COVID-19 is a unique opportunity to reform our public health sector: Dr Sujeet Ranjan

Dr Sujeet Ranjan, ED, The Coalition for Food and Nutrition Security reflects on the effects of malnutrition on the life of the child, their family, and what does it mean for a country and the significant bottlenecks in the Government’s policy plans. While estimating the socio-economic burden of malnutrition in the post COVID era, he suggests ways to break the cycle of inter-generational malnutrition by focusing on two important target groups: children under two years of age and women, especially adolescent girls, pregnant women and lactating mothers

 The Comprehensive National Nutrition Survey: 2016-18 shows that 34.7 per cent of children under five years of age are stunted (low height for age), 17.3 per cent are wasted (low weight for height), 4.9 per cent severely wasted and 33.4 per cent are underweight (low weight for age). Another figure which alarming is that every second child is anaemic in our country. Please reflect on the effects of malnutrition on the life of the child, their family, and what does it mean for a country?

 India’s greatest state treasure is our people. Although we have made tremendous advances in many other fields, malnutrition remains unacceptably high. Poor nutrition is a major cause of other health problems in the country, including severe wasting and prevalence of anaemia during pregnancy.

Malnutrition remains a major threat to the survival, growth, and development of children. Cost benefit analysis of nutrition interventions report a return of Rs 18 on investment of Rs 1 per child. Adults undernourished as children earn at least 20 per cent less than those that were not. With adult height, a 1 cm increase in stature is associated with 4 per cent increase in wages for men and 6 per cent increase in wages for women (Comprehensive National Nutrition Survey: 2016-18).

Child and maternal malnutrition are by far the largest nutrition related health burden in the country. Malnutrition in the first two years of life reduces the education potential of the children. Asia and Africa lose 11 per cent Gross National Product (GNP) every year owing to poor nutrition. Cost benefit analysis of nutrition interventions report a return of Rs 18 on investment of Rs 1 per child. Undernutrition and micronutrient deficiencies cost up to $2.1 trillion per year. Adults undernourished as children earn at least 20 per cent less than those that were not. With adult height, a 1 cm increase in stature is associated with 4 per cent increase in wages for men and 6 per cent increase in wages for women (Comprehensive National Nutrition Survey: 2016-18).

 We know that malnutrition is a problem which is a multifaceted and multi-dimensional issue, affected by poverty, insufficient food consumption, inequitable food supply, inappropriate infant and child feeding and care practices, equity, and gender disparities, poor hygienic and environmental settings and inadequate access to quality health, social services and education. What are the possible solutions to deal with this problem?

We recognise malnutrition as a complex and multi-dimensional issue, affected by poverty, inadequate food consumption, inequitable food distribution, improper infant and child feeding and care practices, equity and gender imbalances, poor sanitary and environmental conditions and limited access to quality health, education and social services

For a long time, all the key stakeholders have been working in silos. POSHAN Abhiyaan is bringing all the partners together. There are lot of repetitions of work, somewhere synergies are required as the agenda that we are all working is the same. Information technology can be leveraged for ensuring many services related to maternal and child health such as machine learning and AI. Nutri garden should be largely promoted so that mothers can participate in income generation activities and hence cater to the nutrition of their child and themselves. GIS tracking to identify hotspots at the block and sector level can also be done to take required actions. Nutrition needs to be integrated into universal health coverage as an indispensable prerequisite for improving diets, saving lives and reducing healthcare spending, also highlighted in the Global Nutrition Report.

What are the policy initiatives that the government has undertaken, and what were the significant bottlenecks in those policy plans?

Though Government of India has taken some initiatives like Poshan Abhiyaan, Aspirational Districts Programme, Anaemia Mukt Bharat for taking the agenda of nutrition in a mission mode, and while we hope that these initiatives will bring good results in the coming days, it may still take some time to achieve the desired outcomes. Government of India is committed to improving the nutritional status of children and women through POSHAN Abhiyaan. The mission mode approach provides the impetus to strengthen implementation and its monitoring. There are core programmatic inputs including funding, human resources, supplies, and infrastructure that are critical to functioning of these POSHAN Abhiyaan pillars. Overall across the States, there are gaps that require immediate attention to strengthen the inputs and the pillars of POSHAN Abhiyaan as highlighted in the progress report of Transforming nutrition in India: Poshan Abhiyaan, September 2019 by NITI Aayog. The binding constraints in the implementation of the Abhiyaan are gaps in human resources, particularly at the supervisory level, procurement of growth monitoring devices and smartphones and likelihood of attrition in the quality of data collected through ICDS-CAS, fund utilisation, convergence at grassroot level, capacity building etc.

This pandemic has further entrenched and magnified the structural problems present in society, one of which is malnutrition. What would be the socio-economic burden of malnutrition looks like in the post COVID-19 era? How far low has this pandemic set back our battle with malnutrition?

 India has to not only deal with the present health crisis but also with the already existing problems of unemployment, low incomes, rural distress, malnutrition, and widespread inequality which is in a state of aggravating further. The situation has added to the miseries of the poor, with massive job losses and rising food insecurity. Our food systems are already stressed by increasing climate extremes. Containing the virus has caused food and nutrition shortages and driven governments to reduce social services, such as school nutrition programmes, that the most marginalised rely upon. Levels of hunger and malnutrition could double within the space of just a few weeks as highlighted in the Global Nutrition Report 2020 that is likely to increase load of hospitalisation for severe acute malnourished children in the NRCs/MTCs. Undernutrition and micronutrient deficiencies cost up to $2.1 trillion per year (CNNS 2016-18). This is likely to increase further due to COVID.

 Due to the fear of infections amid COVID, screening of children to identify acute malnutrition has been long halted posing a likely scenario of increased burden of malnutrition than before, also immunisation was at halt for some time. The need to suffice the hunger always comes first in such a scenario and hence the nutrition component, the ensuring of which has taken numerous efforts of advocacy tools like behaviour change communication etc was undermined and hence is definitely a setback to the progress made so far.

 How do you seek to strengthen adolescence nutrition to break the cycle of inter-generational malnutrition?

Adolescence is a period of intense social, psychological, and physiological change, particularly for girls. Nutritional deficiencies in adolescent girls are common and have far-reaching implications for them as young women, and for their children when they become mothers. Evidence and programming experience show that significant improvements in nutrition will require sustained changes in behaviours. Particularly important are changes in the areas of breastfeeding, complementary feeding and care of women before and during pregnancy. However, this requires addressing social and cultural issues, such as the status and value of women and girls, son preference etc. This means that empowerment efforts will need to be combined with nutrition education and behaviour change activities.

Promote the improvement of girls’ and women’s nutritional status as a top political and programmatic priority at all levels. Successful programming experience and health and nutrition evidence show that overcoming the curse of malnutrition will require focusing on two important target groups: children under two years of age and women, especially adolescent girls, pregnant women and lactating mothers. The first two years of life represent the critical window of opportunity to break the inter-generational cycle of malnutrition.

How do you see the role of civil society organisations / NGOs in the New Normal?

Role of civil societies organisations today and in coming days will be very important. Even with so much of negativity, there is a silver lining for sector which will make the country stronger and make its own place much relevant in coming years. The crisis brought us together again, with more focused deliverables and objectives. To make India a stronger country and how we should learn managing its human resource. COVID-19 is a unique opportunity to reform our public health sector. A strong public health system will benefit everyone, and there is no better time than now to make it a reality. To boost public-private partnership (PPP), build a data culture, engage communities, and engage private healthcare services. If we reform our public health system now, it creates an opportunity for ripple effects in other areas too: for instance, nutrition and water and sanitation etc.

Involve communities in the planning and implementation of efforts to improve the nutrition of adolescent girls, including involving teachers, peer groups, self-help groups, and other community groups and resource persons. Strengthen the knowledge and skills of frontline workers (especially AWWs, ASHAs, ANMs and teachers) through results focused training, communication materials and job aids, as well as their support systems.