World Health Organization declared Coronavirus as a public health emergency in January 2020 and a global pandemic in March 2020. With over 200 countries being affected by the virus, extensive measures driven by available guidelines and health experts were put in place. These included social distancing, usage of face masks, frequent handwashing, self-isolation in case of exposure and travel restrictions, among others. While necessary, the measures presented varying levels of operations complexities depending on geographic regions. Additionally, even with concerted efforts by the Governments, corporates, developmental organizations, and the society at large the pandemic seems to be far from over.

The pandemic in general and the recommended measures have been particularly challenging for India because of its population density, seasonal or occupation-based migration and stressed public health systems. The Union Government of India announced a countrywide lockdown in March 2020. Economic activity, especially in the non-IT enabled spaces, came to a standstill leading to dwindling of income and uptick in reverse migration from urban to rural areas. An invariable effect of the total lockdown implemented in April 2020 has also been infrequent to unavailable access to key health services, especially for children under 5 years of age, pregnant and new mothers and families dependent on Government health and nutrition services.

The crisis in India

The two major effects of the national lockdown declared in April 2020 were plunging incomes resulting in food insecurity and lack of access to key health services.

Dwindling incomes and food insecurity.

According to estimates by Centre for Monitoring Indian Economy (CMIE), over 122 million people lost jobs in India during April 2020 with 75% of them being small traders and wage labourers. Additionally, over 84% of Indian households saw a fall in income. An internal survey conducted by Action Against Hunger showed 70% households in the slums of Govandi, Mumbai reporting a net zero income in the month of April 2020.

This had a direct impact on nutrition and food security. Reduced incomes had a direct effect on the nutritional intake of families. With lower family budgets available to spend on buying daily ration the groups worst affected were young children and pregnant and lactating mothers. Of the families that responded that the lockdown had impacted their child feeding practices; 76% of the lactating women reported that they were unable to feed vegetables to their children and 12% of the lactating women reported that they were unable to provide enough number of meals to the children. Only 12% of the participating lactating women reported that they were able to provide vegetables in meals to their children.

In a country that already accounts for roughly 30% of the world’s malnutrition burden, food insecurity brought in by reduced incomes threated to further push vulnerable families towards undernutrition.

Access to health services

Government provided health and nutrition services provide the first line of defence against malnutrition, especially in the rural regions. Over 82 million children under 6 years of age and 19 million pregnant and lactating women receive crucial services through ASHAs, Anganwadi Workers, Anganwadi centres and health centres. Some of these include growth monitoring, Take Home Ration (THR), immunization, ANC & PNC services and other necessary services during pregnancy and birth.

With the nationwide lockdown most of these services were partially to completely interrupted. In May 2020, UNICEF estimated that disruption of routine health service could lead to an additional 300,000 child deaths from wasting. Additionally, due to an acute shortage of PPE kits, health and medical workers found it difficult to continue engaging with vulnerable population during the pandemic. This included medical workers providing treatment support to people affected by the COVID19 virus in rural and urban regions.

Our Relief activities

Action Against Hunger India stopped its on ground activities in April 2020 under guidelines issued by the national and state Governments. A bulk of our malnutrition prevention work revolved around consistent engagement with pregnant and lactating mothers and their families through home visits, group discussions and information sessions. With our operations spread in 577 villages in 3 states, this meant reduced to no access to thousands of children under 5 years of age, pregnant and new mothers and their families.

To ensure that continued engagement with vulnerable families, growth monitoring for children and provide support to Government frontline workers, Action Against Hunger India implemented various measures factoring in the on-ground situation.

Phone based counselling.

To ensure that we maintain constant touchpoints with high-risk pregnant women and families with malnourished children, we created a database of contact numbers and initiated phone based weekly counselling sessions. This allowed us to continue provide counselling to parents and help them track the nutritional status of their children.

These weekly sessions included discussions on maternal and child nutrition, hygiene and sanitation, childcare practises, social distancing and COVID19 prevention protocols. We ensured that though their sessions families have access to Government endorsed and accurate information on social distancing measures, common symptoms, Government helpline numbers and treatment options available locally. With families resign in villages with low connectivity or no access to mobile phones, our field teams worked with panchayats, local village heads and neighbours to ensure families remain connected.

By June 2020 we resumed partial on ground operations in rural areas with approval from local authorities. This was done with strict guidelines for the safety of both Action Against Hunger staff and families we work with. Even as we resumed most of our ground operations by August 2020, phone-based counselling remained operational for high risk / high population density regions such as the slums of Mumbai.

Providing dry rations

In terms of reduced incomes and unemployment, the pandemic had severe repercussions for marginalized population including, daily wage labourers, unorganized sector workers, pregnant women and slum population in both urban and rural areas. Lack of income placed these groups on the verge of undernutrition resulting from lower diet diversity and food insecurity. These families typically stay in crowded localities with poor hygiene and sanitation and are therefore vulnerable to undernutrition, hunger and infectious diseases. To address this Action Against Hunger worked with its partners to provide dry ration kits to families in need.

Dry ration kits included wheat, rice, pulses, groundnuts, spices, sugar, oil. Each kit would typically last a month and provide wholesome nutrition to the family. Action Against Hunger staff maintained contact with these families throughout the lockdown and ensured they received additional kits periodically.

Supporting Government frontline workers

Government public health systems faced a huge burden because of rising cases. With health care professionals and medical workers screening and attending to the ever-increasing confirmed and probable caseloads of the Coronavirus infected individuals, they are at the highest risk of contracting. A quickly escalating demand for PPE during this time resulted in an extreme supply side shortage. Additionally, health workers such as Anganwadi and ASHA workers too faced a shortage of face masks and other hygiene equipment necessary to continue providing services to mothers and children.

To help ensure that government frontline workers continue to provide crucial services, Action Against Hunger worked with local authorities and its partners to provide PPE kits and other necessary equipment. We supplied PPE kits to Government hospitals in Mumbai and face masks, gloves, sanitizers to local administrations in Maharashtra, Madhya Pradesh and Rajasthan.

Capacity building of caregivers

Growth monitoring for children below 5 years of age was hampered during initial months of the lockdown due to limited access to health workers and services. Not only did this make them vulnerable to malnutrition as its onset could go undetected but also presented a new challenge to a system that works on one-on-one interaction. This was further compounded by an already curtailed access to wholesome nutrition and diet diversity owing to declining incomes.

Action Against Hunger field teams worked closely with parents to help them track the health status of their children at home and seek immediate assistance if necessary. Through the “Parent MUAC” initiative, caregivers were trained on using a Middle Upper Arm Circumference (MUAC) band that is easy to use and handle. Consisting of 3 colours – green, yellow and red, the band can provide a quick assessment of the child being healthy, moderately malnourished or severely malnourished based on the colours respectively. Parents were provided MUAC tapes trained on using them to track their child’s health on a weekly basis. If the child was found be malnourished, they were referred to the nearest treatment centres and other options available locally.

Advocacy

Action Against Hunger has provided support to the national government, as technical partners in the Poshan Abhiyan and Jan Andolan roll out in Rajasthan, as well as contributed to the formation of National Nutrition Mission Plan 2018. While we work at the national level, our impact has trickled through the layers: from national to state, district and finally village level.

To continue supporting local and state governments during the crisis, Action Against Hunger adopted a three-layered strategy.

• Advocating to Governments to start nutrition services including THR (Take Home Ration) services as per the guidelines issued by the WCD Department. With resources and attention being diverted to the Covid-19 pandemic, nutritionally vulnerable communities were at risk. We worked with local authorities to help ensure that nutrition services remain an important part of essential services for the community.
• Sensitizing Panchayati Raj Institutions representatives at the village level on essential nutritional services, health and hygiene practices during COVID19 and involved them in service delivery and coordination with frontline workers.
• We worked with district administrations to raise mass awareness on social distancing, isolation, hygiene practises and key information on COVID19. This was done through mobile awareness vans and weekly phone calls.