children, particularly girls, to exploitative practices, depriving them of education and putting them at the risk of physical and

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emotional harm. Neglect and emotional abuse further compound the challenges, affecting children’s self-esteem, mental health, and overall quality of life. In the context of SDG-5, which focuses on achieving gender equality and empowering girls, India continues to face various manifestations of gender-based inequality. Limited access to education persists as a significant barrier, with girls facing discrimination, early marriage, cultural norms, and inadequate resources that impede their educational opportunities. Economic disparities further exacerbate gender inequality, as women and girls often encounter limited economic opportunities, unequal pay, and occupational segregation. Additionally, unequal decision-making power marginalizes women and girls, hindering their agency and voice in household, community, and societal contexts. Moreover, gender-based violence remains a critical challenge, affecting girls across various settings, including domestic violence, sexual harassment, and discrimination. Further, deep-rooted social norms, patriarchy, and discriminatory practices contribute to gender-based inequality and violence, inhibiting progress toward SDG-5. Additionally, the lack of safe spaces and support systems for survivors of gender-based violence further obstruct their ability to pursue justice and recover from the trauma they have experienced. While it is important to acknowledge the specific vulnerabilities faced by girls, it is essential to recognize that boys are also victims of gender-based violence and exploitation including trafficking and sexual violence. However, due to stigmatization and societal expectations, these cases are often underreported. Adolescent boys, especially those aged 10 and above, are at higher risk of unfair imprisonment and are often seen as security threats due to their alleged links with anti-social organizations. As a result, these boys may endure torture, abuse, a lack of adequate legal support, or find themselves subjected to living conditions that violate standards of juvenile justice. To address these grave violations, SDG-5 aims to end all forms of gender-based inequality and violence against children. Achieving these goals require collective action and comprehensive strategies that challenge harmful gender norms, promote gender equality, and ensure the protection and support of all children, regardless of their gender. By creating an environment that upholds gender equity, protects the rights of children and adolescents, and addresses gender-based violence, India can strive toward a more inclusive and just society, aligning with the vision set forth by SDG-5.

6.2.2 Missing Children in India The missing children statistics from the National Crime Records Bureau (NCRB) for 2016 and 2021 reveal several significant trends and patterns and shed light on the complex issue of child disappearances (Fig. 6.3). In-depth examination allows for a better understanding of the problem, and it can inform targeted interventions to address this pressing concern.

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14000 12000 10000 8000 6000 4000 2000 0 Madhya Pradesh West Bengal Delhi Bihar Tamil Nadu Maharashtra Telangana Uttar Pradesh Chhattisgarh Andhra Pradesh Rajasthan Karnataka Odisha Haryana Kerala Assam Gujarat Punjab Jharkhand Uttarakhand Jammu & Kashmir Himachal Pradesh Tripura Manipur Meghalaya Sikkim Nagaland Arunachal Pradesh Goa Mizoram

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Fig. 6.3 State-wise number and percentage share of missing children. Source Authors’ calculation based on National Crime Records Bureau Statistics

One notable trend has been the overall increase in the number of missing children from 63,407 in 2016 to 77,535 in 2021, representing a 22.2% rise over the five-year period. This increase is concerning, and it needs immediate attention from policymakers, law enforcement agencies, and society as a whole. While the improvements in reporting mechanisms and data collection might have contributed to the higher figures, the increase could also reflect a genuine rise in missing children cases. Several states consistently reported a high number of missing children in both the years. Madhya Pradesh, West Bengal, and Maharashtra stand out as states with significant challenges in this regard. Madhya Pradesh had the highest number of missing children in both years, with an increase from 8503 in 2016 to 11,607 in 2021. West Bengal had the second highest number of missing children, while Maharashtra reported a slight decrease from 4388 in 2016 to 4129 in 2021. These states not only had a large number of missing children but also held substantial percentage shares, with Madhya Pradesh accounting for 15.0% of all missing children cases in 2021, followed by West Bengal with 12.9%. These figures indicate a considerable burden in terms of child disappearances, which need emphasize in terms of focused efforts to address the issue in these states. On the other hand, Delhi witnessed a noteworthy decrease in both the number of missing children and its percentage share. The number of missing children in Delhi decreased from 6,921 in 2016 to 5,772 in 2021, representing a 16.6% decline. The percentage share of missing children in Delhi also decreased from 10.9% in 2016 to 7.4% in 2021. This decline may be attributed to efforts made to improve child safety measures, reporting mechanisms, and public awareness campaigns. The decrease indicates that effective interventions can make a difference in addressing child disappearances. However, despite this improvement, Delhi still remains a region of concern, given its relatively high percentage share of missing children. Regional disparities are apparent from the data, with states in central India, such as Madhya Pradesh and Chhattisgarh, consistently reporting a high number of missing children. Madhya Pradesh accounted for 13.4% of all missing children in 2016 and

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increased its share to 15.0% in 2021. Similarly, Chhattisgarh reported 3.6% of missing children in 2016, which rose to 4.2% in 2021 (Fig. 6.3). These regions may have faced unique challenges related to socio-economic conditions, population density, law enforcement effectiveness, and social support systems, which contribute to the higher incidence of child disappearances. Conversely, states in the northeast, such as Mizoram and Sikkim, reported zero missing children cases in both the years, indicating lower prevalence of the problem in these regions. While this may be a positive outcome, it is essential to critically examine the reasons behind such low numbers and to understand the factors that contribute to child safety in these regions. The issue of underreporting is also a concern, that is, the reported cases could be only a fraction of the actual number of missing children due to numerous cases not being reported due to social stigma, lack of awareness, fear of authorities, and mistrust in the justice system. Efforts should be made to encourage reporting and create a supportive environment for families to come forward when their children go missing. Strengthening community engagement, enhancing awareness campaigns, and establishing trust-building measures can contribute to addressing the underreporting issue. The analysis of missing children statistics in India reveals concerning trends, regional disparities, and potential areas for intervention. The increase in the overall number of missing children demands urgent attention from policymakers, law enforcement agencies, and society. Comprehensive strategies that focus on prevention, education, victim support, and law enforcement coordination should be implemented to effectively tackle this issue. A comparative picture of the distribution of missing children by gender across states in India is presented in Fig. 6.4. The gender disaggregated missing children data from NCRB report 2021 is used. The findings reveal important insights into the vulnerabilities faced by boys and girls in different states and highlight the need for targeted interventions. At the country level, 76.8% girls were missing as against 23.2% of boys (total 100%) highlighting higher vulnerability and specific challenges faced by girls in terms of their safety, protection, and well-being. 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0

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Fig. 6.4 Percentage of missing children by gender (2021). Source Authors’ calculation based on National Crime Records Bureau Statistics

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Some notable trends emerge at the state level. In states like Odisha, Chhattisgarh, West Bengal (e.g., 84.8% girls, 15.2% boys, total 100% at the state level), Bihar, Punjab, Rajasthan, Himachal Pradesh, Madhya Pradesh, and Andhra Pradesh, the percentage of missing girls is significantly higher than boys (Fig. 6.4). This indicates a higher vulnerability of girls to various forms of exploitation and trafficking. These states should prioritize measures to address the root causes of gender-based violence, promote girls’ education and empowerment, and enhance protective measures to ensure the safety and well-being of girls. On the other hand, in states like Arunachal Pradesh, the percentage of missing boys is much higher than girls. This could be attributed to unique factors such as migration, labor patterns, or cultural practices prevalent in these regions. It is crucial to understand the underlying causes and develop context-specific interventions at the state and district levels to protect boys from risks of forced labor or abduction. The contribution of missing girls to the total missing children population is particularly significant in states like West Bengal, Madhya Pradesh, Tamil Nadu, and Rajasthan. The contribution of missing girls to total missing girls (in the country) is the highest for Madhya Pradesh (15.8%) followed by West Bengal (14.3%). The former also has the highest share of missing boys. This highlights the urgent need to address gender-specific challenges faced by girls in these states. Measures should include community mobilization, improved access to education, vocational training, and creating safe spaces for girls to prevent their vulnerability to exploitation. To address this complex issues, a multidimensional approach is required. It includes strengthening law enforcement agencies’ capacity to respond effectively to missing children’s cases, improving coordination between different stakeholders, enhancing community engagement, and implementing preventive measures such as awareness campaigns, education programs, economic measures, and social support systems. Additionally, gender-specific interventions should be prioritized. This includes empowering girls through education and skill-building initiatives, ensuring access to healthcare services, and providing safe spaces that promote their overall well-being. Similarly, programs targeting boys should focus on preventing their involvement in criminal activities and addressing vulnerabilities associated with labor exploitation. The comparative analysis of gender disaggregated missing children data highlights the need for region-specific and gender-sensitive interventions. By addressing the root causes, enhancing protective measures, and improving awareness and reporting mechanisms, respective states can work toward ensuring safety, well-being, and rights of all children.

6.2.3 Crime Against Children We analyze the crime rate among children in Indian states for the years 2021 and 2016. The analysis highlights some of the worrisome trends involving crime against children. There has been an overall increase in crime against children, rising from

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22.4% in 2016 to 33.6% in 2021 (Fig. 6.5). This upward trajectory could be attributed, at least in part, to the profound effects of the COVID-19 pandemic and the subsequent lockdowns and disruptions experienced in 2021. The pandemic and its aftermath have significantly impacted the society, including children and their families. The economic downturn resulting from the pandemic has further led to increased financial strain, unemployment, and livelihood uncertainties for many households. These socio-economic challenges contributed to heightened stress levels and strained family dynamics, potentially creating an environment conducive to the occurrence of crimes against children. Furthermore, the restrictions imposed during the lockdowns may have inadvertently reduced children’s access to external support systems, such as schools, friends, and community activities, thereby increasing their vulnerability to crimes. Additionally, the shift to virtual platforms and increased reliance on technology during this period may also have exposed children to new risks, including online exploitation, cyberbullying, and grooming. There has been an increase in the crime rate, indicating a rise in offenses committed against children in many states (Fig. 6.5). Several states, including Sikkim, Madhya Pradesh, Haryana, Chhattisgarh, Odisha, Telangana, Kerala, Maharashtra, Assam, Karnataka, Meghalaya, Himachal Pradesh, Uttarakhand, West Bengal, among others, reported higher crime rates in 2021 compared to 2016. This has been a worrying escalation in crimes against children across these states. On the contrary, Delhi, Goa, Mizoram, Tripura, and Nagaland have witnessed a decline in reported crime against children in 2021 as compared to 2016. Notably, Delhi stands out with a decrease in the crime rate among children from 146 per one lakh population in 2016 to 128.5 per one lakh population in 2021. However, it is important to note that despite the decrease, the crime against children in Delhi remains significantly high compared to other states, which highlights the need for continued efforts to address the issue. 160

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Fig. 6.5 Total crime against children in India (per 100,000, and % change). Source Authors’ calculation based on National Crime Records Bureau Statistics

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It is important to recognize that the COVID-19 pandemic has created exceptional circumstances that have impacted the overall societal dynamics, including crime patterns. Addressing the increase in crimes against children necessitates a multifaceted approach that involves strengthening child protection systems, promotes awareness about child rights and safety, and provides support services to vulnerable children and families. It is crucial for policymakers, communities, and stakeholders to work together to address the factors contributing to these crimes so as to create a safer environment for children in the post-pandemic era. Different forms of crime against children in 2021 reveal a deeply concerning situation that demands critical attention and action (Fig. 6.6). The high percentage of kidnapping cases (49.0%) signifies the alarming vulnerability of children to abduction and forced removal from their families. This highlights the urgent need for effective measures to enhance child protection, prevent kidnappings, and ensure swift and efficient response mechanisms to recover abducted children. Furthermore, significant proportion of crimes falling under the Protection of Children from Sexual Offences (POCSO) Act (36.4%) indicates the substantial prevalence of sexual abuse and exploitation faced by children in the country. This highlights the dire need for comprehensive awareness and stringent enforcement of child protection laws to combat these heinous crimes and provide support to the victims. The presence of human trafficking cases (9.0%) also raises serious concerns about the exploitation and trafficking of children, both within and across borders. This underscores the necessity of robust anti-trafficking measures, including preventive strategies, victim support services, and international cooperation, to dismantle trafficking networks and safeguard vulnerable children. The percentages of murder (2.1%), feticide (2.0%), procuration of minor girls (1.8%), abandonment (0.5%), and infanticide (0.1%) reflect the sad reality of violence and grave harm inflicted 2.0 2.1

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Fig. 6.6 Different forms of violence against children in India—2021 (%). Source Authors’ calculation based on National Crime Records Bureau Statistics

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upon children. Each of these forms of crime represents a severe violation of children’s rights and emphasizes the urgency to address the underlying economic and societal issues that contribute to such acts. It is crucial for authorities, policymakers, and communities to critically assess the factors leading to such crimes against children and develop holistic strategies to prevent and respond to them effectively. This entails comprehensive legal frameworks, targeted interventions, public awareness campaigns, improved child protection systems, local economic development, and collaborations among various stakeholders to create a safer environment for children in the country. Protecting children from all forms of harm should be a top priority, ensuring their well-being, development, and right to a safe and secure childhood. The total number of girl child victims reported under the POCSO Act in India in 2021 was 32,994 out of total victim children of 33,503. The shares of girl child victims reported under the POCSO Act in each state are presented in Fig. 6.7. The number of girl child victims under the POCSO Act varies significantly across states. Madhya Pradesh (10.7%) has the highest share, followed by Maharashtra (10.6%), Tamil Nadu (10.4%), Uttar Pradesh (8.3%), Karnataka (6.3%), Gujarat (6.3%), among others. It is important to note that some states report zero cases of girl child victims under the POCSO Act, such as Goa, Arunachal Pradesh, Himachal Pradesh, and Rajasthan (Fig. 6.7). This might be due to variations in reporting mechanisms, awareness levels, or challenges in identifying and reporting such cases. Out of the total victims of murders, 5% of them were children below 18 years. However, among the victims of kidnaping and abduction, 66% of them were children. Further, out of total victim children of kidnaping and abduction, 84% were girls. Among the states Maharashtra, Madhya Pradesh, Uttar Pradesh, and West Bengal have relatively high rates of girl child victims of kidnapping and abduction (Fig. 6.8). This suggests that these states have higher incidence of such crimes, posing a significant concern for girl child safety and security. The figure highlights significant regional variations in the rates of girl child victims. States in northern and central 12.00 10.00 8.00 6.00 4.00 2.00 Rajasthan

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Fig. 6.7 Share of victim girls under POSCO in India (in 2021) out of total victim children. Source Authors’ calculation based on National Crime Records Bureau Statistics

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Fig. 6.8 State-wise share of girl child victims of kidnaping and abduction in 2021 (out of total victim children). Source Authors’ calculation based on National Crime Records Bureau Statistics

India, such as Uttar Pradesh and Madhya Pradesh, have relatively higher crime rates compared to southern states like Tamil Nadu and Kerala (Fig. 6.8). Various factors have contributed to these unfortunate incidents of the kidnapping of children (Fig. 6.9). One of the categories mentioned is “Missing Deemed Kidnapped,” which accounted for 34% of the cases. It refers to the cases where children are reported missing and are presumed to have been kidnapped. This category encompasses situations where children have been forcibly taken or abducted without a specific motive or reason being mentioned. Another significant reason mentioned is “Marriage,” representing 25% of the cases. This indicates that a considerable number of children are kidnapped with the intention of forcing them into early marriages. Child marriage remains a prevalent issue in certain regions of the country, where mainly girls are taken against their will and compelled to enter into marriages at an early age that is not appropriate for the Act from the point of view of their well-being and development. The figure also lists “Elopement,” accounting for 12% of the cases, which involve cases where children voluntarily leave their homes to elope with someone. While not necessarily involving force or abduction, elopement is categorized as a form of kidnapping in this context, as the children are leaving without the consent of their families or guardians. Additionally, the category “Left home by own will” represents 10% of the cases, suggesting that some children choose to leave their homes without any external coercion or influence. These instances could arise from difficult or abusive family circumstances, where children seek to escape and find independence elsewhere. The presence of “Family Disputes” is cited as a reason in 2.8% of the cases, which indicates that a small percentage of kidnappings occurs due to conflicts or disputes within families. These cases may involve one parent taking his/her child during custody battles or due to disagreements among family members. Other reasons cited include “For Illicit Intercourse” (1.4%), “For Unlawful Activity” (1.1%), “Wrongful Confinement” (0.9%), “Domestic Servitude” (0.5%), and

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Fig. 6.9 Reasons for kidnapping of children (%). Source Authors’ calculation based on National Crime Records Bureau Statistics. Note Other includes ransom, revenge, prostitution, adoption, begging, loan recovery, other motive

“Forced Labor” (0.3%). These reasons highlight the grave exploitation that children can be subjected to, whether it is for engaging in sexual exploitation, illegal activities, or various forms of servitude. Understanding the reasons behind child kidnappings is crucial for developing effective prevention strategies and protective measures. It is essential to address these underlying issues, such as child marriage, family conflicts, and the vulnerability of children to exploitation. By raising awareness, strengthening law enforcement, and implementing supportive interventions, states can work toward ensuring the safety and well-being of children, protecting them from the devastating consequences of kidnapping.

6.2.4 Child Marriage The phenomenon of child marriage, particularly of girls, that is, marriage before the legal age of 18 years, is recognized as a significant problem (Chatterjee, 2011; Kumar, 2020). It has a cascading effect on the overall well-being of women and their offspring, restricting women from accessing education, skills, resources, and autonomy, thereby making them more vulnerable to physical and sexual abuse. In 2019–21 (NFHS-5), there were four states where 30% or more women were subjected to child marriage (Fig. 6.10). This percentage was found to be the highest in West Bengal (41.6%), Bihar (40.8%), Jharkhand (32.2%), and Assam (31.8%). Between NFHS-4 and NFHS-5, there has been no changes in child marriage prevalence in

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Fig. 6.10 States-wise percentages of women in the age group of 20–24 years married before the age of 18 years (2015–16 and 2019–21). Source Authors’ calculation based on National Family and Health Survey (different rounds)

West Bengal, while in Bihar there was only 1.7% point reduction. The ongoing efforts by these state governments to restrict child marriage and increase the educational attainments of women, which has otherwise achieved reasonable demographic performance in recent years, do not seem to be working, or the impact is not reflected in terms of an actual reduction in child marriage. On the positive side, less than 10% of the women are subjected to child marriage in states like Uttarakhand, Punjab, Kerala, Himachal Pradesh, and Jammu and Kashmir. Between 2015–16 and 2019–21, the major reduction in child marriage is seen in Rajasthan (10% points), Chhattisgarh (9.2% points), Madhya Pradesh (9.3% point), and Haryana (6.9% points). Women who gets married at early ages also faces the risk of early pregnancy, which could cause irreparable damage to the overall health of both the mother and the child (Chari et al., 2017; Paul et al., 2019). Early marriage also leads to discontinuation of education for women. The lack of education and poor economic status could further lead to child marriage (Binu et al., 2022; Kumari & Shekhar, 2023; Paul, 2019). Even in the case of boys, education, caste and social norms, place of residence, and wealth status played a role in propagating early marriage among boys (Chauhan et al., 2020).

6.3 Child Trafficking and Its Drivers Female victims continue to bear a disproportionate burden of the scourge of trafficking of person. Global data reveals that out of every 10 detected victims, approximately five were adult women and two were girls (UNODC, 2018). Moreover, children comprised of around one-third of the total detected victims, with girls constituting 19% and boys accounting for 15%. Adult men constituted 20% of the victims.

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These statistics highlight the significant impact of trafficking on women and girls, thereby emphasizing the need for targeted interventions to address this gendered issue (UNODC, 2020). Despite numerous commitments made in national and international policy documents to safeguard and promote the well-being of children, significant gaps were found to persist between these goals and the actual situation on the ground (Mehta & Arora, 2015). The National Policy for Children (2013) has made a strong commitment to protect children from all forms of violence, exploitation, and abuse, including economic and sexual exploitation, trafficking, and other harmful activities that infringe upon their rights and hinder their development. However, obtaining accurate data on the nature and extent of vulnerability and exposure to these vitious situations is challenging. Existing data often underestimates the need for protection among vulnerable and exploited children who may lack family support, live in poverty, face community pressures, or endure abuse and ill-treatment within their own families (Mehta & Arora, 2015). To comprehend the multifaceted issue of child trafficking, it is essential to define the key terms and understand the different elements involved. The United Nations Office on Drugs and Crime (UNODC) outlines three essential components of child trafficking. Firstly, it involves the actions of recruiting, transporting, harboring, or receiving individuals. Secondly, the means of trafficking encompass threats, coercion, abuse of power, or targeting victims with vulnerabilities. Lastly, the purpose of trafficking includes heinous acts such as sexual exploitation, forced labor, slavery, and organ removal (Hodge & Lietz, 2007; UNODC, 2012, 2014). Child trafficking is deeply interconnected with issues such as illiteracy and increased urbanization. Reports by the National Human Rights Commission indicate that 71% of trafficked children were illiterate (Darsha, 2013). The process of urbanization has also contributed to the rise in trafficking across the country (Haq, 2016). Moreover, adolescent girls often leave their homes in search of better employment opportunities to support their families (ibid.). In the process, many of them could end up becoming victims of trafficking. Trafficking involves the exploitation and control of the vulnerable children, depriving them of their freedom and dignity, and forcing them to indulge in labor for commercial gain. It primarily targets innocent children and involves adults who are aware of and complicit in the exploitation of victims. Various factors contribute to the vulnerability of individuals to trafficking, which include regional and developmental inequalities, differences between industrialized and agrarian societies, high levels of poverty and deprivation, caste/class disparities, unemployment, labor migration, gender inequality, gender-based violence, and marginalization. These factors are often referred to as push and pull factors in the study of human trafficking. Uneven growth and development, economic crises, political instability, natural disasters, conflicts, gender inequality, gender-based violence, ethnic marginalization, and disparities in market economy development contribute to increased migration and, in its most severe form, human trafficking of underaged individuals. Child trafficking in India is a multifaceted issue influenced by various pull and push factors (Upadhyay, 2021, Vidushy, 2016). These studies underscore the demand

6.4 SDG-5 Targets and Achievement in Key Indicators

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for cheap labor as a significant pull factor, which is driven by poverty and limited economic opportunities. Families in desperate need of financial means may be lured by deceptive recruitment practices, exposing their children to trafficking networks. The push factors include social exclusion and poverty and lack of education (Alexis, 2015; Gezie et al., 2021), which render marginalized children more vulnerable to exploitation by traffickers. These studies emphasize the need to address these underlying vulnerabilities to prevent child trafficking. Furthermore, armed conflicts and natural disasters exacerbate push factors, as documented by UNODC (2016), which highlights the increased vulnerability of children due to displacement, loss of livelihoods, and breakdown of social structures. These adverse conditions create an environment where children seek safety and support, making them easy targets for traffickers. Various theoretical perspectives provide insights into the phenomenon of human trafficking. Migration-based approaches analyze migration patterns, unemployment rates, availability of work in destination areas, globalization, and development strategies (Habibullah, 2021; ILO, 2015). Human rights-based approaches view trafficking through the lens of human rights laws, criminal justice systems, corruption, and state failure to protect the rights, liberties, and welfare of the most vulnerable citizens (UNHR, 2011). Feminist researchers address these issues while examining the intersectionality of sex, class, caste, and power dynamics, recognizing the exploitation and harm experienced by girls and women (Jennifer, 2009). Male demand is also recognized as a significant pull factor in trafficking. To combat child trafficking effectively, comprehensive strategies are needed that can address its underlying causes and provide protection, support, and rehabilitation to victims. Efforts should include strengthening law enforcement, raising awareness, promoting education, empowering vulnerable communities, creating local employment opportunities, and addressing gender inequalities and social disparities. By implementing the principles of the SDGs and working collaboratively, a safer and more just world can be created for all children, that is, free from the horrors of trafficking.

6.4 SDG-5 Targets and Achievement in Key Indicators Target 5.1 Achieve a Sex Ratio at Birth of 954 Females per 1000 Males Some of the states have made significant progress in improving the sex ratio at birth. For instance, Uttarakhand and Karnataka have demonstrated significant improvement in SRB. Kerala, even though experienced a decline, continues to have a favorable sex ratio at birth, surpassing the target of 954 females per 1000 males. This achievement can be attributed to various factors, including education, awareness, migration, and implementation of girl child-friendly policies. Haryana, which previously had a very low sex ratio at birth, has shown improvement in recent years albeit the SRB in the state still remains much below the desired target. Through campaigns, stricter

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enforcement of laws, and awareness programs, the state has witnessed a positive change in improving gender equality measured by SRB. Despite progress by some of the states, many states continue to face challenges in achieving the desired SRB. Several states, including Punjab (904), Haryana (893), Himachal Pradesh (875), Odisha (894), and Rajasthan (891) among others, still grapple with imbalanced sex ratios, indicating a prevalence of preference for male child. Social and cultural factors, such as son preference, patriarchal norms, and dowry practices, contribute to the persisting gaps in achieving the target SRB. These deeply ingrained attitudes and practices pose challenges in achieving this SDG5 target. Limited access to healthcare, including inadequate prenatal care and the misuse of technology for sex determination, could also contribute to the imbalanced SRB in some of these states. Target 5.2: Eliminate All Forms of Violence Against All Children With reference to the SDG target of eliminating violence, an overall increase in the number of missing children in India could be observed during 2016 and 2021. This trend is of concern, and it needs immediate attention from policymakers and law enforcement agencies. Certain states, such as Madhya Pradesh, West Bengal, and Maharashtra, consistently reported a higher number of missing children. These states require targeted efforts to address the violence against children effectively. On the other hand, several states witnessed a notable decrease in the number of missing children (such as Delhi, Karnataka), which indicates to the positive impact of efforts to improve child safety measures. Another concern in achieving this target lies in the presence of significant gender disparities in missing children in which girls are predominantly missing compared to boys. This points to the serious vulnerability of girls to various forms of exploitation and trafficking. This necessitates focused interventions to protect their rights and well-being. Our analysis reveals an alarming increase in crime rates against children across several states. Kidnapping cases constitute a significant proportion, emphasizing the vulnerability of children to abduction and forced removal from their families. Sexual offenses against children and human trafficking cases also reflect depressing realities in several states. There is urgent need to address crime against children through comprehensive legal frameworks, enforcement of child protection laws, education, and awareness programs. In sum, our analysis indicates both achievements and gaps with reference to SDG targets 5.1 and 5.2. While some states have shown good progress in reducing violence against children and creating a safer environment, there are others where significant challenges persist due to an increase in the number of missing children as well as rising crime rates. The findings underscore the need for targeted interventions, improved reporting mechanisms, effective law enforcement, community mobilization, and comprehensive strategies to protect children against violence and ensure their personal development and educational attainment (refer Chap. 5 on ensuring quality education).

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6.5 Government Policy Addressing Violence and Gender Equity Gender-based violence against children is a grave issue that has long-lasting physical, emotional, and psychological effects. Recognizing the urgent need to address these problems, the Government of India has implemented several programs and policies aimed at combating gender-based violence and promoting gender equity among children. These policies encompass legislative measures, awareness campaigns, support services, and collaborations with various stakeholders. Some of the important measures are listed below. 1. Protection of Children from Sexual Offences (POCSO) Act: The POCSO Act, enacted in 2012, is a comprehensive legal framework that provides protection to children against sexual offenses, including rape, molestation, and pornography. It ensures stringent punishment for offenders and includes provisions for childfriendly procedures during investigation, trial, and rehabilitation. The Act also emphasizes the importance of reporting and encourages the establishment of special courts for speedy disposal of cases. 2. Beti Bachao, Beti Padhao (Save the Girl Child, Educate the Girl Child): Launched in 2015, this campaign aims to address the declining child sex ratio and promote education among girls. By raising awareness about the value of the girl child and combating gender-based violence, this initiative seeks to empower girls to create a more equitable society. It includes measures such as conditional cash transfers, girls’ education schemes, and community mobilization efforts. 3. Integrated Child Protection Scheme (ICPS): ICPS, initiated in 2009, focuses on preventing and responding to violence against children, including genderbased violence. It aims to create a protective environment by strengthening child protection systems, promoting community participation, and providing support services. ICPS facilitates the establishment of child-friendly institutions, crisis intervention centers, and rehabilitation programs for victims. 4. One-Stop Centers (OSC): To provide integrated support services for survivors of violence, OSCs were established under the Ministry of Women and Child Development. These centers offer medical assistance, legal aid, counseling, and rehabilitation services, ensuring that survivors have access to a range of resources under one roof. OSCs play a crucial role in addressing gender-based violence against children and promoting their overall well-being. 5. Nirbhaya Fund: In response to the heinous 2012 Delhi gang rape incident, the government established the Nirbhaya Fund to support initiatives aimed at enhancing the safety and security of women and children. The fund provides financial assistance for projects focused on preventing violence, improving infrastructure, and strengthening support systems. Several initiatives under the Nirbhaya Fund directly benefit children and contribute to combating gender-based violence.

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The Government of India has made significant strides in addressing gender-based violence against children and promoting equity through various programs, policies, and initiatives. The implementation of the POCSO Act, Beti Bachao, Beti Padhao campaign, ICPS, One-Stop Centers, and the Nirbhaya Fund highlights the commitment to protect children, provide support services, and create a safe and equitable environment for their development. Child helplines have also been made operational across different states. However, there is still much work to be done to ensure the effective implementation and monitoring of these policies and programs, as well as to strengthen the collaboration among government bodies, civil society organizations, and communities. By continuing to prioritize the fight against gender-based violence, and promoting gender equity, India can create a better future for her children, free from violence and discrimination, and achieve SDG-5 goals in time.

6.6 Conclusion and Way Forward In conclusion, our analysis of violence and gender equity in the context of SDG-5 progress in India reveals some of the imminent challenges and areas for improvement. The sex ratio at birth continues to be biased against girls, with some states exhibiting a more significant bias than others. Efforts to address gender bias and discrimination against girls should include improving societal norms, promoting gender equality, and enforcing measures to prevent any prenatal sex selection and discrimination. We highlight the increase in the number of missing children in India as some of the states continue to consistently report high numbers. Efforts to address child disappearances should focus on improving reporting mechanisms, data collection, and targeted interventions in states with a high burden of missing children. Regional disparities in missing children cases also require immediate attention, with central Indian states facing unique challenges compared to the northeastern states. The analysis of crime against children reveals an overall increase in crime rates. There is urgent need to protect children from various forms of exploitation and harm. Kidnapping, sexual offenses, and human trafficking remain significant concerns, highlighting the importance of effective child protection measures, comprehensive education, awareness, and stringent enforcement of child protection laws. The number of girl child victims under the POCSO Act underscores the vulnerabilities and specific challenges faced by girls, calling for targeted interventions and support services. Child marriage also remains a pressing issue in certain regions, affecting the wellbeing and potential of girls. Efforts to combat child marriage should focus on raising awareness, improving access to education, creating employment prospects, and addressing the underlying societal factors that contribute to this undesired practice. Going forward, addressing violence and gender equity in relation to SDG-5 requires a multifaceted approach. The approach shall involve comprehensive efforts to challenge gender biases, promote gender equality, improve reporting mechanisms, strengthen child protection systems, enhance law enforcement effectiveness,

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improve employment prospects, and provide support services for victims. Collaboration between government agencies, policymakers, civil society organizations, and communities is crucial to create a safer environment for children, ensure their wellbeing, and protect their rights. Continued monitoring, evaluation, and data gathering will be essential to assess the impacts of the interventions and to identify areas that would require further attention. By prioritizing the safety, protection, and empowerment of all children, regardless of their gender or social identity, India can work toward achieving SDG-5 and creating a more inclusive and equitable society in which children would experience holistic development.

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Chapter 7

Child Well-Being and SDG Status of Indian States

7.1 Introduction Monitoring progress toward the SDG targets and understanding their status in relation to the well-being of children in India states are crucial. We assess whether the child-specific SDGs will be achieved by 2030 by extrapolating the observed rates of change in the target parameters. In this chapter, we present an assessment of the Indian states and Union Territories (UT) based on their progress toward meeting the SDGs targets related to under-five and adolescent children. Our analysis is based on data from the National Family Health Surveys for the years 2015–16 and 2019–21 and UDISE Plus, which provide valuable insights into the status of various SDG related indicators in the specific domains of SDG-1, SDG-2, SDG-3, SDG-4, SDG5, SDG-6, SDG-7, and SDG-16. The survey conducted during the period of 2015–16 aligns with the worldwide adoption of the Sustainable Development Agenda, serving as a benchmark for our evaluation. In this assessment, we focus on more than 30 indicators associated with the eight identified goals out of the total 17 SDGs. These indicators cover a wide range of dimensions related to child well-being and provide a comprehensive understanding of the progress made by each state. By examining the state-level data, we aim to identify priority areas for improvement and guide policymakers and governments in formulating effective strategies to address the challenges faced by children in different regions of India. In the previous chapters we have explored the progress made across states, socioeconomic classes, genders, and places of residence, providing a detailed analysis of indicator-wise advancements. In this chapter, our focus shifts to the SDG progress made by individual states based on their respective base values (in the year 2015–16). By analyzing these values, we can better understand the starting point of each state and determine the extent of progress achieved till 2021–22. The detailed methodology for assessing the progress of the states in terms of achieving SDG targets in each dimension is provided in Appendix of the Chapter.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_7

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To have a comprehensive evaluation of child well-being, we develop an overall achievement score for the years 2015–16 and 2019–21. The methodology of construction of child well-being index is also given in Appendix. This score enables us to compare and rank the states based on their performance in meeting the SDG targets. By identifying the states that have made significant strides and those that require more attention, public policies can be directed to prioritize interventions and resource allocation to ensure that no child is left behind. Our assessment presented in this chapter aims to provide policymakers, governments, organizations, researchers, and stakeholders with a thorough awareness of India’s existing status of child well-being. By highlighting the progress made by each state and identifying areas that require urgent attention, targeted interventions and policies can be adopted which will contribute to the overall improvement of children’s lives across the country, by keeping children at the forefront of the development agenda.

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators 7.2.1 Multidimensional Poverty (SDG-1) Status with Reference to Under-Five and Adolescent Children The analysis of multidimensional poverty among under-five and adolescent children in India provides valuable insights into the SDG progress made across different states. By examining the data, we identify states that have achieved their SDG targets, states with weak progress, states facing insufficient progress, and states that are “on track” to achieve the targets by 2030. In the case of multidimensional poverty among under-five children, four states and UTs are found to have achieved their target early (Table 7.1). This indicates that these states (Goa, Kerala, Tamil Nadu, and Lakshadweep) have successfully reduced multidimensional poverty to the desired level. On the other hand, six states have shown a very insignificant growth rate, meaning that their current rate of decline in multidimensional poverty is much lower than the required rate of decline to meet the target by 2030. Another six states have shown a weak progress, with their present growth rate lower than the required rate. Nevertheless, 20 states are “on track” to achieve the goal by 2030, as their present rate of decline is higher than the required rate of decline. In the case of adolescent children, 18 states and UTs have made significant progress and achieved their SDG targets of reducing multidimensional poverty. This demonstrates their successful efforts in improving the well-being of adolescents. The remaining 16 states and UTs are “on track” to reduce the level of multidimensional poverty among adolescent children by 2030, indicating positive progress and alignment with the SDG targets.

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Table 7.1 SDG status of under-five and adolescent multidimensional poverty State/UT

Under-five

Adolescent

Andaman & Nicobar Islands

On track

Achieved

Andhra Pradesh

On track

Achieved

Arunachal Pradesh

On track

Achieved

Assam

Weak

On track

Bihar

Insufficient

On track

Chandigarh

On track

On track

Chhattisgarh

On track

On track

Dadra & Nagar Haveli and Daman & Diu

On track

Achieved

Delhi

On track

Achieved

Goa

Achieved

Achieved

Gujarat

Insufficient

On track

Haryana

On track

Achieved

Himachal Pradesh

Weak

Achieved

Jammu & Kashmir

On track

Achieved

Jharkhand

Insufficient

On track

Karnataka

On track

Achieved

Kerala

Achieved

Achieved

Lakshadweep

Achieved

On track

Madhya Pradesh

On track

On track

Maharashtra

On track

Achieved

Manipur

On track

On track

Meghalaya

Insufficient

On track

Mizoram

On track

Achieved

Nagaland

Weak

On track

Odisha

On track

On track

Puducherry

On track

Achieved

Punjab

On track

Achieved

Rajasthan

On track

On track

Sikkim

On track

Achieved

Tamil Nadu

Achieved

Achieved

Telangana

Weak

On track

Tripura

Weak

On track

Uttar Pradesh

Insufficient

On track

Uttarakhand

On track

Achieved

West Bengal

Insufficient

On track

All India

Weak

On track

Source Authors’ Calculation based on NFHS-4 and NFHS-5

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7 Child Well-Being and SDG Status of Indian States

These findings highlight the variation in progress across different states and underscore the importance of targeted interventions and policies particularly for the underfive children to address multidimensional poverty among children. By learning from the success stories of states that have achieved their targets, and by continuing efforts in states that are “on track” or facing challenges, Indian states can work toward reducing multidimensional poverty and thereby improve the lives of under-five and adolescent children.

7.2.2 Nutrition (SDG-2) A mixed picture of SDG achievement in relation to child nutrition can be seen from stunting, wasting, overweight, and anemia prevalence in various states of India. While some states have progressed well and are “on track” to meet the targets, others face challenges with weak or insufficient growth rates. Among the 35 states and UTs in India, nine states are making steady progress and are “on track” to achieve the SDG target for stunting by 2030. However, 10 states have experienced a slower growth rate, indicating challenges in reaching the SDG target by 2030. Additionally, five states have shown an insufficient growth rate, raising concerns about their ability to achieve the SDG targets. Notably, 11 states have witnessed an increase in stunting between 2015–16 and 2019–21, implying a worsening of situation and posing significant obstacles in achieving the stunting-related SDG goal by 2030. It is important to note that Puducherry is the only state/UT that has already achieved the SDG stuntingrelated target, demonstrating exemplary progress in addressing this issue. When it comes to wasting among under-five children, only three states/UTs have made noteworthy strides in reducing the percentage of wasted children and are “on track” to achieve the SDG goal by 2030. On the other hand, another three states have shown a weak growth rate in reaching the SDG wasting-related target for underfive children. Importantly, 11 states have demonstrated an insufficient growth rate, indicating challenges in achieving the SDG wasting-related target by 2030. However, the remaining 11 states have experienced an increase in the number of wasted children during this period, implying a worsening of situation (Table 7.2). Urgent attention and interventions are required in these states to address this concerning trend. In the case of overweight among under-five children, majority of the states have already achieved the SDG target. However, between 2015–16 and 2019–21, these states have experienced an increase in the number of overweight children. It is crucial for these states to take timely corrective action to prevent further deterioration. Out of the 35 states and UTs, 28 fall into this category. The remaining 7 states have also witnessed an increase in overweight children, but they are far from reaching their SDG target and are experiencing a worsening of situation. Urgent attention and targeted interventions are required in these states to address the growing issue of overweight among children.

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

165

Table 7.2 SDG achievement in nutrition related indicators for under-five and adolescent children State/UT

Under-five stunting

Under-five wasting

Under-five overweight

Anemia_(15–19) girls

Andaman & Nicobar Islands

On track

Insufficient

Need action

On track

Andhra Pradesh

Weak

Insufficient

Need action

Insufficient

Arunachal Pradesh

Weak

Insufficient

Worsen

Insufficient

Assam

Insufficient

Worsen

Need action

Worsen

Bihar

Insufficient

Worsen

Need action

Worsen

Chandigarh

On track

Insufficient

Need action

On track

Chhattisgarh

Insufficient

Insufficient

Need action

Worsen

Dadra & Nagar Haveli and Daman & Diu

Insufficient

Insufficient

Need action

On track

Delhi

Weak

Weak

Need action

On track

Goa

Worsen

Insufficient

Need action

Worsen

Gujarat

Worsen

Insufficient

Need action

Worsen

Haryana

On track

On track

Need action

Insufficient

Himachal Pradesh

Worsen

Worsen

Need action

Worsen

Jammu & Kashmir

Weak

Worsen

Worsen

Worsen

Jharkhand

Weak

Insufficient

Need action

Worsen

Karnataka

Insufficient

Insufficient

Need action

Worsen

Kerala

Worsen

Insufficient

Need action

On track

Lakshadweep

Worsen

Worsen

Worsen

On track

Madhya Pradesh

Weak

Insufficient

Worsen

Worsen

Maharashtra

Worsen

Insufficient

Need action

Worsen

Manipur

On track

Worsen

Need action

Worsen

Meghalaya

Worsen

Weak

Need action

Insufficient

Mizoram

Weak

Worsen

Worsen

Worsen

Nagaland

Worsen

Worsen

Need action

Worsen

Odisha

Weak

Insufficient

Need action

Worsen

Puducherry

Achieved

On track

Need action

Worsen

Punjab

On track

On track

Need action

Worsen

Rajasthan

On track

Insufficient

Need action

Worsen

Sikkim

On track

Insufficient

Worsen

Worsen

Tamil Nadu

On track

Insufficient

Need action

Worsen

Telangana

Worsen

Worsen

Need action

Worsen

Tripura

Worsen

Worsen

Worsen

Worsen

Uttar Pradesh

Weak

Insufficient

Need action

Insufficient

Uttarakhand

On track

Weak

Need action

Weak (continued)

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7 Child Well-Being and SDG Status of Indian States

Table 7.2 (continued) State/UT

Under-five stunting

Under-five wasting

Under-five overweight

Anemia_(15–19) girls

West Bengal

Worsen

Worsen

Need action

Worsen

All India

Weak

Insufficient

Need action

Worsen

Source Authors’ Calculation based on NFHS-4 and NFHS-5

The prevalence of anemia among 15–19-year-old girls in several states exceeds the SDG target, and unfortunately, the rates have shown either weak growth or insufficient improvement between the two periods analyzed. Out of the 36 states and UTs, only six are currently “on track” to achieve the SDG target for anemia among adolescent girls by 2030. These states have demonstrated the required growth rate necessary to reach the target. On the other hand, six states have a very insufficient growth rate, while one state has a very weak growth rate in addressing anemia among adolescent girls. These states face significant challenges in achieving the SDG target and require focused interventions and strategies to accelerate progress. Most importantly, 23 states and UTs have experienced an increase in the prevalence of anemia among adolescent girls, indicating a deterioration of condition. This trend is concerning and calls for immediate attention and comprehensive efforts to tackle the root causes of anemia and improve the health outcomes of these girls. Addressing anemia among 15–19-year-old girls remains a critical priority, as it has far-reaching implications for their overall health and well-being. Efforts should be focused on implementing targeted interventions, such as nutrition programs, access to healthcare, and awareness campaigns, to effectively address anemia and improve the condition of adolescent girls across all states.

7.2.3 Health (SDG-3) Diverse levels of progress and achievement in meeting the SDG targets can be observed from the analysis of child-related health indicators. In terms of the Neonatal Mortality Rate (NMR), seven states have already achieved the SDG target relating to NMR, while six states are “on track” to achieve the goal by 2030. However, seven states have experienced a weak rate of decline in NMR, indicating slower progress in reducing neonatal mortality. Additionally, another six states have shown an insignificant rate of decline, which implies that their current rate of progress is not sufficient to achieve the target by 2030 (Table 7.3). It is surprising to note that nine states have witnessed an increase in the NMR during the given period, exacerbating their situation and posing challenges to the SDG target achievement. Regarding under-five mortality, nine states have successfully achieved their targets, demonstrating significant progress in reducing the mortality rates among under-five children. Furthermore, eight states are “on track” to achieve the goal by

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

167

Table 7.3 SDG achievement status in health related indicators for under-five and adolescent children State/UT

NMR

U5MR

Immunization Institutional Skilled Adolescent delivery birth rate pregnancy

Andaman & Nicobar Islands

Worsen

Worsen

Weak

Achieved

On track

Insufficient

Andhra Pradesh

Weak

On track

Weak

On track

On track

Worsen

Arunachal Pradesh

Achieved

Achieved

On track

On track

On track

Insufficient

Assam

On track

On track

On track

On track

On track

Insufficient

Bihar

Insufficient Insufficient On track

On track

On track

Insufficient

Chandigarh

Achieved

Weak

On track

On track

On track

Chhattisgarh

Insufficient Weak

Weak

On track

On track

Insufficient

Achieved

Dadra & Worsen Nagar Haveli and Daman & Diu

Weak

On track

On track

On track

Insufficient

Delhi

Weak

On track

Weak

On track

On track

Worsen

Goa

Worsen

Achieved

Worsen

Achieved

On track

Insufficient

Gujarat

Weak

Weak

On track

On track

On track

Insufficient

Haryana

Insufficient Weak

On track

On track

On track

Insufficient

Himachal Pradesh

Weak

On track

On track

On track

On track

Worsen

Jammu & Kashmir

Achieved

Achieved

On track

On track

On track

On track

Jharkhand

Insufficient Weak

On track

On track

On track

Insufficient

Karnataka

On track

Weak

On track

On track

On track

Insufficient

Kerala

Achieved

Achieved

Worsen

Achieved

Achieved Insufficient

Lakshadweep Weak

Weak

Worsen

Achieved

Achieved Worsen

Madhya Pradesh

Weak

Weak

On track

On track

On track

Insufficient

Maharashtra

Worsen

Weak

On track

On track

On track

Insufficient

Manipur

Worsen

Worsen

Weak

On track

On track

Worsen

Meghalaya

Worsen

Worsen

Insufficient

On track

Weak

Insufficient

Mizoram

Worsen

On track

On track

On track

On track

Insufficient

Nagaland

Achieved

On track

On track

Weak

On track

Insufficient

Odisha

Insufficient Weak

On track

On track

On track

Insufficient

Puducherry

Achieved

Achieved

Worsen

Achieved

Achieved Worsen

Punjab

Worsen

Weak

Worsen

On track

On track

Worsen

Rajasthan

On track

On track

On track

On track

On track

Insufficient (continued)

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7 Child Well-Being and SDG Status of Indian States

Table 7.3 (continued) State/UT

NMR

U5MR

Immunization Institutional Skilled Adolescent delivery birth rate pregnancy

Sikkim

Achieved

Achieved

Worsen

On track

Worsen

Tamil Nadu

On track

Achieved

On track

Achieved

Achieved Worsen

Telangana

On track

On track

On track

On track

On track

Insufficient

Tripura

Worsen

Worsen

Worsen

On track

On track

On track

Worsen

Uttar Pradesh Insufficient Weak

On track

On track

On track

Insufficient

Uttarakhand

Worsen

Weak

On track

On track

On track

Insufficient

West Bengal

On track

Achieved

On track

On track

On track

Insufficient

All India

Weak

Weak

On track

On track

On track

Insufficient

Source Authors’ Calculation based on NFHS-4 and NFHS-5

2030, indicating positive trajectories in their efforts. However, 13 states have a rate of decline that is lower than the required rate, suggesting slower progress in reducing under-five mortality. Additionally, one state has a rate of decline that is significantly lower than the required rate, indicating considerable challenges in meeting the target. Moreover, four more states and UTs have experienced an increase in under-five mortality (Tripura, Meghalaya, Manipur, and Andaman & Nicobar Islands) during the 2015–16 to 2019–21, further highlighting the need for targeted interventions to address this concerning trend. When it comes to full immunization among children aged 12–23 months, significant progress has been made in 22 states and UTs, placing them “on track” to reach the target by 2030. However, six states and UTs have shown a weak growth rate in terms of full immunization coverage, while one state has experienced a significantly poor growth rate, indicating challenges in achieving the immunization-related target. Alarmingly, six states have witnessed a decline in the percentage of fully immunized children between the periods analyzed (Goa, Kerala, Lakshadweep, Puducherry, Punjab, Sikkim), raising concerns about their ability to achieve the SDG target by 2030. Immediate attention and targeted interventions are required in these states to address the decline and ensure progress toward achieving the SDG immunization target. Regarding institutional delivery, six states have already achieved the target, highlighting their success in promoting and increasing the number of institutional deliveries. Moreover, 28 states and UTs are making significant progress and are “on track” to achieve the required target by 2030. Notably, only one state is experiencing a slow growth rate, indicating the need for improvement in their efforts to meet the target. The states’ dedication to promoting institutional delivery plays a vital role in ensuring the well-being of expectant mothers and improving maternal and child health outcomes. In case of skilled birth attendants during delivery, four states have successfully achieved the target, signifying their efforts in ensuring skilled assistance during childbirth. Additionally, 29 states and UTs are “on track” to meet the target, showcasing

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

169

positive progress in this area. However, one state has shown a slow growth rate, indicating the need for more efforts to increase the presence of skilled birth attendants. Furthermore, another state has experienced a decline in the availability of skilled birth attendants during delivery (Sikkim), emphasizing the urgent need for focused interventions and strategies to address this concerning trend. Enhancing the availability of skilled birth attendants is crucial for improving maternal and child health outcomes, and continued efforts are necessary to ensure that every woman receives adequate care during childbirth. Adolescent pregnancy remains a significant area of concern in many states of India. Currently, only two states have shown “on track” progress in achieving the SDG goal related to adolescent pregnancy. On the other hand, 23 states and UTs have experienced a very poor rate of decline, indicating significant challenges in reaching the adolescent pregnancy-related goal by 2030. Furthermore, 10 states have witnessed an increase in adolescent pregnancy during the period analyzed (Table 7.3), highlighting the urgent need for targeted interventions and strategies to address this issue. These findings indicate that efforts must be intensified across the states to reduce adolescent pregnancy rates and ensure the well-being and overall prospects of young girls.

7.2.4 Education (SDG-4) Education related SDG targets include the net enrolment ratio at the elementary and secondary levels, the dropout rate at the secondary level, learning achievement, among others (see Chap. 5). The progress made by states was assessed using these indicators. Several observations can be made with respect to the SDG-4. In terms of enrolment at the elementary level, 13 states have already achieved the target, highlighting their progress in ensuring access to education for children at the elementary level. Additionally, six states have shown sufficient growth rates to remain “on track” in achieving the SDG target for enrolment at the elementary level. However, one state has experienced a weak growth rate, indicating the need for improved efforts in ensuring enrolment. Surprisingly, 15 states and UTs have witnessed a decline in enrolment between the period analyzed (Table 7.4), which can be mainly attributed to the challenges posed by the COVID-19 outbreak. These declining rates pose significant obstacles for these states in achieving the SDG target by 2030. Moving on to the secondary enrolment, none of the states have achieved their target thus far. Six states are “on track” demonstrating positive progress in improving secondary-level enrollment rates. On the other hand, five states have shown a weak growth rate, indicating the need for enhanced efforts to increase secondary enrollment. Additionally, five states have experienced a very low growth rates, highlighting significant challenges in ensuring access to education at the secondary level. Most notably, 20 states and UTs have witnessed a decline in enrollment at the secondary level, which is primarily attributed to the COVID-19 outbreak.

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7 Child Well-Being and SDG Status of Indian States

Table 7.4 SDG status of education related indicators for children State/UT

Enrolment_primary Enrolment_secondary Dropout_secondary

Andaman & Nicobar Islands

Worsen

Worsen

Achieved

Andhra Pradesh

On track

On track

Worsen

Arunachal Pradesh

Worsen

Worsen

On track

Assam

Achieved

Insufficient

Worsen

Bihar

Worsen

Insufficient

On track

Chandigarh

Worsen

Worsen

Achieved

Chhattisgarh

Worsen

Weak

On track

Dadra & Nagar Haveli and Worsen Daman & Diu

Worsen

Worsen

Delhi

Achieved

On track

Achieved

Goa

Worsen

Worsen

Achieved

Gujarat

Worsen

Weak

Weak

Haryana

On track

Weak

On track

Himachal Pradesh

Achieved

Worsen

Achieved

Jammu & Kashmir

Weak

Worsen

Achieved

Jharkhand

Worsen

Worsen

Achieved

Karnataka

Achieved

On track

On track

Kerala

On track

Worsen

Achieved

Lakshadweep

Worsen

Worsen

Achieved

Madhya Pradesh

Worsen

Worsen

Worsen

Maharashtra

On track

Worsen

On track

Manipur

Achieved

Worsen

Achieved

Meghalaya

Achieved

Insufficient

Worsen

Mizoram

Achieved

Worsen

Worsen

Nagaland

Worsen

Insufficient

Worsen

Odisha

Achieved

Worsen

On track

Puducherry

Worsen

Worsen

Achieved

Punjab

Achieved

On track

Achieved

Rajasthan

On track

On track

Achieved

Sikkim

Worsen

Weak

Worsen

Tamil Nadu

On track

Worsen

Achieved

Telangana

Achieved

Worsen

On track

Tripura

Achieved

Worsen

Insufficient

Uttar Pradesh

Achieved

Weak

Achieved

Uttarakhand

Worsen

Worsen

Worsen (continued)

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

171

Table 7.4 (continued) State/UT

Enrolment_primary Enrolment_secondary Dropout_secondary

West Bengal

Achieved

On track

On track

All India

Worsen

Insufficient

On track

Source Authors’ Calculation based on UDISE Plus (2015–16 and 2020–21)

When it comes to dropout rates at the secondary level, 15 states have achieved the set goals, reflecting their success in reducing dropout rates and promoting continued education. Additionally, another nine states are “on track” to achieve the target by 2030, indicating positive progress in this area. However, one state is experiencing a weak rate of decline in dropout rates, suggesting the need for stronger measures to prevent students from leaving school prematurely. Another state is experiencing a very insignificant rate of decline, highlighting the urgent need for targeted interventions to address the dropout issue. Furthermore, nine states and UTs have witnessed an increase in dropout rates during the period analyzed. These include Andhra Pradesh, Assam, Madhya Pradesh, Meghalaya, Mizoram, Nagaland, Sikkim, Dadra & Nagar Haveli And Daman & Diu. the experience of these states signals the challenges faced in ensuring completion of secondary education. It is crucial for these states to prioritize efforts to prevent dropout, providing necessary support and incentives to promote continued education and improve educational outcomes for all students.

7.2.5 Violence and Gender Equality (SDG-5) Progress in SDG-5 in the context of children is tracked using the sex ratio at birth (SRB) and child marriage among girls aged 15–19. The following observations can be made: In terms of SRB, 13 states have already achieved the set targets, reflecting their success in improving the SRB. Additionally, six states are on track to achieve the goal, indicating positive progress in this area. Two states have experienced a weak growth rate, suggesting the need for enhanced efforts to further improve the SRB. However, 13 states have witnessed a deterioration in the SRB, indicating a significant distance from reaching the SDG target. Furthermore, one state, despite already achieving the SDG target in an earlier time period, has experienced a worsening SRB during the period analyzed (Table 7.5). Regarding child marriage, five states are “on track” to reduce child marriage rates, demonstrating positive progress in tackling the issue. Four states have experienced a weak rate of decline, highlighting the need for more focused efforts to address child marriage effectively. Additionally, 20 states and UTs have shown an insignificant rate of decline, indicating challenges in achieving the SDG goal related to child marriage (Table 7.5). However, six states have experienced an increase in child marriage

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7 Child Well-Being and SDG Status of Indian States

Table 7.5 SDG progress in violence and gender equality related indicators for children State/UT

SRB

Child marriage

Andaman & Nicobar Islands

On track

Insufficient

Andhra Pradesh

On track

Insufficient

Arunachal Pradesh

Achieved

Insufficient

Assam

Achieved

Insufficient

Bihar

Worsen

Insufficient

Chandigarh

Worsen

On track

Chhattisgarh

Worsen

Weak

Dadra & Nagar Haveli and Daman & Diu

Worsen

Insufficient

Delhi

On track

Worsen

Goa

Worsen

Worsen

Gujarat

Achieved

On track

Haryana

On track

Insufficient

Himachal Pradesh

Worsen

Insufficient

Jammu & Kashmir

Achieved

On track

Jharkhand

Worsen

Weak

Karnataka

Achieved

Weak

Kerala

Worsen

On track

Lakshadweep

Achieved

Weak

Madhya Pradesh

Achieved

Insufficient

Maharashtra

Worsen

Insufficient

Manipur

Worsen

Worsen

Meghalaya

Need attention

Insufficient

Mizoram

Achieved

Insufficient

Nagaland

Worsen

On track

Odisha

Worsen

Insufficient

Puducherry

Achieved

Worsen

Punjab

On track

Worsen

Rajasthan

Weak

Insufficient

Sikkim

Achieved

Insufficient

Tamil Nadu

Worsen

Insufficient

Telangana

Weak

Insufficient

Tripura

Achieved

Worsen

Uttar Pradesh

On track

Insufficient

Uttarakhand

Achieved

Insufficient

West Bengal

Achieved

Insufficient

All India

On track

Insufficient

Source Authors’ Calculation based on NFHS-4 and NFHS-5

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

173

rates (Delhi, Goa, Manipur, Puducherry, Punjab, and Tripura), which puts them at a disadvantage in achieving this SDG targets by 2030.

7.2.6 Access to Cleaned Drinking Water and Improved Sanitation Facility (SDG-6) Access to clean drinking water is essential for the well-being and health of individuals. Among the states in India, 16 states are making commendable progress and are “on track” to achieve SDG-6 targets, which focuses on ensuring access to clean drinking water. This progress demonstrates the states’ commitment to providing safe and reliable water sources for the populations. However, 10 states have shown a weak growth rate in achieving access to clean water, indicating the need for concerted efforts to improve infrastructure and expand access to clean drinking water in these regions. Furthermore, nine states and UTs have experienced a worsening of the situation in terms of access to clean drinking water (Table 7.6). This calls for the urgent and targeted interventions and investments in these states to address the challenges faced in providing clean water to their populations. Access to clean drinking water is not only a basic necessity but also crucial for preventing waterborne diseases and promoting public health. Providing universal access to improved sanitation facilities is essential for promoting public health, reducing waterborne diseases, and improving overall wellbeing. Among the states and UTs, 30 states and UTs are making remarkable progress and are “on track” to achieve the SDG goal in terms of sanitation. This progress underscores the commitment to providing access to improved sanitation facilities for respective populations. However, four states have shown a weak growth rate in improving access to sanitation facilities (Table 7.6), highlighting the need for enhanced efforts and targeted interventions. These states should prioritize investments in sanitation infrastructure and promote awareness about the importance of sanitation practices. It may be noted that one state has experienced a decline in access to improved sanitation facilities (Sikkim). This decline is concerning and calls for immediate attention to address the challenges faced in providing adequate sanitation. It is crucial for the state to reassess its strategies and take prompt action to reverse the declining trend. When it comes to handwashing, an essential practice for promoting hygiene and preventing the spread of diseases, 23 states and UTs in India are making commendable progress and are “on track” to achieve the SDG target. This indicates their commitment to promoting the habit of using soap to wash hands and ensuring good hand hygiene practices. However, seven states have shown a weak growth rate in increasing the adoption of handwashing with soap, highlighting the need for awareness campaigns in these regions. It is crucial to prioritize educational programs and community initiatives to

174

7 Child Well-Being and SDG Status of Indian States

Table 7.6 SDG status of drinking water and sanitation related indicators for children State/UT

Drinking water

Sanitation

Handwashing

Andaman & Nicobar Islands

Worsen

On track

Weak

Andhra Pradesh

Worsen

On track

Worsen

Arunachal Pradesh

On track

On track

On track

Assam

Weak

On track

On track

Bihar

Worsen

On track

On track

Chandigarh

Worsen

Weak

Weak

Chhattisgarh

On track

On track

On track

Dadra & Nagar Haveli and Daman & Diu

Worsen

On track

On track

Delhi

On track

Weak

On track

Goa

On track

On track

On track

Gujarat

Weak

On track

Weak

Haryana

Weak

Weak

On track

Himachal Pradesh

On track

On track

On track

Jammu & Kashmir

On track

On track

On track

Jharkhand

Weak

On track

On track

Karnataka

Weak

On track

Weak

Kerala

On track

On track

On track

Lakshadweep

On track

On track

On track

Madhya Pradesh

Weak

On track

On track

Maharashtra

Weak

On track

Worsen

Manipur

Worsen

On track

Weak

Meghalaya

Weak

On track

Worsen

Mizoram

On track

On track

On track

Nagaland

On track

On track

Weak

Odisha

On track

On track

On track

Puducherry

Worsen

On track

On track

Punjab

On track

Weak

Worsen

Rajasthan

On track

On track

On track

Sikkim

Worsen

Worsen

Worsen

Tamil Nadu

Worsen

On track

On track

Telangana

On track

On track

Weak

Tripura

Weak

On track

On track

Uttar Pradesh

On track

On track

On track

Uttarakhand

On track

On track

On track

West Bengal

Weak

On track

On track

All India

Weak

On track

On track

Source Authors’ Calculation based on NFHS-4 and NFHS-5

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators

175

promote the importance of proper handwashing techniques and the use of soap. It is noteworthy that five states have experienced a decline in the trend of handwashing with soap (Andhra Pradesh, Maharashtra, Meghalaya, Punjab, and Sikkim), which raises concerns regarding achieving the SDG target in this aspect. Immediate attention and coordinated efforts are required in these states to reverse the declining trend and reinforce the significance of handwashing as a preventive measure against diseases.

7.2.7 Access to Electricity and Cooking Fuel (SDG-7) Access to electricity and cooking fuel is crucial for child well-being and it has direct implications for their health outcomes. Among the 35 states and UTs, 16 have successfully achieved the SDG target relating to access to electricity, indicating positive progress. Additionally, 19 states and UTs are currently “on track” to meet the SDG target, showcasing promising advancements (Table 7.7). This has been aided by policy emphasis on providing electricity connection to every household. The situation regarding access to safe cooking fuel is more varied. Currently, 16 states and UTs have made progress and are “on track” to achieve the SDG target by 2030, which is encouraging. On the other hand, eight states are experiencing a weak growth rate in increasing access to safe cooking fuel, while another 10 states and UTs have experienced a significantly slow growth rate. These states with insufficient or weak progress could face challenges in reaching the SDG target for safe cooking fuel by 2030. It is worth noting that one UT, despite being close to the SDG target, has witnessed a decline in access to safe cooking fuel between 2015–16 and 2019–21. This decline emphasizes the importance of addressing and reversing such negative trends to ensure sustained progress in child well-being related to cooking fuel accessibility.

7.2.8 Birth Registration of Under-Five Children (SDG-16) Birth registration is crucial for providing children with self-identity and protection. Among the 35 states and UTs in India, “on track” progress in ensuring birth registration can be observed for 29 states and UTs, demonstrating their commitment to this important aspect. Additionally, one state has already achieved this target, setting a positive example for others to follow. However, three states are experiencing a weak growth rate in increasing their birth registration process, indicating the need for improved efforts in these states. Moreover, two states, despite having achieved the targets, have witnessed a decline in the proportion of children with birth registration between the two periods analyzed. This decline raises concerns and highlights the necessity of sustaining and monitoring progress even after achieving the target. Enhancing birth registration initiatives is necessary to ensure that every child is registered so as to deliver rights and protections associated with it (Table 7.8).

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7 Child Well-Being and SDG Status of Indian States

Table 7.7 SDG status of electricity and cooking fuel related indicators for children State/UT

Electricity

Cooking fuel

Andaman & Nicobar Islands

On track

On track

Andhra Pradesh

Achieved

On track

Arunachal Pradesh

On track

Weak

Assam

On track

Weak

Bihar

On track

On track

Chandigarh

Achieved

Need attention

Chhattisgarh

On track

Insufficient

Dadra & Nagar Haveli and Daman & Diu

Achieved

On track

Delhi

Achieved

On track

Goa

Achieved

On track

Gujarat

On track

Weak

Haryana

Achieved

Insufficient

Himachal Pradesh

Achieved

Weak

Jammu & Kashmir

Achieved

Weak

Jharkhand

On track

Insufficient

Karnataka

Achieved

On track

Kerala

Achieved

On track

Lakshadweep

Achieved

On track

Madhya Pradesh

On track

Insufficient

Maharashtra

On track

On track

Manipur

On track

On track

Meghalaya

On track

Insufficient

Mizoram

On track

On track

Nagaland

On track

Insufficient

Odisha

On track

Weak

Puducherry

Achieved

On track

Punjab

Achieved

On track

Rajasthan

On track

Insufficient

Sikkim

On track

On track

Tamil Nadu

Achieved

Weak

Telangana

Achieved

On track

Tripura

On track

Insufficient

Uttar Pradesh

On track

Weak

Uttarakhand

Achieved

Insufficient

West Bengal

On track

Insufficient

All India

On track

Weak

Source Authors’ Calculation based on NFHS-4 and NFHS-5

7.2 Dimension Specific SDG Status Using Child Well-Being Indicators Table 7.8 SDG status of birth registration related indicators for under-five children

177

State/UT

Birth registration

Andaman & Nicobar Islands

On track

Andhra Pradesh

On track

Arunachal Pradesh

On track

Assam

On track

Bihar

On track

Chandigarh

On track

Chhattisgarh

On track

Dadra & Nagar Haveli and Daman & Diu

On track

Delhi

On track

Goa

On track

Gujarat

On track

Haryana

On track

Himachal Pradesh

On track

Jammu & Kashmir

On track

Jharkhand

Weak

Karnataka

On track

Kerala

On track

Lakshadweep

On track

Madhya Pradesh

On track

Maharashtra

On track

Manipur

On track

Meghalaya

Weak

Mizoram

On track

Nagaland

Weak

Odisha

On track

Puducherry

Achieved

Punjab

Need attention

Rajasthan

On track

Sikkim

Need attention

Tamil Nadu

On track

Telangana

On track

Tripura

On track

Uttar Pradesh

On track

Uttarakhand

On track

West Bengal

On track

All India

On track

Source Authors’ Calculation based on NFHS-4 and NFHS-5

178

7 Child Well-Being and SDG Status of Indian States

7.3 Child Well-Being Index The child well-being index (CWI) is a comprehensive measure that encompasses multiple dimensions. We construct CWI using six dimensions namely, nutrition, health, education, gender equality, basic amenities, and child protection. States with higher CWI values are considered more advanced compared to states with lower values. Each dimension includes relevant variables that are also part of the identified SDG indicators. The indicators used in calculating the composite CWI should demonstrate a positive relationship with the index. To achieve this, some variables have been reversed. Based on the composite index score, states are classified into three groups: leading, moderate, and lagging. The CWI is calculated for the two reference years to assess states’ progress in each of the six dimensions and overall well-being.

7.3.1 Nutrition Achievement Index (NAI) Based on the NAI, the categorization of states reveals that in 2016, only four states were classified as lagging, while 12 states were categorized as leading. However, in 2021, a majority of states experienced deficiencies in nutrition indicators, resulting in 13 states falling into the lagging category, and only 5 states remained in the leading category (Table 7.9; Map 7.1a, b). This shift signifies a decline in the ranking status of certain states such as Meghalaya, Chhattisgarh, West Bengal, Maharashtra, Gujarat, Assam, Jammu and Kashmir, which reverse-transitioned from the moderate category in 2016 to the lagging category in 2021. Additionally, Telangana, previously classified as leading in 2016, shifted to the lagging category in 2021. States like Bihar and Jharkhand remained in the lagging category in both the years, whereas Madhya Pradesh improved from lagging to moderate status during the period of assessment.

7.3.2 Health Achievement Index (HAI) The categorization of states using HAI indicates an overall improvement in state rankings. In 2016, 14 states were classified as lagging, while only 7 states were in the leading category, and the remaining states fell into the moderate category. In 2021, the number of states in the lagging category decreased to 7, the number of states in the leading category increased to 10 and the remaining 18 states and UTs were in the moderate category. Notably, in 2021, states such as Gujarat, Chhattisgarh, West Bengal, Rajasthan, Arunachal Pradesh, and Madhya Pradesh, which were previously categorized as lagging in the health dimension, have recorded desired progress and transitioned to

7.3 Child Well-Being Index

179

Table 7.9 Nutrition achievement index States

NAI_2021

NAI status_2021

NAI_2016

NAI status_2016

Andaman & Nicobar Islands

61.9

Moderate

54.2

Moderate

Andhra Pradesh

56.7

Moderate

56.3

Moderate

Arunachal Pradesh

51.3

Moderate

54.7

Moderate

Assam

41.4

Lagging

56.6

Moderate

Bihar

41.0

Lagging

43.7

Lagging

Chandigarh

69.9

Leading

59.3

Leading

Chhattisgarh

48.3

Lagging

49.0

Moderate

Dadra & Nagar Haveli and Daman & Diu

46.1

Lagging

30.5

Lagging

Delhi

62.3

Moderate

58.9

Leading

Goa

61.7

Moderate

62.7

Leading

Gujarat

36.8

Lagging

45.5

Moderate

Haryana

61.4

Moderate

47.5

Moderate

Himachal Pradesh

51.6

Moderate

62.6

Leading

Jammu & Kashmir

37.1

Lagging

56.4

Moderate

Jharkhand

42.7

Lagging

37.9

Lagging

Karnataka

53.4

Moderate

49.2

Moderate

Kerala

68.4

Leading

65.5

Leading

Lakshadweep

49.9

Lagging

60.5

Leading

Madhya Pradesh

52.9

Moderate

45.0

Lagging

Maharashtra

42.7

Lagging

50.5

Moderate

Manipur

77.0

Leading

72.1

Leading

Meghalaya

50.4

Lagging

47.3

Moderate

Mizoram

57.9

Moderate

71.3

Leading

Nagaland

56.7

Moderate

67.1

Leading

Odisha

50.9

Moderate

52.3

Moderate

Puducherry

65.5

Leading

55.3

Moderate

Punjab

63.6

Moderate

58.9

Leading

Rajasthan

54.4

Moderate

49.1

Moderate

Sikkim

58.6

Moderate

47.4

Moderate

Tamil Nadu

61.0

Moderate

51.3

Moderate

Telangana

47.2

Lagging

59.5

Leading

Tripura

39.9

Lagging

59.8

Leading

Uttar Pradesh

52.0

Moderate

48.4

Moderate

Uttarakhand

66.1

Leading

52.5

Moderate

West Bengal

43.4

Lagging

51.2

Moderate

Source Authors’ Calculation based on NFHS-4 and NFHS-5

180

7 Child Well-Being and SDG Status of Indian States

Map 7.1 a Nutrition achievement index 2021, b nutrition achievement index 2016

the moderate category (Table 7.10; Map 7.2a, b). This shift signifies an encouraging improvement in the overall health and well-being index for children.

7.3.3 Education Achievement Index There has been an overall improvement in the status of states in education achievement index. In 2016, there were nine states categorized as lagging in the education index, which reduced to 7 states in 2021. Additionally, the number of leading states

7.3 Child Well-Being Index

181

Table 7.10 Health achievement index States

HAI_2021

HAI status_2016

HAI_2016

HAI status_2021

Andaman & Nicobar Islands

76.4

Leading

80.9

Leading

Andhra Pradesh

57.9

Moderate

57.6

Moderate

Arunachal Pradesh

63.7

Moderate

41.0

Lagging

Assam

48.2

Lagging

37.3

Lagging

Bihar

37.0

Lagging

37.3

Lagging

Chandigarh

88.8

Leading

73.5

Moderate

Chhattisgarh

59.2

Moderate

52.7

Lagging

Dadra & Nagar Haveli

76.9

Leading

59.1

Moderate

Delhi

71.8

Moderate

65.5

Moderate

Goa

88.5

Leading

92.8

Leading

Gujarat

66.2

Moderate

55.3

Lagging

Haryana

68.9

Moderate

58.3

Moderate

Himachal Pradesh

72.9

Moderate

64.1

Moderate

Jammu & Kashmir

86.0

Leading

69.8

Moderate

Jharkhand

46.1

Lagging

39.1

Lagging

Karnataka

74.6

Moderate

66.1

Moderate

Kerala

90.2

Leading

93.0

Leading

Lakshadweep

94.0

Leading

82.5

Leading

Madhya Pradesh

58.7

Moderate

45.6

Lagging

Maharashtra

67.2

Moderate

63.8

Moderate

Manipur

57.1

Moderate

62.3

Moderate

Meghalaya

40.3

Lagging

50.6

Lagging

Mizoram

70.4

Moderate

60.3

Moderate

Nagaland

42.0

Lagging

37.1

Lagging

Odisha

64.6

Moderate

61.2

Moderate

Puducherry

90.3

Leading

86.5

Leading

Punjab

70.9

Moderate

75.7

Leading

Rajasthan

71.5

Moderate

51.6

Lagging

Sikkim

85.3

Leading

74.1

Moderate

Tamil Nadu

80.7

Leading

77.5

Leading

Telangana

71.9

Moderate

61.8

Moderate

Tripura

36.4

Lagging

49.4

Lagging

Uttar Pradesh

49.8

Lagging

38.5

Lagging

Uttarakhand

59.9

Moderate

53.4

Lagging

West Bengal

61.1

Moderate

52.6

Lagging

Source Authors’ Calculation based on NFHS-4 and NFHS-5

182

7 Child Well-Being and SDG Status of Indian States

Map 7.2 a Health achievement index 2021, b health achievement index 2016

7.3 Child Well-Being Index

183

in this dimension increased from 10 to 12 during the same period (Table 7.11; Map 7.3a, b). It is noteworthy that Bihar, Odisha, Assam, and Andhra Pradesh, which were classified as lagging in 2016, have transitioned to the moderate category in 2021. Moreover, states in the moderate category have also shown improvements in the education index between 2016 and 2021, indicating overall progress within this category. Furthermore, Haryana and West Bengal, which were initially categorized as moderate in 2016, have now shifted to the leading category, signifying improvements in the education dimensions in these states.

7.3.4 Gender Equality Index The gender equality index is a comprehensive measure that evaluates the level of gender equality among children. It focuses on two key indicators: the sex ratio at birth and child marriage rates among girls aged 15–19 years. The sex ratio at birth indicates the number of girls born per 1000 boys in a given population. A balanced sex ratio signifies gender equality, whereas a lower ratio suggests potential discrimination or a preference for boys over girls. On the other hand, child marriage refers to the practice of marrying girls at a young age, typically before they completes 18 years of life. High rates of child marriage hinder gender equality as it restricts girls’ education, health, and overall development. We construct an overall gender equality index (GEI) using the two indicators. The index reflects the level of gender equality within the given states. Our analysis shows that there has not been significant improvement in the overall status of gender equality across states between the two periods examined. In 2016, 19 states were classified as lagging, which reduced to 15 in the later period. Furthermore, 5 states were leading in 2016, but this number decreased to 4 in the subsequent period. Several states namely West Bengal, Assam, Bihar, Jharkhand, Rajasthan, Andhra Pradesh, Tripura, Telangana, and Maharashtra consistently remain in the lagging category in both the periods (Table 7.12; Map 7.4a, b). However, there have been notable shifts, with Gujarat, Haryana, Karnataka, Delhi, Arunachal Pradesh, Sikkim, and Madhya Pradesh moving from lagging to moderate positions. However concern arises due to the unexpected shift of Tamil Nadu from the moderate category to lagging, which is attributed to a sudden drop in the sex ratio at birth. Similarly, Odisha and Himachal Pradesh slipped from moderate to lagging category. This shift highlights the need for timely attention and targeted interventions to address the underlying reasons affecting gender equality in the states.

184

7 Child Well-Being and SDG Status of Indian States

Table 7.11 Education achievement index States

EAI_2021 EAI status_2021 EAI_2016 EAI status_2016

Andaman & Nicobar Islands

34.0

Lagging

58.9

Moderate

Andhra Pradesh

59.3

Moderate

28.2

Lagging

Arunachal Pradesh

55.6

Moderate

63.2

Moderate

Assam

43.4

Moderate

39.3

Lagging

Bihar

46.5

Moderate

42.0

Lagging

Chandigarh

65.8

Moderate

82.9

Leading

Chhattisgarh

53.0

Moderate

51.1

Moderate

Dadra & Nagar Haveli and Daman 37.0 & Diu

Lagging

49.9

Moderate

Delhi

87.8

Leading

79.4

Leading

Goa

67.9

Leading

83.7

Leading

Gujarat

39.6

Lagging

39.5

Lagging

Haryana

66.6

Leading

52.3

Moderate

Himachal Pradesh

84.1

Leading

88.4

Lagging

Jammu & Kashmir

41.0

Moderate

21.5

Lagging

Jharkhand

48.5

Moderate

45.6

Moderate

Karnataka

69.9

Leading

46.2

Moderate

Kerala

81.2

Leading

78.8

Leading

Lakshadweep

50.9

Moderate

59.1

Moderate

Madhya Pradesh

29.0

Lagging

37.7

Lagging

Maharashtra

66.9

Leading

62.2

Moderate

Manipur

69.1

Leading

62.4

Moderate

Meghalaya

39.4

Lagging

46.6

Moderate

Mizoram

51.9

Moderate

51.4

Moderate

Nagaland

15.1

Lagging

28.7

Lagging

Odisha

49.6

Moderate

44.0

Lagging

Puducherry

52.5

Moderate

74.3

Leading

Punjab

90.1

Moderate

72.4

Leading

Rajasthan

61.0

Moderate

45.9

Moderate

Sikkim

27.4

Lagging

30.9

Lagging

Tamil Nadu

85.0

Leading

90.9

Leading

Telangana

62.5

Moderate

68.8

Leading

Tripura

50.9

Moderate

59.3

Moderate

Uttar Pradesh

75.6

Leading

72.7

Leading

Uttarakhand

51.2

Moderate

59.3

Moderate

West Bengal

70.5

Leading

57.1

Moderate

Source Authors’ Calculation based on UDISE Plus (2015–16 and 2020–21)

7.3 Child Well-Being Index

Map 7.3 a Education achievement index 2021, b education achievement index 2016

185

186

7 Child Well-Being and SDG Status of Indian States

Table 7.12 Gender equality index States

GEI_2021 GEI status_2021 GEI_2016 GEI status_2016

Andaman & Nicobar Islands

64.2

Moderate

50.8

Lagging

Andhra Pradesh

48.7

Lagging

40.9

Lagging

Arunachal Pradesh

70.8

Moderate

52.8

Lagging

Assam

53.9

Lagging

43.8

Lagging

Bihar

39.4

Lagging

38.6

Lagging

Chandigarh

49.9

Lagging

84.4

Leading

Chhattisgarh

76.9

Moderate

77.9

Leading

Dadra & Nagar Haveli and Daman 37.8 & Diu

Lagging

50.7

Lagging

Delhi

66.0

Moderate

46.9

Lagging

Goa

49.9

Lagging

79.3

Leading

Gujarat

58.8

Moderate

46.5

Lagging

Haryana

59.9

Moderate

45.8

Lagging

Himachal Pradesh

57.9

Lagging

73.4

Moderate

Jammu & Kashmir

84.0

Leading

71.8

Moderate

Jharkhand

44.0

Lagging

39.6

Lagging

Karnataka

70.4

Moderate

53.2

Lagging

Kerala

79.1

Leading

98.2

Leading

Lakshadweep

99.0

Leading

70.3

Leading

Madhya Pradesh

66.9

Moderate

54.5

Lagging

Maharashtra

52.5

Lagging

52.3

Lagging

Manipur

61.8

Moderate

70.1

Moderate

Meghalaya

75.3

Moderate

79.7

Leading

Mizoram

76.6

Moderate

71.5

Moderate

Nagaland

74.5

Moderate

72.0

Moderate

Odisha

50.8

Lagging

58.4

Moderate

Puducherry

74.4

Moderate

54.1

Lagging

Punjab

63.9

Moderate

58.6

Moderate

Rajasthan

48.2

Lagging

36.1

Lagging

Sikkim

76.5

Moderate

45.7

Lagging

Tamil Nadu

54.4

Lagging

72.3

Moderate

Telangana

56.6

Lagging

39.9

Lagging

Tripura

44.9

Lagging

42.0

Lagging

Uttar Pradesh

69.7

Moderate

59.8

Moderate

Uttarakhand

82.2

Leading

64.1

Moderate

West Bengal

38.9

Lagging

31.9

Lagging

Source Authors’ Calculation based on NFHS-4 and NFHS-5

7.3 Child Well-Being Index

Map 7.4 a Gender equality index 2021, b gender equality index 2016

187

188

7 Child Well-Being and SDG Status of Indian States

7.3.5 Basic Amenities Index The basic amenities index comprises indicators such as access to clean drinking water, sanitation, electricity, and safe cooking fuel, all of which have significant implications for child well-being, even though these are household-level indicators. There have been notable improvements in the status of access to basic amenities in certain states. For instance, Rajasthan, Chhattisgarh, and Madhya Pradesh, which were in the lagging category in 2016, have shifted to the moderate category, reflecting positive progress in providing access to basic amenities (Table 7.13; Map 7.5a, b). Conversely, West Bengal and Meghalaya, classified as moderate category states in 2016, have now shifted to the lagging category in 2021, indicating a decline in access to these essential amenities in the respective states. Moreover, Bihar, Jharkhand, Odisha, Manipur, Uttar Pradesh, and Assam have consistently remained in the lagging category over the two consecutive time periods, suggesting ongoing challenges in improving access to basic amenities for children in these states. Efforts to address the underlying issues and prioritize targeted interventions in these states are necessary to enhance child well-being in terms of access to basic amenities.

7.3.6 Child Protection Index The child protection index is constructed using the birth registration data of children under the age of five. In 2021, 26 states and UTs were classified as leading, four states as moderate, and five states as lagging in terms of child protection. Notably, Nagaland, Uttar Pradesh, Bihar, and Jharkhand have consistently remained in the lagging category, indicating persistent challenges in birth registration (Table 7.14; Map 7.6a, b). However, Rajasthan, Manipur, and Arunachal Pradesh have shown progress by transitioning from the lagging to the moderate category, indicating improvement in the birth registration processes in the respective states. Additionally, Madhya Pradesh, Andhra Pradesh, Chhattisgarh, Uttarakhand, and Jammu and Kashmir have moved from the moderate category to the leading category, highlighting advancements in the child protection measures. Efforts to address the issues of birth registration and child protection measures should get additional focus in the lagging states for transitioning from lagging to moderate or from moderate to leading category. Strengthening birth registration systems and promoting awareness among parents and communities are crucial steps toward ensuring effective child protection across the states.

7.3 Child Well-Being Index

189

Table 7.13 Basic amenities index States

BAI_2021 BAI status_2021 BAI_2016 BAI status_2016

Andaman & Nicobar Islands

76.1

Leading

77.4

Leading

Andhra Pradesh

55.9

Moderate

56.8

Moderate

Arunachal Pradesh

60.4

Moderate

54.6

Moderate

Assam

29.3

Lagging

34.0

Lagging

Bihar

38.5

Lagging

22.8

Lagging

Chandigarh

88.1

Leading

90.5

Leading

Chhattisgarh

56.1

Moderate

39.6

Lagging

Dadra & Nagar Haveli and Daman 62.9 & Diu

Moderate

44.9

Moderate

Delhi

86.1

Leading

82.1

Leading

Goa

92.4

Leading

86.3

Leading

Gujarat

57.8

Moderate

62.4

Moderate

Haryana

72.9

Leading

70.9

Leading

Himachal Pradesh

69.6

Moderate

65.3

Moderate

Jammu & Kashmir

69.4

Moderate

63.0

Moderate

Jharkhand

25.6

Lagging

21.1

Lagging

Karnataka

67.6

Moderate

64.6

Moderate

Kerala

85.5

Leading

80.6

Leading

Lakshadweep

84.7

Leading

73.0

Leading

Madhya Pradesh

48.7

Moderate

38.1

Lagging

Maharashtra

65.2

Moderate

64.7

Moderate

Manipur

47.5

Lagging

42.0

Lagging

Meghalaya

41.7

Lagging

54.5

Moderate

Mizoram

86.7

Leading

81.9

Leading

Nagaland

62.8

Moderate

59.5

Moderate

Odisha

35.5

Lagging

27.5

Lagging

Puducherry

82.2

Leading

72.2

Leading

Punjab

82.1

Leading

83.1

Leading

Rajasthan

52.6

Moderate

43.7

Lagging

Sikkim

82.4

Leading

86.7

Leading

Tamil Nadu

70.7

Moderate

63.6

Moderate

Telangana

73.0

Leading

62.0

Moderate

Tripura

51.8

Moderate

47.5

Moderate

Uttar Pradesh

44.5

Lagging

42.8

Lagging

Uttarakhand

72.3

Leading

69.2

Leading

West Bengal

40.4

Lagging

47.3

Moderate

Source Authors’ Calculation based on NFHS-4 and NFHS-5

190

7 Child Well-Being and SDG Status of Indian States

Map 7.5 a Basic amenities index 2021, b basic amenities index 2016

7.3 Child Well-Being Index

191

Table 7.14 Child protection index States

CPI_2021 CPI status_2021 CPI_2016 CPI status_2016

Andaman & Nicobar Islands

90.3

Leading

96.9

Leading

Andhra Pradesh

70.9

Leading

57.8

Moderate

Arunachal Pradesh

54.1

Moderate

6.9

Lagging

Assam

86.2

Leading

87.4

Leading

Bihar

9.0

Lagging

1.3

Lagging

Chandigarh

91.0

Leading

89.7

Leading

Chhattisgarh

87.3

Leading

66.6

Moderate

Dadra & Nagar Haveli and Daman & Diu

92.9

Leading

85.9

Leading

Delhi

79.1

Leading

71.5

Leading

Goa

100.0

Leading

99.5

Leading

Gujarat

90.7

Leading

91.5

Leading

Haryana

81.7

Leading

87.4

Leading

Himachal Pradesh

92.2

Leading

90.2

Leading

Jammu & Kashmir

82.5

Leading

44.2

Moderate

Jharkhand

1.1

Lagging

12.3

Lagging

Karnataka

90.7

Leading

89.2

Leading

Kerala

96.3

Leading

96.4

Leading

100.0

Leading

100.0

Leading

Madhya Pradesh

78.0

Leading

55.8

Moderate

Maharashtra

86.2

Leading

89.7

Leading

Manipur

53.0

Moderate

10.5

Lagging

Meghalaya

33.2

Lagging

50.4

Moderate

Mizoram

97.8

Leading

96.9

Leading

Lakshadweep

Nagaland

0.0

Lagging

21.3

Lagging

Odisha

65.7

Moderate

56.3

Moderate

Puducherry

97.4

Leading

99.7

Leading

Punjab

91.4

Leading

97.9

Leading

Rajasthan

67.9

Leading

16.5

Lagging

Sikkim

86.9

Leading

98.5

Leading

Tamil Nadu

93.7

Leading

97.9

Leading

Telangana

62.7

Moderate

58.9

Moderate

Tripura

76.9

Leading

80.7

Leading

Uttar Pradesh

23.5

Lagging

0.0

Lagging

Uttarakhand

69.8

Leading

42.4

Moderate

West Bengal

93.3

Leading

94.3

Leading

Source Authors’ Calculation based on NFHS-4 and NFHS-5

192

7 Child Well-Being and SDG Status of Indian States

Map 7.6 a Child protection index 2021, b child protection index 2016

7.4 Conclusion and Way Forward

193

7.3.7 Child Well-Being Index The overall child well-being index (CWI) reflects a mix of improvement by states and indicates areas that require attention. Between 2016 and 2021, several states have shown improvement in their CWI rankings. These states include Andhra Pradesh, Arunachal Pradesh, Chhattisgarh, Delhi, Haryana, Jammu and Kashmir, Karnataka, Madhya Pradesh, Manipur, Puducherry, Punjab, and Rajasthan. On the other hand, some of the states, such as Meghalaya, and Tripura, have experienced a decline in their CWI rankings leading to downward movement from moderate to lagging category (Table 7.15; Map 7.7a, b). Certain states have consistently remained in the leading category over the years, demonstrating a strong focus on child well-being. These states and UTs include Kerala, Tamil Nadu, Punjab, Himachal Pradesh, Goa, Mizoram, Puducherry, Lakshadweep, and Chandigarh. Moreover, Karnataka, Haryana, Sikkim, and Delhi have transitioned from the moderate category to the leading category, indicating progress in their improving child well-being. However, there are states that continue to face challenges in improving child wellbeing. Nagaland, Bihar, and Jharkhand consistently remain in the lagging category, requiring targeted efforts to address the underlying issues in order to uplift the wellbeing of children in these states. Additionally, Meghalaya and Tripura have shifted from the moderate category in 2016 to the lagging category in 2021, emphasizing the need for significant attention and timely interventions. Several states have made noticeable progress over the years, transitioning from lagging to the moderate category states in improving child well-being. This includes states like Uttar Pradesh, Rajasthan, Andhra Pradesh, Arunachal Pradesh, Assam, and Odisha showcasing their successful effort in improving child well-being. Overall, the child well-being status of Indian states has seen differential progress and fluctuations in both upward directions over the years. Some states have consistently performed well, while others have made efforts to catch up and improve their performance. The CWI provides valuable insights for policy in terms of guiding both policymakers and stakeholders in identifying areas for improvement and working toward ensuring holistic development and well-being of children across the country.

7.4 Conclusion and Way Forward The assessment presented in this chapter provides a comprehensive overview of the status of child well-being in Indian states in relation to the identified SDGs. By examining the progress made across various dimensions, including nutrition, health, education, gender equality, basic amenities, and child protection, we have highlighted areas for improvement and identified states that require timely and targeted interventions.

194

7 Child Well-Being and SDG Status of Indian States

Table 7.15 Child well-being index States

CWI_ 2021

Rank_ 2021

CWI status_ 2021

CWI_ 2016

Rank_ 2016

CWI status_ 2016

Andaman & Nicobar Islands

67.1

14

Moderate

69.8

10

Leading

Andhra Pradesh

58.2

25

Moderate

49.6

28

Lagging

Arunachal Pradesh

59.3

21

Moderate

45.6

31

Lagging

Assam

50.4

30

Moderate

49.8

27

Lagging

Bihar

35.2

34

Lagging

31.0

35

Lagging

Chandigarh

75.6

6

Leading

80.1

3

Leading

Chhattisgarh

63.5

17

Moderate

56.1

20

Moderate

Dadra & Nagar Haveli and Daman & Diu

58.9

23

Moderate

53.5

24

Moderate

Delhi

75.5

7

Leading

67.4

11

Moderate

Goa

76.7

5

Leading

84.1

2

Leading

Gujarat

58.3

24

Moderate

56.8

18

Moderate

Haryana

68.6

13

Leading

60.4

15

Moderate

Himachal Pradesh

71.4

10

Leading

74.0

7

Leading

Jammu & Kashmir

66.6

16

Moderate

54.5

23

Moderate

Jharkhand

34.7

35

Lagging

32.6

34

Lagging

Karnataka

71.1

11

Leading

61.4

14

Moderate

Kerala

83.4

1

Leading

85.4

1

Leading

Lakshadweep

79.7

2

Leading

74.2

6

Leading

Madhya Pradesh 55.7

27

Moderate

46.1

30

Lagging

Maharashtra

63.4

18

Moderate

63.9

13

Moderate

Manipur

60.9

20

Moderate

53.3

25

Moderate

Meghalaya

46.7

32

Lagging

54.9

22

Moderate

Mizoram

73.5

9

Leading

72.2

9

Leading

Nagaland

41.9

33

Lagging

47.6

29

Lagging

Odisha

52.8

28

Moderate

50.0

26

Lagging

Puducherry

77.0

3

Leading

73.7

8

Leading

Punjab

77.0

4

Leading

74.4

5

Leading

Rajasthan

59.3

22

Moderate

40.5

33

Lagging

Sikkim

69.5

12

Leading

63.9

12

Moderate

Tamil Nadu

74.3

8

Leading

75.6

4

Leading

Telangana

62.3

19

Moderate

58.5

16

Moderate

Tripura

50.1

31

Lagging

56.5

19

Moderate (continued)

7.4 Conclusion and Way Forward

195

Table 7.15 (continued) States

CWI_ 2021

Rank_ 2021

CWI status_ 2021

CWI_ 2016

Rank_ 2016

CWI status_ 2016

Uttar Pradesh

52.5

29

Moderate

43.7

32

Lagging

Uttarakhand

66.9

15

Moderate

56.8

17

Moderate

West Bengal

57.9

26

55.7

21

Moderate

Source Authors’ Calculation based on NFHS-4 and NFHS-5

Map 7.7 a Child well-being index 2021, b child well-being index 2016

196

7 Child Well-Being and SDG Status of Indian States

We find that several states have made progress, and some states have already achieved some of the SDG targets successfully. However, there are states that face challenges and need timely and focused attention to accelerate progress to ensure that no child is left behind. It is crucial to prioritize and allocate resources effectively to address the specific needs in each state and improve the well-being of children across the country. To further enhance child well-being in India and to ensure the achievement of the SDGs by 2030, the following strategies and recommendations could be considered: 1. Strengthening Nutrition Interventions: Efforts should be on for improving access to nutritious food, promoting breastfeeding practices, and implementing effective nutrition programs. Targeted interventions should be designed in states with weak progress in reducing stunting, wasting, and anemia among children. 2. Enhancing Healthcare Infrastructure: Additional investments should be made to improve healthcare infrastructure, particularly in states with weak progress in reducing neonatal and under-five mortality rates. This includes strengthening healthcare facilities, ensuring the availability of skilled birth attendants, promoting institutional deliveries, and expanding immunization coverage. 3. Quality Primary and Secondary Education for All: States should put more efforts to improve enrollment rates, reduce dropout rates, and enhance the overall quality of education and learning outcomes. This can be achieved by investing in infrastructure, providing teacher training and support, and addressing barriers to education, especially for marginalized communities and girls. 4. Promoting Gender Equality: Efforts should be intensified to address the issues of gender inequality, including child marriage and the lower sex ratio at birth. Comprehensive strategies are needed that focuses on empowering girls, promoting gender-sensitive policies and programs, and increasing awareness about the importance of gender equality. 5. Improving Access to Basic Amenities: States need prioritize investments in providing access to clean drinking water, sanitation facilities, electricity, and safe cooking fuel universally. This will require infrastructure development, awareness campaigns, and innovative solutions to ensure that every child has access to these essential amenities. 6. Strengthening Child Protection Measures: States should focus on improving birth registration processes, enhancing child protection systems, and promoting awareness among parents and communities. Targeted interventions should be designed to address the challenges faced of low birth registration rates. 7. Enhancing Data Collection and Monitoring: It is essential to strengthen the data collection mechanisms and statistical system at the state and national levels to improve the availability of reliable and timely data on child well-being indicators. This will facilitate evidence-based decision-making, monitoring progress, and identifying areas that require immediate attention.

Appendix

197

8. Strengthening Inter-sectoral Coordination: To achieve the SDGs, there is a need for effective coordination and collaboration among various sectors, including health, education, social welfare, women and child development, new and renewable energy, among others. Inter-sectoral partnerships should be fostered to develop integrated strategies and ensure the effective implementation of policies and programs related to child well-being. 9. Empowering Communities and Stakeholders: Community participation and engagement are crucial for sustainable change at the grass-root level. Efforts should be made to empower communities, involve stakeholders, and promote ownership of child well-being initiatives. This includes promoting community-led interventions, fostering partnerships with civil society organizations, spreading the reach of digital technologies, and creating platforms for meaningful participation. 10. Monitoring and Evaluation: Regular monitoring and evaluation of progress are essential to track effective implementation of policies and programs and assess their impacts. Robust monitoring mechanisms should be established to ensure accountability, identify gaps, and make informed decisions for continuous improvement. Adoption of these strategies would accelerate progress in achieving the SDGs related to child well-being in India. Furthermore, policymakers, governments, organizations, researchers, and stakeholders need to work together to realize the goals in time. It is crucial to prioritize investments, develop evidence-based interventions, and foster collaboration to create an enabling environment where every child in India can thrive and reach their full potential. With concerted efforts and a focus on childcentered development, India can build a brighter future for its children, ensuring their well-being and contribute to sustainable and inclusive growth. India being the country with most number of children (359 million in 2022 in the age group 0–14), her progress will also prove to be instrumental in achieving the global SDG targets with reference to children.

Appendix Methodology The study has used National Family and Health Survey data for 2015–16 and 2019– 21 for all the states of India to understand their position in terms of achieving SDG focusing on child related indicators, Annual average rate of reduction (AARR): In case of negative indicators like (stunting, Poverty), annual average rate of reduction was calculated based on following formula: Present rate of reduction, i.e., reduction between 2015–16 and 2019–21, i.e., 5 years

198

7 Child Well-Being and SDG Status of Indian States

 AARR = 1 −

I2019−21 I2015−16

 n1

∗ 100 , n = 5.

Required rate of reduction (RRR), i.e., reduction to reach the SDG target by 2030  RRR = 1 −

SDGtarget.i I2019−21

1/9 ∗ 100.

In case of positive indicators like (immunization, institutional delivery), annual average rate of increase (AARI) between 2015–16 and 2019–21 was calculated based on following formula:  AARRI =

I2019−21 I2015−16

 n1

 − 1 ∗ 100.

Required rate of increase (RRI), i.e., increase rate of growth to reach SDG target by 2030  RRI =

SDGtarget.i I2019−21

1/9

 − 1 ∗ 100.

Now based on present and required rated of decline/ rate of growth states were categorized on the following way to understand the progress of the states in achieving SDG targets. If Present rate of decline/increase = Required rate of decline/increase = Achieved. If Present rate of decline/increase > Required rate of decline/increase = On track. If Present rate of decline/increase < Required rate of decline/increase by 4% = Weak. If Present rate of decline/increase < Required rate of decline/increase by 5% and above = Insufficient. If states have already achieved SDG target but between 2015–16 and 2019–21 the values of the indicators have fallen in 2019–21 then states are identified as “need attention.” If 2019–21 indicators have deteriorated than 2015–16 and the average state value is behind SDG target then states are identified as “worsen” category.

Construction of Child Well-Being Index (CWI) The study has also calculated overall child well-being index using UNDP methods. Child well-being index is consisted of nutrition achievement index, health achievement index, education achievement index, gender equality index, basic amenities index, and child protection index.

Appendix

199

Dimension

Indicators

Nutrition

Percentage of under-five children stunted Percentage of under-five children are wasted Percentage of under-five children are over weight Percentage of under-five children are anemic Percentage of below 6 months children received exclusive breastfeeding Percentage of 15–19 years girls are anemic

Health

Percentage of 12–23 months children have received full immunization Percentage of children born in an institutional setup Percentage of children have skilled birth attendant during delivery Neonatal mortality Infant mortality Under-five mortalities Percentage of 15–19 years girl already pregnant

Education

Adjusted net enrollment at elementary level Adjusted net enrollment at secondary level Annual average dropout rate at secondary level

Gender equality

Sex ratio at birth Percentage of 15–19 years girls got married before 18 years

Basic amenities

Access to safe drinking water by children Access to safe sanitation facility by children Access to handwashing material like soap by children Having electricity in house Having safe cooking fuel

Child protection

Percentage of under-five children have registered their birth

Before arriving at the score, the normalization of the indicators values on a scale of 0–100 is required to compare the score across the states and over time. The lower the score indicates lower the performance of the states whereas the higher the score indicates the better-performing states. For the indicators for which higher the value means better-performing states the following formula is used to calculate the score: CWI =

x − min(x) ∗ 100, Max(x) − min(x)

where x indicator raw values. Min(x) the minimum observed value of indicator x. Max(x) Maximum observed value of indicator x. CWI Normalized child well-being index. For the indicators for which higher value means poor performing states the following formula is used to calculate the score:

200

7 Child Well-Being and SDG Status of Indian States

  CWI = 1 −

x − min(x) max(x) − min(x)

 ∗ 100.

Finally, all the states of India were grouped into three broad categories based on equal range method, i.e., leading (blue), moderate (green), and lagging (red).

Chapter 8

Conclusion

8.1 SDGs and Children: A Comprehensive Assessment of Child Well-Being Children are at the heart of the Sustainable Development Goals (SDGs), with several indicators specifically focused on their well-being and rights. In this book, we have undertaken an in-depth examination of SDGs related to child welfare, tracking the progress and challenges associated with eliminating poverty (SDG-1), achieving zero hunger (SDG-2), promoting good health and well-being (SDG-3), ensuring quality education (SDG-4), achieving gender equality (SDG-5), providing clean water and sanitation (SDG-6), securing affordable and clean energy (SDG-7), and establishing peace, justice, and strong institutions (SDG-16) in the context of children. Each SDG is carefully analyzed using multiple parameters to gain a comprehensive understanding of child well-being. Throughout our research, we track more than 30 child-related indicators spanning across these eight SDGs. For example, when assessing SDG-1, we consider deprivation indicators related to nutrition, healthcare, education, information, housing, sanitation, water, air quality, and child protection. Similarly, for SDG-2, we evaluate anthropometric indicators such as stunting, wasting, underweight, overweight, anemia, and BMI. SDG-3 is examined based on child mortality, morbidity, access to healthcare, immunization, and institutional birth. SDG-4 is assessed through enrollment ratios, dropout rates, pupil–teacher ratio, and learning achievement. SDG-5 is analyzed using gender equity parameters, including sex ratio, missing children, violence against children, and child marriage. Furthermore, we also access to drinking water, sanitation, electricity, cooking fuel, and birth registration to evaluate SDG-6, SDG-7, and SDG-16, respectively. Moreover, the multidimensional assessment goes beyond tracking individual indicators, as we construct a comprehensive child well-being index (CWI). This index measures the nutrition (NAI), health (HAI), education (EAI), violence and gender equality (GAI), access basic amenities (BAI), and institutional birth registration as a

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024 S. Dutta and K. C. Das, Mapping Sustainable Development Goals for Children in India, India Studies in Business and Economics, https://doi.org/10.1007/978-981-99-8901-0_8

201

202

8 Conclusion

proxy of child protection (CPI). By employing this index, we identify achievements and deficiencies in child well-being across various dimensions of SDGs. This comprehensive analysis provides valuable insights into the current state of child well-being in India and identifies areas that require focused attention and targeted interventions. By understanding these dimensions and their interconnectedness, child development implementing agencies and people at large can collectively work toward achieving the SDGs to ensure a brighter and more promising future for every child. Our findings underscore the critical role of multidimensional approaches and evidence-based interventions in advancing child welfare and contributing to sustainable development for all.

8.2 Global Importance of Child SDG from Indian Context The global progress towards SDGs has been meagre as just 12 percent of SDG targets were on track (UN. 2023). India, which has turned out to be the world’s most populous country in 2023, holds the key to the success of SDG 2030 agenda. The UN (2020) observes. India’s commitment to the SDGs is reflected in its convergence with national development agenda as reflected in the motto of Sabka Saath Sabka Vikaas (Collective Efforts for Inclusive Growth). Based on the evidence from the SDG India Index, which measures progress at the subnational level, the country has developed a robust SDG localization model created on adoption, implementation, and monitoring at the state and district levels.

As the country with the largest population, the challenge is to ensure holistic development of children. With 358 million children in the age group of 0–14 India accounts for 18% of world’s children (which is 2 billion approx.) in 2022. However, there are multiple deprivations faced by children in the country hindering not only holistic development but also the achievement of SDGs. Our analysis of SDG achievement in relation to children and adolescent identifies important areas of deprivation in the dimensions pertaining to SDG-1, SDG-2, SDG-3, SDG-4, SDG-5, SDG-6, SDG-7, and SDG-16 and it provides insights for policy. Many of the challenges faced, such as malnutrition, inadequate access to quality education, and child protection issues, are shared by children in other developing countries as well (Marguerti et al., 2018). Progress made in addressing these challenges in the Indian states provides valuable learning and best practices that can be adapted and applied globally to improve child well-being.

8.3 Assessing SDGs and Child Well-Being in India: Progress and Spatial …

203

8.3 Assessing SDGs and Child Well-Being in India: Progress and Spatial Variation Our analysis reveals positive progress in several SDG indicators for children in India. At the national level, with reference to SDG-1, deprivations are reduced in the case of housing, indoor air pollution, and sanitation dimensions. With reference to anthropometric failure among children, anthropometric indicators have been reduced at the country level to 35.5% stunting, 19.2% wasting, and 32.7% underweight in 2019–21. To achieve SDG-2 targets, these rates need to reduce further to 21% for stunting, 5% for wasting, and 5% for underweight and overweight. When it comes to child mortality, the NMR has been reduced to 24.9 per 1000 live births. To achieve SDG-3 target, it needs to be brought down to 12 per 1000 live births. U5MR have been reduced to 41.9 per 1000 live births which needs to be further reduced to 25 per 1000 live births to meet SDG-3 target. With respect to the goal of achieving 100% access to institutional delivery the achievement has so far been 89% leaving a gap of 11% to be filled by 2030. In the case of full immunization coverage target, the achievement stands at 77% in rural India and 75% in urban area till 2019–21. This leaves a substantial gap of approximately 23–25% that needs to be covered by 2030. Education plays a key role in holistic development of children. India’s progress in education parameters (SDG-4) is assessed using enrollment ratios, dropout rates, pupil–teacher ratio, and learning outcomes. The adjusted net enrollment ratio has increased to 96.5% in 2021–22, which is closer to the SDG-4 target of 100% enrollment at elementary and secondary levels. In case of SDG-5, India’s SRB increased from 919 in 2016 to 929 in 2021. However, to meet SDG-5 target, SRB needs to increase to 954. At the state level, when it comes to multidimensional poverty among underfive children, we observe that four states and territories have already achieved their targets ahead of the schedule, showcasing their dedication to eradicating poverty and improving child well-being. Additionally, 20 states are “on track” to achieve the SDG target by 2030, indicating significant progress in reducing poverty-related deprivations. In terms of adolescent children, 18 states and UTs have made significant strides in reducing multidimensional poverty, demonstrating the effectiveness of targeted interventions. However, it is crucial to acknowledge the challenges faced by six states with insignificant growth rates and another six states with weak growth rates in relevant SDG parameter. These states need focused attention and resources to accelerate progress to achieve the SDG targets. In addressing child malnutrition, nine states have made steady progress and are “on track” to achieve the SDG target for stunting by 2030. However, 10 states face slower growth rates, while five states have insufficient growth rates, indicating the need for urgent interventions to address this issue. Furthermore, 11 states have experienced an increase in stunting, thereby posing significant obstacles in achieving the SDG goal.

204

8 Conclusion

Regarding wasting among under-five children, only three states/UTs have made noteworthy strides and are “on track” to achieve the SDG goal. On the other hand, 11 states have demonstrated insufficient growth rates, requiring urgent attention to address this concerning trend. The prevalence of overweight among under-five children is a growing concern, with 28 states witnessing an increase in the number of overweight children. These states need to take timely corrective action to prevent further deterioration and promote healthier lifestyles for children. Efforts to tackle anemia among 15–19-year-old girls need reinforcement, as its prevalence in several states exceeds the SDG target, and the rates have shown weak or insufficient improvement between the two periods analyzed. On a positive note, the evaluation reveals progress in reducing neonatal mortality, with seven states achieving the SDG target relating to NMR, and six states are “on track” to achieve it by 2030. Additionally, significant progress has been made in reducing under-five mortality, with nine states successfully achieving their targets so far. In terms of education, 13 states have already achieved the elementary-level enrollment target, while six states have demonstrated positive progress in improving secondary-level enrollment rates. However, efforts are needed to achieve the secondary-level enrollment targets in all states. Regarding clean drinking water and sanitation, 16 states and UTs are “on track” to achieve SDG-6, and 30 states and UTs are making remarkable progress in SDG-6 and SDG-7 targets. This reflects the commitment of various states in ensuring access to clean drinking water and improved sanitation facilities. Furthermore, encouraging trend could be seen in ensuring birth registration, with 29 states and UTs are “on track” to meet the target, emphasizing the importance of registering every child-birth for their legal recognition and access to essential services. Assessment of child well-being in relation of identified SDGs provide diverse insights. Our assessment of children’s well-being using nutrition (SDG-2), health (SDG-3), education (SDG-4), violence and gender equality (SDG-5), access to drinking water and sanitation (SDG-6), access to electricity and cooking fuel (SDG7), and birth registration (SDG-16) identifies progress made by states and UTs. Through our assessment, we identify leading, lagging, and states with moderate progress between two time periods. The evaluation of child well-being across identified SDGs presents diverse insights, with achievements varying across states and UTs. Moreover, socioeconomic status plays a significant role in determining the level of improvement. Our assessment categorizes states and UTs into five achievement status namely “achieved,” “on track,” “weak,” “insufficient,” and “worsened,” thereby highlighting areas that require targeted actions to foster achievement of the SDG targets. Moreover, to better capture the nuances of progress, we further classified states as leading, moderate, and lagging based on their performance in each dimension of the child well-being index as well as the overall well-being index. This additional categorization allows for a more nuanced and comprehensive analysis and insights,

8.4 Addressing Critical Concerns for Achieving SDGs

205

taking into account the various factors that contribute to a state’s progress toward achieving the child-specific SDGs. Spatial variation in progress underscores the importance of tailored interventions based on regional context and socio-economic disparities. By incorporating insights from these findings, policymakers and implementing agencies can develop evidencebased strategies to accelerate progress and ensure a more inclusive and bright future for children in India as well as contribute to the global discourse of holistic and sustainable development.

8.4 Addressing Critical Concerns for Achieving SDGs Achieving the SDGs for children in India requires careful attention to critical concerns and challenges that persist in various dimensions of child well-being, from early infancy through adolescence. The first 1000 days of a child’s life, from conception to two years of age, are crucial for their physical and cognitive development. However, several challenges continue to influence the overall well-being of children, including nutrition, health, clean drinking water, sanitation, and safe cooking fuel. As children transition into adolescence, new concerns arise, such as adolescent anemia, adolescent pregnancy, and child marriage. These issues demand focused efforts and interventions to ensure the well-being and future prospects of young individuals. Addressing the critical concerns at each stage of childhood and adolescence is vital for creating a more inclusive and sustainable society thereby leaving no child behind in our journey toward a better tomorrow. 1. Addressing Malnutrition and Anthropometric Indicators: While progress has been made in reducing chronic malnutrition at the national level, certain states have experienced an increase in anthropometric failures, signaling the need for targeted interventions. Between 2005–06 and 2019–21, Assam, Delhi, Goa, Jharkhand, Karnataka, Maharashtra, Meghalaya, and Nagaland witnessed an increase in (composite) anthropometric failure. Similarly, during 2015–16 and 2019–21, nine states experienced an increase in multiple anthropometric failures, including Assam, Delhi, Gujarat, Himachal Pradesh, Kerala, Maharashtra, Meghalaya, and Nagaland. Additionally, 18 states have a prevalence of stunting exceeding 40%, with Bihar recording the highest prevalence. Despite majority of states experiencing a reduction in stunted children over the past 15 years, there was an increase in severely stunted children in 17 out of 29 states between 2015– 16 and 2019–21. Moreover, 19 out of 29 states witnessed an increase in severely underweight children during the same period. The NFHS-5 data reveals a significant increase in overweight among under-five children in the majority of the states compared to NFHS-4 data, with Himachal Pradesh, Kerala, Goa, Meghalaya, Andhra Pradesh, and Madhya Pradesh experiencing the highest increase. Anemia and overweight are opposites but both are not desirable.

206

8 Conclusion

2. Urgent Attention to Anemia Among Under-Five Children: Anemia among children under-five is a critical concern that demands urgent attention and targeted interventions. The prevalence of anemia in India is high, with 68 percent of children are found to be affected by it in 2019–21. Moreover, there has been a concerning increase of 9.4 percentage points between 2015–16 and 2019–21, indicating a insignificant progress in reducing anemia among young children. In 2019–21, at the state level, higher prevalence of anemia (over 70%) is observed across several states, including Gujarat, Madhya Pradesh, Jammu and Kashmir, Punjab, Rajasthan, Haryana, Bihar, Assam, and Telangana. These states require urgent attention and comprehensive strategies. 3. Addressing Child Mortality and Immunization Coverage: Child mortality and immunization coverage require critical attention as well. States with high child mortality rates need targeted policies to improve healthcare access, quality, and outreach. Similarly, states with low immunization coverage require strategies to enhance access, awareness, and uptake of immunization services. 4. Improving Education Outcomes and Addressing Social Concerns: The assessment of learning outcomes is constrained by various factors. Data availability with respect to educational outcomes poses additional challenge. Nevertheless, the available evidence suggests that the proportion of standard VIII children who can do division was found to be 41.8% in government schools, significantly below the SDG-4 national target of 57.17%. Reduction in dropout at the secondary level is also an area of concern in several states that still have dropout rates in excess of 10%. Additionally, some states are found to struggle with imbalanced sex ratio at birth, missing children, and an increase in crime against children in the form of kidnapping, child marriage, sexual offences, and trafficking. 5. Challenges of Adolescent Well-Being: Adolescent well-being is another area of concern, particularly regarding adolescent anemia, adolescent pregnancy, and child marriage. The study’s findings show that many adolescent girls in India are suffering from anemia, with 60 percent affected during 2019–21. There has been a significant increase of 4.2 percentage points between 2015–16 and 2019–21. Only two states are currently on track to achieve the SDG goal for adolescent pregnancy, while 23 states and UTs face significant challenges. Efforts must be intensified to reduce adolescent pregnancy rates and ensure the well-being of young girls. Additionally, focused efforts are needed to bring down child marriage rates, as four states have experienced a weak rate of decline, and 20 states and UTs have shown an insignificant rate of improvement.

8.5 Interventions to Be Made to Achieve Child-Specific SDGs/Way Forward Achieving the SDGs for children in India requires a child-centric approach that places the well-being and rights of children at the forefront of policy and programmes. Children are the most vulnerable members of society and their development is crucial for the overall progress and sustainability of the nation. As we strive to build a better

8.6 Pathway for Achieving SDG Goals for Children–Under-Five …

207

future, it is essential to address the critical concerns and challenges that persist in various dimensions of child well-being. Timely policy and investment in child development programs are needed to bring about quality health and learning outcome for children. It is well recognized that health, nutrition, and education outcomes take longer time to reflect. This should not discourage progressive policymaking. Hyperbolic behavior in resource allocation can bring long-term underperformance in these important sectors. Apart from resource allocation to address identified shortcomings in the health and education related aspects of children, implementation of laws preventing violence against children should be given priority. Dynamic nature of monitoring of outcomes are required. Even when there is progress toward achieving the SDG target, any lapse in monitoring could bring laxity and jeopardize achievement of targets. Therefore, even though achieved or not, continuous monitoring and evaluation are essential. To achieve real transformation in child development, apart from improving amenities and income of households, awareness and social changes would be required. For example, child marriage can be avoided when the parents are mindful of child development that can bring about better opportunities in the future by emphasizing on schooling and skill development. Multipronged and coordinated approach to tackle deprivation, health, education, and violence should be attempted. States need to put much more effort to bring out such coordination among implementing departments to improve the realities on ground.

8.6 Pathway for Achieving SDG Goals for Children–Under-Five and Adolescent We highlight a few specific and targeted interventions that need to be implemented to address the well-being of under-five children and adolescents. 1. Early Childhood Development (ECD) Initiatives: The need is to prioritize the implementation of comprehensive early childhood development programs that address nutrition, healthcare, and cognitive stimulation during the critical first 1000 days of a child’s life. These initiatives must ensure proper maternal and child healthcare, adequate nutrition, and early learning opportunities to support optimal physical and cognitive development. 2. Malnutrition Reduction: The need of the hour is to implement targeted interventions to reduce and early detect malnutrition among under-five children. This includes promoting exclusive breastfeeding, ensuring access to nutritious food, and fortifying staple foods with essential vitamins and minerals. Additionally, addressing micronutrient deficiencies and promoting nutrition education among parents and caregivers will be crucial. To effectively combat malnutrition, it is vital to establish strong linkages between service providers and communities. Healthcare professionals, including doctors, nurses, and community health workers, should be trained to recognize early signs of malnutrition and provide appropriate interventions. Empowering and training community

208

3.

4.

5.

6.

7.

8.

9.

10.

11.

8 Conclusion

health workers to play a pivotal role in early detection and management is equally essential. Conducting regular growth monitoring, educating parents on nutrition practices, and timely referral of malnourished children to healthcare facilities are imperative steps. Improved Healthcare Access: There is need to enhance healthcare access for children by strengthening healthcare systems, particularly in underserved regions. It is crucial to ensure the availability of essential healthcare services, immunization programs, and an adequate number of skilled healthcare personnel to address child health needs effectively. Education Quality Enhancement: The quality of education needs further enhancement at both the primary and secondary levels. Improved teacher training, enhanced classroom infrastructure, and better learning materials are to be provided. Additionally, emphasis on innovative teaching methods is needed to boost learning outcomes and to reduce dropout rates. Violence Prevention: The need to prioritize the implementation and enforcement of laws to prevent violence against children is immense to create safe environments for children, both at home and in the community. Increasing awareness and education on child protection and establishing child-friendly reporting mechanisms for violence cases are crucial. Adolescent Health Programs: Implementing targeted health programs specifically designed for adolescents would address issues related to anemia, adolescent pregnancy, and early marriage through comprehensive health services, awareness campaigns, and behavior change programs. Awareness and Social Change: Raising awareness among parents, communities, stakeholders, and adolescents themselves about the importance of child development and education is paramount in promote positive social changes to eliminate harmful practices like child marriage and early pregnancy. Empowering adolescents to become advocates for their own rights and well-being, and involving them in community discussions and decision-making processes assume significance. Data Monitoring and Evaluation: Development of dynamic and robust monitoring and evaluation systems to track progress toward SDG targets is crucial. Continuous assessment of outcomes and adaptive strategies will be needed to ensure robust progress in child well-being. Multi-Sectoral Coordination: There is an urgent need to facilitate coordination and collaboration among various sectors, including health, education, social welfare, and law enforcement. A multi-pronged and coordinated approach is essential to address diverse challenges faced by children. Strengthen Partnerships: Fostering strong partnerships among government agencies, civil society organizations, international bodies, and local stakeholders can help in pooling resources, expertise, and efforts to maximize the impact on child development and welfare. Capacity Building: Investing in capacity building for frontline workers, educators and trainers, healthcare professionals, and community leaders is essential to effectively deliver child development programs and services.

References

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By following these pathways and adopting an inclusive and comprehensive approach, it is possible to make significant strides in achieving the SDG goals for under-five children and adolescents in India. Timely and focused efforts, along with continuous monitoring and evaluation, will contribute to better outcome thereby creating a brighter and more promising future for all children.

8.7 Limitations and Scope for Future Research While our book strives to provide a comprehensive analysis of the progress and challenges in achieving the Sustainable Development Goals (SDGs) for children in India, there could be certain limitations that need to be acknowledged. First, the validity of our findings is subject to any bias that may be present in the data sources used in the analysis. Since the data sources used in this book come from recognized and reputed sources we expect the bias to be not systematic. Second, the availability of data on certain age groups and specific dimensions of child well-being is limited. For instance, national surveys like the National Family Health Survey (NFHS) may not provide detailed information for children aged 10–14 years, which hinders a thorough understanding of the well-being of this particular age group. While indicators such as anemia and body mass index (BMI) may be available for 15–19 years age group, comprehensive data on other critical health aspects, including mental health and other health-related issues, may be limited. This restricts our ability to assess and address the broader range of health challenges and well-being dimensions experienced by adolescents in India. Furthermore, the absence of preschool data limits our analysis of early childhood education and development, which is a critical period for child well-being. As per the NEP, preschooling from three to six years is recognized under school curriculum. Data should be collected for this, and other, age group so that the learning effectiveness can be assessed before the final SDG evaluation. Lack of sufficient data is recognised as one of the major challenges in assessing at least two-thirds of all child related SDG indicators globally (UNICEF, 2018). Another limitation in the Indian context could be the small sample sizes at the district level, making it challenging to provide precise district-level estimates and identify localized disparities. Moreover, due to the COVID-19 pandemic and its impact on the quality of learning, we were unable to include 2021 learning data, because the data may not accurately reflect the true learning outcomes due to the disruptive impact of the COVID-19 pandemic on education. These limitations underscore the need for enhanced data collection, age-specific studies mainly at adolescent stages, and further research efforts to address the gaps in knowledge and provide a more comprehensive understanding of the progress and challenges in achieving the SDGs for children in India.

References Marguerit, D., Cohen, G., & Exton, C. (2018). Child well-being and the sustainable development goals: How far are OECD countries from reaching the targets for children and young people?

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