Why do we have more toilets and more child stunting?

Business Standard, 28 December 2020

There is a lot of debate and angst about the recent NFHS data release that has partial results for 2019-20. Some human development indicators seem to have improved, but others have not. An inputs-outputs-outcomes framework helps us understand what is going on. The government apparatus has pushed in favour of increased inputs. Bureaucracies tend to have a tunnel vision, and this has generated a heightened focus on inputs. There are, however, difficulties on outputs and outcomes. There is the problem of broader economic growth, which is ultimately of dominant importance in creating human development outcomes.

NFHS is an important and high quality dataset. Early results for the 5th cross-section, for 2019-20, are visible. This covers 17 states and 5 union territories, which add up to 54 per cent of the population. There has been a long-term trend of progress on many indicators. In the field of health, there was an acceleration in the growth rates of sanitation, in the post-2015 period. This is good news; it suggests that the government's big push for more toilets is yielding some results.

And, there is worrying news. There was a long-term trend of a decline in child stunting in the previous years, but this has switched to stagnation (rural) or deterioration (urban) after 2015. How do we reconcile these contradictory facts? After all, one of the reasons for child stunting is that under poor sanitation, kids repeatedly fall sick, which hampers their physical growth. When the sanitation improves, stunting should go down.

As with many other parts of public policy, it is useful to think in terms of inputs, outputs and outcomes. This framework became famous around education, where the inputs are school buildings and recruitment of teachers, the outputs are kids who are enrolled and attend school, and the outcomes are what the kids actually know. From about 2004 onwards, we have understood that very large increases in public expenditure in the per-pupil expenses were associated with essentially no gains in the outcomes. The education bureaucracy has proclaimed its victories as counted by school buildings, teachers employed or kids enrolled. But at a fundamental level, state spending on elementary education has not delivered: vast increases in the input has not delivered gains in the outcome.

The inputs, outputs and outcomes framework is useful in numerous other areas and readily fits the problem at hand. Toilets are an input. But do toilets actually get used? The extent to which open defacation is eliminated is an output. And then, this is supposed to generate an outcome, healthier children, where child stunting is a useful measure.

Somewhere in this pipeline from inputs to outputs to outcomes, from toilets to child stunting, the connections did not work out. The need of the hour is research which deciphers what happened, which can then kick off improvements to policy positions. The release of the full NFHS data at the record level will help researchers better explore the correlations between toilets, childhood morbidity and stunting. Ideally, we will then get the full feedback loops from data to research to policy modifications.

Politicians are universally concerned about the extent to which the organisational structures of the Indian state are effective in converting money into the desired outcomes. Deeper changes in organisational design require high intellectual capacity and take place slowly. There is the temptation of leaving the malfunctioning structures intact, and try to go after one objective after another in mission mode, without solving deeper problems. This has limitations.

When an organisation is told that it will be measured by some target, employees tend to develop tunnel vision, and pursue that target in a narrow minded way. When traders in banks are told that they have to produce trading profits, they do this while often sacrificing the long-term health of the bank along the way. In similar fashion, when employees of large state organisation are pushed to roll out more toilets, this may happen in a narrow minded way, without adequate attention to the full picture. What matters is not building toilets; what matters is that those toilets should actually get used.

Mission mode is also fine for episodic problems (e.g. Kumbh Mela) but is not a substitute for deeper reform. It is about whipping a weak organisation into performance through pure energy from the top: this can sometimes be done for a short time but is not a sustainable steady state. An organisation placed in such a state tends to run unthinkingly, intensifying policies without questioning them.

Alongside this, we should not lose sight of the most important determinant of human development outcomes: high GDP growth. When GDP growth is strong, income growth makes it possible for households to spend more on buying food, education, sanitation and health. High growth in the 1991-2011 period made possible a great deal of progress on issues like poverty and human development, not because the Indian state did better on either public goods or programs, but because households got more purchasing power and were able to buy more food, sanitation, health and education.

Conversely, the difficulties of the economy from 2011 onwards have hampered human development outcomes. The problem of underweight and stunted children is ultimately grounded in inadequate GDP growth. Government programs that invest in nutrition for kids are important, but they ultimately cannot solve the problem of low growth.

Looking forward, the decline in GDP of 2020 will adversely affect the purchasing power of many households. This is likely to adversely impact the five key health outcome measures: infant mortality, maternal mortality, all-causes mortality, self-reported health and child stunting. There is a role for better utilising limited state resources in order to deliver nutrition and health services to the poor. But ultimately, there is no running away from the fundamental problem. Private investment has retreated in India, from 2011 onwards, and this is required for achieving sustained GDP growth.

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