Stung by the realization that it faced a child malnutrition crisis worse than in most African countries, India is finally waking to the scale of the problem.

Progress is slow and political will patchy, but there are signs that a new approach to fighting malnutrition is beginning to reap dividends.

Efforts to improve rural health and education have combined with an expansion of a child welfare program that employs nearly 2 million village health workers to focus on maternal and infant health and nutrition. A rural jobs plan has helped raise wages in the countryside, and new programs are educating adolescent girls, nearly half of whom will marry before age 18, about feeding and hygiene.

Signs of progress appeared in an independent survey of malnutrition in 100 of India’s least-
developed districts. Released in January, it showed the proportion of underweight children falling to 42 percent, a drop of 11 percentage points.

Even more dramatic are preliminary data from the western state of Maharashtra released last month, which show a decline in the number of children who were stunted, to 22.8 percent from 39 percent in 2006, thanks to a government program aimed at the needs of infants and mothers.

Child malnutrition in India

“We are confident that there is a good story in the making,” said Victor Aguayo, head of UNICEF’s India nutrition program. “There is excitement that what can happen is happening.”

Maharashtra is home to India’s financial capital, Mumbai, and is the country’s economic powerhouse. But malnutrition rates did not begin falling significantly until the state government started showing the political will to tackle the problem head-on.

Nationally, the wake-up call came in 2007 with the realization that a decade and a half of buoyant economic growth had scarcely dented child malnutrition rates, which remained higher than the average in sub-Saharan Africa. Nearly half of Indian children younger than 5 were stunted and underweight for their age, a government survey released that year showed, permanently impairing their mental and physical development.

But in a country where many middle-class people find the subject of malnutrition rather boring, it took the idea that India was underperforming — not just compared with Africa but also with neighbors such as Bangladesh — to embarrass the government into action. In 2007, Prime Minister Manmohan Singh called it a “national shame,” and a failed strategy began to be reevaluated.

“India as a nation had been overemphasizing economic growth in the hope it would somehow solve the problem,” Aguayo said. But growth has not been equitably distributed, and experts argue that the health sector has been neglected.

Malnutrition, Aguayo said, has been undermining India’s ambitions to be the nation “it wants to become.”

Grueling reality

Despite the progress, India has a long way to go. In a poor tribal district of Banswara, in the western state of Rajasthan, the mismatch between India’s aspirations and its problems, between its self-image and the grueling reality in the lives of millions of its citizens, is striking.

On the outside of one family’s simple home, between paintings of Hindu gods, were two pictures. One was a drawing of a woman cradling her baby, titled “Mother’s Love.” The other was a photo of a pudgy white-skinned baby wearing only a woolly hat.

But beneath the posters, a filthy and thin Indian baby named Jitendra sat listlessly on the veranda, dirt caking his cheeks, flies gathering around his eyes, nose and mouth.

Three months ago, when Jitendra was 15 months old, health workers found that he weighed just 12.1 pounds — less than two-thirds the minimum global standard for his age. The workers began visiting regularly and giving the family supplementary food, and Jitendra has gained about two pounds. But he remains severely malnourished.

Although he was not underweight when he was born, repeated illnesses have taken a toll.

“He has been sick for a long time,” said his slight, 18-year-old mother, Sundari Dhindor. “Where is the money? How do you expect me to feed him? He is still on my breast milk.”

The family’s situation illustrates what nutritionists call a perfect storm of factors driving India’s malnutrition crisis. Many children are born to teenage, anemic, malnourished mothers. Feeding practices are poor, and the environment — a crowded country where 600 million people have no access to toilets — is rife with fecal matter.

Health programs were largely failing to reach infants in the first two years of their lives, when malnutrition usually sets in and causes permanent mental and physical damage, Aguayo said.

Fewer than half of Indian children start nursing within their first 24 hours, receiving water rather than the early, antibody-rich breast milk that helps protect against infections. Most spend their first few years subsisting on protein- and vitamin-poor diets of rice or bread. Other major factors include persistent poverty in communities that have not benefited from economic growth, and the low status of women in India.

Child marriages

In Banswara, village health workers blame rampant malnutrition on the prevalence of child marriages. Dhindor, Jitendra’s mother, got married when she was 13 to a man she describes as a “good-for-nothing drunkard.” She said she spends most of her day cooking, washing, cleaning and fetching firewood or water for her in-laws, or trying to earn money as a day laborer in local fields.

India’s progress in fighting malnutrition fails to impress many experts.

Save the Children and World Vision recently ranked India alongside Congo and Yemen at the bottom of a global nutrition barometer for its commitment and performance.

While the nation frets constantly about whether economic growth and the stock market are up or down, the government has not collected data on child malnutrition since 2004 — something Purnima Menon of the International Food Policy Research Institute calls “mind-boggling.”

Last month, India’s president and a leading Bollywood actor launched a national publicity campaign to combat malnutrition. The government has also promised a huge rise in health-care spending during the next five years.

Nevertheless, experts say the government lacks a coherent plan to overcome the shortcomings of the child health program, which depends on village health workers who are overburdened and poorly educated, trained and paid.

Spending comes easily to the government, critics say, but setting up mechanisms to monitor performance and raise accountability seems far less instinctive. Meanwhile, the Ministry of Women and Child Development remains a junior cabinet post, a department where few civil servants want to work, said A.K. Shiva Kumar, an independent adviser to the government on development.

“The problem of malnutrition is not visible or in-your-face,” he said. “The political attraction of working on nutrition is very low. It doesn’t really sell.”