Introduction

While the world is battling the new coronavirus known as SARS-CoV-2, which is expected to disrupt and derail public health and nutrition services, it is pertinent not to overlook the other existing lags in our journey toward attaining the holistic Sustainable Development Goals (SDGs) [1]. It is now well established that people with co-morbidities, especially malnourishment, diabetes, cardiovascular diseases, and respiratory or kidney problems, experience exacerbated pathogenesis of COVID-19 due to an already compromised immune response [2]. The whole world is off track in achieving SDG 2 also known as Zero Hunger. At the current pace, approximately 37 countries including India will fail to even reach low hunger by 2030. India ranks 104 out of 117 countries as per the used metric—the global hunger index [3]. Furthermore, these projections do not account for the impact of the COVID-19 pandemic, which may worsen hunger and undernutrition in the near term and affect countries’ trajectories into the future [4].

While the share of undernourished people in the world has stagnated, the absolute number of undernourished people is on the rise. As of 2019, 8.9% of the world’s population was undernourished, unchanged from 2018. This amounted to nearly 690 million undernourished people in 2019, up by 10 million since 2018 and by nearly 60 million since 2014 [5]. Undernutrition contributes to about 45% of deaths in children under age five [6]. India already features as one of the poorest performing countries when it comes to public health and nutrition (PHN) statistics (Table 9.1).

Table 9.1 Nutrition indicators in India
Full size table

Although nutritional deficiencies are found in all age groups, children under five years of age are more vulnerable. The prevalence of stunting in children aged 0 to 59 months decreased from 48% in 2005–2006 to 38% in 2015–2016. Similarly, the proportion of underweight children decreased from 43 to 36% over the same time period. However, the same decade witnessed an increase in overweight populations from 1.5 to 2.3%. During this decade, the wasting rate also increased from 17 to 21%. Among non-pregnant women (15–49 years) specifically, there was a decrease in the prevalence of those underweight from 35.5% in 2005–2006 to 22.9% in 2015–2016 and an increase in obesity/overweight from 12.6% in 2005–2006 to 20.7% in 2015–2016 [7]. Micronutrient (vitamins and minerals) deficiencies, referred to as ‘hidden hunger,’ affect cognitive and mental development, thereby impacting productivity and overall quality of life [8]. In India, over 0.5% of the total deaths in 2016 were due to nutritional deficiencies. In 2017, the prevalence of anemia was 60% in children and 54% in women. Nutritional anemia is caused by deficiency in iron, folate, and vitamin B12. Anemia increases the risk of adverse birth outcomes, infant and maternal mortality, and results in poor cognitive and mental development in children. The introduction of various interventions for anemia control by the government has decreased its prevalence in preschool children from 74.3% in 1998–1999 to 58.5% in 2015–2016 [9].

The government launched the National Iodine Deficiency Disorder Control Program in 1992 to tackle the problem of goiter. This program focused on universal iodization of salt and imposed a ban on direct selling of non-iodized salt to consumers [10]. The consumption of iodized salt in households increased from 71.6% in 1998–1999 to 93.1% in 2015–2016 [11, 12].

As is evident from the nutrition card of India, it is imperative that if the nation is to become a global leader in all spheres of development, nutrition security and public health must be improved. Governments and donors must maintain nutrition as a priority, continue to support nutrition programs, and ensure the efficient use of resources (Box 1).

Impact of COVID on the Already Grim Statistics for Public Health and Nutrition

Malnutrition and COVID-19 are intrinsically linked [11]. Undernutrition can exacerbate COVID-19 pathogenesis. And obesity and diet-related non-communicable diseases are associated with more severe COVID-19 outcomes. The pandemic is also likely to result in a fall of 6–10% in the global gross domestic product (GDP), which would push more people into extreme poverty and malnutrition. COVID-19 will severely disrupt livelihoods, especially for the 1.6 billion people working in the informal economy. At the same time, the production, transportation, storage, and sale of food have been disrupted. The crisis is threatening to erase the gains made in recent years in the SDGs related to child protection, education, health, and nutrition [13, 14].

The nutritional crisis created by the COVID-19 pandemic in low- and middle-income countries (LMICs) will have immediate and long-term consequences [4, 12]. The pandemic and the related global economic recession have caused a severe setback to the already inadequate progress made by India to achieve the global nutrition targets for stunting, wasting, maternal anemia, and breastfeeding by 2025. Food and nutrition security is threatened by the pandemic. For example, schools were shut down at various points in 2020 preventing access to nutritious meals for children. The global economic recession due to the pandemic could leave up to 80 million additional people undernourished in net food-importing countries alone [15]. For each percentage point drop in the global GDP, 700,000 additional children are expected to suffer from stunting, a symptom of chronic undernutrition. And 6.7 million children in middle-income countries will experience wasting. Nearly 1,30,000 additional child deaths associated with this spike in child wasting and pandemic-induced reductions in nutrition and health services could occur.

Box 1

Why is attention to nutrition critical?

  • Malnutrition can affect the course of illness in individuals and populations.

  • The pandemic and associated policy actions together will shape India’s course in malnutrition in the short, medium, and long term.

  • Multiple systems that affect nutrition—food, health, social, and economic situations—are being disrupted by the pandemic.

  • India and the world simply cannot afford to backslide on the momentum in tackling malnutrition.

  • Food and nutrition security must be safeguarded by protecting the poor and most vulnerable from hunger and malnutrition.

  • Essential preventative and curative nutrition interventions must continue for child survival, health, and development.

Several reports have recently surfaced regarding the mental health of children and young adults. The National Mental Health Survey 2015–16 reported that 10% of adults meet the diagnostic criteria for a mental health condition (ranging from mood and anxiety disorders to severe mental illness) [16]. The Global Burden of Disease Study estimated that nearly 200 million people in India experienced a mental disorder and nearly half of them suffered from depressive or anxiety disorders [17]. The ‘FEEL-COVID’ Survey (February–March, 2020) of 1,106 participants across 64 cities reported that a third of the respondents faced significant ‘psychological impact’ because of COVID-19 [18].

The following are some effects of COVID-19 on public health and nutrition.

Disruption and Slowdown in National and Global Food Production and Supply Chains of Perishables

Projections show that feeding a world population of 9 billion people in 2050 would require raising overall food production by some 60% [19]. High food output achieved in the past has placed great stress on natural resources. The agriculture sector specifically is a major source of greenhouse gas (GHG) emissions. Agriculture, forestry, and associated land use changes contribute to 20 to 30% of the total anthropogenic greenhouse gas emissions. The expansion of the livestock and biofuel sectors plays a major role in deforestation and land degradation, thereby contributing to climate change. Other GHG emissions stem from fossil fuel use in the field as well as from the whole food system continuum, such as food transport, storage, cold chains, processing, and food loss and waste. Furthermore, globally about one-third of food produced for human consumption per year is lost or wasted [20]. The recommendations of the Second International Conference on Nutrition (ICN2) for sustainable food systems are presented (Box 2).

Box 2

The Second International Conference on Nutrition: Framework for action

Policy actions for developing sustainable food systems and promoting healthy diets are as follows:

  • Review national policies and investments and integrate nutrition objectives into food and agriculture policy, program design, and implementation in order to enhance nutrition-sensitive agriculture, ensure food security, and promote healthy diets.

  • Strengthen local food production and processing, especially for small landholders and family farmers, giving special attention to women’s empowerment while recognizing that efficient and effective trade is key to achieving nutrition objectives.

  • Promote the diversification of crops including underutilized traditional crops, production of fruits and vegetables, and appropriate production of animal-source products as needed, by applying sustainable food production and natural resource management practices.

  • Improve storage, preservation, transport, distribution technologies, and infrastructure to reduce seasonal food insecurity and food and nutrient loss and waste.

  • Establish and strengthen institutions, policies, programs, and services to enhance the resilience of the food supply in crisis-prone areas, including areas affected by climate change.

As per a recent International Food Policy Research Institute (IFPRI) analysis, India seems to be in a comfortable position for rice with a surplus of 27.1 million metric tons (MMT), wheat (53.2 MMT), onion (11.6 MMT), sugar (25.4 MMT), potato (29.5 MMT), and milk (77.8 MMT). However, some high import-dependent commodities were identified, such as edible oil and pulses for which India had a short fall due to import restrictions or trade disruptions [21]. The COVID-19 supply susceptibility index (COSSI) quantifies potential supply chain constraints that could come from labor markets (e.g., casual labor/migrants, share of agricultural workers to the total number of workers), farmers’ illiquidity, and lack of infrastructure (e.g., for cold storage). COSSI for Punjab (30.2) and Maharashtra (61.4) shows that Punjab has better infrastructure and market density. Punjab transported more food grains than Maharashtra during the lockdown. Maharashtra has less irrigated area and is highly dependent on seasonal migrants for most crops, making it more susceptible to COVID-19-related disruptions. States in eastern India have high COSSI due to poor infrastructure and a low share of irrigated area. This information could help policy-makers identify the levels and drivers of susceptibility in their states.

Longer Shelf Life, Easy Availability, and Lower Price of Ultra-processed Foods (High Energy–Low Nutrient Value)

World Vision (WV) conducted rapid recovery assessments in 335 communities in nine countries including Bangladesh, Cambodia, India, Indonesia, Mongolia, Myanmar, Nepal, the Philippines, and Sri Lanka to better understand the socioeconomic impact of COVID-19 on the lives of vulnerable children in Asia. More than 60% of parents/caregivers confirmed that their livelihoods had been severely affected by the COVID-19 pandemic diminishing core assets in 32% of households (HHs). Twenty-four percent of parents and caregivers shared that there was stress on the families related to loss of income, lack of school, and change in children’s behavior during quarantine [22].

Disruption of Nutrition and Social Protection Programs, Preschool Nutrition, Mid-Day Meal Programs, and Rural Employment Guarantee Scheme

India has been trying to combat the problem of child and maternal nutrition since decades through the introduction of a number of government programs like the Integrated Child Development Scheme which was started in 1975, the National Nutrition Policy in 1993, the Mid-day Meal Scheme for school going children started in 1995, the National Food Security Act 2013, and Poshan Abhiyaan launched in 2018. Promotion of optimal child growth and development to prevent overweight and child growth failure is addressed by the Infant and Young Child Feeding Guidelines of the government through programs such as the Integrated Child Development Scheme and the National Breastfeeding Promotion Program. Schools in India are not only places offering education but are also a means to access meals, immunization programs, and skill development opportunities. COVID-19 caused about 192 countries to shut down schools [23]. As a result, 1.5 billion children no longer had access to education in schools; 368 million children were no longer being fed at schools, and 400 million children were no longer benefiting from school health programs such as deworming. There is evidence to show that children appear to have few direct health consequences of COVID-19. But they did not benefit from school closure. The longer marginalized children are out of school, the less likely they are to return to school, particularly girls. Being out of school is associated with increased risk of early marriage, early pregnancy, child abuse especially in girls, inappropriate child labor, poor educational attainment, and lower future earnings and career prospects. A case study showing the effects of COVID-19 on nutrition in Uttar Pradesh is presented in Box 3.

Job Loss, Family Income Threatened, and Purchasing Power Reduced

Given the precarious livelihoods of many Indians, food security, safety net policies, and program responses are urgently required. The economic shock is likely to be much more severe in India for two reasons. First, the economy was already slowing down pre-COVID-19 compounding existing problems of unemployment, low incomes, rural distress, malnutrition, and inequality. Second, India’s large informal sector is particularly vulnerable. In 2017–18, out of the national total of 465 million workers, around 91% (422 million) were informal workers. Lacking regular incomes, agriculture migrants, and other informal workers were hardest hit during the lockdown period. The non-availability of migrant labor is affecting harvesting activities, particularly in the northwest of India where wheat and pulses are harvested.

Public Health and Nutrition Policy Responses to Tackle Multiple Forms of Malnutrition Especially in COVID Times

Eradication of all forms of malnutrition in developing countries like India has been a well-recognized challenge, which has become much bigger with the COVID-19 pandemic. To deal with malnutrition, the Government of India, both at the central and state levels, operationalized a range of robust and effective nutrition-related policies. State-level initiatives are tabulated in Appendix 1.

Box 3

School meal in the time of COVID-19: Uttar Pradesh case study

No. of districts 75

No. of blocks 880

No. of schools 1.67 lakh

No. of teachers 5.75 lakh

No. of children 1.81 crore

No. of cooks engaged 3.78 lakh

Mid-day meal scenario pre-COVID

Hot cooked mid-day meal (MDM) served to the students present on school days.

Mid-day meal provided to the children on each school day as per weekly menu.

Average no. of student availing MDM was 102.88 lakh per day.

Food grains for hot cooked meal:

  • 100 g per child per day in class 1–5

  • 150 g per child per day in class 6–8

Cooking cost for hot cooked meal:

  • Rs. 4.48 per child per day in class 1–5

  • Rs. 6.71 per child per day in class 6–8

  • 150 ml and 200 ml hot milk provided on every Wednesday to children in classes 1–5 and 6–8, respectively.

  • One seasonal fruit provided every Monday (from state budget).

Mid-day meal scenario during COVID-19

Due to COVID-19 lockdown and summer vacations, schools were closed from 24.03.2020.

As per directions of the state government, food security allowance was provided to all 1.81 crore children enrolled in primary and upper primary schools.

Food grains provided for 76 days–7.6 kg per child in primary schools and 11.4 kg per child in upper primary schools.

Cooking cost for 76 days transferred to parents’ bank account—Rs. 374/- per child in primary schools and Rs. 561/- per child in upper primary schools.

  • Cooking cost since 01.04.2020 was Rs. 4.97 per child per day in primary schools and Rs. 7.45 per child per day in upper primary schools.

Core response strategies

A centralized database was created for information regarding bank account details of school children and their parents through a survey done by teachers in a mission mode.

Under the provision of the food security allowance, the following measures were undertaken:

  • Transfer of cooking cost as direct benefit transfer (DBT) to the beneficiaries’ bank account through schools by teachers.

  • Issuance of authority ledger to the beneficiaries for the collection of food grains from kotedar.

An online monitoring system was developed to monitor the distribution of food grains and cooking costs. Process of confirmation through interactive voice response system (IVRS) call is underway.

1.45 lakh metric tonnes of food grains and Rs. 722 crore of cooking cost were distributed to the beneficiaries.

COVID-19 has induced a colossal nutrition crisis and has affected the momentum of almost every nutrition-related program. The pandemic has again underscored the need for strong multi-sectoral convergence among national policies for addressing the nutritional needs of vulnerable groups in society. Government ministries including the Ministry of Health and Family Welfare (MOHFW), the Ministry of Women and Child Development (MoWCD), the Ministry of Education, the Ministry of Rural Development, the Ministry of Consumer Affairs, Food and Public Distribution, and the Ministry of Social Justice and Empowerment as well as departments, particularly the Department of Food and Public Distribution and the Department of Agriculture and Farmers Welfare have instituted several measures to ensure nutrition security.

The five major nutrition-related policies and programs addressing the nutritional needs of the population during the COVID-19 pandemic are as follows:

  1. 1.

    Integrated Child Development Services

    The Integrated Child Development Services (ICDS) program was started in the year 1975 under the Ministry of Women and Child Development. Key beneficiaries of the program include children below six years, pregnant and breastfeeding women (15–44 years), and adolescent girls from low-income families. Under the ICDS, beneficiaries are entitled to services for supplementary nutrition and nutrition education. They receive complementary nutrition for 300 days in a year, which is usually provided in the form of a hot cooked meal at anganwadi centers (AWCs) or as take-home rations. The Government of India has invested a good amount of Rs. 21,933 crore (29.9 billion USD) and has allocated 2.19 million tonnes of rice and wheat under this program. In response to COVID-19, the funds and food allocation for ICDS were increased to Rs. 2.3 lakh crore (314.27 billion USD) with 75 million tonnes of cereals. However, to stop the spread of COVID-19, services were limited to the provision of dry rations and ready-to-eat or cooked food, which was delivered at the doorsteps of the beneficiaries and was no longer distributed at the AWCs.

  2. 2.

    Mid-day Meal Scheme

    Mid-day Meal (MDM) Scheme, one of the largest school meal programs in the world, was launched by the Ministry of Education in 1995 with the objective of improving the nutritional status and enrollment of children in school. Children studying in primary and upper primary classes in government schools/government-aided schools and schools run by local bodies are the target beneficiaries of the program. Since it is a nationwide program, every year a budget of Rs. 160 crore (21.8 million USD) is allocated for 2.54 million tonnes of rice and wheat which is provided in the form of cooked meals to school children. The scheme faced massive challenges during the COVID-19 pandemic. However, as per the guidance of the Ministry, all states and union territories (UTs) continued to provide mid-day meals by giving a security allowance for food grains and cooking costs to meet the nutritional requirements of children eligible under the scheme. Instead of cooked food, some state governments (e.g., Maharashtra and Bihar) transferred the cost of the MDM to the accounts of upper primary and primary students, while others were provided food grains.

  3. 3.

    Targeted Public Distribution System

    In 1997, the Ministry of Consumer Affairs and the Department of Food and Public Distribution initiated the Targeted Public Distribution System (TPDS) with the aim of supplying food grains, rice, and/or wheat at specially subsidized prices (at half the cost) to poor households. Under TPDS, beneficiaries are divided into two categories: (1) households below the poverty line (BPL) who are provided 35 kgs of food grains and (2) households above the poverty line (APL) who are provided 15 kgs of food grains. This program has an annual budget of Rs. 18.9 lakh crore (2596.2 billion USD) and distributes 58 million tonnes of wheat and rice to needy families. To deal with the COVID-19 pandemic, the government launched the Pradhan Mantri Garib Kalyan Anna Yojana (Prime Minister’s plan for well-being of the poor) in March 2020 and used the platform of TPDS to deliver free food grains (rice/wheat and pulses) at a scale of 5 kg per person and 1 kg per household, respectively, over and above their regular monthly entitlements—till November 2020.

  4. 4.

    National Food Security Act

    The enactment of the National Food Security Act (NFSA) in the year 2013 by the Ministry of Consumer Affairs, Food, and Public Distribution was a paradigm shift in the approach to food security—from welfare to a rights-based approach. This act covers 75% of the rural and 50% of the urban population. The beneficiaries under this act are entitled to receive subsidized food grains at Rs. 3 per kg for rice, Rs. 2 per kg for wheat, and Rs. 1 per kg for coarse grains for a period of three years from the date of commencement of the act. Thereafter prices were suitably linked to minimum support price (MSP) under the Targeted Public Distribution System. The act covers two-thirds of India’s population. There are two categories of beneficiaries: (1) Antyodaya Anna Yojana (AAY) households and (2) priority households (PHH). To ensure that poor, vulnerable people do not suffer on account of the non-availability of food grains during the unprecedented time of the COVID crisis, approximately 60.7 lakh new beneficiaries were added under NFSA. They could take rations as per the Pradhan Mantri Garib Kalyan Anna Yojna and the Aatma Nirbhar Bharat package.

  5. 5.

    POSHAN Abhiyan

    The National Nutrition Mission commonly known as POSHAN Abhiyan, a flagship program, was launched in March 2018, under the Ministry of Women and Child Development (MoWCD). The goal of the program is to eradicate all forms of malnutrition in India by the year 2022. The mission employs a comprehensive approach which involves mapping of various schemes that address malnutrition. It focuses on strategies and appropriate practices according to the Infant and Young Child Feeding Guidelines for food and nutrition, immunization, sanitation and hygiene, food fortification, dietary diversification, and maternal health and nutrition. The mission has an overall budget of Rs. 9,046 crore (1.2 billion USD). It allocated Rs. 950 crore (129.7 million USD) for the year 2017–18, which was increased to Rs. 3,061.30 crore (418 million USD) for 2018–19 and was further raised to Rs. 3,400 crore (464.3 million USD) for the year 2019–20. COVID-19 has weakened the health system and has impaired regular nutrition services. The services of POSHAN Abhiyan were also badly impacted. In an effort to bring all health and nutrition services back on track, Poshan Maah was celebrated in September 2020. Following the theme of identification of severe acute malnutrition (SAM) children and plantation of kitchen/nutrition gardens, aanganwadi workers referred 1,758 SAM children to public health centers and undertook plantation drives at 166 places. Along with these, an immunization drive was implemented. Approximately, 6,000 children were immunized. Adolescent girls and women were encouraged to have nutritious and immunity boosting foods. Activities addressing the importance of appropriate breast feeding and adequate nutrition during the first 1,000 days of life were also a part of the 2020 Poshan Maah.

Recognizing the importance of nutrition services, national and state-level guidelines were released by the government to resume operations in a safe manner. Appendices 1 and 2 list the recent or new initiatives which several states undertook during COVID-19 times.

The Ministry of Women and Child Development has issued operational guidance to inform states to restore essential nutrition services including supplementary nutrition, growth monitoring, counseling, and early childhood education. Anganwadi centers in non-containment areas are to reopen following all preventive safety measures including masking, hand-washing, sanitation, and ensuring physical distance. It is recommended that pregnant women and children under 10 years visit the centers for essential services. Persons above 65 years of age and those with co-morbidities are advised against entering anganwadi centers. The government responded quickly to the COVID crisis and announced a $22 billion relief package which included food and cash transfers. Several state governments announced their own support packages (Appendix 2). The central government’s relief package, the Pradhan Mantri Garib Kalyan Yojana, aims to provide safety nets for those hit the hardest by the COVID-19 lockdown. However, the amount allocated is viewed as inadequate by several leading economists—$22 billion in spending is only 0.85% of India’s GDP which is much lower than packages provided by the United States, Europe, and some Asian countries.

Experts have identified the following implementation challenges in the existing nutrition schemes of the government [24]:

  • PDS coverage in urban areas is low (about 50%) which leaves out many urban poor.

  • Access to adequate diets is problematic.

  • There are exclusion and inclusion errors.

  • The government has implemented a One Nation, One Ration Card (ONORC) program in 20 states. But in other states, PDS ration cards are neither portable across locations nor can rations be divided.

  • It is important to ensure food quality and not just quantity.

  • Extra grains pumped into the system are likely to depress prices which, in the long run, may affect small farmers and small businesses.

International Community Responses to COVID’s Nutrition Challenge

Globally, approximately 83–132 million more people could become undernourished in 2020 depending on COVID-19 mitigation and economic recovery. The nutritional status of the most vulnerable is likely to further deteriorate due to the health and socioeconomic impacts of COVID-19. COVID-19 is expected to exacerbate all forms of malnutrition, rendering vulnerable people even more vulnerable. An additional 6.7 million (14.3%) young children will be wasted (58% or 3.9 million live in South Asia), with over 10,000 additional child deaths per month globally in 2020. The world is off track in achieving the SDG targets for hunger and malnutrition. More efforts (including mitigation of COVID-19) are needed to reach SDG targets by 2030. The International Food Policy Research Institute predicts that in 2020 an additional 140 million people will be thrown into extreme poverty (<$1.90/day). According to the World Food Program, the number of people in LMICs facing acute food insecurity will nearly double to 265 million by the end of 2020.

Dr. Shenggen Fan, Global Panel Member and Chair of the China Agricultural University opined ‘The effect of the virus goes far beyond immediate health and economic impacts. We are seeing a fragmentation of food systems which could have serious long-term implications for food security, nutrition, diets, and the environment, particularly in lower income countries’ [25].

The following measures for consumer protection against COVID-19 are recommended by the Global Panel on Agriculture and Food Systems and Nutrition (GLOPAN):

  • Protect all consumers (rural as well as urban) against lasting damage to their health by ensuring that their immediate nutritional needs are met.

  • Monitor food prices and be prepared to intervene to protect affordability of healthy diets.

  • Ensure effective public messaging on the importance of consuming healthy diets during the pandemic and accompany this information with steps being taken locally to enhance access to food containing essential micronutrients.

  • Actively regulate and prosecute fake claims on the safety of food products and food supplements.

  • Keep trade in food commodities flowing.

  • Promote an enhanced supply of nutrient-rich local foods as well as staples.

  • Protect the viability of small and medium-sized businesses throughout the food chain.

  • Avoid measures that cause longer-term harm to food system viability.

  • Assess and monitor policies and actions in real time.

  • Monitor medium-term projections closely.

The Joint UN Statement by the World Health Organization (WHO), the Food and Agricultural Organization (FAO), and the World Food Program (WFP) on nutrition in COVID-19 times provides similar recommendations. It advocates for and urges all to prioritize and promote healthy diets and avoid diets high in fat, salt, and sugar (HFSS), improve maternal infant and young child health and nutrition, manage wasting, provide micronutrient supplements, implement school feeding and nutrition programs, and undertake nutrition surveillance. It recommends mobilizing efforts to save lives and livelihoods, focusing attention on where the risk is most acute (preserving critical humanitarian food, livelihood, and nutrition assistance, expanding near-real-time food security monitoring systems, providing relief and stimulus packages) and strengthening social protection systems for nutrition to protect the vulnerable through nutrition-sensitive social protection measures, improving health care, investing in a sustainable future by supporting evidence-based resilient, green recovery measures, and transforming food systems.

Way Forward

India, the second-most populous country in the world, is currently under tremendous pressure. As the pandemic left deep scars around the globe, India was able to foresee the extent of the socioeconomic hit that would be caused by the pandemic and implemented lockdown and other measures to curtail the impact of COVID-19. While COVID-19 disrupted lives and livelihoods, thereby impacting several public health and nutrition programs, it is important to take cognizance of some of the positive aspects of this pandemic. The concept of ‘Innate Immunity’ received a lot of media attention which made people realize the importance of healthy diets. The concern of the public health community for the health of children was amplified with greater focuses on diet and physical activity. There were also some reports of reduction in out-of-home food consumption and take away foods—a feature which had become rampant in the last decade. People were able to join the dots between factory farming of livestock, poultry, and zoonotic diseases and so raised questions about sustainability and the robustness of food systems [5]. It is critical that India’s progress on nutrition is not derailed by the pandemic. Research, academia, development, and civil society organizations must advocate for greater political and financial commitment to public health and nutrition (PHN) in the response to COVID-19. This broadly means paying attention to two major areas:

  1. 1.

    Healthy dietary patterns need fundamental food systems transformation at all levels. Policy actions and investment are needed to reduce cost and increase affordability of healthy diets. Examples include:

    • Regulate and legislate food manufacturers on advertising and promotion of HFSS foods; support poor households to access nutrition-sensitive social protection schemes and community programs; start with where people with poor diets are (e.g., urban settlements).

    • Prioritize where people can acquire nutritious foods (informal traders/open markets/education and care facilities/community networks).

    • Focus on getting the whole food chain working (including demand), not just one part of it, to deliver to people who need it the most (producer innovations in selling nutritious foods for example, ‘collection centers’ and ‘ambulances’ in Nepal maintain markets for small farmers. Value addition (tomatoes into sauce) and selling online in Malawi; farmer ‘call centers’ in Bangladesh; and Agriculture Produce Market Committee Act amended in India.

    • Build on existing innovations to incentivize production, distribution, and consumption of nutritious foods over the longer term (e.g., community innovations in food access such as community kitchens in Cape Town townships; community self-organizing of food hamper deliveries in Rio favelas).

    • Limit junk food availability/advertising through a ‘double duty’ approach. Policy innovations for social protection such as complementary entitlements in Indonesia, Peru, and South Africa.

  2. 2.

    Create an enabling environment for consumers to raise awareness and influence consumer behavior in favor of healthy diets, preferably with synergies with environmental sustainability.

    Strategies need to focus on enhancing capacity and skills of the consumer to make informed choices, for example, by empowering consumers to make healthier food choices based on food-based dietary guidelines, through social media, public campaigns, nutrition education, school food programs, and community interventions. Another example is teaching ways to reduce food wastage in schools, workplaces, communities, and social gatherings.

The unanimously agreed upon actions to be taken and tracked immediately for ensuring nutrition security in COVID times and other such health and nutrition disasters in the future include [11]:

Safeguard and promote access to safe, nutritious, and affordable diets as a cornerstone of the response to COVID-19 by protecting food producers, processors, and retailers, discouraging trade bans, designating food markets, and keeping them functioning and safe for workers and consumers.

Invest in improving maternal and child nutrition by protecting breastfeeding and preventing the inappropriate marketing of infant formula, ensuring access to diverse, nutritious foods to children and women, and providing accurate information on infant feeding to caregivers.

Re-activate services for the early detection and treatment of child wasting while maintaining and scaling-up nutrition services including vitamin A and micronutrient supplementation for children and nutritional support for pregnant and breast-feeding women.

Maintain the provision of nutritious and safe school meals by reaching vulnerable children through home delivery, take-home rations, and cash or vouchers when schools are closed, ensuring adequate nutritional value of school meals and food packages, and avoiding the provision of unhealthy foods and beverages.

Expand social protection to safeguard access to nutritious diets and essential services for the poorest households, including access to fortified foods. And ensure that such schemes reach families with young children and pregnant and breast-feeding women.

Concluding Comments

The COVID-19 pandemic is undermining nutrition services across the world, particularly in low-and middle-income countries. The worst consequences are borne by young children. Some of the strategies to respond to COVID-19—including school closures, trade restrictions, and country lockdowns—are impacting food systems by disrupting the production, transportation, and sale of nutritious and affordable foods forcing millions of families to rely on nutrient-poor alternatives. Strained health systems and interruptions in humanitarian responses are eroding access to essential and often life-saving, nutrition services. Social protection systems in many low- and middle-income countries are overloaded as vulnerable families struggle to access food and services they need in the context of an economic downturn. The COVID-19 pandemic has increased wasting in children and other forms of child malnutrition including stunting, micronutrient deficiencies, and overweight. Measures implemented by the central and state governments to address the problems of hunger and malnutrition during the COVID-19 pandemic are discussed.

Appendix 1. Initiatives by the Central and State Governments to Ensure Food Security During COVID-19

State

Child stunting (percent) 2015–16

Public distribution system rations

Children’s and women’s nutrition

Social pensions

Employment guarantee

Registered unorganized workers

Community kitchens

Others

All India (central government)

36

5 kg free food grain and 1 kg dal to those with ration cards for three months

Supplementary nutrition rations for children under six years, and pregnant and lactating women at home or compensatory food security allowance

Rs. 1,000 for social pensioners in two installments over three months

Nothing additional

 

Rs. 100 per homeless person to feed three meals a day in night shelters

Rs. 1,500 in Jan Dhan account in two installments over three months

Jharkhand

48

 

Home delivery of dry rations for anganwadi children

  

Full wage payment for lockdown period for registered daily-wage workers

Free dal bhat kendras in every panchayat. Free food from existing dal bhat kendras

Rs. 10,000 to every village mukhiya to distribute to eligible families with pending applications for ration cards to provide rice at Rs. 1/kilo procured from local markets

Bihar

44

One-month free ration. Rs. 1,000 per eligible ration card is to be deposited into their bank accounts

Dry rations for all anganwandi children

Three months advance pensions

   

Shelter homes for the inbound migrants at the borders. Migrants outside Bihar to receive Rs. 1,000 from Chief Minister’s Relief Fund; 10 community kitchens in Delhi

Madhya Pradesh

43

Free ration for one month to BPL households

Home delivery of ready-to-eat food by self-help groups

  

Rs. 1,000/- one-time payment to registered workers

 

One time payments of Rs. 2,000/- to Baiga, Sahariya, and Bhariya families. Free food to homeless and destitute people

Uttar Pradesh

40

Free food grains for two months in advance only to widows, old people, and handicapped pensioners. Food grains free of cost for laborers, MGNREGA cardholders, Antyodaya scheme and daily-wage workers

   

Rs. 1,000 grant to 3.5 lakh daily-wage laborers and construction workers through bank accounts

  

Chhattisgarh

38

Free advance ration for two months

Dry rations for anganwadi children and for 40 days for school children

 

NREGA works to open with safety of workers agricultural laborers Rs. 7,555/ month or Rs. 352 per day

Rs. 1,000 grant to 3.5 lakh daily-wage laborers and construction workers through bank accounts

Free cooked food to caretakers of patients admitted in government hospitals. Beggars, destitute to get food packets from NGOs

Rice for migrant laborers

Rajasthan

37

Dry ration, including 5 kg wheat, 0.5 kg oil, 0.5 kg salt, 1 kg pulse, and 1 kg rice, available to all without demanding any paper or money

Door-to-door delivery of take home rations for anganwadi children

Two months welfare pension in advance

 

One-time payment of Rs. 1,000 to 25 lakhs construction workers and registered street vendors

Urban laborers not covered under PDS, to be provided free food packets

 

Maharashtra

36

 

Home delivery of cooked food for pregnant and lactating women and children under six years in tribal areas. Supply of eggs and bananas to weak children

MDM cost to be transferred in account of students (primary and upper primary)

   

Shiv Bhojan Thalis at Rs. 5 instead of Rs. 10 but not free

Schools as shelter homes for migrants

Karnataka

35

Two months ration to all ration cardholders to be given in advance

Supply of rice, egg, and chikkies (jaggery and groundnut cakes) for all working days till March 31. 100 g rice per day for the students studying in first to fifth class and 150 g rice for those studying in fifth to tenth class to be distributed with the help of gram volunteers

Rs. 1,000 per family for ration cardholders

  

Food packets to be provided to daily-wage workers affected by lockdown

All government and private establishments to pay full salaries for the period of lockdown to both permanent and contractual workers

Odisha

34

Home delivery of three months advance rations for both NFSA and state ration cards. The selection and appointment process of 2,590 women SHGs in place of private fair price shops. Biometric scanning has been waived off

Dry rations, for preschool and school children and pregnant and nursing women. Eggs to be distributed on a weekly basis monitored by members of mothers and Jaanch committees

Home delivery of four months pension in advance to 48 lakh social security pension beneficiaries

Safety guidelines for NREGA works

Rs. 3,000/- to each registered street vendors (65,000)

Hot cooked food to around 10 lakh sick and destitute in all panchayats. Rs. 60 per adult per day and Rs. 45 per child per day

Financial assistance of Rs. 1,000 each to 94 lakhs households covered under PDS

Andhra Pradesh

32

Free rations for April with 1 kg toor dal to be delivered to BPL ration cardholders. Rs1,000/ one-time support to all BPL ration card families

Supply of rice, egg, and chikkies (jaggery and groundnut cakes) for all working days till March 31. 100 g rice per day for students studying in first to fifth class and 150 g rice for those studying in fifth to tenth class will be distributed with the help of gram volunteers

Door delivery of social pensions to 58 lakhs beneficiaries including widows, elderly, and differently abled

   

Rice and red gram dal to NGOs running old age homes during lockdown period

West Bengal

32

Free rations for six months to those who get subsidized ration under PDS, maximum of 5 kg of grains per person

2 kg of rice and potato per month to be handed over to guardians

    

Food and shelter for migrant workers

Haryana

29

One-month free rations to all BPL families as per their entitlements, mustard oil, and 1 kg sugar

Dry rations to school children and children registered in AWCs till these places are closed

  

Registered workers will receive Rs. 4,500 per month on weekly basis from March 30 as DBT. Daily wagers may register on a portal to receive Rs. 1,000 per week

 

Coronavirus patients would get free hospitalization in government or private hospitals

Telangana

28

12 kg of rice per person for 14 lakhs ration cardholders and Rs. 1,500 in banks

   

One time income support of for ration cardholders. Full wage payments to permanent and contractual workers for lockdown period

Free hot cooked meal under Annapurna centers. Akshay patra to help in this

3,40,000 migrant workers to avail the 12 kg rice and Rs. 500 benefit

Delhi

27

Food grains free of cost and 50 percent increase in quantity for ration cardholders—7.5 kg free ration to 72 lakh beneficiaries for one month

 

Double pension for widows, differently abled, and elderly for March

 

Rs. 5,000 to 8.5 lakh wage laborers and construction workers by April 7, 2020

Free lunch and dinner for anybody approaching government-run night shelters

 

Tamil Nadu

24

All the ration cardholders to get Rs. 1,000 and free rice, dal, cooking oil, and sugar. Construction workers and autorickshaw drivers to get 15 kg of rice, 1 kg of dal, and 1 kg of cooking oil

  

MGNREGA workers to get a two-day special salary

   

Punjab

22

Free food and medicines for the needy

Food grains for mid-day meal in sealed packets to students’ homes

  

Immediate relief of Rs. 3,000 to each registered construction worker

 

Punjab police to distribute 1.5 lakh dry food packets to needy

Uttarakhand

  

Deposit money in student's account. Anganwadi rations to the doors of beneficiaries’ homes

    

Cash transfers of Rs. 1,000 to unregistered workers in labor department

Himachal Pradesh

21

Ration including flour and rice for two months will be given to Targeted Public Distribution System cardholders

Distribution of take home ration

First quarter social security pension to widows and differently abled will be provided in the first week of April

 

About 105,000 workers registered with the Building and Construction Workers Board will be provided Rs. 2,000 as one-time relief

  

Kerala

16

Free provisions to all ration cardholders in the state. BPL cardholders would get an additional 35 kgs of rice free next month. Government would give free provision kits to those under home quarantine irrespective of their income status

Dry rations to three lakhs pregnant women and breast-feeding mothers, along with two lakhs adolescent girls and 4.75 lakhs children below the age of three in AWCs

Rs. 1,000 per family. Pension for families not covered under earlier schemes

Employment guarantee in April–May

Village employment assurance program for April and May

Subsidized meals (at Rs. 20)

 

Appendix 2. New Initiatives During COVID-19

S. No.

Name of the policy/program

Year

Ministry/department

Key features

1

Pradhan Mantri Garib Kalyan Anna Yojana

March, 2020

Ministry of Consumer Affairs, Food and Public Distribution

For 1.7 lakh crore families belonging to BPL. The Pradhan Mantri Garib Kalyan Anna Yojana was implemented for a period of three months, i.e., April, May, and June 2020, so poor and vulnerable beneficiaries under National Food Security Act (NFSA) do not suffer on account of the non-availability of food grains during this unprecedented time of crisis

Under this special scheme, about 81 crore NFSA beneficiaries were provided with an additional quota of free food grains (rice/wheat) at a scale of 5 kg per person per month, over and above their regular monthly entitlements

2

One Nation, One Ration Card

June, 2020

–

Enabled in many states/UTs, by 31 March 2021 the scheme will be operational all over India.

All eligible ration cardholders/beneficiaries covered under the National Food Security Act to access their entitlements from anywhere in the country

3

Aatma Nirbhar Bharat Package (Food grain distribution to migrant workers)

May 2020

 

Under Atma Nirbhar Bharat Package, Government of India provided 8 lakh million tonnes of food grains to about 8 crore migrant laborers and needy families who were not covered under NFSA or state scheme PDS

5 kg of food grain per person distributed free of cost for the months of May and June to all migrants. The states and UTs lifted 6.39 LMT of food grains. States and UTs distributed 1,06,141 MT of food grains to 121.00 lakh beneficiaries in May and 91.29 lakh beneficiaries in June 2020

4

FSSAI Eat Right During COVID-19: Food Hygiene, Safety and Nutrition Guidelines

July 2020

MoHFW

Dietary and lifestyle guidelines and key nutrients provided for better immunity

5

State initiatives

 

For migrant workers, daily-wage earners, and others

Jharkhand: Free dal bhat kendras in every panchayat. Free food from existing dal bhat kendras. Rs. 10,000 to every village mukhiya to distribute to eligible families with pending applications for ration cards, rice at Rs. 1/kilo procured from local markets

Madhya Pradesh: Free food to destitute and homeless people

Chhattisgarh: Free cooked food to caretakers of patients admitted in government hospitals. Rice for migrant workers

Maharashtra: Community kitchens in nine schools of Mumbai. Food packets for 6,000 homeless. Shiv Bhojan Thali at Rs. 5 instead of Rs.10

Karnataka: Food packets to be provided to daily-wage workers affected by lockdown

Odisha: Hot cooked food to around 10 lakhs sick and destitute in all panchayats

Andhra Pradesh: Rice and red gram dal to NGOs running old age homes during lockdown period

West Bengal: Food for the migrant workers

Telangana: Free hot cooked meal under Annapurna centers with the help of Akshay patra

Delhi: Free lunch and dinner to anybody approaching government-run night shelters

Punjab: Distributed 1.5 lakhs dry food packets to the needy

Kerala: Subsidized meals at Rs. 20

  1. Source UNICEF