India is where the largest number of undernourished children in the world live. Despite various ongoing government programmes focusing on maternal and child nutrition, recently released National Family Health Survey – 5 (2019-2020) data show an increase in child wasting in states like Telangana, Kerala, Bihar and Assam, compared to the previous round of the same survey in 2015-16. Moreover, in a few states like Telangana, Kerala, Himachal Pradesh and Goa, there is an increase in child stunting. While state-specific reasons for this trend need to be understood, this scenario is worrisome as these trends were seen before the Covid-19 pandemic hit the country. After that, the impact of the pandemic has only exacerbated the problem.

Improving maternal and child nutrition is a high priority for the government. The POSHAN Abhiyan, India’s flagship programme to tackle under-nutrition, has ambitious targets of reducing child stunting by 2% per annum and reducing anaemia in women and children by 3% per annum.? The programme gained momentum through inter-sectoral convergence and a Jan Andolan in 2019. It has, however, faced several challenges in the face of Covid-19 and tackling malnutrition has become even harder. However, post the first wave of the pandemic, the POSHAN Abhiyan has been intensified in the form of Mission POSHAN 2.0 and the “Saksham Anganwadi” is envisioned to control the backsliding of nutrition indicators.

The current pandemic may worsen child nutrition through multiple pathways: Causes of undernutrition can be classified as immediate, underlying and basic. The pandemic has affected multiple facets of life, influencing almost all of these causes. The first nationwide lockdown in 2019 affected food supply chains, making it harder to access perishable nutritious foods like fruits, vegetables, poultry and meat at least for some time. Added to it were the fears about viral transmission and the confusion about disinfecting these foods. Fortunately, Indian agriculture and food supply chains showed exceptional resilience with the speedy restoration of operations.

Nevertheless, critical government nutrition supplementation programmes like the Anganwadi Centre-based system that is a key pillar of the Integrated Child Development Scheme (ICDS), catering to the vulnerable groups of pregnant and lactating women and young children, have been operating at a basal level owing to the pandemic and lockdowns. The hot cooked meals are still suspended, and instead, beneficiaries are receiving Take Home Rations. The diets of the vulnerable groups have also been affected through a larger impact on food systems and loss of livelihoods. Earlier data from the National Nutrition Monitoring Bureau (NNMB) surveys (2012) show that low-income group women were unable to meet their nutritional requirements during pregnancy and lactation. It is likely that the pandemic has further aggravated the situation. This is a serious concern because nutrition insecurity during the critical period of the first 1000 days of life is known to have long-lasting impact on child growth and development.

Child care is critical for child nutrition and the pandemic has likely taken a toll on child care through the displacement of families, increased stress and domestic violence. Health services are still under unprecedented pressure to manage the prevention and treatment of Covid-19 and this obviously means an inevitable impact on routine health services. Health care services including immunization have been affected as parents hesitated to visit the health facilities due to various reasons including the fear of contracting infection. The impact of the pandemic related disruptions is likely to be far-reaching, but in the absence of data, the magnitude is not yet known fully.

• Why reducing child stunting is important

Lack of adequate nutrition coupled with high prevalence of infections results in impaired growth and development in children. Should access to food and health care increase in later periods, improvement in body weight is relatively easier. However, the deficit in a child’s height does not get corrected fully beyond the critical period of the first 1000 days of life. Research studies across the world have shown that stunted children suffer from a higher risk of chronic diseases in adulthood and tend to have lower intelligence and poorer income compared to non-stunted children. Child growth improved substantially in developed countries largely as a byproduct of economic progress as the diets, control of infections and healthcare services improved. Increase in average height of the population, therefore, reflects the progress of the society. Reduction of child stunting indicates that the fruits of economic progress have reached the vulnerable sections of the population.

• What efforts are underway?

The government-run ICDS programme in India is the largest nutrition supplementation programme in the world. The Anganwadis implement the supplementary nutrition programme (SNP) in two ways: 1. Take Home Ration (THR) of food supplements for 6-36 months-old children and, 2. On-site Hot Cooked Meals (HCM) for pregnant and lactating women and children aged 3-6 years. Coverage, quality and delivery, the long-standing implementation challenges for these programmes, have intensified with Covid-19 and by the pandemic.

The union and state governments recognized the importance of continuing the nutrition supplementation despite these novel challenges of the last year and a half, and have swiftly altered ways of intervention delivery. The doorstep delivery of the supplementary food rations, both THR and HCM combined, to the beneficiaries started in April 2020. The provisions received by the Anganwadi beneficiaries differ in each state and include either premix or food grains or a combination of both. An example from Telangana is shown in the table:

In addition to THR through the Anganwadis, some states are providing doorstep delivery of mid-day meal rations for school children and adolescents which include staple grains, pulses, oil, spices and eggs (in a few states like Tamil Nadu). In Kerala, essential groceries such as pulses and spices are given by the government along with subsidized food grains through the Public Distribution System. Recently, states like Bihar have initiated direct bank transfer (DBT) instead of food rations to the ration card holders.

While coping with the challenges related to the pandemic, there have been some positive changes in intervention delivery. Wider use of digital technology to improve tracking has resulted in transparency in implementation and monitoring. However, bulk delivery of THR foods once a month has problems like food meant for beneficiaries getting shared among all the members of the household, and spoilage of perishable foods. So far as the DBT money transfer goes, although it helps mitigate food insecurity, gaps in receiving the DBT money have been reported as many households that do not possess ration cards or KYC verification of their bank accounts are unable to access the benefits.

• What more can be done?

Opening of Anganwadi centres is crucial to ensure that the beneficiaries are receiving the interventions. It is also important to include nutrient dense foods such as fruits, vegetable, eggs and milk in the THR for women and children to enhance diet quality and diversity as the households can access staples through the PDS. But a prerequisite is strengthening the supply chains of the nutrient-dense perishable foods, a formidable challenge in the current scenario. It is also important to enhance support to Anganwadiworkers in the form of protection through priority vaccination and resources to maintain a safe environment so as to enable them to provide SNP services.

• Understanding the impact of the pandemic is key to remedial measures

Monitoring the impact of the pandemic on nutritional status of all vulnerable population groups is crucial so that remedial measures are implemented. Additionally, we need a deeper understanding of the multiple determinants of undernutrition for designing more effective interventions. The National Institute of Nutrition of the Indian Council of Medical Research (NIN, ICMR) has recently initiated a study “Action against Stunting Hub”, funded by the Grand Challenges Research Fund of UK Research and Innovation (https://actionagainststunting.org/) with an aim to identify the multifactorial determinants of child stunting. Apart from assessing the wide spectrum of determinants ranging from deep biology to the food and household environment, the biological and social impacts of Covid-19 will be captured in this study. This multi-country study being done simultaneously in India, Indonesia and Senegal holds potential to generate evidence on effective interventions to improve child growth.

All new knowledge that can help us unpack and understand the impact of the pandemic, including efforts to strengthen research and interventions focusing on mothers and children, will be really significant going forward. This would help craft interventions that can reducefuture and long-drawn impact of the pandemic.

(The author is Scientist & Head, Clinical Division, ICMR- National Institute of Nutrition)