Reducing Child Malnutrition – Action Backed By Data

After many stops and starts, the National Nutrition Mission (NNM) is being launched by the Prime Minister on 8 March (International Women’s Day) at Jhunjhunu in Rajasthan. I have heard some rumblings about the NNM’s excessive focus on data monitoring and the lack of a specific programmatic focus. This is but to be expected from the Indian intelligentsia, which always looks upwards for policy and programme inspiration. In the last fifteen years, we have been snowed under with programmes designed to improve access to healthcare, employment and food. Most of these programmes have not fitted in with the lumbering public service delivery mechanisms that are a characteristic of most Indian state governments. Additionally, their implementation has been bedeviled by inadequate budgetary provisions. It is time that we move from policy obsession to action focus, as admirably enunciated by my friend Sanjeev Ahluwalia in his recent article (Junk Policy for Action). Hence, my two bits on what needs to be done in the sphere of reducing child malnutrition.

For a start, with the Fourteenth Finance Commission mandating an increased devolution of central financial resources to the states from 32% to 42%, the time has come for state governments to stop crying that they are being deprived of “mother’s milk” by the centre. Along with such budgetary provisions as accrue to them from the centre, state governments need to responsibly start making significant budget provisions for the nutrition, health and education sectors, which will contribute most to reducing the incidence of child malnutrition and mortality. States also need to take a hard look at their policies for supplementary nutrition provision to mothers and children under the Integrated Child Development Services (ICDS) programme. This area that has seen phenomenal corruption enriching contractors, politicians and bureaucrats and has drawn the ire of even the Supreme Court but has not altered politico-bureaucratic behaviour in the least, except the search for more ingenious methods to pull wool over the eyes of the Court. Schemes like the Karnataka Mathru Poorna programme, which provides a hot midday meal to pregnant and nursing mothers, need to be replicated, with close social monitoring to minimise leakages. Supplementary nutrition to children in anganwadis (and, where they are under-3, at home) needs to rely on local food preparation by mothers’ and self-help groups.

At the same time, the central government can help matters by acting as a funnel for data dissemination and technical advice. A huge volume of data relating to maternal and child health and nutrition process and outcome indicators flows into the central government data servers every month. The ICDS monthly progress report is supposed to be sent online every month by all state governments to the Ministry of Women & Child Development, Government of India (MWCD). Even if it is sent (itself a matter for investigation), no one looks at it, let alone sends analysed data back to the state government for remedial action. The Mother and Child Tracking System (MCTS) was introduced by the Ministry of Health & Family Welfare, Government of India (MOHFW) with much fanfare in 2011 to track the health and nutrition status of mothers and children from conception through delivery to the time the child reaches the age of 5 years. Not a byte of this voluminous data collected over the past seven years has been made available to, or has been used by, state government health and nutrition machineries to improve their capabilities to better serve mothers and children. If the NITI Aayog, MWCD and MOHFW work together to make all this extremely useful field-level data available to state government formations right down to the anganwadi and health sub-centre levels, they will have contributed more to reducing child malnutrition and mortality than all the central government efforts over the past forty years.

But having all the data is not enough; using it judiciously is even more crucial to successful outcomes. Since the Prime Minister is launching the NNM in Rajasthan, an example from that state will highlight what I mean. May I refer you to a report in the Hindustan Times of 27 February 2018 (Programme to address all malnutrition causes). This piece details the programme to tackle severe wasting or severe acute malnutrition (SAM) through community involvement, known in nutrition circles as Community Management of Acute Malnutrition (CMAM). The first phase of the CMAM initiative was undertaken in 2015-16 in 41 blocks in 13 districts of Rajasthan. That over 2.25 lakh under-5 children were screened and nearly 10,000 children were enrolled in the programme, of whom over 90% are reported to have recovered from SAM is good news. At the same time, this is still touching only the tip of the iceberg. These 13 districts are home to over 24.50 lakh under-5 children, of whom, if one goes by the latest National Family Health Survey (NFHS-4) figures, over 2.50 lakh children fall in the SAM category. Even if one takes just a cross-section of blocks in these 13 districts, the CMAM screening of 2015-16 ought to have uncovered a far greater number of SAM children than 10,000. Screening of entire child populations in selected areas was probably the reason for the lower number of SAM children identified, since the ICDS-health machinery would have been able to reach only a limited number of children with the resources available. Since the ICDS is supposed to record weights of all under-5 children monthly, it would have been a far more effective strategy to identify severely underweight (SUW) children (those with weights less than three standard deviations below normal) and then record the heights of these SUW children to arrive at an accurate assessment of the number of severely wasted children.

The news report states that the Mission Director of the National Health Mission, Rajasthan claims success for the CMAM exercise. Apart from the low numbers of SAM children reached, there is no supporting evidence to show the extent of non-relapse into SAM of the over 9000 children who are supposed to have moved out of SAM. I would be rather sceptical of a CMAM programme which does not give specific data on the same children one year after their release from the facility where they underwent treatment. The Rajasthan government now plans to expand the programme of Integrated Management of Acute Malnutrition (IMAM) to 50 blocks in 20 districts (which include the original 13 districts) of the state. IMAM is a programme developed in geographical contexts where civil strife and ethnic unrest lead to worsening of children’s nutrition status. It has to be applied cautiously in settings where child malnutrition is a chronic condition rather than an emergency situation. Rather than getting caught up in acronyms, it is desirable to focus on the fundamentals. The 20 chosen districts have an under-5 child population of over 45 lakhs, with a reasonable estimate (based on NFHS-4 data) of about 5 lakh SAM children. To avoid spreading resources (financial and manpower) too thin and to get the maximum mileage for the money spent, it would be advisable to track the weight of every child in every anganwadi in these districts and to identify the anganwadis with the maximum burden of SAM children. The heights of children falling in the SUW category could be recorded by a health functionary, who would also assess any prevalence of disease in the child requiring treatment. These SAM children could then be treated under the prescribed SAM protocols, with the highest-incidence anganwadis being taken up first, and other lesser-incidence anganwadis being taken up subsequently, depending on the financial and organisational capacity to treat the children. The condition of these children should be followed up for a year subsequently by the three As, the Auxiliary Nurse Midwife (ANM), the Accredited Social Health Activist (ASHA) and the Anganwadi Worker (AWW).

I am not discounting the importance of an integrated approach to treating child malnutrition, covering behavioural changes in families and communities and the need to focus on policy interventions in nutrition-sensitive sectors like drinking water, sanitation, hygiene and livelihoods. What I am worried about is that in the enthusiasm to do too many things, the central issue of tackling the immediate problem of SAM will be lost sight of. This is the reason why the Rajmata Jijau Mother-Child Health and Nutrition Mission of Maharashtra, the first of its kind in the country, focused on specific action areas in a sequential order, with fairly gratifying outcomes. Unless we adopt the same talisman that Gandhiji adopted, substituting the “most malnourished child” for the “poorest and weakest man”, we are unlikely to remove what has been, and continues to be, a blot on India’s development story.

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Child malnutrition: Using data more effectively

The National Nutrition Strategy (NNS), released by the NITI Aayog in September 2017, is an important milestone in India’s long fight against child malnutrition. And not just because it points to a welcome focus on child malnutrition at the highest levels of the Central government. It is in the wake of the release of this strategy that, perhaps for the first time, we are seeing a clear focus on data related to child nutrition.

Soon after the NNS was released, the Ministry of Women & Child Development (MWCD) held a national-level workshop with top policy makers, health and nutrition experts, and district collectors from over a hundred districts in the country. It was here that the spotlight was turned on child nutrition data, with the MWCD highlighting the performance of states in improving child nutrition indicators between the 2005 and 2015 National Family Health Surveys (NFHS-3 and NFHS-4, respectively).

It went on to commend three states—Chhattisgarh, Arunachal Pradesh and Gujarat, in that order—for performing the best in reducing under-5 child stunting over the 10-year period. However, the selection of these three states seems incongruent with NFHS-3 and -4 data, which shows Arunachal Pradesh, Tripura and Himachal Pradesh as having the greatest percentage declines in stunting between 2005 and 2015. Chhattisgarh and Gujarat, in contrast, came in only sixth and eleventh, respectively, in the state rankings (highlighted in the table below).

Ramani table

Why the discrepancy when the data was available?

The criterion for selecting states was based on the absolute percentage reduction in stunting between 2005 and 2015. This method was flawed (and embarrassing) on two counts.
First, it failed to follow an accepted statistical principle: when computing reductions in any variable, the percentage fall relates to the reduction in value in relation to the previous base value. Second, it disregarded the NNS data, which had already highlighted reductions in stunting rates across different states over the 10-year period, rightly based on percentage reductions over the NFHS-3 percentages.

Further, departing from the NNS figures and rewarding states for good performance unnecessarily raises questions as to whether the Central government wished to name certain states because their political affiliations coincided with those of the party ruling at the Centre.

What the numbers don’t tell us

It is significant to note that the largest decreases have been recorded in the less populated states (under 25 million people). Larger states, with their high population densities (often in congested urban sprawls), their geographical diversity and greater administrative challenges, are often likely to find the issue of stunting reduction more difficult to tackle.

Also important to recognise is that states like Goa, Kerala and Tamil Nadu—already well ahead in indicators like stunting rates—would never win any national prize for reducing child stunting. This is because their base is already low and the scope for further improvement is, therefore, circumscribed. This may well demotivate the ICDS machinery in such states.

Since the NITI Aayog and the MWCD are going to use a new Nutrition Monitoring System (NMS) to identify states/districts/blocks that are performing well and those that are lagging, it is even more critical to employ a rational methodology in order to get a true picture of the progress registered in any area.

What we can do to get the numbers right

There are a few steps that can help present a more accurate picture for policy making.

Categorisation of states
A three-tier state structure could be developed to assess performance between successive surveys of malnutrition, whether of stunting, underweight or wasting. For instance, in the case of stunting rates, states could be classified into three categories, as detailed in the tables below.

Ramani table 2

Increase frequency of district-level surveys
With NFHS-4 releasing district surveys along with the state surveys, for the first time we have a picture of the districts’ performance in different states and the worst indicators in respect of the three parameters of stunting, under weight and wasting. We need national surveys to be carried out more often so our attention remains focused on the problem.

Regular monitoring and use of critical data
We need greater commitment from the state and Central governments to develop systems for regular collection, monitoring and use of data on child growth. For instance, child growth monitoring has been highlighted as an important component of the ICDS for many years, but has largely been ignored in practice.

While all states are required to send monthly weight data of all children in all ICDS projects to the centre, the MWCD and the states have paid no attention to this data till date. States (barring Maharashtra) do not publish this data on their websites either, although the Right to Information Act mandates placing all such information in the public domain. The result is the extremely dubious quality of data.

Specific focus on indicators and districts with poor progress
NFHS-4 lists the top 100 districts with the highest underweight rates as well as the top 100 with the highest stunting rates. While as many as 55 districts overlap across both these lists, 32 belong to just three states: Bihar, Madhya Pradesh and Uttar Pradesh.

Interestingly, the NFHS-4 data shows a prevalence of high wasting rates in most states, including those that have performed better in reducing child and infant mortality rates in the past decade.
In general, while reduction in stunting percentage rates has been reasonable to very good in many states, reduction in percentages of underweight children has not been so encouraging.

With wasting remaining alarmingly high in many districts, taking up programmes to reduce severe or moderate acute malnutrition through state and community efforts will have to be one of the major focus areas of governments in different states.

Going forward, the MWCD and NITI Aayog will be faced with the onerous job of working with different states, especially Category A states, in devising practical, workable plans and programmes to make a significant impact on child malnutrition.

The first steps have been taken, with the NNS publication and the decision to set up the National Nutrition Mission. However, unless these are backed up by enlightened leadership at the Central and state levels, with a dedicated resolve to reduce the incidence of child malnutrition in all three aspects, India will continue to be an underperformer in an area that is key to the future of its population.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

The commercialisation of nutrition – Maharashtra comes full circle

The flip-flops in India’s child nutrition policies are nowhere better exemplified than in the recent decision of the Maharashtra government to issue a tender for the supply of fortified ready-to-cook pre-mixes for feeding children, aged three to six years, in rural anganwadis.

Maharashtra has, for many years now, outsourced the supply of take home rations (THR) for mothers and children below the age of three years to so-called Mahila Sansthas that in turn have subcontracted this work to private manufacturers in the state and outside.

With the tendering for ready to cook pre-mixes, Maharashtra is turning the clock back on the important Supreme Court (SC) decision of 2004 that mandated state governments to serve hot cooked meals prepared by women self-help groups, or similar locally based women’s organisations, to children attending anganwadis.

What does this imply for the ICDS* supplementary nutrition programme and what are its likely ramifications?

Quality of food supply is the first and most important concern.
It is difficult to take at face value the tender stipulations that quality checks will be carried out by the supplier organisation at in-house laboratories. Nor can one take comfort from the provision for quality checks at independent laboratories ordered by the ICDS Commissioner. Public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

The 2012 report of the SC Right to Food Commissioners to the SC highlighted the poor quality of THR supplies in Maharashtra. However, despite complaints about poor THR quality, no action has ever been taken in the past against politically powerful suppliers, either in Maharashtra or other states. In any case, public laboratories in India are notorious for delays in furnishing reports, enabling defaulters to get away.

There is also the issue of whether pre-mixes supplied to children will be as nutritious as hot cooked meals, apart from the question of palatability. Even adults who use pre-mixes to quickly rustle up upmaor sheera at home will testify that the pre-mixes’ taste is nowhere close to that of items prepared from fresh natural ingredients.

With a provision of only INR 6 per child per day, there is also the very real apprehension that the suppliers will be tempted to compromise on quality to maintain their profit margins.

Quantities of pre-mixes supplied to anganwadis, and used for meal preparation, will be the next issue.
At one time, probably about four decades ago, states such as Maharashtra and Gujarat set the standard for efficient, responsive administration. Unfortunately, these states too have degenerated in administrative efficiency and probity to the levels of their counterparts in northern and eastern India. The travesty that represents ICDS nutrition supplies in Uttar Pradesh has been well documented.

When the then Minister for Women & Child Development, Government of India pushed for commercial supply of food items in the ICDS in 2008, it did not meet with the approval of the Cabinet Committee on Economic Affairs (because it would open the doors to large-scale corruption).

The apprehensions of poor programme delivery are amplified by the top-down approach adopted in this tendering system. There is no mention anywhere in the tender document of social accountability through monitoring of supplies and service delivery by village level institutions like the gram panchayats, their health and nutrition committees and mothers’ groups, let alone their involvement in the process of meal preparation.

As one who was involved with the ICDS in Maharashtra through the first decade of this millennium, I can vouchsafe for the beneficial multiplier effects of involving local bodies from the Zilla Parishad to the Gram Panchayat, as well as local communities, in the management of child nutrition. In the present scenario, the pre-mix will be distributed from the project to the anganwadi, with no check on whether the right quantities are reaching the anganwadi.

Stipulations within the tender raise questions around corruption and the concentration of production among a handful of large players.
What is disturbing about the tender are the numerous conditions which straight away disqualify smaller groups from participating in the supply of nutrition to children. Although the tender document specifies that only women self-help groups, Mahila Mandals, Mahila Sansthas and village communities are eligible to bid, the requirements to be fulfilled by the successful bidder rule out the possibility of the tender being awarded to any small group.

There are onerous conditions regarding the high annual turnover needed to qualify, the need for a functional and operative licensed manufacturing unit and an in-house testing facility to test the quality of the premix. The three Mahila Sansthas that were awarded the THR contract had leased facilities for THR production from private agro-companies; ownership and operational control of the Sansthas as well as the companies were vested in the same family.

With the present tender also permitting the participation of Mahila Sansthas, there is ample scope for the same stratagem being employed to circumvent the SC rulings on contractors and private suppliers.

From an equity viewpoint too, the concentration of production in a few organisations denies economic benefits to a very large number of rural women’s groups, which earn their daily bread through the preparation of meals for children.

Ultimately, the issue boils down to whether government programme funds of about INR 2,500 crores should be channelled to a few organisations with, if previous experience is any guide, links to private producers.

Other states are adopting more equitable and empowering solutions
The move of Maharashtra to premix supplies comes at a time when other states are innovatively experimenting with public systems to improve nutrition supplies to mothers and children.

Karnataka has introduced eggs and milk in the daily diet for 3-6 years children, Orissa is promoting the cultivation of local millets and Chhattisgarh has improved its public distribution system to ensure regular food grain supplies to families.

As the foregoing discussion brings out, this policy serves neither the ends of efficiency (given the scope for possible quality and quantity aberrations), nor those of equity (concentration of supply in a few hands) or empowerment (with no role for participation of local governments and communities). Whether such a policy behoves a land that is the karmabhumi of Shahu Maharaj, Jyotiba Phule and Babasaheb Ambedkar is the question that ought to concern us today.

*ICDS (Integrated Child Development Services) is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under six years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here 

What trips street-level bureaucracy?

“There’s many a slip ‘twixt the cup and the lip.”  Nowhere is this proverb truer than in the government machinery of India that is tasked with the staggering responsibility of delivering various crucial services to the 1.3 billion inhabitants of this country.

Whether it is the police guaranteeing the security of the common citizen, the doctor attending to patients at the public health facility or the teacher imparting basic education to children in schools in remote areas, it is glaringly evident that citizens of India are being seriously short-changed in availing public services that are their inalienable right.

We in India, especially the middle class, are quick to blame the street-level bureaucracy (SLB) for faulty implementation of what we consider to be impeccably-designed policies.

Where does the truth really lie? An examination of the functioning of SLBs, covering anganwadi workers and their immediate supervisors in the Integrated Child Development Services (ICDS)*, reveals some home truths on where things are going wrong.

I. Policy vs implementation

The first unpleasant truth is that programmes as packaged in statutes and administrative regulations are not quite what the SLB implements on the ground. There are quite a few reasons for this:

Focus on a limited set of activities
While the ICDS manual prescribes several duties for the anganwadi worker, the ICDS machinery focuses only on supplementary nutrition provision to mothers and children. It excludes activities such as monitoring the growth of children, counselling of caregivers on health and nutrition, and early childhood education.

Food supply is the only concern of the officials of ICDS directorates and the departments at the state level. As a result, the anganwadi worker is considered to have done her duty if she has distributed take home rations (THR) to mothers and children aged under three, and handled cooked meals for children in the 3-6 age group.

Emphasis on paperwork versus outcomes
The anganwadi worker is also required to complete a huge load of paperwork on the supply of food and on the nutrition status of children, to be sent to her superiors every month. If these duties are completed and reports sent to the state and central governments regularly, there is no accountability for outcomes. For example, the nutrition status of children—as revealed by their height and weight measurements, which are critical for determining and addressing stunting and wasting in children below five years—is never addressed in a systematic manner.

II. Leakage in programme implementation

The second shocking fact lies in the subversion of the supplementary nutrition programme by the contractor-politician-bureaucrat nexus. An average Indian state has around 75 lakh children aged below six. With a provision of supplementary nutrition at a rate of INR 6 per day to each child, the annual bill works out to approximately INR 1,350 crore. This huge budget lends itself to manipulation by vested interests.

A recent LANSA study documents the systematic siphoning of public money in Uttar Pradesh through this programme. While a few packets of the THR (daliya) are distributed to families, the bulk of the supplies are sold as cattle feed, giving additional illegal income to the anganwadi worker. Silence is bought through the complicity of all those who are part of the supply chain.

The situation is not much better in respect of hot, cooked meals, where the proceeds of funds received (even if irregularly) are distributed among all stakeholders, including the anganwadi worker and the ICDS supervisor, with very little reaching children in the form of improved nutrition.

III. Socio-cultural barriers

Traditional social prejudices and behavioural patterns also adversely impact the messages being understood and acted upon. Two examples come to mind. Promoting early breastfeeding within an hour of birth has been recommended for a variety of reasons. However, social practices have often militated against this, with the belief that the child must be fed specific fluids before breastfeeding is initiated.

In the area of sanitation, proper hygiene practices and the absence of open defecation are known to promote the healthy growth of children. A recent study by Diane Coffey and Dean Spears has attributed the failure in restricting open defecation in India to social and cultural forces unique to the country. These are centred around religious practices of purity and pollution and the consequent reluctance to locate toilets in proximity to the house.

While these instances reflect the demand factor impacting the efficacy of public services, there are also supply aspects that affect client response to public services.

IV. Inadequate infrastructure

Irregularly functioning Primary Health Centres, which are often closed when the citizen has spent time and money to make her way there, act as a disincentive to use public health facilities. The problem is compounded when the health provider behaves indifferently, and/or demands illegal payments. Such experiences discourage citizens from using the facility and force many to shift to private doctors, sometimes of very dubious quality.

What is being done to address this?

India’s policy mandarins are frustrated by this lack of success at translating significant budgetary allocations and governmental effort into improved outcomes in different social sectors. They are, thus, increasingly seduced by direct cash transfers to clients and privatisation of health, education and corrective services.

However, this approach still begs the question: are citizens guaranteed access to improved services? There will still be need for regulatory agencies that monitor how private agencies function, including the quality and pricing of their services. Poor governance in direct management of public service delivery systems can easily transfer to equally poor oversight of private providers.

Take the case of the Universal Basic Income (UBI), which has caught the fancy of academics and policymakers in India. Apart from the vital issue of who will be entitled to UBI, and its fiscal implications, the question of fair and equal access to services critical to human health and development is still a moot point.

Is there a solution?

The few short-lived successes in child nutrition programmes in certain states have been the result of inspiring bureaucratic leadership, backed by political commitment. Unfortunately, results show only as long as the bureaucratic champion is around.

But long-term success in reducing key indicators of malnutrition, such as stunting and wasting, require sustained efforts to put in place functional systems that can operate irrespective of personalities and governments. These include:

  1. Evidence-based, nutrition-specific and nutrition-sensitive interventions, backed by committed government budgets and active participation of different government departments and agencies.
  2. Health and nutrition protocols that are scrupulously followed, with rigorous monitoring of child nutrition outcomes to ensure accountability.
  3. Empowering local governments and frontline workers and supervisors with financial and administrative authority to deliver meaningful outcomes.

Above all, the political and bureaucratic leadership in the various states must provide a conducive and supportive environment for the effective functioning of SLBs, something that has been sorely lacking till now.

*ICDS is the largest programme in the world devoted to the care of pregnant and nursing mothers and children under 6 years of age.

This article was originally published on India Development Review (IDR), the country’s first independent online media platform for leaders in the development community. You can access the article here

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/17/himalayan-blunders-in-healthcare-gorakhpur-and-beyond/

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped. Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulverma08) based on the replies to a Right To Information (RTI) query of 2011.


image 1 principal BRD Medical college RTI.png

Reply from the office of the Principal, B.R.D. Medical College, to an RTI application.


The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the non-functioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.


image 2 staffin shortage.png

Staffing shortages in medical and nursing personnel (Jan 2012)


The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 40% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.


status of equipment and machinery.jpg

Status of equipment and machinery in PICU and NICU.


But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir NagarSiddharth NagarMaharajganjKushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care, medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per 1000 live births and of infants (0-1 year) from 62 to 87 per 1000 live births, with 80% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over 10% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.


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The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons – especially children – constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confrères but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors – man-made and natural – have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”

Improving child nutrition: the way ahead for Maharashtra

The recently released National Family Health Survey (NFHS-4) data on maternal and child health and nutrition outcomes in Maharashtra provides sobering food for thought. This data does not provide the cheer that the 2012 UNICEF Comprehensive Survey on Nutrition in Maharashtra (CNSM 2012) brought to Maharashtra, with the showing of a stunning reduction in under-2 child stunting rates (between 2006 and 2012) from 39% to 23% and a corresponding reduction in under-2 child underweight rates from 30% to 22%. The NFHS-4 figures, which cover under-5 children, show a reduction in stunting from 46% to 34% and in underweight from 37% to just 36% over a ten-year period between 2005 and 2015. More tellingly, the NFHS-4 data reveals that high malnutrition rates are not a feature only in predominantly tribal districts; districts like Parbhani and Yavatmal (with tribal population percentages of 2.2% and 18.5% respectively) show stunting rates over 45%. As many as 13 districts in the state show underweight percentages in excess of 40%. What is disquieting is the fact that districts in Vidarbha, like Buldhana and Washim (apart from Yavatmal), and in Marathwada, like Jalna and Osmanabad (apart from Parbhani), show a high percentage of underweight children. Considering that the campaign to reduce child malnutrition in Maharashtra had its beginnings in Marathwada in 2002, the regression in performance of districts in this region indicates that the gains in child nutrition in the first ten years of this century seem to have been lost in the past few years.

Another noticeable feature of the NFHS-4 data for Maharashtra is the variance of its figures from the ICDS monthly progress reports (MPRs) of the corresponding period. Since the NFHS-4 survey was carried out in mid-2015, a comparison of district-wise under-5 children underweight percentages as shown in the June 2015 ICDS MPR was made with the district-wise figures of the NFHS-4 data. The analysis shows that as many as 20 districts showed ICDS MPR underweight percentages which were more than 25 percentage points below the corresponding NFHS-4 percentages (Table 1). Unless one wishes to contest the accuracy of the results of the NFHS-4 sample survey, the only conclusion that can be drawn is that the ICDS MPR figures are understated. My personal experience, as a former Director General of Maharashtra’s Rajmata Jijau Mother Child Health and Nutrition Mission (“the Mission”), is that there is generally a tendency, on the part of the ICDS machinery (not just in Maharashtra, but in most states) to underreport underweight numbers, both because of lack of emphasis on accurate growth monitoring, as also to avoid criticism.

TABLE 1: MAHARASHTRA – STATE AND DISTRICT VARIATIONS IN UNDERWEIGHT PERCENTAGES

 

District NFHS-4 Under-5 under-weight (%) ICDS MPR June 2015 figures (MUW+ SUW) (%) Variation between NFHS-4 and ICDS (%)
Ahmednagar 31.1 11.15 19.95
Akola 39.3 7.13 32.17
Amravati 33 16.02 16.98
Aurangabad 36 7.99 28.01
Bhandara 32.5 4.99 27.51
Beed 36.9 7.84 29.06
Buldhana 41.3 10.21 31.09
Chandrapur 40.3 16.06 24.24
Dhule 47.5 11.56 35.94
Gadchiroli 42.1 19.98 22.12
Gondia 40.1 7.42 32.68
Hingoli 36.9 9.82 27.08
Jalgaon 36.4 12.78 23.62
Jalna 43.6 7.50 36.10
Kolhapur 31.2 4.30 26.90
Latur 34.5 6.26 28.24
Mumbai 22.7 17.81 NA
Mumbai Suburban 28.9
Nagpur 33.6 11.83 21.77
Nanded 34.4 6.68 27.72
Nandurbar 55.4 31.05 24.35
Nashik 42.9 10.64 32.26
Osmanabad 44.5 8.80 35.70
Parbhani 42.3 7.37 34.93
Pune 25.6 8.64 16.96
Raigarh 38.6 6.01 32.59
Ratnagiri 28.9 8.24 20.66
Sangli 24.8 3.87 20.93
Satara 27.8 7.93 19.87
Sindhudurg 25.2 11.85 13.35
Solapur 34.6 6.58 28.02
Thane 40.3 17.21 23.09
Wardha 36.1 9.73 26.37
Washim 42.9 6.51 36.39
Yavatmal 49.1 8.79 40.31
Maharashtra State 36.0 10.55 25.45

Sources: NFHS-4 (2015-16) and Maharashtra ICDS MPR (June 2015)

 The above analysis becomes even more relevant in the context of the recent furore over child deaths in Palghar district (newly carved in 2014 out of the existing Thane district and comprising the predominantly tribal-populated talukas), attributed to the high child malnutrition rates in this tribal region. Why has this state of affairs come about in a state which, barely a few years ago, was in the forefront of efforts to reduce child malnutrition and whose achievements gained national and international recognition?

Over the last five years, during the second phase of the Mission, there was a move away from data monitoring at a disaggregated level ranging from the district down to the Anganwadi. The Mission focused on behavioural change processes at community and family levels and on pilot initiatives to promote nutrition-sensitive projects in association with corporates/nonprofits. While these yielded results at the micro-level, there was no specific focus on scaling up these initiatives or ensuring their sustainability. More importantly, the emphasis on strengthening health and nutrition systems at the cutting edge levels, a significant feature of the operations of the first phase of the Mission, was not stressed in the second phase. Neither was there systematic follow up of the under-5 child nutrition status at the ICDS project level, a measure which is crucial to monitor the high malnutrition burden areas. With little pressure on them to monitor or ensure achievement of key nutrition outcomes, the ICDS machinery at the Zilla Parishad level and below paid little attention to outcomes.

There was also a diminution in the role of the Mission in terms of coordinating the nutrition-specific and nutrition-sensitive activities of different government departments. Departments continued to function in their respective silos; even fundamental activities like the medical facility based treatment of severe acute malnutrition and the community management of acute malnutrition suffered setbacks on account of budgetary cuts and what can only be termed as the absence of a clear policy focus. The lack of coordination in the nutrition-sensitive/specific programmes of different departments is manifest even to date in the manner of implementation of the Abdul Kalam Amrut Aahar Yojana, a maternal nutrition scheme aimed at pregnant and nursing mothers. The ICDS machinery is yet to wholeheartedly take responsibility for making this programme a success; delayed fund transfers to the village level and failure to put in place effective monitoring systems continue to bedevil the programme even a full year after its commencement. Few systematic reviews of the child malnutrition position have been undertaken at the apex levels of the political and administrative hierarchies in recent years.

The need for a mission approach to tackling child malnutrition in Maharashtra arose in the early 2000s out of the perceived inability of the ICDS machinery to make a significant impact on reducing child malnutrition despite almost three decades of its existence: its overwhelming focus on supplementary nutrition, the lack of attention to under-3 children and the failure to adopt a data-based implementation strategy. Frequent transfers of officers at the helm of affairs of the ICDS and the Department of Women & Child Development (DWCD) and absence of accountability for outcomes have bred a “business as usual” approach. The situation on the ground has deteriorated to the extent that over 70% of posts of Child Development Project Officers, the lynchpin of the ICDS programme, lie vacant today, with the DWCD apparently unable to draw up a recruitment policy for this crucial post. The creation of the Mission was expected to engender a sense of purpose in the ICDS, improve its coordination of activities with other departments and enforce accountability for measurable outcomes. This approach, largely successful in the first phase of the Mission till 2010, has been diluted greatly in the second phase.

As matters stand, the government of the day, despite having in hand a clear proposal on the modalities for launching the third phase of the Mission, has not been able to take a decision for over eighteen months. Current thinking seems to be in favour of subsuming the operations of the Mission within the ICDS Commissionerate, a move that will make the Mission a toothless entity and, in effect, ensure a regression to the status quo prevailing prior to 2005.

Ultimately, any structure to tackle child malnutrition can only be effective if it is staffed with personnel with the passion and commitment to make a difference. The indifferent experience of a number of other states that launched Nutrition Missions based on the Maharashtra model is a clear indication that standard bureaucratic interventions will not work. Maharashtra is free to experiment with any governance structure for addressing the issue of child malnutrition. There are, however, certain fundamental steps that are a sine qua non for making a significant dent on the problem:

  • Accurate, real-time data has to be the basis for a strategic approach. Both the health department and the ICDS need to use technology to gather real-time data on maternal and child health and nutrition to strengthen systems to tackle underlying causes. Maharashtra made a beginning in 2011-2012 using the Janani and Jatak software systems for individual mother and child tracking to monitor maternal and child health and nutrition outcomes with a view to build service delivery capabilities of the health and ICDS systems. Unfortunately, both departments have not made use of these softwares, specifically customized for Maharashtra, to aid them in efficient service delivery.
  • A far greater sense of accountability needs to be enforced in the ICDS and public health systems, as well as in other departments with a role to play in reduction of child malnutrition and mortality, from the Secretariat to the village level. A clear political message needs to go out that the death of even one child or the continued prevalence of stunting, underweight and wasting in under-5 children will not be tolerated.
  • Whether as a Mission or as a high-level council under the Chief Minister, there needs to be an organisational structure that coordinates the activities of government departments/agencies, nonprofits and civil society organisations. This body would plan strategies for high incidence areas, garner financial and other resources for tackling malnutrition, help develop innovative, sustainable programmes and set time-bound, measurable goals.

 

 

 

 

 

 

 

 

The politics of infant mortality…and the tragedy

“There are three kinds of lies – lies, damned lies and statistics”

(Mark Twain: Chapters from My Autobiography)

A recent comment by India’s Prime Minister (PM) during an election speech comparing the infant mortality rate (IMR) in the tribal areas of Kerala state with those in Somalia kicked up a furore. A wounded Chief Minister of Kerala (from the opposing political party) has threatened to sue the PM, though the exact nature of the offence is not clear. Now that the electoral battle in Kerala has been lost and won, it is time we dispassionately analysed the contention of the PM and the implications for health policy in India. Let us first get to the numbers; at 60 deaths per 1000 live births in the tribal areas of Northern and Eastern Kerala, he felt that the area was not lagging far behind the African country of Somalia, which, as per the number he had, registered 85 deaths per 1000 live births in 2015. This is where statistics can be dangerous, and it does not need a Mark Twain to convey this message. Firstly, there seems to be no basis for concluding that the tribal areas of Kerala have an IMR of 60: whether this covers just the tribal population or the districts with a larger proportion of tribal population is not clear. Secondly, the PM’s information feeders seem to have culled the magic number of 85 from the latest country wise estimates of infant mortality released by the UN Inter-agency Group for Child Mortality Estimation (www.childmortality.org). The problem, as with all statistics, lies in the level of confidence reposed by the estimators in their own estimates. In the present case, three sets of numbers are given for each country: low, median and high. While the variation in these three numbers in countries like the United Kingdom with excellent reporting systems is minimal (3.0 to 3.5 to 4.1) and reasonable for a country like India (34.1 to 37.9 to 41.8), the range from the low to high figure is from 53.3 to 143.3, with a median figure of 85, for a country like Somalia with underdeveloped reporting systems. The UNICEF State of the World’s Children Report 2015 gives an IMR of 108 for Somalia and the CIA Fact Book places it at 98, showing that there is no unanimity on the number. With such a vast range of uncertainty regarding the numbers, it would be hazardous to plump for a number like 85 with any degree of confidence. The matter is further complicated when we compare the tribal population of Kerala with that of Somalia – 0.49 million versus 34 million. A small population, especially when it is largely comprised of poor tribals, will display higher figures of mortality in infants, given the prevalence of poverty and the poor reach of essential health services. The law of averages operates as the sizes of populations increase. To give one graphic example: just two infant deaths in a village with a population of 1000 (with an annual population growth rate of 2%) imply an IMR of about 100 per 1000 live births: which is why mortality statistics are never calculated below the district level. As statistics combine disadvantaged with more prosperous areas, these numbers come down, in the case of Kerala state to 12 per 1000 live births, which compares very favourably with many developed country figures.

The tragedy lies in the lessons that are not learnt from areas in Kerala like Wayanad, Idukki and Attappady, Palakkad (in the news a couple of years ago for infant deaths in significant numbers) and the mistakes committed through apathy and misgovernance across much larger swathes of India. Politicians would do well to remember the adage “Those who live in glass houses shouldn’t throw stones”. Of the nine states that are at the top of the high child malnutrition pecking order, seven are presently ruled by the party whose PM has spoken disparagingly about IMR levels in the tribal areas of Kerala, and all nine, including his own state of Gujarat, have or have had BJP governments (either on their own or in alliance with other parties). Barring two states where the BJP has recently come to power, its governments have had ample time to tackle the menace of child malnutrition, which is attributed by experts to contribute at least 45% of child deaths in India (and probably an even greater percentage of infant deaths, given that an overwhelming majority of under-5 children die before they cross the age of one). And yet, it is precisely these states which are the greatest contributors to infant mortality and child malnutrition. Don’t get me wrong: I am not in any way absolving other political parties which have ruled these states for many years without making a significant difference to the problem. The fault, dear Brutus, lies not in our stars, but in ourselves: in our dysfunctional systems, our cavalier disregard of data, our failure to focus on key geographical areas with a high child malnutrition burden and our failure to evolve a coherent, time bound public policy to effectively tackle the problem.

Let us start with our dismal grasp of the magnitude of the problem. Growth monitoring has always been one of the main components of the ICDS strategy right from its inception. Unfortunately, the monthly exercise of weighing of all under-5 children by the Anganwadi Worker (AWW) has been treated mostly as a routine task, with little or no importance being given to the use of this massive body of raw data. In the absence of weighing scales, weighing is sometimes not carried out; where weighing is done, there is no analysis of the data to chart out a meaningful course of remedial action in case of underweight children at any level, whether the anganwadi, ICDS project, district or state. Almost no state posts aggregated data, ICDS project wise, on the nutritional status of children online and it is doubtful if any administrator, at the project, district or state level, pays any attention to this data.

This blissful neglect of valuable data leads to governmental failure to identify and focus attention on the geographical regions requiring urgent, sustained intervention, be they remote tribal areas or congested urban slums. Aggregated data of monthly weights of children helps identify the specific localities (villages, hamlets, slums, etc.) that need to be focused on to reduce the burden of child malnutrition. The common budgetary approach of allocating funds to areas on a child population basis, without weightage for high burden malnutrition areas, discriminates against the latter. Poor infrastructure and inadequate staff in tribal areas lead to underutilisation of even allocated budgets. Resources of different departments are generally not combined in an innovative manner to deliver the crucial health and nutrition (both nutrition-specific and nutrition-sensitive) services to children and women that can reduce undernutrition and mortality. The new methodology of untying central fund releases to states is likely to see even further diminution in fund allocations to politically weak tribal regions of states and to urban slums. Public nutrition and health services for mothers and children are in short supply in urban slums. There are no systematic efforts to reach out to urban communities to develop their capacities to self-manage their nutrition and health issues. This limited attention given to identified high burden geographical areas is likely to see a continuation of high child malnutrition and mortality rates in these areas.

Resource misallocation to this critical area is aggravated by the absence of a clear cut vision on how to most effectively tackle the problem in the short run. India’s policy makers refuse to use height/length of under-5 children as a measure of nutrition status, in addition to weight (which has been used for nearly four decades). This would enable an immediate estimation of wasting (weight/height) status for taking action to improve the health and nutrition status of children suffering from severe acute malnutrition. Software exists to record both anthropometric measures digitally so that the wasting status of any child can be immediately established (a pilot project in Attappady, Kerala has proven the feasibility of such a digital approach to recording data using IVRS technology). Tackling moderate and severe wasting in India’s children (which goes upto 25% in many states) through inpatient and outpatient methods would significantly reduce malnutrition. But India’s ICDS and public health departments are unconvinced that they need to make this programme a key step to reduce child malnutrition and mortality. Adequate international evidence linking child malnutrition (especially wasting) to a higher incidence of mortality has had little to no impact on the thinking processes of the bulk of India’s medical professionals. Governments (at central and state levels) have failed to make such a programme the cornerstone of efforts to reduce malnutrition/mortality. The ICDS Commissionerates/Directorates are obsessed with centralised, contractor-dominated food supplies (rather than child feeding practices and micronutrient interventions), a policy which has drawn much critical comment from the Supreme Court and High Courts (the reasons are not difficult to fathom!). The resultant haphazard, ill-directed programmes to manage malnutrition, with no systematic measurement of nutrition outcomes and no focus on geographical areas most in need of such programmes, are the reason for India’s dismal world ranking in child nutrition indicators.

Finally, there is gross underutilisation of one of the most extensive systems set up anywhere in the world to deal with the issue of maternal and child nutrition — the ICDS. With anywhere from 50,000 to over 100,000 AWWs in each state of India, spread over almost every habitation in the country, this valuable human resource could well be the underpinning for a revolutionary transformation of the child malnutrition scenario in India. Unfortunately, with the ICDS largely functioning as a khichdi kitchen, these workers have never been empowered with the knowledge, skills and resources necessary to fulfil their innate potential. My experience in the nutrition sector in Maharashtra opened my eyes to the fantastic work they can do given the right working environment — upgraded knowledge/skills, access to resources, appreciation for their good work and the development of self-esteem for the important tasks they are undertaking. Even the huge public health system has no specific focus on the preventive aspects of health and good nutrition that could develop a generation of healthy girls and mothers, leading ipso facto to the birth of healthy, normal weight children.

For a country on the cusp of economic power and a growing global presence, it reflects poorly on India that she takes her place among the league of failed and failing nations in indices of child/infant mortality and undernutrition, whenever the exercise of evaluating each country’s performance in these areas is taken up. Latin America and East Asia have left us behind, as they made significant strides over the past few decades. Our immediate southern neighbour, Sri Lanka, is an object lesson to us that improvement in human development indicators can be achieved. Even within India, states like Goa, Kerala, Maharashtra and Tamil Nadu have performed far better than their counterparts in Northern and Eastern India in reducing IMR, though they still need to reduce wasting rates in under-5 children. If “Make in India” is to have any real meaning, children born in India need to have the guarantee of a healthy, disease-free, long and productive life.