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)
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
[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
On March 22, Bihar registered its first two cases of the new coronavirus disease (COVID-19), one of whom died the same day. Since then, the number of cases has increased steadily. As of April 19, Bihar has 86 confirmed cases of COVID-19, of which 47 are active cases and 37 have recovered. 33 new cases have been registered since last week. One more death has been registered since March 22.
Given the highly contagious nature of the disease, on March 22, the Government of Bihar announced a state-wide lockdown till March 31. This was followed by a nation-wide lockdown enforced by the central government between March 25 and April 14, now extended up to May 3. During the lockdown, severe restrictions have been placed on the movement of individuals. Establishments have remained closed, except those providing essential goods and services. Restrictions are likely to be relaxed in less-affected districts post-April 20.
In this blog, we look at key measures taken by the state government in response to COVID-19 so far.
Early-stage: screening of travellers, awareness on precautionary measures
The initial responses from the state government were aimed towards: (i) raising awareness about precautionary measures to be taken against the disease, and (ii) screening of international travellers. In this context, on February 25, the Bihar State Health Society issued advisories for: (i) measures to be taken in schools and colleges, and (ii) reporting of airline passengers and tourists with symptomatic cases to the district health administration. On March 11, 104 Call Centre was designated as the COVID-19 control room, to address public queries related to the disease.
Prior to lockdown: limiting mass gatherings, mobilisation of the public health system
Limiting mass gatherings
Between March 13 and March 18, the state government issued orders to shut down various premises until March 31. These include Anganwadi centres, educational institutions, and commercial establishments such as cinema halls, parks, and shopping malls. The government staff was directed to come to office on alternate days. Gathering of more than 50 persons at one place was prohibited including any mass family gathering (except marriages). The transport department was asked to restrict both public and private transport.
Healthcare measures
On March 13, the government issued directions to: (i) ensure availability of 100 extra ventilators in the government hospitals, (ii) arrange for testing of COVID-19 in AIIMS, Patna and PMCH, Patna hospitals, and (iii) cancel leaves of all employees of the Health Department, and (iv) strengthen screening of travellers entering through the Bihar-Nepal border.
On March 17, the Health Department issued The Bihar Epidemic Diseases, COVID-19 Regulation 2020 under The Epidemic Diseases Act, 1897. The Act provides for better prevention of the spread of dangerous epidemic diseases. These regulations specify the protocol to be followed in both private and government hospitals for screening and treatment of COVID-19 patients. It also empowers the district administration to take containment measures including sealing of specific areas and conducting surveillance for COVID-19 cases. It makes spreading of rumour or unauthenticated information with mala fide intent a punishable offence.
Welfare measures
On March 16, the Chief Minister announced that treatment costs for COVID-19 for residents of Bihar will be sponsored from the Chief Minister Medical Assistance Fund. Moreover, the state government will provide assistance of four lakh rupees to the family of a person dying due to COVID-19.
The government issued directions to provide direct cash transfer in place of the food provided under the Mid-Day Meal scheme in schools, and at Anganwadi centres.
Essential goods and services
On March 21, the Food and Consumer Protection Department directed the district administration to ensure implementation of the Bihar Essential Article (Display of Prices and Stocks) Order, 1977. The Order requires sellers of specified items to display stock and price for the public’s reference. The specified items include food items, edible oilseeds, and petroleum products. The Department also directed the district administration to send proposals for adding any new items to the list of specified items.
During lockdown: strengthening medical response, welfare measures
Upon announcement of the lockdown on March 22, state-level and district-level coordination committees were set up. During the lockdown, the state government’s measures have been aimed towards: (i) strengthening the medical response in the state, (ii) providing relief to various sections of society from issues being faced during the lockdown, and (iii) addressing difficulties with the supply of essential goods and services.
Healthcare measures
On March 25, the Health Department constituted the Bihar COVID-19 Emergency Response Team which is responsible for the control and coordination of all health-related response.
Protocols for containment and treatment: Directions have been issued to implement several guidelines related to containment and treatment measures. These include: (i) set up and operationalization of isolation centres and quarantine centres, (ii) containment plan to address local transmission and community transmission through cluster containment strategy, (iii) surveillance program for Influenza-like Illness (ILI) and Severe Acute Respiratory Illness (SARI), (iv) handling of waste generated during treatment/diagnosis/quarantine, and (v) sanitation of residence and nearby areas of a COVID-19 positive person.
Door-to-door screening campaign: On April 14, the Chief Minister issued directions to start door-to-door screening campaign for suspected cases in affected districts including Siwan, Begusarai, and Nalanda. Such screening campaign will also be run in districts in border-areas, and an area within 3 km radius of the residence of COVID-19 positive patients.
Increasing manpower: The government invited medical professionals including doctors, nurses, and paramedics to volunteer. It also directed the district administration to engage retired doctors, nurses, and paramedics from defence services for volunteer work. Leaves of all employees of the Health Department were cancelled until April 30. The Health Department deputed AYUSH practitioners to assist at isolation and quarantine centres.
Dedicated infrastructure for COVID-19: On April 5, certain government hospitals were designated as exclusive hospitals for treatment of COVID-19 patients. The Health Department also directed certain big private hospitals in Patna to stop OPD services.
Other health-related measures: On March 23, the state government announced payment of one-month basic salary as an incentive to all doctors and health workers. On April 13, the Health Department issued an order prohibiting spitting in public places by tobacco, cigarette, and Pan users. Further, the state government announced that it will procure test kits from the private sector.
Welfare measures
Relief package: On March 23, the state government announced a relief package for people affected due to lockdown. Key features of the relief package are:
ration of one-month to all ration cardholders for free,
one-time cash transfer of Rs 1,000 per family to ration cardholders,
payment of pensions for three months in advance to all pensioners including pension for old age persons, widows, and physically challenged, and
release of pending scholarships to all students.
Help for migrants: On March 26, Rs 100 crore was allocated from the Chief Minister Relief Fund to provide aid to the migrants from Bihar stuck in other parts of the country due to the lockdown. On April 2, the state government announced that a one-time cash transfer of Rs 1,000 will be provided to the migrants. On April 13, an additional Rs 50 crore was allocated from the Relief Fund for this purpose. State-wise nodal officers have been appointed for coordination of relief efforts for migrants. The state government is running 10 food centres in Delhi to help migrants from Bihar.
Relief camps: On March 28, the state government decided to start relief camps along the border (including Nepal border) offering food, shelter, and medical help to persons coming in the state. Community kitchens and relief camps have been started in government school campuses to provide food and shelter.
Electricity tariff: On April 8, the State Cabinet approved the proposals for: (i) reducing electricity tariff for domestic and agricultural consumers by 10 paise per unit and (ii) waiving the monthly meter fee.
Measures for businesses and agricultural activities
The state government provided certain relaxations to businesses in matters related to taxation. These include:
extension in the deadline for payment of GST from March 31 to June 30, no interest or penalty charges to be levied for late payment in certain cases,
three-month extension in the deadline for one-time settlement scheme for pre-GST tax disputes, and
cancellation of orders regarding attachment of bank accounts of certain tax defaulters.
On April 16, the Chief Minister issued directions to start procurement of wheat through the Primary Agriculture Credit Society (PACS).
Essential goods and services
Various departments issued guidelines to the district administration to facilitate operational continuity of essential goods and services including (i) food items, (ii) seeds, fertilisers, and other agriculture-related items, (iii) livestock fodder, and (iv) petroleum products.
On March 27, the Food and Consumer Protection Department brought certain new items under the purview of The Bihar Essential Article (Display of Prices and Stocks) Order, 1977. These include: (i) wheat and wheat products, (ii) masks and hand sanitisers, and (iii) potato and onion.
Other Measures
Education: On April 8, the cabinet approved the proposal to promote students of Class I to XI (except class X) without annual examination.
Legislature: Salaries of MLAs and MLCs have been reduced by 15% for one year. The amount will be donated to the state’s Corona relief fund.
Labour and employment: On April 16, the Chief Minister issued directions to resume public works under the Saat Nischay Programme, Jal Jeevan Hariyali Yojana, and MNREGA.
For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.
