POSHAN Abhiyaan: Fighting Malnutrition in the Time of a Pandemic

Introduction

• The COVID-19 crisis has put the world on the brink of a nutrition crisis, with pandemic-related malnutrition projected to kill an average of 153 children a day over the next two years if action is not taken.
• In addition, a COVID-19-induced spike in the number of global malnutrition cases could push an additional 9.3 million children to suffer from wasting, a result of acute malnutrition that can lead to death.
• The impact of COVID-19 has led to an increase in poverty, a loss of livelihoods, and less access to health and nutrition services, pushing up rates of hunger and malnutrition.
• The Global Hunger Index2020, which measures levels of undernourishment, stunting, wasting, and mortality rates among our children, is a stark reminder of how deep this crisis runs in the country — India ranks at 94th position out of 107 countries.

Mapping the nutrition crisis

• Under nutrition: Child and maternal under nutrition is the single largest health risk factor in India, responsible for 15 percent of India’s total disease burden.
• Stunting: Malnutrition in children manifests either in the form of ‘stunting’ (low height in relation to age) or ‘wasting’ (low weight in relation to height) or both.
  • India is home to almost one-third of all the world’s stunted children (46.6 million out of 149 million) and half the world’s wasted children (25.5 million out of 51 million).
  • Data from the fourth National Family Health Survey (NFHS-4) of 2015-16 shows that 38 percent and 21 percent of children under five years are, respectively, stunted and wasted.
• Obesity: At the same time, the rate of obesity in children under five, adult women and adult men has risen to 2.4 percent, 20.7 percent and 18.9 percent, respectively.  
• India thus faces the double burden of malnutrition and obesity.
• Anaemia: India also lags behind on other nutritional indicators, with high levels of anaemia in women of reproductive age and low prevalence of exclusive breastfeeding of infants during their first six months.
  • Almost 50.4 percent of women in the 15-49 age group suffer from iron deficiency anaemia, and only 55 percent of children are exclusively breastfed for six months.
• The Global Nutrition Report 2020notes that India is among the 88 countries that will miss their global nutrition targets of 2025.
• India has the highest rates of domestic inequalities in malnutrition, and the biggest disparities in children’s heights.

Global Hunger Index 2020

• In the Global Hunger Index 2020, India falls in the category of ‘serious hunger’, ranking 94th among 107 countries.
• India has progressed since the last such ranking, when it stood at 102 out of 117 countries. On the World Bank’s human capital index, India ranks at 116 out of 174 countries, showing steady progress in building human capital conditions for children.
• However, the pandemic has put at risk the decade-long progress in improving human capital, including health, survival, and reduction of stunting, leading to food insecurity and poverty.
• At the same time, the lack of adequate investment in health and education has also led to slower economic growth.
• Stunting has lasting effects – a World Bank study suggests that a one-percent shortening in adult height because of childhood stunting is associated with a 1.4-percent loss in economic productivity.
• Despite substantial economic growth in India over the past decades, stunting in children under five reduced by only one-third between 1992 and 2016, and continues to remain high at 38.4 percent.
• Barring Puducherry, Delhi, Kerala and Lakshadweep, all other states have a higher proportion of stunted children in rural areas than in urban. Data indicates that stunting increases with age in the early years, peaking at 18-23 months. It is irreversible after the first 1,000 days.
• Stunting also leads to an intergenerational cycle of malnutrition.

How COVID-19 has affected the progress?

• This year, the COVID-19 pandemic has potentially reversed much of the progress made towards meeting the second of the Sustainable Development Goals (SDGs): ending hunger, achieving food security, and improved nutrition.
• The spread of COVID-19 and the subsequent lockdowns have thrown the economy and government finances into turmoil.
• The scale of the challenge in tackling child malnutrition is undeniable and calls for nutrition-specific budgets for the nation, states and cities.
• Eastern India, in particular, has been hit by twin disastrous events—the pandemic and Cyclone Amphan, which struck in May and left death and destruction in its wake.
• This has placed the region, and consequently its most vulnerable population, its children, at higher risk of malnutrition, food insecurity, and disease exposure.

What are the major initiatives taken by Indian government?

• Integrated Child Development Services (ICDS): This programme is operational in India since 1975. It aims to provide food, preschool education, primary healthcare, immunization, health check-up and referral services to children under 6 years of age and their mothers.
• Mid-Day Meal Scheme: The Scheme has been implemented since 1995, where a nutritious meal is provided by the school to better the nutritional standing of school-age children nationwide
• Indira Gandhi Matritva Sahyog Yojna: Launched in 2010, it aims to provide incentives for improved health and nutrition to pregnant and lactating mothers. The scheme also educated the women about the benefits of breastfeeding for the optimal nutrition of their newborns.
• Rajiv Gandhi Schemes for Empowerment of Adolescent Girls (RGSEAG): Also known as SABLA, it was launched in 2011 and aims to improve nutrition and health status of adolescent girls aged between 11–18 years.
• National Health Mission (NHM): Initially launched in 2013, it aims to address the health needs of 18 states that had been identified as having weak public health indicators, this was later scaled up to the entire nation.
• The National Food Security Act, 2013: It provides for subsidised food grains under the targeted public distribution system. It covers almost one-third of the population.
• Pradhan Mantri Matru Vandana Yojana (PMMVY): The PMMVY is a maternity benefit programme, launched nationally in 2016, that provides a conditional cash transfer to pregnant women for safe delivery, and good nutrition and feeding practices.
• Janani Suraksha Yojana (JSY): Complementing the PMVVY, is the Janani Suraksha Yojana (JSY), wherein the beneficiaries are also eligible for a cash incentive after institutional delivery.
• POSHAN Abhiyaan: In 2018, India launched the POSHAN Abhiyaan—a flagship national nutrition mission to improve nutrition amongst children, pregnant women, and lactating mothers. 
• Budget 2020-21: Budget 2020-21 witnessed an enhanced allocation of INR 35,600 crore for nutrition-related programmes and an additional INR 28,600 crore for women-related programmes.
  • Odisha set an example by becoming the first state to prepare a separate budget document for nutritional interventions.
• Indirect interventions: Besides, indirect interventions to improve nutritional status include:
  • Targeted Public Distribution System (TPDS)
  • National Horticulture Mission
  • National Food Security Mission, Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS)
  • Swachh Bharat Abhiyan
  • National Rural Drinking Water Programme

Have these programmes improved the nutritional status?

• Low uptake of services: Despite an array of programmes providing for food security and improved maternal and child health and nutrition, the uptake of services has remained low. 
  • Only 51 percent of pregnant women attend a minimum of four antenatal clinics and only 30 percent consume iron folic acid (IFA) tablets.
  • Uptake of supplementary nutrition varies from 14 to 75 percent among children, and is 51 percent and 47.5 percent among pregnant and lactating women respectively.
• Low enrolment: Only 50 percent of pregnant and lactating women are enrolled in the maternity benefit scheme across states.
• Low breastfeeding practice: Correct infant and young child feeding practices remain low.
  • Timely initiation of breastfeeding is only at 42 percent, despite 79 percent deliveries being institutional.
  • Exclusive breastfeeding for six months is just 55 percent, and timely introduction of complementary feeding fell from 52.6 percent in 2015 to 42.7 percent in 2016.
• High level of malnutrition: Despite numerous schemes directly and indirectly targeting the nutritional status of children (0-6 year age) and pregnant women and lactating mothers, level of malnutrition and related problems in the country remains high.

Assessing the progress of POSHAN Abhiyaan

• The POSHAN Abhiyaan launched in 2018, is India’s flagship programme to improve nutritional outcomes for children, pregnant women and lactating mothers.
• The misison is being implemented by the MWCD as a ‘Jan Andolan’ or ‘People’s Movement’ to create maximum awareness towards the problem of malnutrition and address it in a mission-mode.
• All states and union territories are part of the POSHAN Abhiyaan, except West Bengal. Odisha joined the POSHAN Abhiyaan in September 2019.

Status

• POSHAN Abhiyaan’s progress report (October 2019-April 2020) takes stock of its on-ground status and the implementation challenges it has encountered at various levels.
• There is marked improvement in breastfeeding counselling, consumption of IFA tablets, Institutional births, and food supplementation, to name a few parameters.
• There is convergence in delivery of nutrition interventions, such as the Village Health and Nutrition Days – a national programme by which health workers convene a gathering at every village once a month to promote healthcare – and the state’s maternal conditional cash transfer scheme (called Mamata Scheme) by which mothers are paid INR5,000 in two installments provided they follow a set of laid down health practices.
• Odisha’s interventions have shown how convergence of socio-economic factors can lead to holistic nutrition success.
• Poshan Abhiyaan has been able to bring nutrition to the centre-stage in the political discourse around reducing malnutrition. However, it needs more improvement to achieve the target.
• The progress report of Poshan Abhiyaan shows that the coverage of most targeted interventions such as food supplementation, breastfeeding counselling is only about 50 per cent.
• Hence, to ensure that we meet our targets, this coverage needs to be stepped up and requires the involvement of the community.
• Focusing on the health of mothers can help break this cycle across generations, due to which interventions like ante-natal care, institutional delivery, birth spacing are of utmost importance.
• Recommendations
• To further improve complementary feeding using behavioural change, maintaining that this can avert 60 percent of total stunting cases.
• To invest in education of girls and women, and improved sanitation are other interventions which can avert a quarter of stunting cases.

What is the ‘cost’ of malnutrition?

Malnutrition, in all its forms, carries huge direct and indirect costs to individuals, families and to entire nations.

• Mortality: Up to 45% of all preventable child deaths are attributable to undernutrition. Severely undernourished children are up to 9 times more likely to die than well-nourished children.
• Intergenerational cycle of malnutrition: Poor nutrition in the first 1,000 days after birth leads to stunted growth, leading to an intergenerational cycle of malnutrition.
• Affecting social and economic development: Malnutrition keeps people from reaching their full potential, affecting not only their health, but also their social and economic development.
• Impaired physical growth: Sub-optimal physical growth, often coupled with life-long susceptibility to illnesses, reduces economic productivity through lowered labour productivity or absenteeism from work. 
• Impaired cognitive development: Poor nutrition from birth, continuing through school and adolescence, impairs cognitive development, delays school-attendance and reduces attainment, resulting in lost employment and socialisation opportunities throughout life. 
• Huge economic cost: The cost of malnutrition on the global economy is huge, at US$3.5 trillion per year or US$500 per individual.
• Additional cost borne by families: As well as the direct costs to the global economy of US$3.5 trillion, additional costs of malnutrition are borne by families, in the form of higher medical bills, lost income including due to illness, reduced school performance and later earnings due to cognitive impairment.

What are the reasons behind ‘nutrition crisis’?

• Vicious cycle of poverty: Poverty and hunger exist in a vicious cycle. People in poverty face hunger, as they cannot afford nutritious food. On the flip side, hunger fuels poverty, as it’s difficult for people to earn.
• Climate change: Unpredictable rainfall pattern can destroy harvests or substantially reduce the amount of animal pasture available. Unfortunately, these fluctuations often affect the poorest regions of the world the most.
  • The World Bank estimates that climate change has the power to push more than 100 million people into poverty over the next decade.
• Lack of infrastructure: Systemic problems, like poor infrastructure or a lack of investment in agriculture, often make it hard for food and water to reach those who need it most.
• Economic performance: Much like the poverty-hunger cycle, nutritional resilience at a national level is tied to a country’s economic resilience
• Wastage of food
• Gender inequality: In its outline of the Sustainable Development Goals, the UN reveals that “if women farmers had the same access to resources as men, the number of hungry in the world could be reduced by up to 150 million.”
  • Female farmers are responsible for growing, harvesting, preparing, and selling the majority of food in poor countries.
  • Women are on the frontlines of the fight against hunger, yet they are frequently underrepresented at the forums where important decisions on policy and resources are made.

What needs to be done?

• Keep agrifood systems functioning
• Support enhanced homestead food production to increase access to nutrient-rich vegetables, fruits, and eggs and improve diet quality. 
• Establishing a dedicated day for nutrition education, screening and growth monitoring in every village (VHSND)
• Improved supplementary nutrition program for children and pregnant women
• Establishment of Nutrition Rehabilitation in district and sub-district level
• Nutrition Missions at the national and regional levels
• Prevent the collapse of basic maternal and child health services
• Set up or scale up food and nutrition surveillance systems.
• Improved coverage of de-worming
• Improved monitoring and reporting

Conclusion

In the given situation, proactive measures are required to address the longstanding issues of malnutrition and food insecurity in India. The imperative is to devise structured, time-bound and location-specific strategies. Due consideration needs to be given to the effects of socio-economic factors, and the impact of the pandemic. A comprehensive approach is also needed to be created to address the different sectors and dimensions of nutrition.