Budget 2021: Policy measures in the nutrition sector

India's food security policy framework includes many proven nutrition interventions. In 2015, India committed to achieving the Sustainable Development Goal (SDG) of zero hunger. As a step towards meeting the targets by 2030, the Government of India launched the Prime Minister's Overarching Scheme for Holistic Nutrition (POSHAN) Abhiyan in 2017. Targets were set to reduce stunting, under-nutrition and low birth weight by 2% each and anaemia by 3% by 2022.

Unfortunately, COVID-19 has increased the risk factors for child malnutrition in India. With the disruption of Anganwadi services and Mid-Day Meal (MDM), a large number of children no longer have access to regular, nutritious meals.

The overburdening of health systems has impaired service delivery of critical health and nutrition interventions for children. Finally, the economic impact of the pandemic has reduced the frequency and quality of meals consumed by households. India has a significant burden of child malnutrition.

It has been predicted that India will fail to meet targets for improvement in nutrition indicators set under POSHAN Abhiyan (earlier National Nutrition Mission) for 2022, and WHO-UNICEF targets for 2030 (Lancet, 2019).

The recently released National Family Health Survey (NFHS)-5, 2019-20 shows that in some of the states the prevalence of malnutrition among children has increased as compared to the previous survey year, 2015-16.

Of the partial data released for 22 states and Union Territories (UT), childhood stunting saw an increase in 13 states, wasting in 12 states and underweight in 16 states (NFHS-5, 2020). While all these data pertain to the period before the pandemic, it can only be expected that the situation is much worse now.

Malnutrition needs to be addressed through a combination of nutrition-specific interventions, which target diet and health, along with nutrition-sensitive interventions which target complementary sectors including social protection, education, and water and sanitation. With increasing recognition of the 'shadow pandemic' of hunger, this is an opportunity for governments to take strong, multi-sectoral measures to improve child nutrition and accord budgetary priority to targeted measures for addressing these gaps.

The attached policy brief highlights the need for increased public provisioning on child health and nutrition and identifies a range of short-term and long-term policy measures to build a resilient nutrition system. The section below discusses the policy measures to deal with the challenges.

Disruption in service delivery of feeding programmes

The allocation for Anganwadi services increased by 3.5% over last year, while the allocation for MDM remained the same. The 15th Finance Commission identified the need for higher spending on nutrition and recommended additional grants of Rs. 7735 crore to States for increased spending under the Special Nutrition Programme (SNP), based on inflation and the need for food fortification.

Policy measures needed

• The government should ensure continued home delivery of meals and cooking material to beneficiaries in the coming months, for as long as Anganwadis and schools remain closed. If needed, additional budgetary support should be provided to States/UTs for the logistics of meal distribution and monitoring.
• Guidance should be provided to Anganwadi workers, parents and teachers on nutritious and well-balanced diets for children, along with proper hygiene practices, for the duration that Anganwadis and schools remain closed.
• The SNP budget should be increased in line with the recommendation of the 15th Finance Commission, and local ingredients and items with high nutritional value such as eggs and milk should also be prioritised.
• Higher allocations should be made to set up more Anganwadis in urban areas which are under-serviced. In the long term, there should be a move towards universalisation of Anganwadi Services.
• The Centre should provide budgetary support to States/UTs to fill up vacant supervisory posts under Anganwadi Services.
• The National Education Policy (NEP), 2020 has recommended that provisions be made for serving breakfast along with the MDM meals to improve foundational learning (MHRD, 2020). In order to effectively implement these recommendations, the government will have to significantly increase the budget for MDM in the current and forthcoming financial years.

Disruption in health services for children

Several key nutrition-specific interventions for children are delivered through primary health infrastructure and the National Health Mission (NHM). These include immunisation, Iron and Folic Acid (IFA) supplementation, and prevention and treatment of childhood diarrhoea, and tracking and treatment of Severe Acute Malnutrition (SAM).

Policy measures needed

• Sufficient allocations should be made to ensure stock of iron, calcium and Vitamin A supplements, and essential medicines for children at Primary Health Centres, for distribution by frontline workers. Gaps in supply chains of IFA tablets under Anemia Mukt Bharat (AMB) should be addressed.
• Tracking of acute malnutrition during the pandemic should be accelerated through regular, mobile-based communication by frontline health workers (ASHAs and ANMs). Budgetary support for facilitation and training for these activities should be provided.
• The government must invest in personal protective equipment (PPE) and appropriate incentives for frontline workers including ASHAs and ANMs in the coming months.
• States must invest in decentralised procurement and decision-making so that zones with different levels of COVID-19 transmission can choose between mechanisms for service delivery (doorstep delivery or community level).
• Allocations for important schemes addressing child and adolescent health such as Rashtriya Kishor Swasthya Karyakram (RKSK) and Scheme for Adolescent Girls (SAG) must be increased in the coming years.
• Critical shortages of health professionals in rural and urban health facilities must be addressed and adequate investments made to upgrade physical infrastructure at existing facilities. For this, there must be adequate provisioning under NHM and the Health and Wellness Centre component of Ayushman Bharat.

Reduction in food security

The State of Food Security and Nutrition in the World Report 2020 shows that India continues to have the largest population of food-insecure people accounting for 22 per cent of the global burden of food insecurity. In fact, food insecurity in India has increased by 3.8 percentage points between 2014 and 2019 (Bansal, 2020). Plummeting means of income and depleting savings due to COVID-19 will further increase the proportion of food insecure people in India which directly affects children's nutrition.

Policy measures needed

• The government should continue the distribution of free grains under PMGKY after November 2020.
• Effective measures are needed to solve issues that hamper the distribution of PDS. In a situation of the hunger crisis, the biometric identification and legal documentation should be eased. Ration should be provided to all regardless of whether they have linked their ration card to Aadhar card and a system should be in place to update the ration cards to include names of children born after 2011.
• It is critical to strengthen the coverage of the food based social security nets to include the large number of vulnerable people who are currently out of the food system across different States. The PDS should be universalised and expanded to include all vulnerable groups, like migrant workers, homeless, sex workers, and transgender people.
• The Government of India should provide an adequate budget to strengthen the system of Food Corporation of India (FCI).
• There is a need to maintain transparency and improve accountability in the distribution system. Inspections and grievance redressal constituted with the PDS or local government should be strengthened to ensure smooth functioning of the food distribution system and minimize power asymmetries.
• Food-based social security nets i.e. PDS, ICDS and MDM should be strengthened by adding food grains with a higher nutritive value like ragi, bajra, jowar etc.

Reduction in dietary quantity

Financial constraints due to the pandemic will impact the dietary intake of poor households as they shift towards cheaper and less nutritious food.

Policy measures needed

• Food assistance programmes should move towards nutritional improvement rather than staple grain sufficiency by providing non-staple food grain such as pulses and millets at subsided costs. PDS can be a useful instrument in ensuring that the poor have adequate access to a healthy, balanced and diverse diet.
• Similarly, more nutrient-rich food such as eggs, milk, and fruits should be included in existing programmes like MDM and SNP to improve nutrition among children.
• Nutri-gardens can be set-up at scale with technical support from agricultural institutions as they provide a cost-effective way to grow nutrient-rich crops for personal/community consumption. It can be executed in Anganwadi Centres and schools to improve the quality of food provided in SNP and MDM. States such as Mizoram, Chhattisgarh and Chandigarh are already implementing the model in schools and Anganwadis.
• Agricultural policies should enhance farmers' ability to diversify production systems to non-staple foods since it is now heavily based on three major staple crops – rice, wheat and maize. Zero Budget Natural Farming (ZBNF) should be promoted.
• Measures need to be adopted to sensitise and educate communities on the importance of an overall nutritious diet and effective ways to improve the diet of children by changing family feeding practices. Importantly, there needs to be focused counselling on making intra-household distribution of food more gender-equitable.

Increase in food prices

Accessibility and affordability of food highly depend on the price of the food products. In response to the COVID-19 and subsequent lockdown, while the staple grain prices have remained stable, prices for more nutritious foods like pulses, vegetables, and eggs have risen, making it more difficult for Indian consumers to afford them. Thus, the access to nutrient-rich food which was already skewed has become more inequitable during this pandemic.

Policy measures needed

• Government procurement and public distribution can be important measures to preserve food system functioning and avoid food price inflation. The government should implement a universal PDS and provide larger quantities of food grains to each individual at least for the next six months.
• The sustained relative stability of cereal prices and higher prices for other food groups will distort consumer spending, preserving excessive reliance on staples as a major component of the Indian diet at the cost of more nutritious options. Therefore, insulating non-staple supply chains from price shocks and fluctuations is critical to the objective of improving nutrition.

The marginalised at risk

Children from the marginalised sections of the population including Dalits, Adivasis, Persons with Disabilities, migrants, and homeless are already vulnerable to malnutrition. Girls belonging to marginalised sections, especially adolescent girls, are the worst affected during the pandemic.

Policy measures needed

• The Centre must allocate resources for additional supplementary nutrition or booster meals for children from vulnerable communities. This can be done under SNP, or through a new targeted initiative.
• The Centre and States/UTs must invest resources in collecting, monitoring and publishing beneficiary data disaggregated by social identity for all-important nutrition and health schemes for children. This can make nutrition and health service delivery more responsive to vulnerable children.
• As lack of livelihood options is one of the basic causes of the nutrition deficit in most vulnerable members of the households, especially during the pandemic, the Government needs to focus on employment generation programmes.

The policy brief by CBGA and CRY is available here - Impact of COVID-19 on Child Nutrition in India: What are the Budgetary Implications?