Keshav Sahani
Over the past two decades, India has significantly improved various maternal, newborn, and child health (MNCH) service indicators. Institutional deliveries, antenatal check-up coverage, immunisation rates, and postnatal care have all shown a sharp and consistent upward trend. However, progress on nutritional outcomes for women and children, such as child stunting, wasting, anaemia, and low birth weight, has been comparatively slower, more uneven, and at times even regressive.
A key reason for this disparity lies in the distinct nature of these outcomes and the interventions required to achieve them. Health service indicators can often be improved through point-in-time interventions: a woman receives antenatal check-ups during each trimester, a child is vaccinated according to schedule, and a newborn receives postnatal care during home visits.
These concrete, event-based actions can be effectively delivered by enhancing frontline worker capacities, supported by regular monitoring and reviews. In addition, targeted campaigns and outreach activities can bridge gaps when service coverage is low in a particular area. Initiatives such as Mission Indradhanush and Pulse Polio Campaign are excellent examples that significantly boosted immunisation coverage.
| Indicator | NFHS-3 (2005-06) | NFHS-4 (2015-16) | NFHS-5 (2019-21) |
| Institutional Births | 38.7% | 78.9% | 88.6% |
| At least four antenatal care visits | 37.0% | 51.2% | 58.1% |
| Child Immunisation (full, 12–23 months) | 43.5% | 62.0% | 76.4% |
| Postnatal Care (within 2 days of birth) | 37.0% | 62.4% | 78.0% |
| IFA Supplementation (pregnant women 100+ days) | 15.2% | 30.3% | 44.1% |
Source: National Family Health Survey, India (2005-06, 2015-16, 2019-21) assessed at https://www.nfhsiips.in/nfhsuser/publication.php
Contrary to health outcomes, nutritional outcomes are shaped more by daily behaviours, household environments, and socio-economic conditions. The nutritional status of a mother and child depends not only on access to services but also on sustained access to diverse foods, regular consumption of micronutrients, hygienic living conditions, and a nurturing caregiving environment. These habits must be embedded across entire communities and households. While nutrition campaigns can raise awareness, real improvements depend on consistent and meaningful changes in daily practices.
For example, iron and folic acid (IFA) supplementation for pregnant women has increased from 15% to 45% over the last three NFHS rounds. Yet, anaemia among pregnant women remains nearly unchanged. And while exclusive breastfeeding rates have steadily improved, only about 1 in 10 children aged 6–23 months receive an adequate diet, a stark reminder of the persistent gaps in child nutrition beyond infancy. The nutritional status has not improved for men either; although their indicators are relatively better than women’s, progress has been negligible.
| Indicator | NFHS-3 (2005-06) | NFHS-4 (2015-16) | NFHS-5 (2019-21) |
| Stunting (<5 years) | 48.0% | 38.4% | 35.5% |
| Wasting (<5 years) | 19.8% | 21.0% | 19.3% |
| Underweight (<5 years) | 42.5% | 35.8% | 32.1% |
| Low Birth Weight (<2.5kg) | 22.0% | 18.2% | 18.2% |
| Anaemia in Children (6-59 months) | 69.5% | 58.6% | 67.1% |
| Anaemia in Women (15-49 years) | 55.3% | 53.1% | 57.0% |
| Anaemia in Pregnant Women | 57.9% | 50.4% | 52.2% |
| Adolescent Girls Anaemia (15-19 years) | -NA- | 54.1% | 59.1% |
| Anaemia in adolescent boys (15–19) | -NA- | 29.2% | 31.1% |
| Anaemia in men (15–49) | 24.2% | 22.7% | 25.0% |
| Exclusive breastfeeding (up to 6 months) | 46.3% | 54.9% | 63.7% |
| Children (6-23 months) with an adequate diet | 15.9% | 9.6% | 11.3% |
Source: National Family Health Survey, India (2005-06, 2015-16, 2019-21) assessed at https://www.nfhsiips.in/nfhsuser/publication.php
Why is nutrition harder to fix?
Malnutrition is not a short-term issue. It is a long-term, self-perpetuating cycle. Unlike many MNCH service outcomes that fall within the 1,000-day window (period from conception to a child’s second birthday), nutritional care, such as iron supplementation, is needed across the entire lifecycle: from childhood, through adolescence, during pregnancy and postpartum, and again for the next generation. In contrast to vaccines like TD or Pentavalent, where a fixed number of doses provides lasting protection, nutritional support demands continuity, discipline, and long-term commitment, not just one-time coverage.
Adding to the complexity is the increasing prevalence of unhealthy eating habits, especially in urban and semi-urban areas. Consumption of packaged, processed, fried, and sugary foods has surged, leading to a dual burden of malnutrition: undernutrition coexists with rising obesity and diet-related non-communicable diseases. While undernutrition remains the larger concern in India, obesity is growing steadily and poses an emerging nutritional challenge.
An interesting anecdote from a colleague who has worked with rural and tribal communities for over two decades illustrates this shift: In many tribal households in central India, traditional, nutrient-rich grains are being replaced by wheat and rice. These grains are now readily available, are easier and quicker to cook, and above all, perceived as tastier. Meanwhile, traditional crops such as millets have transitioned from dietary staples to cash crops.
Such gradual but widespread shifts in behaviour are worsening the nutritional crisis, quietly and pervasively.
Personal, practical, and persistent: A new nutrition playbook
India has implemented several programs to improve nutritional outcomes, including direct interventions such as hot cooked meals and take-home rations from anganwadi centres, mid-day meals in schools, fortified food initiatives, iron and folic acid supplementation, and awareness initiatives such as Poshan Abhiyaan. These programs, along with many initiatives supported by social impact organizations, have significantly contributed to better nutrition. However, behaviour change communication (BCC) has often remained generic, episodic and one-size-fits-all, broadcasting messages en masse rather than tailoring them to individual needs. For actual behaviour change, the message must answer: “How it impacts ME and MY CHILD?”, not just offer abstract advice on “how it impacts”.
With increasing digital access, we now have tools to make nutrition messaging more personal and actionable. Imagine a pregnant woman not just being told about the importance of iron but being shown her haemoglobin trend over time and advised based on her dietary patterns and local food availability. It is essential to make health messages contextual and aligned with local diets, cultural habits, and what is practically accessible. It is not enough to say, “Eat spinach,” if spinach is expensive or unavailable. Behaviour change messaging cannot succeed if the food is out of reach, economically or physically.
The messaging must be grounded in daily realities: simple, achievable, and motivating. Families should see tangible benefits, have access to required resources, and find it convenient to act. Remember, malnutrition is not always seen as a medical problem. Families may not follow nutritional advice as readily as they would a doctor’s prescription.
Another way behaviour change works is by catching the supply while it is young. The success of food fortification shows that systemic solutions, such as changing the flow (making it nutrient-rich), can deliver nutrients without needing individual behaviour change. Fortified wheat, oil, and salt are examples of this quiet and scalable transformation. According to the 2024 Global Survey of School Meal Programs, only 55% of school meal programs globally included fortified foods, leaving ample room for expansion.
Solving malnutrition demands more than campaigns and point-in-time solutions. It calls for a shift in mindset: from events to ecosystems, information to personalisation, and one-off services to sustained behavioural change. Communities must have ownership. Health workers must be empowered with tools for meaningful dialogue, not just data collection. Programs must unify the supply and demand sides of nutrition.
Nutrition is not just a health issue, it is a societal challenge, and addressing it will require time, trust, and tenacity.
About the contributor:
Keshav Sahani is the Chief Strategy Officer, Digital Health at The Antara Foundation, where he oversees strategy, innovation, and the development of digital public health platforms.
Disclaimer: All views expressed in the article belong to the author and not necessarily to the organisation.
Acknowledgement: This article was posted by Atharva Salunke, a research intern at IMPRI.
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