Arjan De Wagt, Head, Nutrition, UNICEF India speaks to The Hindu’s Bindu Shajan Perappadan on how high levels of maternal and child under nutrition continue to plague the country, and the impact COVID-19 has had on the gains India has made in economic and human development in recent decades. He notes that for the future of children in India, controlling COVID-19 and ending malnutrition are equally important and urgent.
How has India fared on child and maternal nutrition in recent times?
Overall, India has made impressive gains in economic and human development in recent decades. It has transitioned from being a food-deficit nation to a self-sufficient food-producing country in the last 30 years.
However, high levels of maternal and child under nutrition continue to plague the country. Large-scale surveys like the Comprehensive National Nutrition Survey (CNNS) and National Family Health Survey-4 (NFHS) show that about one-third of children under five years of age in India are stunted, a third of them are underweight and almost two out of ten children are nutritionally wasted; many of these children suffer from multiple anthropometric deficits. The CNNS also highlight the emerging problems of overweight, obesity and micro-nutrient deficiencies.
The government has put in place several programmes to address the triple burden of malnutrition. Particularly the launch of the Poshan Abhiyan in March 2018 refocused the national development agenda on nutrition. Building in Jan Andolan, or people’s movement, into Poshan Abhiyaan further intensified regular communication on nutrition behaviours and community leadership. Very recently, in the 2021-22 Budget speech, Poshan 2.0 was announced as a next step towards addressing malnutrition in the country. However, with the spectre of COVID-19, there is a heightened risk of increasing malnutrition and parts of progress made in the past may get undone.
How is COVID-19 likely to affect nutritional interventions in India?
Broadly, we know that the impact of COVID-19 has adversely affected access to livelihoods. The containment measures to prevent the spread of the virus threatened livelihoods, resulted in price hikes due to reduced production of goods and services, and in disruption in supply chains for many families.
Global research in 2020 on the effect of COVID-19 estimated about 14.3% increase in wasting globally. No specific data are available yet on the impact of COVID-19 on the nutritional status of the Indian population. Some data has been gathered from telephone surveys, community assessments and the Health Management Information System (HMIS) on the negative impact of COVID-19 on community food security and uptake of health, nutrition, and food security services. But these are not adequate in providing a comprehensive scenario on the potential impact of COVID-19 in the future. However, from global and India experience, it is increasingly evident how COVID-19 is interacting with under nutrition and exacerbating nutritional insecurities.
First of all, like other infections, the COVID-19 infection negatively affects the nutritional status of a child, and those with poor nutritional status are more likely to have higher risk of morbidity and mortality.
Secondly, disruption to food systems due to reduced food availability and broken supply chains, as well as dried income sources and depleted family savings is likely to have decreased financial and physical access to healthy food. As the period of pandemic prolongs, food insecurities and nutritional challenges will intensify too. It is also the compounding of such livelihood shocks due to COVID outbreaks and other factors, for example, in communities affected by floods. This will have more damaging impact on the most vulnerable communities that experience repeated natural calamities, as well the youngest children.
On completion of six months, children need nutrient dense complementary foods in addition to breast milk to adequately fuel the growth of their growing bodies and brain. Lack of adequate nutrition at this stage can irreversibly damage physical growth, mental and cognitive development as well, with lifelong adverse effects. Additionally, adequate nourishment helps boost children’s immunity. Food insecurity arising out of the pandemic may cause families to shift to cheap food with low nutritive value, causing long-term adverse impact on the cognitive development of children.
Third, health and social services such as anganwadi centres, nutrition rehabilitation centres, and village health sanitation and nutrition days (VHSND) were disrupted. As schools remained closed for a large part of 2020 and well into 2021, we also noticed that distribution of iron and folic acid tablets to children in schools was significantly reduced, and awareness campaigns in schools on nutrition were suspended. It was not until early 2021 that more and more States started opening anganwadi centres again, but centre-based activities soon were suspended due to the second wave of COVID-19.
As COVID-19 demanded extraordinary attention, health workers were diverted from nutrition programmes for contact tracing, vaccination, and other response and services. This is likely to continue as vaccination coverage for such a large population will take more time.
Fourth and most importantly, COVID-19 related priorities could threaten delivery and financing of nutrition and nutrition security responses, which we had seen in recent times, especially since the launch of the Poshan Abhiyaan. Poshan Abhiyan is a great platform and opportunity to accelerate reduction of child malnutrition in India. However, with competing priorities like the vaccination drive, there is a risk of resources and attention being diverted away, when the situation demands additional resources to accelerate multi-sectoral responses to urgently address the nutrition situation. For instance, when COVID-19 struck in March 2020, Poshan Pakhwara had to be abandoned mid-way. Community-based events have also been suspended in many States due to the pandemic. It is great to see many of them resume in the ‘Poshan Maah’ (nutrition month).
Given that the threat of subsequent COVID-19 waves looms, what do you foresee as the biggest challenge in the nutrition space?
We fear double threats here. On the one hand, pandemic response services such as COVID-19 vaccination will need to be prioritised. However, it is important to recognise that this puts a tremendous strain on systems, capacity and resources earlier dedicated to deliver routine health, nutrition and social protection interventions. On the other hand, COVID-19 may inflict repeated shocks on families and communities. Health expenses of families and communities are going up significantly when so many people fall ill, and at the same time, their economic productivity is going down.
If it was about dealing with one shock of a COVID-19 wave of limited duration, systems, services and personnel would have found a way. But the compounding effect of repeated shocks on income and resilience might have a much more serious and longer lasting impact than we expect. Here we are not even factoring in the annual cycle of shocks that families in many parts of India face due to natural hazards such as droughts, floods and cyclones.
As Covid-19 affects resources and priorities, how should then the government address those nutrition related challenges?
Prior to COVID-19, Poshan Abhiyan had a strong potential to significantly reduce child malnutrition in India by 2030. However, the onslaught of COVID-19 risks are significantly reducing this potential progress that Poshan Abhiyan could have yielded by 2030, unless nutrition gets back on track again among the top priorities in leadership, financing, and service delivery at all levels, from Central and State governments down to the communities.
Six areas need immediate attention. First and foremost, a strong leadership at all levels — from national to district — is essential to bring back focus to address food, income and nutritional security.
Second, uninterrupted, universal, timely and high-quality coverage of essential evidence-based nutritional services must be ensured, with special focus on children below two years of age, pregnant women and adolescent girls, which are the critical growth and development periods of life.
Thirdly, the pandemic calls for strategies adapting to COVID-19 guidelines and innovations in the service delivery mechanism. Urgent attention is needed to address food security, dietary diversity, micronutrient supplementation, social protection, economic support, gender, and financial inclusion. Keeping girls in school and delaying the age of marriage should be emphasised. The mid-day meal programme benefits should continue uninterrupted even when school services are disrupted.
Fourthly, adequate financing is needed to ensure delivery of high impact interventions, and additional financing will be required for ensuring food and nutritional security, especially for the vulnerable population groups. Accelerating fund release to States and decentralised decision making are required to improve fund utilisation. The main causes of underutilisation of funds potentially available for nutrition responses must be identified and addressed.
Multisectoral interventions that directly or indirectly impact nutrition, like health, nutrition and social protection schemes need to be delivered effectively to the same household, same woman, same child. Migrant labourers and urban poor need special focus.
Finally, nutrition needs to be retained as a key indicator for development. Regular reviews aided by robust data systems, like HMIS, Poshan Tracker, and NFHS, which track changes in coverage, continuity, intensity and quality of interventions, are essential to help identify areas where urgent actions are needed. Data quality needs to improve for better policy and programme decisions.
We must realise that COVID-19 has compounded manifold the nutrition-related challenges but giving up at this critical juncture is not an option. If children needed nutrition interventions before COVID-19, they need it much more now than ever before. For the future of children in India, stopping COVID-19 and stopping malnutrition are equally important and urgent.
