Palghar – lessons for Maharashtra (and other states)

It was that time of the year again…the rains came and, with them, the sense of déjà vu that stories of child deaths in tribal areas of Maharashtra evoke in the public mind. The procession seems endless: Melghat in the 1990s, then Nandurbar in the first decade of this century and now Palghar in the second decade of the twenty first century. The political and administrative actors have changed in the intervening years, economic and social changes have taken place in town and countryside but the same problem seems to return to haunt us with a recurring, almost numbing regularity. Opposition politicians (who seem to forget that they were in power for a decade and a half till very recently) are ready with their criticism of the first two years of the present ruling dispensation. The usual knee-jerk reactions are on full display, with Ministers of the concerned departments undertaking flying visits to the affected areas and attempts being made to rope in the medical fraternity, nonprofits and civil society to tackle the problem. Unfortunately, there is no well thought out strategy to tackle the problem of child malnutrition on a long-term basis, whether it be in Maharashtra or in any other state in India. It might, therefore, be apposite to outline what should not be the focus of public policy in the immediate future — both short and medium-term — and what strategy could yield handsome dividends in the next few years.

What is definitely a losing proposition is the obsessive focus on the centralised supply of nutrition to affected mothers and children. There seems to be a misconceived notion (at various levels of government, nonprofits and civil society) that augmenting supplementary nutrition to mothers and children through the existing channels of the Integrated Child Development Services (ICDS) system will help matters. The past (and more recent) history of state-directed and centralised nutrition provision through the ICDS system has been controversial, with repeated attempts (across many states) to circumvent the Supreme Court-directed policy of empowering local communities and families to meet the nutrition requirements of their mothers and children. The experience, over the last one year, of the Abdul Kalam Amrut Aahar Yojana in Maharashtra, aimed at providing one hot cooked meal to pregnant mothers and to nursing mothers in the first three months after delivery, has not been very heartening either, given the less than enthusiastic involvement of the ICDS machinery and the glitches in timely fund allocation to local committees tasked with provision of the nutritious meal. Since the National Food Security Act, 2013 has mandated a cash maternity entitlement of Rs. 6000 to mothers, in addition to access to food supplies through the Public Distribution System and through specific nutrition programmes for pregnant and nursing mothers, the possibility of cash transfer of the entire entitlement to women through Aadhaar-linked bank accounts needs to be closely looked at. This would not only check programme leakages but also reduce wasteful expenditure on overheads on state-run programmes. However, this requires a separate study, so the issue will not be further pursued here.

Reducing chronic malnutrition in under-5 (“U5”) children is a process that involves factors like accelerated economic development and the behavioural changes that rising income levels bring. But, rather than passively waiting for economic development to reduce child malnutrition, governments (and their extensive machineries) can take proactive steps in the short-term to reduce acute malnutrition (and the accompanying mortality) in U5 children. This article focuses on these measures.

The first step is the use of real-time, accurate data, based on anthropomorphic indicators, to get a grip on the exact geographical regions (going right down to every individual anganwadi) where child malnutrition levels are highest, be they remote tribal hamlets or congested urban slums. Currently, monthly recording of weight for age (based on the WHO growth norms) is the only criterion used to assess child undernutrition in the ICDS. This exercise is carried out (if at all) perfunctorily in anganwadis in most states in India. In any case, no systematic analysis of this data, for policy planning and implementation purposes, is undertaken by any official of the departments or directorates/commissionerates tasked with improving the status of child nutrition in India. What is needed is a rigorous exercise to weigh all children in the state every month. If this is not done monthly for logistic reasons (although required as per the existing job chart of the anganwadi worker), weights of all U5 children should be scrupulously recorded at least once in two months. The Jatak software, already developed for use in some areas of Maharashtra, Kerala and West Bengal, would enable porting child weight data online through use of interactive voice response systems and obtaining immediate anganwadi-wise data on the number of severely underweight (SUW) U5 children.

Step number two would involve the lists of these SUW children (anganwadi-wise) being made available online (through a web-based health module linked to the Jatak SUW child data) to the Primary Health Centres (PHC) in whose area the anganwadi falls. The Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs) working in a PHC area would then record the height/length and weight of each U5 SUW child in the health sub-centre area, with this data being subsequently ported into the health module. The software would automatically provide to the PHC, anganwadi-wise, the list of U5 children falling in the severe acute malnutrition (SAM) category.

Once the U5 SAM children are identified, they need to be medically examined to assess whether their condition requires them to be admitted to Nutrition Rehabilitation Centres, also termed as Child Treatment Centres (CTCs) and located in Primary Health Centres. Children suffering from environmentally induced diseases (tuberculosis, pneumonia, etc.) or congenital conditions (sickle cell anemia, heart disease, etc.) would be admitted to CTCs. Apart from children requiring treatment at specialist medical facilities, others would stay in the CTCs for a period of up to thirty days. The treatment protocol prescribed by the WHO would be followed to improve the health and nutrition status of these SAM children. It would also be desirable to provide health, hygiene and nutrition education to the caregivers (mostly mothers) who stay with the children in the CTCs, so that there is no relapse in the nutrition status of the children after their return home. Maharashtra had started the salutary practice of providing an allowance to the caregiver staying with the child in the CTC to compensate for loss in wages; this was an added incentive to ensure that children were admitted to and underwent the full course of treatment in the CTCs.  Monitoring of the health and nutrition status of these children by health workers needs to be done regularly for one year after their discharge from the CTC to ensure there is no relapse.

Children in the SAM category not requiring medical attention can, along with children in the moderate acute malnutrition (MAM) category, attend the Village Child Development Centres (VCDCs) at the local anganwadis to receive supplementary nutrition at two hour intervals in accordance with a laid-down nutrition protocol. As the pioneer in developing the VCDC concept, which has been internationally acclaimed, it is unfortunate that the Government of Maharashtra has not financially supported this initiative for the past three years.

Zeroing in on the geographical areas with the worst incidence of severe wasting (SAM) in U5 children would definitely reduce child mortality, given that SAM children have a mortality rate over nine times as high as children in the normal category. It would also check the impairment of cognitive and physical capabilities of U5 children, enabling them to lead fuller, more productive lives as adults. The tragedy lies in the failure of governments in India to systematically adopt the approach outlined above. My experience as Director General of Maharashtra’s Rajmata Jijau Health and Nutrition Mission is that, when U5 child mortality occurs, no attempt is made to trace the case history of such children: specifically, their nutrition and health status in the months before their death and whether any efforts were made to improve this status. A systematic use of real-time U5 children nutrition data to enable focused health and nutrition interventions followed by rigorous monitoring of treated children on an ongoing basis would help reduce mortality rates. Even using the current ICDS projectwise monthly progress reports (MPRs) on U5 children nutrition status (in terms of child weights) would give some idea of the areas in a state most prone to child malnutrition. If we examine the latest available ICDS MPR for Maharashtra for March 2016 (available at www.icds.gov.in), we observe that the ICDS projects with the highest percentages of severely underweight children are largely located in the tribal pockets in the districts of Palghar, Nandurbar, Amravati, Nasik and Gadchiroli, the very areas which have been at the centre of child death controversies for over two decades. If all the ten states of India with a percentage of SUW children over 10 percent of the U5 child population, as revealed by the 2013-14 Rapid Survey on Children (RSOC) data released by the Ministry of Women and Child Development, Government of India, were to rigorously monitor the monthly weights of children, they can put in place strategies to tackle SAM and reduce mortality in U5 children in the high burden areas.

India has the rather dubious distinction of being ranked 120 out of 130 countries in the prevalence of wasting in U5 children (Global Nutrition Report 2016). The 2015-16 National Family Health Survey (NFHS-4) shows that large states like Maharashtra and Madhya Pradesh have as many as 14 (out of 35) and 23 (out of 50) districts respectively with a severe wasting (SAM) rate of over 10 percent of the U5 child population, while U5 child mortality rates are as high as 58 and 65 (per 1000 live births) respectively for Bihar and Madhya Pradesh. So what holds our governance systems back from taking positive, proactive steps? Firstly, a complete absence of focus on what is the extent of the problem, where the problem exists and what policy measures are needed. Secondly, a failure to enforce accountability (in the ICDS and public health bureaucracies) for high rates of child malnutrition and mortality. And, finally, indifference to the debilitating consequences of child malnutrition, which society and the polity contribute to through inaction on a variety of fronts and a lack of compassion.

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