In the recent past, there has been a renewed discussion around nutrition in India.  A few months ago, the Ministry of Health and Family Welfare had released the National Health Policy, 2017.[1]  It highlighted the negative impact of malnutrition on the population’s productivity, and its contribution to mortality rates in the country.  In light of the long term effects of malnutrition, across generations, the NITI Aayog released the National Nutrition Strategy this week.  This post presents the current status of malnutrition in India and measures proposed by this Strategy.

What is malnutrition?

Malnutrition indicates that children are either too short for their age or too thin.[2]  Children whose height is below the average for their age are considered to be stunted.  Similarly, children whose weight is below the average for their age are considered thin for their height or wasted.  Together, the stunted and wasted children are considered to be underweight – indicating a lack of proper nutritional intake and inadequate care post childbirth.

What is the extent of malnutrition in India?

India’s performance on key malnutrition indicators is poor according to national and international studies.  According to UNICEF, India was at the 10th spot among countries with the highest number of underweight children, and at the 17th spot for the highest number of stunted children in the world.[3]

Malnutrition affects chances of survival for children, increases their susceptibility to illness, reduces their ability to learn, and makes them less productive in later life.[4]   It is estimated that malnutrition is a contributing factor in about one-third of all deaths of children under the age of 5.[5]  Figure 1 looks at the key statistics on malnutrition for children in India.

Figure 1: Malnutrition in children under 5 years (2005-06 and 2015-16)

NFHS Survey

Sources: National Family Health Survey 3 & 4; PRS.

Over the decade between 2005 and 2015, there has been an overall reduction in the proportion of underweight children in India, mainly on account of an improvement in stunting.  While the percentage of stunted children under 5 reduced from 48% in 2005-06 to 38.4% in 2015-16, there has been a rise in the percentage of children who are wasted from 19.8% to 21% during this period.[6],[7]  A high increase in the incidence of wasting was noted in Punjab, Goa, Maharashtra, Karnataka, and Sikkim.[8]

The prevalence of underweight children was found to be higher in rural areas (38%) than urban areas (29%). According to WHO, infants weighing less than 2.5 Kg are 20 times more likely to die than heavier babies.2  In India, the national average weight at birth is less than 2.5 Kg for 19% of the children.  The incidence of low birth-weight babies varied across different states, with Madhya Pradesh, Rajasthan and Uttar Pradesh witnessing the highest number of underweight childbirths at 23%.[9]

Further, more than half of India’s children are anaemic (58%), indicating an inadequate amount of haemoglobin in the blood.  This is caused by a nutritional deficiency of iron and other essential minerals, and vitamins in the body.2

Is malnutrition witnessed only among children?

No.  Among adults, 23% of women and 20% of men are considered undernourished in India.  On the other hand, 21% of women and 19% of men are overweight or obese.  The simultaneous occurrence of over nutrition and under-nutrition indicates that adults in India are suffering from a dual burden of malnutrition (abnormal thinness and obesity).  This implies that about 56% of women and 61% of men are at normal weight for their height.

What does the National Nutrition Strategy propose?

Various government initiatives have been launched over the years which seek to improve the nutrition status in the country.  These include the Integrated Child Development Services (ICDS), the National Health Mission, the Janani Suraksha Yojana, the Matritva Sahyog Yojana, the Mid-Day Meal Scheme, and the National Food Security Mission, among others.  However, concerns regarding malnutrition have persisted despite improvements over the years.  It is in this context that the National Nutrition Strategy has been released.  Key features of the Strategy include:8

  • The Strategy aims to reduce all forms of malnutrition by 2030, with a focus on the most vulnerable and critical age groups. The Strategy also aims to assist in achieving the targets identified as part of the Sustainable Development Goals related to nutrition and health.
  • The Strategy aims to launch a National Nutrition Mission, similar to the National Health Mission. This is to enable integration of nutrition-related interventions cutting across sectors like women and child development, health, food and public distribution, sanitation, drinking water, and rural development.
  • A decentralised approach will be promoted with greater flexibility and decision making at the state, district and local levels. Further, the Strategy aims to strengthen the ownership of Panchayati Raj institutions and urban local bodies over nutrition initiatives.  This is to enable decentralised planning and local innovation along with accountability for nutrition outcomes.
  • The Strategy proposes to launch interventions with a focus on improving healthcare and nutrition among children. These interventions will include: (i) promotion of breastfeeding for the first six months after birth, (ii) universal access to infant and young child care (including ICDS and crèches), (iii) enhanced care, referrals and management of severely undernourished and sick children, (iv) bi-annual vitamin A supplements for children in the age group of 9 months to 5 years, and (v) micro-nutrient supplements and bi-annual de-worming for children.
  • Measures to improve maternal care and nutrition include: (i) supplementary nutritional support during pregnancy and lactation, (ii) health and nutrition counselling, (iii) adequate consumption of iodised salt and screening of severe anaemia, and (iv) institutional childbirth, lactation management and improved post-natal care.
  • Governance reforms envisaged in the Strategy include: (i) convergence of state and district implementation plans for ICDS, NHM and Swachh Bharat, (ii) focus on the most vulnerable communities in districts with the highest levels of child malnutrition, and (iii) service delivery models based on evidence of impact.

[1] National Health Policy, 2017, Ministry of Health and Family Welfare, March 16, 2017, http://mohfw.nic.in/showfile.php?lid=4275

[2] Nutrition in India, Ministry of Health and Family Welfare, 2005-06, http://rchiips.org/nfhs/nutrition_report_for_website_18sep09.pdf

[3] Unstarred Question No. 2759, Lok Sabha, Answered on March 17, 2017, http://164.100.47.190/loksabhaquestions/annex/11/AU2759.pdf

[4] Helping India Combat Persistently High Rates of Malnutrition, The World Bank, May 13, 2013, http://www.worldbank.org/en/news/feature/2013/05/13/helping-india-combat-persistently-high-rates-of-malnutrition

[5] Unstarred Question No. 4902, Lok Sabha, Answered on December 16, 2016, http://164.100.47.190/loksabhaquestions/annex/10/AU4902.pdf

[6] National Family Health Survey – 3, 2005-6, Ministry of Health and Family Welfare http://rchiips.org/nfhs/pdf/India.pdf

[7] National Family Health Survey – 4 , 2015-16, Ministry of Health and Family Welfare, http://rchiips.org/NFHS/pdf/NFHS4/India.pdf

[8] National Nutrition Strategy, 2017, NITI Aayog, September 2017, http://niti.gov.in/writereaddata/files/document_publication/Nutrition_Strategy_Booklet.pdf

[9] Rapid Survey On Children, Ministry of Women and Child Development, 2013-14, http://wcd.nic.in/sites/default/files/RSOC%20National%20Report%202013-14%20Final.pdf

As of April 26, Rajasthan has 2,083 confirmed cases of COVID-19 (fifth highest in the country), of which 493 have recovered and 33 have died.  On March 18, the Rajasthan government had declared a state-wide curfew till March 31, to check the spread of the disease.  A nation-wide lockdown has also been in place since March 25 and is currently, extended up to May 3.  The state has announced several policy decisions to prevent the spread of the virus and provide relief for those affected by it.  This blog summarises the key policy measures taken by the Government of Rajasthan in response to the COVID-19 pandemic.

Early measures for containment

Between late January and early February, Rajasthan Government’s measures were aimed towards identification, screening and testing, and constant monitoring of passenger arrivals from China.  Instructions were also issued to district health officials for various prevention, treatment, & control related activities, such as (i) mandatory 28-day home isolation for all travellers from China, (ii) running awareness campaigns, and (iii) ensuring adequate supplies of Personal Protection Equipments (PPEs).  Some of the other measures, taken prior to the state-wide lockdown, are summarised below:

Administrative measures

  • The government announced the formation of Rapid Response Teams (RRTs), at the medical college-level and at district-level on March 3 and 5, respectively.

  • The District Collector was appointed as the Nodal Officer for all COVID-19 containment activities.  Control Rooms were to be opened at all Sub-divisional offices.  The concerned officers were also directed to strengthen information dissemination mechanisms and tackle the menace of fake news.

  • Directives were issued on March 11 to rural health workers/officials to report for duty on Gazetted holidays.  Further, government departments were shut down between March 22 and March 31.  Only essential departments such as Health Services were allowed to function on a rotation basis at 50% capacity and special / emergency leaves were permitted. 

Travel and Movement

Health Measures

  • Advisories regarding prevention and control measures were issued to: (i) District Collectors, regarding sample collection and transportation, hotels, and preparedness of hospitals, (ii) Police department, to stop using breath analysers, (iii) Private hospitals, regarding preparedness and monitoring activities, and (iv) Temple trusts, to disinfect their premises with chemicals. 

  • The government issued Standard Operating Procedures for conducting mock drills in emergency response handling of COVID-19 cases.  Training and capacity building measures were also initiated for (i) Railways, Army personnel etc and (ii) ASHA workers, through video conferencing. 

  • A model micro-plan for containing local transmission of COVID was released.  Key features of the plan include: (i) identification and mapping of affected areas, (ii) activities for prevention control, surveillance, and contact tracing, (iii) human resource management, including roles and responsibilities, (iv) various infrastructural and logistical support, such as hospitals, labs etc, and (v) communication and data management.

  • Resource Management: Private hospitals and medical colleges were instructed to reserve 25 % of beds for COVID-19 patients.  They were also instructed to utilise faculty from the departments of Preventive and Social Medicine to conduct health education and awareness activities. 

  • Over 6000 Students of nursing schools were employed in assisting the health department to conduct screening activities being conducted at public places, railways stations, bus stands etc.

  • Further, the government issued guidelines to ensure the rational use of PPEs.

Welfare Measures

During the lockdown

State-wide curfew announced on March 18 has been followed by a nation-wide lockdown between March 25 and May 3. However, certain relaxations have been recommended by the state government from April 21 onwards.  Some of the key measures undertaken during the lockdown period are: 

Administrative Measures

  • Advisory groups and task forces were set up on – (i) COVID-19 prevention, (ii) Health and Economy, and (iii) Higher education.  These groups will provide advice on the way forward for (i) prevention and containment activities, (ii) post-lockdown strategies and strategies to revive the economy, and (iii) to address the challenges facing the higher education sector respectively. 

  • Services of retiring medical and paramedical professionals retiring between March and August have been extended till September 2020. 

Essential Goods and Services

  • A Drug Supply Control Room was set up at the Rajasthan Pharmacy Council.  This is to ensure uninterrupted supply of medicines during the lockdown and will also assist in facilitating home delivery of medicines.

  • The government permitted Fair Price Shops to sell products such as masalas, sanitisers, and hygiene products, in addition to food grains.

  • Village service cooperatives were declared as secondary markets to facilitate farmers to sell their produce near their own fields/villages during the lockdown. 

  • A Whatsapp helpline was also set up for complaints regarding hoarding, black marketing, and overpricing.

Travel and Movement

  • Once lockdown was in place, the government issued instructions to identify, screen, and categorise people from other states who have travelled to Rajasthan.  They were to be categorised into: (i) people displaying symptoms to be put in isolation wards, (ii) people over 60 years of age with symptoms and co-morbidities to be put in quarantine centres, and (iii) asymptomatic people to be home quarantined.

  • On March 28, the government announced the availability of buses to transport people during the lockdown.  Further, stranded students in Kota were allowed to return to their respective states. 

  • On April 2, a portal and a helpline were launched to help stranded foreign tourists and NRIs.

  • On April 11, an e-pass facility was launched for movement of people and vehicles. 

Health Measures

  • To identify COVID-19 patients, district officials were instructed to monitor people with ARI/URI/Pneumonia or other breathing difficulties coming into hospital OPDs.  Pharmacists were also instructed to not issue medicines for cold/cough without prescriptions. 

  • A mobile app – Raj COVID Info – was developed by the government for tracking of quarantined people.  Quarantined persons are required to send their selfie clicks at regular intervals, failing which a notification would be sent by the app.  The app also provides a lot of information on COVID-19, such as the number of cases, and press releases by the government.

  • Due to the lockdown, people had restricted access to hospitals and treatment.  Thus, instructions were issued to utilise Mobile Medical Vans for treatment/screening and also as mobile OPDs

  • On April 20, a detailed action plan for prevention and control of COVID-19 was released.  The report recommended: (i) preparation of a containment plan, (ii) formation of RRTs, (iii) testing protocols, (iv) setting up of control room and helpline, (v) designated quarantine centres and COVID-19 hospitals, (vi) roles and responsibilities, and (vii) other logistics. 

Welfare Measures

  • The government issued instructions to make medicines available free of cost to senior citizens and other patients with chronic illnesses through the Chief Minister’s Free Medicine Scheme.  

  • Rs 60 crore was allotted to Panchayati Raj Institutions to purchase PPEs and for other prevention activities. 

  • A one-time cash transfer of Rs 1000 to over 15 lakh construction workers was announced.  Similar cash transfer of Rs 1000 was announced for poor people who were deprived of livelihood during the lockdown, particularly those people with no social security benefits.  Eligible families would be selected through the Aadhaar database.  Further, an additional cash transfer of Rs 1500 to needy eligible families from different categories was announced.

  • The state also announced an aid of Rs 50 lakh to the families of frontline workers who lose their lives due to COVID-19.

  • To maintain social distancing, the government will conduct a door-to-door distribution of ration to select beneficiaries in rural areas of the state.  The government also announced the distribution of free wheat for April, May, and June, under the National Food Security Act, 2013.  Ration will also be distributed to stranded migrant families from Pakistan, living in the state.

  • The government announced free tractor & farming equipment on rent in tie-up with farming equipment manufacturers to assist economically weak small & marginal farmers.

Other Measures

  • Education: Project SMILE was launched to connect students and teachers online during the lockdown.  Study material would be sent through specially formed Whatsapp groups.  For each subject, 30-40 minute content videos have been prepared by the Education Department.

  • Industry:  On April 18, new guidelines were issued for industries and enterprises to resume operations from April 20 onwards.  Industries located in rural areas or export units / SEZs in municipal areas where accommodation facilities for workers are present, are allowed to function.  Factories have been permitted to increase the working hours from 8 hours to 12 hours per day, to reduce the requirement of workers in factories.  This exemption has been allowed for the next three months for factories operating at 60% to 65% of manpower capacity.

For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.