Nutrition in India in a Post-COVID World: A Policy Review
- GGI
- Aug 15, 2022
- 15 min read
Updated: Nov 13, 2022
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Introduction
The COVID-19 pandemic revealed several cracks in the world’s healthcare infrastructure. As governments and institutions fought to limit the spread and impact of the virus, it has left a mark on all sectors of the economy. And in this fight against the virus, attention and resources from several critical issues were diverted. One such issue is malnutrition, which got worsened because of lockdowns, broken supply chains, and disrupted policy implementation among many other reasons. India’s fight with malnutrition has been a long and tedious one with marginal improvement over the decades. The Food and Agriculture Organization (FAO) estimated that 194.4 people in India are currently malnourished. The Global Hunger Index (GHI) in 2021 showed that India currently ranks 101 in terms of food security out of 116 countries. The Global Nutrition Report 2021 has shown how India has shown limited progress in a few indicators.
This paper estimates the nutritional status of the Indian population in regards to timelines pre-COVID and post-COVID from multiple national-level surveys evaluates different policies taken up by the states and the centre, and identified the 6 key problems in the nutrition of Indians that have been created or aggravated by the pandemic. We have then attempted to broadly discuss the key points within each of these 6 buckets to get an overall picture of what needs to be done. In the end, we have provided recommendations for changemakers to design solutions based on certain approaches.
The National Family Health Survey & KPIs of Nutrition
The National Family Health Survey or NFHS is a nationwide survey carried out by the Ministry of Health and Family Welfare (MoH&FW) to bring out reliable data on Nutrition, Fertility, Maternal, and Child Health, Reproductive Health, Anemia, Infant, and Child Mortality, and Family Planning.
67 indicators are used to cover the latest NFHS 5 data collected in 2018-19.
Thus, we will use NFHS data throughout our discussions due to its robustness and credibility.
A few important indicators directly affecting the nutrition status of a country, which are included in NFHS as well as available in the literature, are-
Nutrition and feeding practices
Anemia
Treatment of childhood diseases
Maternal and child health
Diabetes and Hypertension
Marriage, fertility, and family planning
Delivery care
Vaccinations
In addition to these indicators, factors like increased income levels, WASH (water, sanitation, and hygiene), education, women empowerment, etc. act as drivers for nutrition, about which more shall be discussed in the later sections.
We will now look at the major policies of nutrition in India, nutritional status during the time of drafting, and their associated targets for the government.
Nutritional Baseline during the drafting of the major nutrition policies in India
In addition to the above, the government also came up with the following new schemes during the pandemic:
Source- UNICEF
This allocation was in addition to normal allocation done under the National Food and Security Act, 2013, to ensure that people can access food at affordable prices.
At a global level, several institutions have set targets to achieve nutrition, the most prominent being SDG-2 under the United Nations Sustainable Development Goals which aims to end all forms of malnutrition by 2030.
The World Health Assembly (the decision-making body of the World Health Organisation) has also identified six nutrition targets to be met by 2025. These include:
Reduce stunting by 40% in children under 5.
Reduce the prevalence of anemia by 50% among women in the age group of 19-49 years.
Ensure a 30% reduction in low-birth weight.
Ensure no increase in childhood overweight.
Increase the rate of exclusive breastfeeding in the first six months up to at least 50%
Reduce and maintain childhood wasting to less than 5%.
India’s performance across key metrics
1. Children’s anthropometric, anemia indicators (under 5 years)
The 3 direct indicators of child malnutrition are stunting (low height for age), wasting (low weight for height) and underweight (low weight for age). The combined NFHS 5 data shows a decrease in progress of all of these 3 indicators.
The most alarming thing is the increase in anemia rates across age groups. Anemia has debilitating effects on overall health and is therefore characterized as a serious public health concern by WHO. 20-39% incidence is considered moderate. In India, all states except Kerala fall under the “severe” category for Anemia. Anemia is also a modifiable risk factor for infant and maternal mortality, and early attention to anemia during reproductive age is essential.
2. Overweight
Being overweight can also reflect malnutrition, with serious health consequences in the form of non-communicable diseases and decreased productivity.
The values are a percentage of the total population of respective classes.
3. State-wise distribution
NFHS 5 Phase 1:
Based on the above data points and the targets of the government, 3 key issues have emerged:
Uneven development across different geographies
Anemia
Overweight/Obesity
Note that these issues existed before COVID-19. So before analyzing these points, let us look at the possible impacts of COVID-19 on the nutrition structure in India.
Immediate effects of COVID on nutrition in India
India suffered 3 significant COVID-19 waves: continuous lockdowns in 2020, an acute second wave in the summer of 2021, and an outbreak by the Omicron variant in early 2022.
Part 1- Income and Supply shocks
Most of the vulnerable people who depend on daily wages lost their jobs during the lockdown and were only partially reinstated once the lockdown was lifted because businesses had been crippled.
However, the impact was more pronounced due to supply shocks, due labor unavailability, and transport and entry restrictions (FAO 2020 a,b,c).
Income loss directly affected the food security and dietary diversity of the households, particularly in poorer districts. The bottlenecks affected perishable, non-staple food consumption-fruits, vegetables, and eggs; as they have higher price elasticity than the non-perishables-cereals and pulses (Tome et al.2020).
To put light on the above point, let us look at the food consumption via calorie intake, pre and post-COVID (short-term). Although consuming empty calories does not provide for the nutrition requirements of the body, calorie intake continues to be a vital indicator to track malnutrition and hunger in developing nations like India.
Pre-COVID
The trend in calorie intake in India: 1993-94 to 2011-12
Source- ICAR- S.K. Srivastava and Ramesh Chand, NITI Aayog
The sharp decline in 2009-10 is due to the abnormal cause of the drought. The levels of calorie intake are lower than the Indian Council of Medical Research (ICMR) norms of 2400 kcal in rural areas and 2100 kcal in urban areas in 2011-12.
Post-COVID
Income is a direct indicator of food consumption in households. So we will use income forecasts for the year 2020-21 and data from scholarly work to establish the income-induced effects of COVID 19 on the consumption pattern. This was done by modeling consumer behavior and estimating expenditure elasticities of different food groups and non-food expenses.
Expected changes in consumption patterns due to COVID-19 led to income shock(%)
This indicates that food is an important commodity in households and its income allocation is likely to increase during the pandemic, but a decline of INR 52 to INR 223 is expected for the monthly food expenditure. Therefore, one can expect a decline in the consumption of high-value food commodities like milk, non-vegetarian products, fruits and vegetables, etc.
If we look at nutrient allocation within households, even pre-COVID, it was uneven for women and girls owing to the societal norms and women’s roles in meal preparation, agriculture, and employment. Telephonic interviews with women from poorer sections revealed the changes in meal preparation after lockdown, like preparing thinner dals and avoiding fruits and vegetables.
The pandemic is likely to have long-term implications on the food systems in the form of structural changes in the supply chain and changes in food consumption patterns.
Part 2- Effect on the existing infrastructure
1. Anganwadi Centres (AWC)
In every Anganwadi center, an Anganwadi worker (AWW) takes care of women and children, educates the community, and collects health and nutrition data on women and children. The AWW is supported by three people: an Anganwadi helper; an auxiliary nurse midwife who provides health services to pregnant and breastfeeding mothers and delivers babies; and an Accredited Social Health Activist, or ASHA, who is a community health advocate and provides services like first aid, special needs referrals, and reproductive health counseling.
As per the norms for construction of AWC building prescribed by the Ministry of Women and Child Development (2011), an AWC must have a separate sitting room for children/women, a separate kitchen, a store for storing food items, child-friendly toilets, separate space for children to play(indoor and outdoor activities) and safe drinking water facilities.
Coverage:
Overall ICDS has an extensive network of AWCs, however, there are areas for improvement.
a. ~2 lakh AWCs have no building to locate their activities.
b. Over 2 lakh vacancies of Anganwadi workers(AWW) and helpers (AWH) indicate an acute shortage of workers.
c. Of the 13,89,110 operational AWCs;
Over 20% don’t have toilets
Over 90% are running in semi-pucca buildings (buildings where either the roof or the wall, but not both, are made of pucca materials like brink/cement/concrete)
Over 10% don’t have drinking water facilities.
Accessibility:
a. Migrants, as they move from one state to another fall through the cracks of AWCs and stop receiving the benefits of the flagship ICDS scheme.
A survey done in 11 states by Dalberg and NITI Aayog in 2021-22 found:
~43% of households with pregnant or lactating women faced challenges receiving food from AWCs
~43% of households with children received less or no food from AWCs.
The time spent by Anganwadi workers undertaking various nutrition-related activities decreased, with less than half — 47 percent — of them having spent more time providing take-home ration to children / PLW and nearly none of them — 95 percent — providing hot meals.
In almost all states except one, AWWs served a population of more than the mandated 1000.
More than half of these workers have reported increased stress levels.
Food distribution:
In 2020, a great majority of the population had access to PDS which prevented the worst-case scenario. However, the effectiveness of the relief programs is unknown.
A national study conducted with 25,300 respondents across 20 states and UTs revealed:
>70% of HHs have also complained about the difficulty in accessing the foodgrains
Diet diversity also took a toll as discussed in the earlier estimates.
In addition to this, regional disparities in the availability of food grains and pulses resulted in inequitable access.
Thus the additional set of challenges that have come up from this discussion:
AWC changes affecting early childhood development (ECD)
PDS and individual identification
Worsened dietary diversity
Uneven development across different geographies
Anemia
Overweight/Obesity
The last 3 points are carried out from our analyses from NFHS data.
In addition to the identified 6 challenges, we have considerations like education, women's education, WASH and other socioeconomic factors for developing a holistic solution.
We are now in a position to present the above 6 points and their emerging solutions.
Problems identified and way forward
1. Infrastructure to support the existing and future policies
a. The Anganwadis
Digitization/Automation of door-to-door data collection and record maintenance work of AWW, AWHs, etc will ensure that an already stressed workforce is able to do its primary work related to nutrition.
Similarly, migrants’ right to aids and services under ICDS should not be disrupted as they move districts or even states and that can be done through digitization of the registration process as well as training the AWWs with a protocol to deal with such families.
As states are reopening AWCs, they should be closely tracked to ensure maximum attendance of the same. This is because, studies have shown change in household responsibilities and behaviour, which can affect the goals of ICDS, if not checked
Rationalizing the roles and responsibilities of AWWs to recognise and celebrate their work as well as giving a considerable price hike, at least matching the inflation levels, will incentivise women to join the stressed workforce.
b. Child nutrition programs
i. Mid-day meal scheme
Various state-wide research on the implementation of mid-day meal schemes have revealed challenges like increasing workload and frustration of teachers, delays in release of funds, quality of rations provided to the schools, storage of food, and maintenance of kitchens. These results have aggravated since COVID-19.
A robust monitoring committee for regular quality checks of meals and delivery of nutritional requirements via an indexing tool, especially in aspirational districts, can solve the above
ii. Overweight/Obesity
Current initiatives:
To tackle obesity in India the Government of India announced that it will annually release a State of Nutrition Report, however, India lacks a robust national level policy for obesity.
FSSAI has started Eat Right India Initiatives to reduce obesity and the burden of non-communicable diseases. Under this, eating guidelines have been established, and it is being incorporated into the National Nutrition Policy.
The School Health Program is another program which conducts health screening in schools. It also works on creating Health Promoting Schools where physical activity and Yoga are encouraged for 60 min/day.
The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) addresses early screening of metabolic indicators through prevention, early screening and integration into the Primary Health System.
Way forward:
The government needs to focus on screening and preventing obesity and working on a lifestyle approach. Addressing the obesogenic environment and marketing HFSS foods is another way forward for tackling obesity.
Integrate screening in all National Nutrition programs. The imposition of additional taxes called the FAT TAX on junk foods and food high in salt and sugar has shown success in other countries.
Multi-sectoral involvement and merging of programs such as FSSAI eat right, and school health programs can give better results at the population level.
c. Anemia- National Iron Plus Initiative (NIPI)
Anemia is a complex issue that has existed at alarming levels in India since its independence, so we will discuss this topic very broadly.
Studies have found anemia as not just an iron deficiency but rather a mix of other micronutrient deficiency and water, sanitation, and hygiene (WASH) factors.
The states that have shown drastic improvement in decreasing anemia (Odisha, Chhattisgarh, Kerala) don’t actually have had a successful IFA (iron and folic acid) supplementation. However, they do show an improvement in their WASH infrastructure and education of the caregiver (general women in a rural setting).
If we look at the IFA supplement program then challenges persist in areas like prioritization by state governments, counselling of the beneficiaries, transportation, and storage of the supplements, overburdening the ASHA workers and teachers and poor intersectional convergence among the ministries (Health, WCD, and Tribal Affairs).
The NIPI needs to be strengthened in areas like revision of its guidelines, counselling, and training of workers to administer the doses regularly, thus requiring additional budget allocation, interventions for other causes of anemia like certain vitamin deficiencies, documenting the whole process, etc.
Popularizing anemia like the polio campaign will be crucial in generating public awareness.
One can refer this to deep dive into the issue.
2. Water, Sanitation, and Hygiene (WASH)
a. Effects of WASH on nutrition
The World Health Organisation (WHO) estimates that globally, 50% of malnutrition is associated with repeated diarrhea (the cause of death of about 1 lakh children in India every year) or intestinal worm infections (leads to anemia, poor physical and cognitive development) as a result of unsafe water, inadequate sanitation or insufficient hygiene. The same also acts as a catalyst for anemia, as discussed in the previous section.
The high levels of stunting in children with just marginal improvements in the last few years suggest chronic nutritional deficiencies and repeated ingestion of animal or human feces due to unsafe waste management practices.
According to World Bank, open defecation accounts for most or all excess child stunting in India and although the construction of toilets has amped up over the decade due to Swachh Bharat Mission, safe treatment and disposal of waste continues to be a major threat to the ecology.
b. Ways to improve:
Decentralised sewage management is taken up in the states of Madhya Pradesh, Odisha, Tamil Nadu, and Telangana while keeping women and the poor at the centre of the policy.
Community indifference towards to sanitation workers and participation in waste management needs to be improved via nationwide campaigns, for example by involving students and the youth as volunteers say for cleaning our rivers and neighborhoods, similar to Swachh Bharat volunteers, and incentivizing them with some extra credits, to encourage inclusivity beyond societal roles.
Expediting the process of setting up labs across geographies to enable faster pathogen testing of treated biosolids and wastewater to approve them for reuse/re-treatment will help in the storage issue of the process.
Stricter norms/fines for factories on non-compliance of releasing industrial waste into waters and landfills need to be implemented.
3. The Public Distribution System (PDS) and Ration Card
a. Universalising PDS
Non-ration card holders were entitled to 5 kg of wheat/rice and 1kg of chana per person per month. Even if we assume that the scheme was perfectly implemented, the government met only a third of the nutritional requirement (600 calories against the prescribed 2000 calories per person)
Linking Aadhar to Ration card under One Nation One Ration Card again does not consider this group, risking them being left out of the food security net. This calls for the universalization of PDS, as basic food needs have to be fulfilled before addressing the overall nutrition profile of an individual.
b. Digitisation of ration cards
Critics have mentioned that biometrics (fingerprints) tend to change (say in case of an injury to the hand). Digitising ration cards or smart cards that includes the beneficiary’s name, head of household, address, etc. Such as those done in Tamil Nadu, can be considered as it can be used by families of migrant workers who are left behind and also independent of biometrics.
4. Hidden hunger/micronutrient malnutrition
A few solutions for this problem can be in the following areas:
a. Improving millet consumption and accessibility
i. Millets have culturally been a part of the Indian diet and cropping system. They're a
great source of dietary fiber, protein, iron, and calcium and are climate-resistant
crops with low carbon and water footprint.
ii. Policies have been devised for this category, but challenges persist in the supply
chain of millets.
Farmers prefer sowing rice/wheat as they are extensively covered under Minimum Support Price (MSP) and although the government has approved including millets into the PDS with increased MSP, behaviour has shifted towards consuming and producing wheat/rice in the majority.
Processing millets is challenging due to their tough seeds. So despite a huge variety, Ragi is the dominant millet due to its ease of processing.
Due to this inconsistent supply and demand, millets tend to have higher price despite low costs of production.
iii. Thus, the supply-demand gap calls for a decentralized procurement system for
millets.
iv. Attractive MSP and timely payment to farmers, adequate training of professionals
for quality assessment, and creation and maintenance of adequate storage facilities
suited for millets shelf life are crucial to incorporating millets back into the Indian
plate.
b. Bio-fortication
Biofortification refers to nutritionally enhanced food crops with increased bioavailability to the human population that are developed and grown using modern biotechnology techniques, conventional plant breeding, and agronomic practices.
Incorporating bio-fortified foods into the PDS is an effective and cost-effective measure in the long-term to address the severe nutritional deficiencies within the vulnerable population.
c. Protein, fruits and vegetables
The following measures can help in curbing and preventing acute nutritional challenges of the individual:
Collaborating with dairy farms/fisheries and promoting state level co-operatives to implement mass level consumption of proteins per month, to match an individual’s protein requirement
Community gardens where a group of people contribute to taking care of plants for self-consumption, under the assistance of a local volunteer/worker. This can also help in enthralling positivity into the locals.
5. Nutritional education, especially for women
a. Importance
Undernourished mothers give birth to undernourished babies. Mother is the direct caregiver and point of contact for a newborn and is the most important stakeholder in the process of early-childhood development (ECD) that the government focuses so much on.
Educating women before, during and after pregnancy in the form of post-ante-natal care with respect to delivery, nutrition, immunisation, sanitation, myth-busting etc is critical for having a healthy young population.
In addition to the above, women's education with respect to menstrual health and hygiene, marriage at legal age, family planning, financial aid available to them by the government, skill development opportunities and building a community culture to support women in their decision-making, together will enable a behavioural change in the households, be it with respect to food allocation and traditional duties of women or overall empowerment of women.
b. Gaps
India’s unorganised sector employing more than 95% of the female workforce is a major reason why social security schemes for pregnant/lactating women at the workplace have not been successful at the grassroots level.
Basic sanitation, access to quality healthcare, clean drinking water and electricity continue to hinder the economic prospects of women.
Lack/absence of support from the father and other family members in addition to the burden of unpaid care work is deep-rooted in many cultures.
c. Way forward
Identifying ways to involve the father during and after 3 years of pregnancy via initiatives like the MenCare, an initiative from Odisha where fathers were involved in ECD can be studied and piloted elsewhere. Sharing of care work between genders will contributing to uprooting gender roles, wherein mothers can bring attention to their family’s and their own nutrition.
Monitoring that the financial aids aimed for women are actually utilised by them for their upliftment and not for familial purposes.
The informal sector and daily-wage contract workers, especially the women, were most affected during and post-pandemic. Air-tight provisions should be made in areas of their food security and physical and financial safety during pregnancy.
Final Thoughts and Closing Remarks
1. Approach for food production and storage
a. Bridging Agriculture and Nutrition
Finding an approach to integrate agriculture and nutrition by incentivising the production of nutrient-dense foods, getting fair prices for products, improving agriculture support and infrastructure and increasing awareness about health benefits of foods such as millets, traditional grains etc along with working on its palatability. Promoting local and seasonal food research and finding ways to preserve indigenous foods in each region and its promotion for good nutrition and health.
b. Improving Storage Capacity
Devising a way to maximise food utilisation and prevention of food waste through correct distribution and preservation methods. Improving storage capacity and warehouse management to get the correct idea of inventory and regular dissemination in the supply chain to prevent food waste and post-harvest losses.
2. Approach for supporting food safety nets
Improving efficiency of targeted food safety programs - Food security and nutrition security can be achieved when the poorest of the poor are included in the system. Having a system that is regularly monitored and regulated and is constantly updated based on needs is important. Creating stronger PDS systems and preventing adulteration and leakages is also important. Using indigenous grains, and fortified food items and providing nutrition education is also important.
Resuming discontinued programmes because of the pandemic and monitoring the current status - It's essential to pay immediate attention to child health and nutrition. During the pandemic, school nutrition programmes and midday meals were stopped and the ration was given. Now as schools have opened up its crucial to focus on hot cooked meals and provide adequate supply of IFA tablets to schools. The government at all levels must work ensuring compliance by regularly monitoring consumption and progress in terms of different indicators of child health and nutrition like weight, height and observing signs and symptoms of deficiencies.
Health promotion and region specific outlines - Health promotion through innovative mass media campaigns at the national and regional level with tailored messages to improve nutritional knowledge.
Nutrition is a dynamic indicator of health and is a vast topic to its merit. Long term nutritional status can be achieved through a multi-sectoral and multidimensional approach. While challenges persist, the government continues to revise its policies for better implementation and acknowledging the cracks, which shows the commitment for this topic. However, there is a need to collect exhaustive data like the NFHS since we are now living in a changed world which demands to update and mend the existing policies and design innovative solutions to suit the same, through collaboration of public and private bodies.
Meet the Thought Leaders
Akshay Cyril is a consultant at Boston Consulting Group (BCG), with a background in Mathematics from St. Stephen's College.
Meet the Authors
Swagatika Mohapatra is a graduate from Sri Venkateswara College, University of Delhi with interests in economics, clean-tech and impact consulting. She is currently interning at Ernst & Young in their public policy division and volunteers as a teacher during her free time.
Rashi Nandwani is a Public Health Nutritionist, postgraduate from Symbiosis Institute Of Health Sciences with interests in Health-Tech, Maternal and Child Nutrition and Non-communicable diseases. She is currently completing her research study on the impact of digital marketing on dietary behaviour of young adults. She is also a select writer with Terribly Tiny Tales and Pepper content.
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