Prevalence and Correlates of Double and Triple Burden of Malnutrition Among Children and Adolescents in India: Comprehensive National Nutrition Survey.

BACKGROUND: Limited information on the co-prevalence of undernutrition, micronutrient deficiencies, overnutrition, and abnormal levels of noncommunicable disease biomarkers at the same time in children and adolescents in India hinders efforts to comprehensively address their health. This study aims to examine the prevalence and correlates of double and triple burden of malnutrition (DBM, TBM) among children and adolescents (5-19 y) to inform policies and programs. METHODS: A total of 17,599 children (5-9 y) and 16,184 adolescents (10-19 y) with available biomarker data from the Comprehensive National Nutrition Survey were included. Malnutrition was defined based on either undernutrition based on anthropometry, overnutrition/abnormal metabolic markers, and anemia/micronutrient deficiency. DBM was defined as the coexistence of any two forms of malnutrition. DBM+ was defined as the coexistence of undernutrition and/or micronutrient deficiency along with overnutrition. TBM was defined as having the coexistence of all three forms of malnutrition. The prevalence of DBM, DBM+ and TBM was estimated accounting for probabilistic selection. We used mixed effects binomial regression to determine correlates of DBM/TBM in children and adolescents separately. RESULTS: The prevalence of DBM, DBM+ and TBM was 50.8%, 37.2%, and 14.4%, respectively, in children, and 53.4%, 36.1%, and 12.7%, respectively, in adolescents. The prevalence of DBM+ was significantly higher in children girls compared to boys. In children, being in a disadvantaged caste group, having a lower wealth index, having inadequate diet diversity, having no maternal schooling and having a recent history of acute illness were associated with DBM. In adolescents, being in a disadvantaged caste group, maternal occupation, and lower paternal age were correlated with DBM. A similar set of variables was associated with TBM in both age groups. CONCLUSION: The prevalence of DBM and TBM is substantial in children and adolescents in India and varies across states. Socioeconomic factors and acute illness were the main correlates for DBM and TBM.

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review.

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

Modelling the cost-effectiveness of subepidermal moisture measurement as part of a process of assessment and intervention to prevent hospital-acquired pressure ulcers.

Skin tissue assessment is traditionally used to identify early signs of pressure damage from changes observed at the skin surface. However, the early onset of tissue damage induced by pressure and shear forces is likely to be on soft tissues beneath the surface of the skin. Subepidermal moisture (SEM) is a biophysical marker for the detection of early and deep pressure-induced tissue damage. Measurement of SEM can detect early pressure ulcers up to 5 days before visible skin changes occur. The aim of this study was to evaluate the cost-effectiveness of SEM measurement compared with visual skin assessment (VSA). A decision-tree model was developed. Outcomes are the incidence of hospital-acquired pressure ulcers, quality-adjusted life-years (QALYs) and costs to the UK National Health Service. Costs are at 2020/21 prices. The effects of parameter uncertainty are tested in univariate and probabilistic sensitivity analysis. In a representative NHS acute hospital, the incremental cost of SEM assessment as an adjunct to VSA is -£8.99 per admission, and SEM assessment is expected to reduce the incidence of hospital-acquired pressure ulcers by 21.1%, reduce NHS costs and lead to a gain of 3.634 QALYs. The probability of cost-effectiveness at a threshold of £30 000 per quality-adjusted life year is 61.84%. Pathways that include SEM assessment make it possible to implement early and anatomy-specific interventions which have the potential to improve the effectiveness of pressure ulcer prevention and reduce healthcare costs.

Association of basic vaccination with cognitive and learning ability among children: insights from the India Human Development Survey, 2004-05 and 2011-12.

Basic vaccination is important to protect children from infectious diseases and illnesses. Adequate levels of vaccination coverage reduce the morbidity and mortality burden among children and promote their physical and mental development. This study aimed to assess the association between basic childhood vaccination and the cognitive and learning ability of school children in India. Nationally representative follow-up data on 6183 children from the Indian Human Development Surveys conducted in 2004-05 and 2011-12 (IHDS I & II) were analysed. Children aged 8-10 years who had received all basic vaccines by the age 12 months performed better in a maths test than partially vaccinated or unvaccinated children (OR: 1.87, 95% CI: 1.48, 2.35). Similarly, fully vaccinated children performed better in writing tasks than partially vaccinated or unvaccinated children (OR: 1.77, 95% CI: 1.44, 2.18). Likewise, fully vaccinated children had better reading skills than fully unvaccinated children (OR: 1.60, 95% CI: 1.23, 2.09). The results suggest that enhancing child vaccination coverage can have significant benefits beyond health and can potentially improve the long-term educational outcomes of children.

Improving nutrition budgeting in health sector plans: Evidence from India's anaemia control strategy.

In India, 15 nutrition interventions are delivered and financed through the National Health Mission (NHM). Programmatic know-how, however, on tracking nutrition budgets in health sector plans is limited. Following the four phases of the budget cycle-planning, allocations, disbursements and expenditure, this paper presents a new method developed by the authors to track nutrition budgets within health sector plans. Using the example of the Anemia Mukt Bharat (AMB) or Anemia Free India strategy, it reports preliminary findings on the application of the first two phases of the method, that is, to track and act for improved planning and allocations, covering 12 states. The paper lists out the budget heads, cost norms and developed tools to plan adequately. Supportive action was undertaken through sharing trends and trainings for AMB's budgeting to create opportunities for improvements. It was observed that the AMB budget increased over 3 years despite the COVID situation. It increased from INR 6184 million in FY 2019-2020 to INR 6293 million, a 2% increase in FY 2020-2021, and to INR 7433 million, an 18% increase in FY 2021-2022. The difference in allocations and planned budgets were low (16%, 4% and 11%, respectively) while the difference in required budgets and planned budgets were significant but reduced consistently (41%, 31% and 22%, respectively). The paper concludes that the methods adopted for tracking and acting for improved nutrition budgets helped in informing national and state governments regarding yearly trends. Such methods can be effective and be developed for other nutrition interventions.

Anaemia in Indians aged 10-19 years: Prevalence, burden and associated factors at national and regional levels.

Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10-19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%-46%; boys 11%-28%) and state (girls 7%-62%; boys 4%-32%). Iron deficiency (ferritin < 15 µg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 µg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

Why market orientation matters for agriculture and fishery workers? Unravelling the association between households' occupational background and caloric deprivation in India.

BACKGROUND: Developmental policies in low- and middle-income countries pose immense potential within the agriculture sectors to escalate economic growth and development. Almost one-half of the workforces continue to be engaged in agriculture and allied activities with a relatively lower economic contribution than those employed in other sectors. Hence, realizing such potential however requires tremendous scaling up of skill development activities in the sector. Investing in skill development of workers engaged in agricultural and allied activities can potentially display notable value additions, income generation and therefore reductions in widespread deprivations in the form of food insecurity and undernutrition. Further with the direct link between nutrition and productivity, economic gains, it is further imperative to impart market exposure among subsistence and unskilled workers. This study therefore empirically investigates the association between households' primary occupation and caloric deprivation in India. In particular, in a multivariate and multilevel framework, we identified how closely primary occupation of households explain the variation in caloric deprivation in India. METHODS: Drawing upon data from 68th round (2011-12) of nationally representative cross-sectional Household Consumer Expenditure Survey (HCES) of National Sample Survey (NSS), Government of India, we examined the association between occupational backgrounds of households and caloric deprivation (average caloric consumption as well as low calorie intake) among Indian households. RESULTS: Evidences show that agricultural and fishery labor households have lowest calorie intake (2086 kcal) across all the occupational groups. However, market oriented skilled agricultural and fishery workers' (2261 kcal - rural, 2165 kcal - urban) have higher calorie intakes than those belonging to subsistence agricultural (2165 kcal - rural, 2149 kcal - urban). Further, the multilevel logistic regression estimates suggest that in rural areas, households engaged in skilled agricultural and fishery works have significantly (at 5% level) lower odds ratio (OR: 0.72, with 95% CI: 0.63; 0.82) of having insufficient calorie intake compared to the unskilled agricultural and fishery laborer households. Estimates from variance partitioning based on multilevel logistic regression models suggest that the households' occupational group accounts for 7 to 14% of total variation in calorie consumption. CONCLUSION: These insights when combined with the occupation-specific random-effects suggest that investing in skill development of agricultural and fishery workers may have immense potential to strengthen their nutritional status and to reduce deprivation levels.

Children's education and parental old-age health: Evidence from a population-based, nationally representative study in India.

Previous research has documented intergenerational transmission of human capital from children to parents. Less is known, however, about heterogeneity in this 'upward transmission' in low-resource settings. We examine whether co-resident adult children's education is associated with improved health among older parents in India, using nationally representative data from the 2014 Indian National Sample Survey. Parents of children with tertiary education had a lower probability of reporting poor health than parents of children with less than primary education. The benefits of children's education persisted after controlling for economic factors, suggesting that non-pecuniary pathways-such as health knowledge or skills-may play an important role. The association was more pronounced among economically dependent parents and those living in the North and West regions. Taken together, our results point to a strong positive association between children's education and parental health, the role of non-pecuniary pathways, and the importance of subnational heterogeneity in India.

Treatment and rehabilitation of stroke patients in India: A gendered analysis based on repeated cross-sectional national sample surveys on health, 2014 and 2019.

We attempt a gendered inspection of sex differentials in care following stroke in India using data from two rounds of NSSO. While almost all men and women receive allopathic care, a higher percentage of women (51.8%) were treated in public hospitals compared to men (32.6%) in 2014 and 2017-18 (45.8% vs 41.4%). Men were preponderantly treated in private hospitals (67.4%) compared to women (48.2%) in 2014 and 2017-18 (58.6% vs 54.2%). We provide evidence that for rehabilitation, at the highest decile for expenditure, men spend more than women. This preliminary exploration is indicative of a gendered dimension in care-seeking for stroke.

The impact of surgical site infection on hospitalisation, treatment costs, and health-related quality of life after vascular surgery.

Surgical site infections (SSI) substantially increase costs for healthcare providers because of additional treatments and extended patient recovery. The objective of this study was to assess the cost and health-related quality of life impact of SSI, from the perspective of a large teaching hospital in England. Data were available for 144 participants undergoing clean or clean-contaminated vascular surgery. SSI development, length of hospital stay, readmission, and antibiotic use were recorded over a 30-day period. Patient-reported EQ-5D scores were obtained at baseline, day 7 and day 30. Linear regressions were used to control for confounding variables. A mean SSI-associated length of stay of 9.72 days resulted in an additional cost of £3776 per patient (including a mean antibiotic cost of £532). Adjusting for age, smoking status, and procedure type, SSI was associated with a 92% increase in length of stay (P < 0.001). The adjusted episode cost was £3040. SSI reduced patient utility between baseline and day 30 by 0.156 (P = 0.236). Readmission rates were higher with SSI (P = 0.017), and the rate to return to work within 90 days was lower. Therefore, strategies to reduce the risk of surgical site infection for high-risk vascular patients should be investigated.

Changes in socio-economic patterns of energy consumption and insufficient energy intake across India from 1993-94 to 2011-12.

OBJECTIVE: To assess whether disparities in energy consumption and insufficient energy intake in India have changed over time across socio-economic status (SES). DESIGN: This cross-sectional, population-based survey study examines the relationship between several SES indicators (i.e. wealth, education, caste, occupation) and energy consumption in India at two time points almost 20 years apart. Household food intake in the last 30 d was assessed in 1993-94 and in 2011-12. Average dietary energy intake per person in the household (e.g. kilocalories) and whether the household consumed less than 80 % of the recommended energy intake (i.e. insufficient energy intake) were calculated. Linear and relative risk regression models were used to estimate the relationship between SES and average energy consumed per day per person and the relative risk of consuming an insufficient amount of energy. SETTING: Rural and urban areas across India. PARTICIPANTS: A nationally representative sample of households. RESULTS: Among rural households, there was a positive association between SES and energy intake across all four SES indicators during both survey years. Similar results were seen for energy insufficiency vis-à-vis recommended energy intake levels. Among urban households, wealth was associated with energy intake and insufficiency at both time points, but there was no educational patterning of energy insufficiency in 2011-12. CONCLUSIONS: Results suggest little overall change in the SES patterning of energy consumption and percentage of households with insufficient energy intake from 1993-94 to 2011-12 in India. Policies in India need to improve energy intake among low-SES households, particularly in rural areas.

Community involvement, trust, and health-related outcomes among older adults in India: a population-based, multilevel, cross-sectional study.

Objectives: this study examined whether individual and contextual measures of structural and cognitive social capital were associated with six health-related outcomes across older adults in India. Methods: data were collected from a representative sample of adults aged 60 and above across India in 2011-12 (n = 9,174). Personal community involvement and having someone to trust represented individual measures of structural and cognitive social capital. These measures were then aggregated to represent contextual measures of social capital, that is, the mean village level of community involvement and the village proportion having someone to trust. To examine associations between all four social capital indicators and six outcomes including self-rated health, psychological well-being, subjective well-being, memory, activities of daily living (ADL), and instrumental activities of daily living, we fit pooled, sex-stratified, and place-stratified multilevel regression models and adjusted for demographic and socio-economic factors. Results: personal community involvement was positively associated with all outcomes among the full sample. Adjusted odds ratios ranged from 1.05 (95% CI 1.02; 1.08) for good self-rated health to 1.42 (95% CI 1.33; 1.53) for high-ADL function. Personally having someone to trust was associated with four outcomes. Village-level social capital measures were less frequently associated with outcomes than personal social capital measures. Association strength between six health-related outcomes and individual and contextual measures of structural and cognitive social capital varied, however, among older people in India by sex, place and outcome. Discussion: interventions to promote healthy ageing by increasing community involvement and trust may need to be tailored to population subgroups.

Association between anthropometric-based and food-based nutritional failure among children in India, 2015.

Inadequate dietary intake is a critical underlying determinant of child undernutrition. This study examined the association between anthropometric-based and food-based nutritional failure among children in India. We used the 2015-2016 National Nutrition Monitoring Bureau data where anthropometric outcomes and food intake were both measured for each child. We followed the World Health Organization child growth reference standards to define anthropometric failures (i.e., height-for-age z score < -2 SD for stunting, weight-for-age z score < -2 SD for underweight, and weight-for-height z score < -2 SD for wasting), and the Indian Council of Medical Research recommended dietary allowance (RDA) to define adequacy in intake of calorie, protein, and fat. We used descriptive and regression-based assessments to test the association between the two indicators of nutritional failure and also computed the area under the receiver operating characteristic curve (AUC). The prevalence of stunting, underweight, and wasting was 28.6%, 24.3%, and 12.8%, respectively, whereas 78.2%, 27.4%, and 50.8% of the children had below RDA norms consumption of calorie, protein, and fat, respectively. We found weak-to-null correlation between anthropometric failures and food failures (Pearson correlation ranging from -0.013 to 0.147) and poor discriminatory accuracy (AUC < 0.62), suggesting that in the Indian context, anthropometric failures are not directly associated with food intake. This finding highlights the need for improving adequate intake of macronutrients and draws attention toward adopting a multifactorial approach to improve child nutrition in India. Poor food intake itself merits exclusive policy focus as it is an important nutrition and health concern.

Understanding the null-to-small association between increased macroeconomic growth and reducing child undernutrition in India: role of development expenditures and poverty alleviation.

Empirical evidence suggests that macroeconomic growth in India is not correlated with any substantial reductions in the prevalence of child undernutrition over time. This study investigates the two commonly hypothesized pathways through which macroeconomic growth is expected to reduce child undernutrition: (1) an increase in public developmental expenditure and (2) a reduction in aggregate income-poverty levels. For the anthropometric data on children, we draw on the data from two cross-sectional waves of National Family Health Survey conducted in 1992-1993 and 2005-2006, while the data for per capita net state domestic product and per capita public spending on developmental expenditure and headcount ratio of poverty were obtained from the Reserve Bank of India and the Government of India expert committee reports. We find that between 1992-1993 and 2005-2006, state-level macroeconomic growth was not associated with any substantial increases in public development expenditure or substantial reductions in poverty at the aggregate level. Furthermore, the association between changes in public development expenditure or aggregate poverty and changes in undernutrition was small. In summary, it appears that the inability of macroeconomic growth to translate into reductions in child undernutrition in India is likely a consequence of the macroeconomic growth not translating into substantial investments in development expenditure that could matter for children's nutritional status and neither did it substantially improve incomes of the poor, a group where undernutrition is also the highest. The findings here build a case to advocate a 'support-led' strategy for reducing undernutrition rather than simply relying on a 'growth-mediated' strategy. Key messages Increases in macroeconomic growth have not been accompanied by substantial increases in public developmental spending or reduction in aggregate poverty headcount ratio in India. Association between increases in public development expenditure or poverty headcount ratios and changes in child undernutrition, in particular, child stunting, is small to null. Reducing the burden of undernutrition in India cannot be accomplished solely relying on a growth-mediated strategy, and a concerted support-led strategy is required.

Horizontal Inequity in Elderly Health Care Utilization: Evidence from India.

Against the backdrop of population aging, this paper presents the analysis of need-standardised health care utilization among elderly in India. Based on nationally representative morbidity and health care survey 2004, we demonstrate that the need for health care utilization is indeed pro-poor in nature. However, the actual health care utilization is concentrated among richer sections of the population. Further, the decomposition analysis reveals that income has a very strong role in shifting the distribution of health care away from the poor elderly. The impact of income on utilization is well-demonstrated even at the ecological-level as states with higher per capita incomes have higher elderly health care utilization even as the levels of need-predicted distribution across these states are similar. We also find that the distribution of elderly across social groups and their educational achievements favours the rich and significantly contributes to overall inequality. Nevertheless, contribution of need-related self-assessed health clearly favours pro-poor inequality. In concluding, we argue that to reduce such inequities in health care utilization it is necessary to increase public investments in health care infrastructure including geriatric care particularly in rural areas and underdeveloped regions to enhance access and quality of health care for the elderly.

Integrated child development service (ICDS) coverage among severe acute malnourished (SAM) children in India: A multilevel analysis based on national family health survey-5.

Severe acute malnutrition (SAM) can be fatal for children, and potentially limit their cognitive and physical growth. The last three National Family Health Survey (NFHS) in India shows an increase in the prevalence of SAM among under-five children. Given the specific mandates under ICDS (Integrated Child Development Service) for SAM children, it is important to validate the coverage efficiency of ICDS on SAM children. This paper examines a possible association between the coverage efficiency of ICDS on SAM children. The study further aims to identify the determinants of ICDS service utilization among SAM children. We used data from the fifth round of the National Family Health Survey. Descriptive statistics was used to estimate the SAM coverage under ICDS. Multilevel Logistic Regression was used to identify the determinants of ICDS service utilization among SAM children. The burden of SAM is higher among older children (3+ age). Coverage of ICDS was more among younger children and the poorest households in the rural areas. Results from multilevel logistic regression showed that age had a significant relationship with the outcome variable. SAM children living in the rural areas had a significantly higher odds of being covered under ICDS service (OR 1.57; CI: (1.35, 1.82)) than their urban counterparts. Pregnant and lactating mothers who received ICDS services were significant determinants of SAM coverage under ICDS. There is no evidence that ICDS is more efficient in identifying and covering SAM children than non-SAM children. Despite special provisioning in place for SAM children, coverage of different ICDS services was similar to that of non-SAM children, and were in fact lower than non-SAM children for some categories. The study suggests that improving coverage of ICDS services among pregnant and lactating mothers would increase the coverage of ICDS services among SAM children.

Prevalence of overweight and obesity and associated demographic and health factors in India: Findings from Comprehensive National Nutrition Survey (CNNS).

BACKGROUND: Childhood obesity (5-9 years) in India is likely to contribute 11% to the global burden by 2030. METHODS: Data from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018) was used to assess the prevalence and key associated factors of overweight and obesity. Multivariable logistic regression models were applied to identify potential determinants associated with being overweight and obese. RESULTS: Overweight prevalence (including obesity) varied from 1.6% (0-4 years) to 4.8% (10-19 years). The majority of states reported a higher proportion of adolescents overweight and obese, than younger age group 5-9 years. A significantly higher prevalence of children and adolescents with obesity was reported in higher wealth quintiles and residents of urban areas. The prevalence of overweight and obesity and associated demographic and health factors in India included: the presence of NCD risk factor (adolescents: 1.68, 95% CI [1.31-2.14]), micronutrient deficiency (5-9 years children: 1.72, 95% CI [1.30-2.28]), mother's education (5-9 years children: 4.84, 95% CI [2.92-8.03]; adolescents: 2.17, 95% CI [1.42-3.32]), wealth (adolescents: 1.92, 95% CI [1.16-3.19]), place of residence (5-9 years children: 1.68, 95% CI [1.39-2.03]; adolescents: 1.39, 95% CI [1.16-1.66]), child age (5-9 years children: 1.64, 95% CI [1.40-1.93], and screen-time (adolescents: 1.63, 95% CI [1.22-2.19]. CONCLUSION: The findings set out policy and research recommendations to pave the path for curtailing the increasing prevalence of overweight and obesity and achieving the World Health Assembly's Global Nutrition target of 'no increase in childhood overweight (Target 4) by 2025'.

Refining estimates of catastrophic healthcare expenditure: an application in the Indian context.

Empirics of catastrophic healthcare expenditure, especially in the Indian context, are often based on consumption expenditure data that inadequately informs about the ability to pay. Use of such data can generate a pro-rich bias in the estimation of catastrophic expenditure thereby suggesting greater concentration of such expenditures among richer households. To improve upon the existing approach, this paper suggests a multidimensional approach to comprehend the incidence of catastrophic expenditure. Here, we integrate the information on health expenditure with other social and economic parameters of deprivation. An empirical illustration is provided by using nationally representative survey on morbidity and healthcare in India. The results of the multidimensional approach are consistent with the theoretical underpinnings of the ability-to-pay approach and emphasizes on the severity of the problem in rural areas. The suggested methodology is flexible and allows for context-specific prioritization in selection of parameters of vulnerability while estimating the incidence of catastrophic expenditures.

Progress on Sustainable Development Goal indicators in 707 districts of India: a quantitative mid-line assessment using the National Family Health Surveys, 2016 and 2021.

Background: India has committed itself to accomplishing the Sustainable Development Goals (SDGs) by 2030. Meeting these goals would require prioritizing and targeting specific areas within India. We provide a mid-line assessment of the progress across 707 districts of India for 33 SDG indicators related to health and social determinants of health. Methods: We used data collected on children and adults from two rounds of the National Family Health Survey (NFHS) conducted in 2016 and 2021. We identified 33 indicators that cover 9 of the 17 official SDGs. We used the goals and targets outlined by the Global Indicator Framework, Government of India and World Health Organization (WHO) to determine SDG targets to be met by 2030. Using precision-weighted multilevel models, we estimated district mean for 2016 and 2021, and using these values, computed the Annual Absolute Change (AAC) for each indicator. Using the AAC and targets, we classified India and each district as: Achieved-I, Achieved-II, On-Target and Off-Target. Further, when a district was Off-Target on a given indicator, we further identified the calendar year in which the target will be met post-2030. Findings: India is not On-Target for 19 of the 33 SDGs indicators. The critical Off-Target indicators include Access to Basic Services, Wasting and Overweight Children, Anaemia, Child Marriage, Partner Violence, Tobacco Use, and Modern Contraceptive Use. For these indicators, more than 75% of the districts were Off-Target. Because of a worsening trend observed between 2016 and 2021, and assuming no course correction occurs, many districts will never meet the targets on the SDGs even well after 2030. These Off-Target districts are concentrated in the states of Madhya Pradesh, Chhattisgarh, Jharkhand, Bihar, and Odisha. Finally, it does not appear that Aspirational Districts, on average, are performing better in meeting the SDG targets than other districts on majority of the indicators. Interpretation: A mid-line assessment of districts' progress on SDGs suggests an urgent need to increase the pace and momentum on four SDG goals: No Poverty (SDG 1), Zero Hunger (SDG 2), Good Health and Well-Being (SDG 3) and Gender Equality (SDG 5). Developing a strategic roadmap at this time will help India ensure success with regards to meeting the SDGs. India's emergence and sustenance as a leading economic power depends on meeting some of the more basic health and social determinants of health-related SDGs in an immediate and equitable manner. Funding: This work was funded by the Bill and Melinda Gates Foundation, INV-002992.

Public health supply chain for iron and folic acid supplementation in India: Status, bottlenecks and an agenda for corrective action under Anemia Mukt Bharat strategy.

PURPOSE: The IFA supplementation program under the Anemia Mukt Bharat (AMB) program is one of the most ambitious nutrient supplementation programs in India. The delivery of services often suffers due to frequent stock outs and shortages. It is critical to understand the bottleneck in the supply chain adversely affecting the performance and coverage of the program. The paper attempts to identify the bottlenecks of the IFA supply chain in key areas of supply chain i.e., forecasting, procurement, warehousing and inventory management, transportation, distribution, logistic information system and suggests a plan of action aimed at ensuring uninterrupted supplies to the end beneficiaries. DESIGN/METHODOLOGY/APPROACH: The data source for the present paper is the nationwide IFA Supply Chain Assessment (2018-19) conducted across 29 Indian states with a total of 58 districts, 116 blocks, 232 Sub-Centres, 232 Anganwadi centres and 232 schools covered under the assessment as a multi-partner collaborative initiative. Field insights from supply chain strengthening interventions under different public health programs in India and other developing countries were taken to arrive at corrective actions and recommendations. Findings were disseminated to government and an action plan was suggested for connecting service delivery points through an app-based system, developing a micro plan for ensuring fixed distribution schedule, followed by continuous monitoring and review meetings identified for follow up. FINDINGS: The average lead time across states was 35 weeks with top three performing states being Goa, Sikkim, and Telangana. The average per unit cost of procurement was Rs 0.35 for IFA Red, Rs 0.25 for IFA Blue, Rs 0.31 for IFA Pink and Rs 7.30 for IFA syrup. Out of the 704 districts in India, only 213 has IFA Red, only 140 had IFA Blue, 152 had IFA Pink and 163 had IFA Syrup available in four quarters of 2018-19. The key issues identified in the assessment were-a lack of standardized forecasting process, absence of inventory management techniques, no fixed distribution schedule, inadequate availability of transport vehicles and an absence of an integrated MIS. ORIGINALITY/VALUE: The identification of bottlenecks in the IFA supply chain and its impact on the performance of the supply chain would provide policy guidelines for the government as well as development partner agencies to design an effective and efficient supply chain. It would also enable the policy planners to understand the challenges associated with managing different components of a supply chain, their interrelation and impact on the overall performance of the supply chain. The suggested recommendations would equip program managers with the tool to devise and implement field level solutions.