Implications of COVID-19 on India’s Fight to Eliminate Undernutrition
By Rudra Narayan Mishra
22 June 2020
Premise to the problem
The COVID-19 pandemic has reinforced the need for addressing the already existing challenges of social sector development in a fast-developing country like India. While India is staring at a massive loss to gross domestic product (GDP), employment and trade, the downsizing of the economy may lead to disruptions in social safety nets for the weaker sections. As of June 2020, the country has seen 4,25,282 cases of which 13,699 have succumbed.
The World Bank in its report titled Global Economic Prospects, June 2020 (pages 3-7), predicts that the GDP growth in India could fall below 3.0% in 2021 due to disruptions to the economy and the supply chain as a result of the lockdown measures to check the pandemic. The lockdown has disrupted the livelihood of millions of daily wage earners, small producers, artisans and street vendors. The same source also indicates that if panic among migrant labourers is not checked, they could be potential carriers of the highly infectious disease back home into the hinterlands.
The exodus of migrant workers from the manufacturing hubs in various states exposes the vulnerability of urban poor to the pandemic. For them to choose between ‘life and livelihood’ is meaningless due to their hand-to-mouth survival (Mishra and Vijayan 2020). As per Aajiveeka Bureau (2014), more than 120 million people in India migrate from rural areas to the urban labour market, industry and agriculture. Most of these now face a grim future due to the disruption in the economy. Living in slums of urban growth centres, they hardly own any assets or savings to sustain themselves if the economic activities are not restored at earliest. The remittances sent by these migrants to rural areas sustain many others who will also be left vulnerable. This catastrophe will send many millions below the poverty line once again.
The inadequate health infrastructure in the country will be no match if the disease spread to stages III (community spread) or IV (spread of disease is uncontrollable). The recovery of the economy could take at least a couple of years and would need government intervention to help the major sectors to bounce back (Dhasmana 2020). It is also important to remember that in the absence of a full-proof treatment and cure, the nutritional status leading to inherent immunity helps in fighting against the disease to some extent. The loss of livelihood is also associated with loss of affordability and accessibility of nutritious food will further jeopardise the public health scenario already faced with severe problems of under-nutrition and anaemia. Let us discuss the existing status of undernourished people in India and how policies, schemes, programs and overall institutional arrangements in India, as a welfare state, can ensure the nutritional security in the current crises.
Status of undernourished population in India
The immediate challenge the pandemic poses to India is its undernourished population. Despite having experienced tremendous progress in GDP growth along with the growth of per-capita consumption and production of food, at least one-sixth populace is found to be undernourished India leading the country to have the largest share of undernourished population in the world (FAO/IFAD/UNICEF/WFP/WHO 2019). The extent of undernourishment is profound particularly among women with at least half of the women in the reproductive age group of 15-49 years having some form of anaemia and two out of five women having a low weight-to-height ratio (body mass index) (NFHS, 2015-16). Further, two out of five children in the age group of 0-6 years have either growth retardation (stunted) or are underweight, while one among five children of the same age group has wasting (too low for their height) (NFHS, 2015-16).
It is not that India has not made any progress in reducing the curse of undernutrition during the past decades. As per National Family Health Surveys (NFHS) surveys, between 1992-93 (first round) and 2015-16 (fourth round) the prevalence of stunting among pre-school children had declined by 14 percentage points while underweight had declined by 17 percentage points. However, the wasting for the same period has increased by 4 percentage points, from 17 to 21. During the same period, the prevalence of low BMI for reproductive-age women declined by 13 percentage points. Prevalence of anaemia among pre-school children and women has also declined by double digits during the same period. Yet, what is worrisome is that the country has been able to achieve very little in terms of nutritional security even when the economic growth and consumption, as well as production activities, are at higher levels.
Other than the major and minor trace elements and vitamins, one of the major nutrients to fight against any viral infection, is protein. But the food sufficiency gained through the Green Revolution during the 1960s and the agricultural policies from time to time emphasized the adequacy of cereals in the country, often undermining the importance to rich sources of protein in the Indian food system (Rampal 2018). It is also documented that Indian diets derive almost 60% of their protein from cereals with relatively low digestibility and quality (Swaminathan, et. al. 2012). In 2015, it was reported that protein intake in India dropped by 6–10 % in two preceding decades with almost 80 % of rural and 70 % of the urban population not getting the government-designated 2,400 kilocalories (kcal) per day worth of nutrition. The daily intake of oil and fat consumption has increased from 31g to nearly 42g in rural areas and from 42g to 52.5g in urban areas during the same period (PRODIGY, 2015).
Overall, it is also found that at least 68% people in India are protein deficient, while 71% have poor muscle health. Even among those who follow non-vegetarian diets in India, at least 65% are protein deficient. There are two major concerns of nutritional security in India: one is the fulfilment of the calorific requirement in the average diet of an Indian and another is the imbalances in dietary intakes among people, particularly in cities. Alarmingly, the gap in nutrition intake in cities and urban areas is worse. While the richest are found to consume over 2,518 kcal each per day, the poorest are found to consume less than 1,679 kcal — a difference of nearly 50% (PRODIGY, 2015).
As it is mentioned earlier, this was the scenario when India’s economic performance was satisfactory and there was a boom of production and consumption activities. Now, that the lockdown measures are in place, the informal sector workers, particularly the migrant workers, are scattered with little or no disposable income. The urban middle class is also experiencing salary cuts or joblessness due to the interruption of production activities in various industries. A large section of workers within the informal workspace, such as domestic workers and sex workers may not be able to get back to their regular livelihood practices even in the near future. Under such circumstances, the decline in nutritional intake among a large section of society is almost inevitable due to both, the income and price effect of the food consumption behaviour.
The income elasticity of food consumption indicates that with an increase in income people tend to consume more and more animal protein (Swaminathan, et al, 2012) which is a superior source of protein. Similarly, the price elasticity of food consumption indicates that an increase in the price of pulses is associated with increased intake of animal protein (Rampal, 2018). National Sample Survey Office’s (NSSO) Nutritional Intake in India report (2014) shows that the average per-capita calorie intake in rural and urban India were 2233 and 2206 kcal respectively, lower than the ICMR recommended daily per capita calorie intake of at least 2700 kcal per day. S K Srivastava and Ramesh Chand (2017) study has observed a strong calorie-price elasticity in the Indian context. A unit increase in per-capita daily expenditure could increase the per-capita calorie-intake in the rural areas by five times. For urban areas, the same could be more than three times. Thus, the price effect on calorie consumption is very crucial to household food security. The Public Distribution System (PDS) is the only option available to ensure the decline in household income due to the economic slowdown does not result in a decline in food consumption. Perhaps this is the right time to utilise the unspent amount from previous years to provide subsidised food grains to needy Indians.
With disrupted production and supply chain activities in the food market due to COVID-19, it is very likely that the availability of grains, fruits and vegetables will be interrupted in the future. According to Reardon et al (2020) COVID-19 has led to an increase in transaction costs and uncertainty in India’s food supply chains dominated by private players and 92% of food consumption in the country is going to be affected by such disruption. On one hand, the increase in prices of essential food items, and the loss of livelihood on the other, will jeopardise the nutritional security of a large number of people. The essential cereals, pulses, milk and milk products, edible oil and livestock for meat need assured and uninterrupted transportation to maintain supply and stabilise prices in those states which depend upon other states for their needs.
There are three major alleyways to address this immediate need of protecting nutritional security: first is the effective and target-based implementation of schemes and programs designed to achieve nutritional security; second is revamping delivery centres for safe delivery of food grains and other services to limit the spread of COVID–19 among beneficiaries of various nutritional services and the third is to strengthen the nutritional monitoring and awareness through programs like Poshan Abhiyan. Let us discuss these three instruments in brief.
Flagship schemes to address undernutrition
There are many efforts by the government at both central and state levels to fight undernourishment in the country, including one of the largest nutritional intervention programs in the world at present. The prominent flagship schemes/programs for improving the nutritional health of Indian population under National Nutrition Mission are Integrated Child Development Services (ICDS) Scheme for pre-school children in the age group of 0–6 years, SABALA for Adolescent Girls in the age group of 11-18 years, Pradhan Mantri Matru Vandana Yojana (PMMVY) for expecting and lactating mothers, Rajiv Gandhi National Creche Scheme (RGNCS) for working women. All the above programs are being implemented by the Ministry of Women and Child Development, Government of India. Currently, under ICDS alone, 705 lakh children, 14 lakh girls in the age group of 11–14 years, not in school and 169 lakh pregnant and lactating mothers are being provided supplementary nutrition. For the current financial year, there is a 25% increase in the Budget outlay, from Rs 29,165 crores in 2019-20 to Rs 35,600 crores for ICDS based schemes. Half of this allotted budget to ICDS will go towards providing supplementary nutrition, cooked meals or take-home-rations (THR) to young children, expecting and lactating mothers and adolescent girls. The utilisation of monetary allocation to Anganwadi-based services have been over 90% in the past couple of years at the all-India and state levels.
Similarly, the Mid-Day Meal program (MDM) run by Ministry of Human Resources and Development (MoHRD), GoI looks after the nutrition of 11.8 crore school-going children in lower and upper primary classes in government-run schools, schools run by local bodies and private/trust-run schools supported by government aid. In 2020-21, the GoI increased the budget allocation for MDM to Rs 11,000 crore from Rs 9,912 crore, an increase of 11.0% over the previous financial year.
According to the Accountability Initiative (2020), only 14 states could utilise 100% of MDM allocation for the year 2018-19, whereas Telangana, Assam and Goa could utilise only two-third of the fund allotted to them. The situation is particularly grim in Gujarat and Haryana wherein only 40% of the allotted funds towards MDM have been utilised! In the present situation, the MDM is crucial for children attending schools, given the economic hardship their households may likely to face post-lockdown and the slowdown in the economy. Some suggest due to closure of MDM, over 90 million children of which 52% could be girls are deprived of the nutritious meals and for many of them probably this is the only nutritious meal of the day (Shirisha 2020).
The PDS under the Food Security Act (FSA) implemented by the Ministry of Consumer Affairs, Food & Public Distribution, GoI, is the largest subsidised food distribution program in the world. In 2020-21, GoI allocated Rs 1,22,235 crore, an increase of 6% over the previous year to provide subsidised food grains to 81.34 crore Indians. However, a study by PRS Legislative Research (2020) shows that from 2016-17 onwards, actual expenditure on food subsidy has declined from 20 to 40 percentage points.
The recently launched Poshan Abhiyan aims to reduce the prevalence of low birth weight, stunting and underweight among pre-school children below 6 years of age (by 6% each), prevalence of anaemia among children of age group 6-59 months and among women and adolescents of 15–49 age group (9% each), in a period of 3 years starting from 2017-18. To achieve this goal role of ICDS, MDM and PDS are very crucial. These three services are crucial to neutralise the effect of the pandemic to achieve the target.
Another program which could have a direct influence on the nutritional health of the rural poor households is MGNREGS. In previous studies, it has been found that the wages earned by the workers, most of who are females, are being spent on the purchase of food items (Kareemulla et al 2013, Mishra et al 2017). For the financial year 2020-21, Rs 61,500 crore was allotted to MGNREGS which was 13 percentage points less than the previous year. One would expect that the government would pump more resources in MGNREGS keeping the present needs in mind. These programs have the potential to provide poor households with a safety net in times like this, where no one will have to starve because of lack of income. Not only in rural areas but the ICDS, MDM and PDS can provide food safeguards to the urban poor as well.
Safe delivery of food grains among beneficiaries
Since the COVID-19 virus is highly infectious and spreads through surface transmission of every kind, the delivery centres for these programs like Anganwadis, schools and PDS centres now have to be upgraded to have better hygiene, sanitation and space for ‘physical distancing’. Young children, young mothers and adolescent girls can be trained and motivated for behavioural changes like regularly washing hands, wearing clean clothes and maintaining a safe distance from each other to guard not only against the coronavirus but any other communicable diseases. These delivery centres, especially Anganwadis and schools, need to be supported with financial assistance to make provision for safe drinking water, toilets, hand sanitisers, masks and preferably disposable utensils to check the spread of any infection. Take-home-rations can be useful for the time being but in the long run, children dependent upon Anganwadis also need pre-school, non–formal education for which they need to be physically present at the Anganwadi Centres. Some argue against delivering dry ration, since, given the economic hardship in the households, the ration may not reach the children (Shirisha 2020). A recent study predicts, given the economic hardship on vulnerable households and consequential effect on nutritional intake, the prevalence of underweight children below six years of age and lower body mass index (BMI) among reproductive-age women could go up by 5% (Joe et al; 2020).
Ms Smriti Irani, Union Minister for Women and Child Development in a reply to a question in Lok Sabha on December 13, 2019, had mentioned that out of thirteen lack plus (13, 77,595) functional Anganwadi Centres in India, 3.62 lakh do not have toilets and 1.59 lakh are without a safe source of drinking water till December 2019 (The Hindu). This is nearly two out of five functional Anganwadis that lack proper drinking water or toilet or both. According to the NITI Ayog study in 2015, 40% of the Anganwadis did not have adequate space and 60% were running from rented premises. The same study also found that 52% of Anganwadis were not maintaining adequate hygiene. Lack of space and hygiene in Anganwadis will be very crucial to maintain social distance for children to prevent viral infections. According to another study, Annual Status of Education Report (Rural), 2018, a quarter of the 16,000 surveyed primary schools did not have a toilet or drinking water supply. One-third of them either had no separate toilet for girls or the toilet was not available for use for various reasons. These shortcomings could prove detrimental to school children in rural areas when classes resume and there is no vaccination available against the coronavirus disease.
Need for strengthening and monitoring of nutritional programs
The nutritional intervention programs are being carried out at various levels, centre, state and even by local bodies in some cases. The private sector and charitable organisations also carry out such intervention. The Akshaya Patra is one such initiative which feeds 1.8 million school-going children each day in 12 states and 2 union territories. Similarly, the Self–Employed Women’s Association (SEWA) in Gujarat runs day-care centres for children of women working in the informal sector and ‘Kishorie’ programs for adolescent girls to make them aware of their nutritional needs. Several such initiatives from the voluntary sector take care of the nutritional needs of specific target groups throughout the country.
However, what we need is a robust mechanism to bridge the gap between such individual interventions; both horizontal and vertical integration of these programs are needed. For example, a poor household will need nutritional supplementation for the young below six years; they may need both nutritional awareness and supplementary nutrition for adolescent girls if not attending schools; reproductive-age, pregnant and lactating women in that household will need awareness about their health and nutritional needs and also nutrition supplementation. Overall food security for all members in the household will depend upon regular supply from their PDS outlet and in case, the household does not have a regular source of income, MGNREGS can help them have some cash which they can use for non–cereal food items.
There is no system to track if all the eligible members in a given household who are eligible for benefits under different nutritional intervention programs are getting the same or if the household or some members in it are left out. Similarly, it is very important to monitor the level of anaemia among all members in the household, prevalence of stunting, underweight and wasting among children, low body–mass–index (BMI) among adults and maintain information at one place to help planners and grassroots-workers to help the household. At the same time, the awareness about various hygiene and sanitation practices are crucial for a better nutritional outcome. So, the level of awareness about nutritional health and factors that affect the outcome among general public and complete nutritional information of household to implementing agencies are crucial to make successful utilisation and delivery of nutritional programs. Addressing these will also help us to provide adequate nutritional support for those who are vulnerable due to the ongoing pandemic.
POSHAN (Partnerships and Opportunities to Strengthen and Harmonize Actions for Nutrition in India) launched in October 2018 by the Government of India aims to improve coordination among various ministries and agencies in the delivery of nutritional programs. Under this program, the government is trying to raise awareness about different facets of nutritional health among common people through initiative like ‘Poshan Maha’ and ‘Poshan Pakhwada’. Using advanced ICT platforms, POSHAN enables policymakers, program implementers, researchers, and other stakeholders to get access to latest data related to nutrition for effective decision towards delivery and utilisation of the nutritional programs in India. The ongoing pandemic can be an effective test of the gaps in initiatives, like POSHAN and an opportunity to address them.
Conclusion
The once-in-a-century global pandemic, currently sweeping the world, poses a serious health risk to Indians, especially to their nutritional security. The time-tested mechanisms/institutions, such as ICDS, MDM and PDS can save our population from starvation and keep them healthy till normal business restores. Fortunately, India has sufficient storage of food grains to continue its food-based supplementary nutrition program in the coming months. The situation has provided an opportunity to address the shortcomings in the delivery mechanism of these programs/schemes and infrastructure issues which need to be redesigned/remodelled to ensure ‘social distancing’ among the beneficiaries. Programs/schemes like MGNREGS, National Millet Mission, Skill Development programs, promotion of women self-help groups through National Rural Livelihood Mission (NRLM), promotion of horticulture and dairying in rural areas can also help in strengthening livelihood for rural poor as wells as those migrants who are likely to lose jobs in coming months due to disruption in manufacture/service sectors. As nutritionally balanced diet is essential to the ‘Right to Life’ enshrined in our constitution, Article 21, fiscal prudence can hardly be the argument in times like this to scale up our food-based subsidy programs. A cohesive effort will save the country from losing the gains made in ‘nutritional security’ in the last three decades due to the current pandemic.
Acknowledgements: The author expresses gratitude to Professor Udaya S Mishra, Centre for Development Studies (CDS) Trivandrum, Dr Venkatnarayana Motkuri, Programme Officer, Centre for Good Governance (CGG), Hyderabad and Dr Amrita Ghataka, Assistant Professor, Gujarat Institute of Development Research (GIDR), Ahmedabad for their helpful insights on the earlier versions of this article. However, the author is responsible for any shortcomings or errors in the presentation.
AUTHOR
Rudra Narayan Mishra, Assistant Professor, Gujarat Institute of Development Research (GIDR), Ahmedabad.
Disclaimer: The views and opinions expressed in this article are those of the author/s and do not necessarily reflect the official policy or position of Azim Premji University or Foundation.
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