Combating severe malnutrition: Lessons from Rajasthan
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
In the national health index released by NITI Aayog in 2019, Rajasthan has emerged as one of the top two states, which is making the most progress on healthcare indicators between 2015-16 and 2017-18. This assessment is based on strides on many indicators, that include reduced death-rates of newborns and children under five years of age, a falling share of low-birthweight babies, a surge in immunisation rates, and percentage of babies born in hospitals rather than homes. All these indicators have one thing in common - improvement in child health.
There is another area, where emerging evidence, though still in early stages, is showing that Rajasthan is scripting a success-story---in healing its children who are found severely malnourished. Children suffering from severe acute malnutrition (SAM) are eleven times likely to die, and lack immunity towards infection and diseases.
In attempting to cure children suffering from SAM, Rajasthan took the help of an approach that the world had learnt from humanitarian emergencies of Africa in 2000 -- called Community-based Management of Acute Malnutrition (CMAM). Once found effective in managing SAM children, it was adopted as a standard approach by the United Nation (UN) agencies in 2007 in emergency and developmental contexts. Two years later, Médecins sans Frontières, an international humanitarian agency, partnered with the Bihar government, to use this as an emergency response to manage SAM children in Bihar during Kosi floods, and found a dramatic recovery rate of 88.4%. Since then, this evidence-based decentralised approach of CMAM has been implemented in more than 70 countries to manage and treat children under five with acute malnutrition.
Countries have been tweaking this model to suit their local needs, but a few of its central defining features are thus--- health-workers differentiate SAM children on whether they have any other medical complications and are they without medical complications. SAM children with medical complications and poor appetite are treated in facilities like Nutritional Rehabilitation Centres or Malnutrition Treatment Centre. Those without medical complications and with good appetite fall under uncomplicated cases and do not need in-patient care. Such uncomplicated SAM cases could be treated and managed at the community level using some form of energy-dense nutrition supplement with a weekly or bi-weekly visit to a nearby health facility. 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 models of CMAM on a small scale to treat SAM children.
In 2015, the government of Rajasthan under National Health Mission implemented CMAM by adopting POSHAN (Proactive and Optimum care of children through Social Household Approach for Nutrition) strategy to treat severely malnourished children without medical complication using Medical Nutrition Therapy Kit, a type of energy-dense nutrition supplement. The CMAM POSHAN-I was implemented in 2015-16 in ten high priority districts and three tribal districts of Rajasthan. Around 2.3 lakh children aged six-59 months were screened and 9640 children were enrolled under the program for treatment using this energy-dense nutrient supplement at the community level. During this intervention, these children reported to their subcentre every Tuesday, which was called the POSHAN Divas.
During their first week of intervention, SAM children were given a dose of antibiotic Amoxycillin and deworming medicine Albendazole according to their age and weight. On every Tuesday, a Auxillary Nurse Midwife (ANM) measured child’s weight, height and mid-upper arm circumference. The food kit was then given to the caretaker or mother according to the weight of the child. The programme also involved ANM counselling the mother on the importance of feeding the food kit, and a host of other factors that affect malnutrition, such as adequate feeding practices, hygiene, handwashing and immunisation. If the child fell sick, the mother was advised to contact the health worker immediately. Similar counselling was repeated when the ASHAs made home visits to monitor the child. To incentivise mothers to not drop out of the programme, the ANMs, gave them compensation for transportation cost needed to reach the sub-center every Tuesday. After 12 weeks of intervention, a staggering 88% children had recovered from severe acute malnutrition.
Enthused by the success, which was in line with international experiences, CMAM approach was scaled up across 20 districts of Rajasthan in December 2018. As part of this POSHAN-II, around 3.7 lakh children were screened, and 10,344 SAM children were enrolled for intervention. It achieved high survival rates (the death among SAM children was only 0.1%), when compared with international levels (less than 10%), and reported a cure rate of 70.4% which was little lower than international levels ( more than 75%), but still impressive when compared with most states.
The frontline health workers ANM and ASHA acted as a pillar for the success of the intervention. The cured SAM children were followed up by ANM and ASHA for four months to monitor the sustainability of the nutritional status. The evidence from Rajasthan though early stage shows that the community-based approach of treating SAM children can be successfully implemented at a large scale with minimal additional resources and effort. One of the most important findings was this----a follow-up study of all recovered SAM children after four months of intervention, it was found that only three per cent of the recovered children had reverted to malnourished status, which testified to its long-term effect.
But experiences such as that of Rajasthan and other states should become part of a common pool of evidence gathering at the national level so that policymaking is informed by them.
To the shock of the public health community, in July 2019, the National Nutrition Mission reported that out of the total allocated funds for the year 2018-19, the states had utilized only 22 percent. This poor utilisation of allocated funds for the management of the malnutrition problem indicates lack of prioritising, planning and use of funds.
But is this acceptable in a country where international journals estimate that 68.4% of all child deaths can be attributed to various forms of malnutrition? Even our own national surveys, show that about 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. Startlingly, in the last decade, severe wasting has increased from 6.4% (2005-06) to 7.5% (2015-16) in India, as per the National Family Health Survey.
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, that is not only our duty but also their right.
Daya Krishan Mangal is professor of public health and Shobana Sivaramanis senior research officer at IIHMR University
The views expressed are personal