Combating severe malnutrition: lessons from Rajasthan – analysis
In the 2019 NITI Aayog national health index, Rajasthan has become one of the top two states, making the most progress on health indicators between 2015-16 and 2017-18. This assessment is based on progress on many indicators, including reduced mortality rates for newborns and children under the age of five, a declining proportion of low birth weight infants, an increase in immunization rates, and a percentage of babies born in hospitals instead of houses. All of these indicators have one thing in common: improving children’s health.
There is another area, where emerging evidence, albeit still in the early stages, shows that Rajasthan is writing a success story — in curing its severely malnourished children. Children who suffer from severe acute malnutrition (SAM) are eleven times more likely to die and lack immunity against infection and disease.
In trying to cure children suffering from SAM, Rajasthan took the help of an approach the world had learned from Africa’s humanitarian emergencies in 2000, called Community Management of Acute Malnutrition (CMAM). Once found effective in managing SAM children, it was adopted as a standard approach by United Nations (UN) agencies in 2007 in emergency and development contexts. Two years later, Doctors Without Borders, an international humanitarian agency, associated with the Bihar government, to use this as an emergency response to manage SAM children in Bihar during the Kosi floods, and found a dramatic recovery rate. 88.4%. Since then, this CMAM evidence-based decentralized approach has been implemented in more than 70 countries to control and treat children under five with acute malnutrition.
Countries have been adjusting this model to suit their local needs, but some of its central defining characteristics are, therefore, health workers differentiate SAM children on whether they have other medical complications and whether or not they have medical complications. . SAM children with medical complications and poor appetite are treated at centers such as the Nutritional Rehabilitation Centers or the Malnutrition Treatment Center. Those without medical complications and with a good appetite fall into uncomplicated cases and do not need hospital care. These uncomplicated SAM cases could be treated and managed at the community level using some form of high energy density nutritional supplement with a weekly or biweekly visit to a nearby health center. Most of this active case finding is done at the community level by frontline health workers.
In India, many states like Madhya Pradesh, Maharashtra, Rajasthan and Odisha have implemented different CMAM models on a small scale to treat SAM children.
In 2015, the Rajasthan government, under the National Health Mission, implemented CMAM by adopting the POSHAN (Proactive and Optimal Child Care through the Home Social Approach to Nutrition) strategy to treat severely malnourished children without medical complications using the Medical Nutrition Therapy Kit, a type of energy. Dense nutritional supplement. CMAM POSHAN-I was implemented in 2015-16 in ten high-priority districts and three tribal districts in Rajasthan. About 2.3 lakh of children aged six to 59 months were screened and 9,640 children were enrolled in the program for treatment with this high energy-dense nutrient supplement at the community level. During this intervention, these children informed their subcentre every Tuesday, which was called the POSHAN Divas.
During their first week of intervention, the SAM children received a dose of antibiotic Amoxicillin and an antiparasitic drug Albendazole according to their age and weight. Every Tuesday, an assistant nurse midwife (ANM) measured the weight, height, and circumference of the child’s mid-arm. The food kit was then delivered to the caregiver or mother based on the child’s weight. The program also included ANM advising the mother on the importance of feeding the food kit, and a number of other factors that affect malnutrition, including proper feeding, hygiene, hand-washing, and immunization practices. If the child became ill, the mother was advised to contact the health worker immediately. Similar advice was repeated when ASHAs made home visits to monitor the child. To encourage mothers not to abandon the program, the ANMs awarded them compensation for the cost of transportation necessary to reach the sub-center every Tuesday. After 12 weeks of intervention, a staggering 88% of the children had recovered from severe acute malnutrition.
Excited for the success, which was in line with international experiences, the CMAM approach was expanded in 20 Rajasthan districts in December 2018. As part of this POSHAN-II, around 3.7 lakh children were screened and 10,344 enrolled SAM children for intervention. . It achieved high survival rates (death among SAM children was only 0.1%), compared to international levels (less than 10%), and reported a cure rate of 70.4%, which was slightly lower than those of international levels (over 75%), but still impressive compared to most states.
Frontline health workers ANM and ASHA acted as a mainstay for the success of the intervention. The cured SAM children were followed by ANM and ASHA for four months to monitor the sustainability of nutritional status. Evidence from Rajasthan, albeit at the initial stage, shows that the community-based approach to treating SAM children can be successfully implemented on a large scale with minimal additional resources and effort. One of the most important findings was this: A follow-up study of all SAM children recovered after four months of intervention, found that only three percent of the recovered children had returned to the malnourished state, attesting to their effect on long term.
But experiences like that of Rajasthan and other states should be part of a common evidence-gathering group at the national level so that they can inform policy-making.
To the surprise of the public health community, in July 2019, the National Nutrition Mission reported that of the total funds allocated for 2018-19, states had used only 22 percent. This misuse of the funds allocated for the management of the malnutrition problem indicates the lack of prioritization, planning and use of funds.
But is this acceptable in a country where international magazines estimate that 68.4% of all child deaths can be attributed to various forms of malnutrition? Even our own national surveys show that approximately 38.4% of our children under the age of five are stunted, 35.8% are underweight, 21% are wasted, and 7.5% are severely wasted. Surprisingly, in the past decade, severe wasting has increased from 6.4% (2005-06) to 7.5% (2015-16) in India, according to the National Survey of Family Health.
It is the urgent need of the hour that we create a formal mechanism to measure and share the evidence from all states so that we can learn from each other and give a future of health to our children, which is not only our duty but also its Correct.
Daya Krishan Mangal is Professor of Public Health and Senior Research Officer of Shobana Sivaramanis at IIHMR University
The opinions expressed are personal.