BARAN, RAJASTHAN INDIA

AcuteMalnutrition:An everyday emergencyBaran, Rajasthan

Context

One in every twelve children under five in the world today is suffering from a condition that is preventable. These children are at risk of dying because of Acute Malnutrition. What is shocking is

1that India contributes to the maximum number of wasted children in the world . According to UNICEF, every year 1 million children under the age of 5 die due to malnutrition related causes in India. The statistics are alarming, and far above the emergency thresholds admitted by WHO (as per the classification of the severity of malnutrition). One in every five children under the age of

2five in India is wasted . Approximately 50% of deaths in children under 5 are related to

3malnutrition . These deaths are completely preventable if early action is taken to educate, screen, detect, refer, treat and follow up children found to be either severely or moderately acute malnourished.

In the state of Rajasthan, according to NFHS-3, 20% of children under 5 are wasted (11.7% in NFHS-2), 24% are stunted (52% in NFHS-2) and 44% are underweight (50.6% in NFHS-2). The NFHS-3 data also shows that children under 5 belonging to Schedule Tribes in Rajasthan have the highest prevalence of SAM (WHZ below -3SD) at 8.4%, compared to children from Schedule Castes (7.0%) and Other Backward Classes (5.2%).

Infant mortality rates (IMR) are similar in urban and rural Rajasthan with an average of 57 deaths 4

per 1,000 live births that is much higher than the national average, and classifies Rajasthan in the worst demographic data of the country. The rise in malnutrition indicators especially wasting in the State and high prevalence in scheduled tribes and castes is worrisome and it becomes essential that strategies for addressing IMR are adopted on an emergency footing.

ACF-India, a member of Action Against Hunger International s (www.actioncontrelafaim.org/EN) iworking in Baran district in Rajasthan since 2011 to address the issue of Global Acute Malnutrition and specifically Severe Acute Malnutrition (SAM) amongst children under 5.

1 UNICEF's Improving Child Nutrition Report 20132NFHS-3, 2005-20063UNICEF India, http://www.unicef.org/india/children_2356.htm4Annual Health Survey bulletin 2011-2012, Rajasthan

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Nutritional Situation in Baran district of Rajasthan

Baran District (pop. 1,021,653) has 21% tribal population, a very high proportion being from the Sahariya Tribe. There are two blocks in the district where Sahariya Tribe population is in higher concentrations: Shahabad and Kishanganj (respectively 30% and 32%).

The Sahariya Tribe is one of the indigenous tribes of India included in the list of Scheduled Tribes. The Sahariya tribe of Baran district is classified as a Particularly Vulnerable Tribal Group (PVTG). Despite special programs aiming to improve their situation, changing knowledge, atitudes and practices of this particularly vulnerable tribal group has proved quite challenging. Traditionally jungle product gatherers and sedentary, the Sahariya from Baran migrate twice a year together with their family to neighboring Kota and Sheopur districts in search of agricultural labour.

In 2002, during extremely severe drought in Shahabad Block, many deaths were reported from the area, attracting a lot of attention from media, NGOs, UNICEF and Government. Since then, the Sahariya Tribe has received specific attention, through access to free medicines and free rations from the Government Public Distribution System. Additionally, 2 Malnutrition Treatment Centres (MTCs) were set up by the Government, one in Shahabad district with the help of UNICEF and one in Baran (2006). Both centers cater to in-patient treatment for children with SAM.

According to the survey conducted by ACF in Kishanganj block in June 2014 to assess the nutritional status of children aged 6 to 59 months, the situation in Baran remains critically beyond WHO emergency thresholds: the prevalence of Global Acute Malnutrition (GAM) is at 33.7 % [29.6- 37.8 95% CI] while the prevalence of Severe Acute Malnutrition (SAM) alarmingly amounts

57.6 % [5.1 – 10.1 95% CI] .

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5 Based on WHZ or MUAC or bilateral pitting oedema criteria

Table 1: SMART 2014 Survey revealed 7.6% of SAM and 37.6% of Chronic Malnutrition

(stunting)

ALL WHO criteria (WHZ/MUAC/Oedema)

GAM Prevalence(95% CI)

33.7%(29.6%-37.8%)

SAM prevalence(95% CI)

7.6%(5.1%-10.1%)

Global Chronic Malnutrition(95% CI)

37.6%(32.3%-43.3%)

Severe Chronic Malnutrition(95% CI)

14.9%(11.6%-18.9%)

Global Underweight( 95% CI)

47.6%(41.8%-53.4%)

Severe Underweight(95% CI)

15.5%(12.1%-19.6%)

HAZ criteria WAZ criteria

ACF's intervention in Kishanganj, Baran district:

Kishanganj is one of the eight tehsils (sub-districts) of Baran district. The sub-district is comprised of 32 panchayats and 213 villages, and has a total population of 166,864 (as per census

62011 ). In Rajasthan, the indicators of Child health are among the poorest of India states.

7Rajasthan is ranked 6th worst state for Infant Mortality Rate in India, with 1 in every 15 children dying before his/her first birthday.

Kishanganj is one of the eight tehsils (sub-districts) of Baran district. The sub-district is comprised of 32 panchayats and 213 villages, and has a total population of 166,864 (as per census 2011). In Rajasthan, the indicators of Child health are among the poorest of India states. Rajasthan is ranked 6th worst state for Infant Mortality Rate in India, with 1 in every 15 children dying before his/her first birthday.

Kishanganj tehsil is a complete rural area where the main source of income is agricultural business for 82% of the population. During summer season, regular issues related to food security get worsened, as the agriculture activity of the tehsil is mainly dependent upon the rainy season. The area is characterised with deprived living conditions, poor health and hygiene conditions, insufficient basic facilities and high rate of migration.

Based on a situational analysis assessment conducted in 2010, ACF launched a program for raising awareness through a capacity building program focusing on management of Acute Malnutrition in 2011, with the goal to reduce mortality and morbidity related to child undernutrition up to the age of 59 months, through targeted preventive activities integrating nutrition and care practices.

In collaboration with its local partner Cecoedecon and a team of community workers and mobilizers who worked along with Government frontline workers (ASHA, ANMs and AnganWadi

8Workers) , ACF rolls out activities in 36 villages of Kishanganj. The activities raise awareness and build local capacities on detection, referrals, nutrition education and care practices using an integrated approach for addressing acute malnutrition in the community.

To reinforce the early detection of Acute Malnutrition at village level, ACF has trained community workers and conducts every month screening sessions using MUAC tapes and checking of bilateral pitting oedema. On a monthly basis, about 74% of all children under 5 present in the intervention area are screened, and 47% were effectively referred to the Malnutrition Treatment Center (MTC). Besides, more than 1 000 MAM children have been detected and referred to the nearest AWC.

6http://www.geohive.com/cntry/in-08.aspx 7National Family Health Survey (NFHS)-3, 2005-20068Accredited Social Health Activist ( ASHA), Auxillary Nurse Midwife( ANM)

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ACF has also initiated follow-up of SAM children refusing the referral or being discharged from MTC after completion of their treatment. Every month, an average of 380 follow-up visits at home level are performed by frontline and community workers for SAM and MAM children staying at community level. The visits are done together with government and program workers in order to ensure the sustainability of such protocol through the strengthening of the existing health system.

Mother's education and counselling sessions are held through trained Community Health and Nutrition Workers (CHNWs) together with the Anganwadi workers of the villages.

In the past year, ACF's education and counseling sessions have reached every month over 1 250 pregnant and lactating women, along with SAM and MAM caretakers.

For prevention of Malnutrition, awareness camps through theatre-like animations take place directly at community level. An average of 1 600 pe r sons f rom the commun i ty participate every month. In parallel, village Malnutrition Committees have been set up, and meet on a regular basis.

However, despite interventions for the past 3 years, the situation in Baran remains grim as it is evident from the nutrition survey results that show SAM prevalence to be 7.6% and SCM ( Severe chronic malnutrition or Stunting) to be 14.9%.

A typical Education Session would include key messages on:

Awareness of Good Nutrition Practices

Sensitization of Child Care Practices and Mother Child Bonding

IYCF practice promotion focused on the 1000 days of windows of opportunities, for children aged under 2 years

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Gyarsi, a 14-month old child from Moyda village in Kishanganj block died on 17 September 2014.

When he was first admitted in April 2014, his weight was just 3.9 kgs for a height of 58 cm. His MUAC was at 100 mm, classifying him as a SAM patient.

He stayed for a period of 10 days at the MTC and was discharged at 4.1 Kg. Despite this first visit, Gyarsi was readmitted to the MTC a second time in May 2014. His weight had decreased to 3.8 Kgs. He stayed again for 11 days at the MTC and was discharged back to his village.

During the combined home-visits a n d f o l l o w - u p s m a d e b y community workers from ACF and the local NGO, the child did not show significant improvement even after being discharged and receiving appropriate counseling. Gyarsi died due to diarrhea just 4 months after being detected SAM.

Kunjawati from Suwas village died at the MTC on September 25, 2014 d u e t o c o m p l i c a t i o n s o f pneumonia. She was detected as SAM in April 2014 and admitted to MTC for 29 Days in July. In September, Just 6 months after her stay at the MTC, she was re-admitted but did not survive.

In the months of September - October, 10 children like Gyarsi and Kunjawati have died ( 1 at the MTC and 9 in the community) due to malnutrition related diseases in ACF's interventions areas in district of Baran.

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Challenges and limitations of the intervention

• GAM and SAM prevalence of Kishanganj block has not decreased, remaining alarmingly higher than the thresholds admitted by WHO

• Seasonal peaks of acute malnutrition are not anticipated enough:

◦ Post-monsoon season has shown higher number of deaths since the past 3 years of intervention

◦ MTCs are overcrowded in these seasons of acute malnutrition and can not respond to all the needs of SAM treatment

• Large-scale migration happens twice in a year and threatens the nutritional status of children under 5 (The reasons being multiple, with the workload on women increasing and therefore less time available for proper care practices, etc.)

• The current MTC treatment regimen cannot respond to all the needs of SAM children present in Kishanganj block.

• Several SAM children are discharged without being cured from these nutritional centres due to inadequate treatment, lack of bed availabilities there is need to strengthen the existing protocol for SAM management.

• The ICDS workers and the Anganwadi in place at community level are not equipped to handle management of acute malnutrition and therefore, there is no appropriate response for SAM or MAM.

• Consequently, there is no continuum of care available for these children when they are back at their villages.

• There is a preference for traditional ways to treat diseases due to economic reasons and difficulty to avail and then comply with the MTC services.

With all the above challenges, there is an urgent need of committed actions from higher-level ministries so that policies and programs are designed to address SAM in the country.

Facts from Kishanganj, Baran, alarming and needing urgent considerations:

Findings Facts to consider

In the peak summer months, when detection of new SAM cases arises, the MTC's bed capacity is even more alarming.

Regarding those admitted, there is high rates of drop-out due to multiple reasons (workload, other siblings, lack of understanding etc)

There is no continuum of care because the community does not have the means to initiate or to take over the management of the SAM child for his/her treatment until complete recovery.

There is an urgent need to address the issues raised in the table above.

With such high seasonal detection of new SAM cases and given the current bed capacity, admissions are not possible and therefore, children may get released from the MTC despite their fragile nutritional status. There is no other solution than the MTC to treat these children, and they have to be followed-up at home without appropriate and adapted treatment.

Given there is limited social support for thefamily left at home, with the mother not available, and other children to take care of, there is a need to look at approaches that allow those who can be treated through a community-based Outpatient Treatment centers.

There is an urgent need to implement a system of community-based management of acute malnutrition to directly cure SAM children without medical complications at home level. This entails regular community detection of SAM children, counseling and education sessions, home follow up of these children, and adapted therapeutic food responding to WHO requirements that can be provided to the family for home-use.

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Recommendations

Community action and involvement is necessary to adopt the Community-based Management of Acute Malnutrition approach. Involving caregivers and authorities in planning processes for identification, treatment, and prevention of malnutrition. Without this, there will be no change in the statistics.

The CMAM approach has 4 components:

1. Under-nutrition awareness and prevention to reinforce Community mobilization:the community ownership, early detection and referral with subsequent follow-up.

2. Once the community workers detect the Outpatient Therapeutic Program (OTP):SAM children, they are referred to the nearest OTP. The OTP sites will open once in a week following a regular rotation, and will admit SAM children without medical complications and provide them appropriate follow-up and home-based treatment. The location of these sites will be strategically determined based on the current program catchment area. A clear therapeutic protocol would need to be prior developed and validated based on national guidelines and latest WHO recommendations. An adapted home-based treatment will allow a recovery for SAM children directly within their community, increasing the coverage of the program and easing the follow-up process when compared to the current facility-based response of 14-day of MTC hospitalization.

3. As currently implemented, moderate Supplementary Feeding Program (SFP):acute malnutrition (MAM) children will keep on being referred to the nearest Anganwadi Centre (ICDS program) to receive supplementary food ration, preventing the risk of deterioration to a SAM condition.

4. In the case of a CMAM approach, this component would mainly Inpatient care:focus on the facility-based treatment of SAM children with medical complications only, threatening their lives and recovery.

The CMAM approach helps creating long-term community-based therapeutic care program to continue throughout the year and decentralizes malnutrition care and treatment, increasing the coverage and making it more accessible to children residing in interior villages.

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Set up an Emergency response system for peak seasons.

Given the seasonal nature of the problem and the monsoons being 'a season of death' , a nutrition surveillance system is essential to ensure that different actors ( NGOs, Government, MTCs) are prepared and ready to meet the emergency with an appropriate response.

Convergent action is necessary.

Involving all government departments and NGOs that relate to malnourished children and their families is essential so that relief efforts can be coordinated. Not only Health and WCD departments need to work together to ensure this, but other departments such as Water-Sanitation, Education, Rural Development , Panchayati Raj, PDS and Agriculture also need to converge as recommended in the Block Operational Plan document of the Coalition of Food and Nutrition Security (www.nutritioncoalition.in)

Nutrition Training for Frontline workers: ANM, ASHA, AWWs and helpers

Continue to provide on the job training to all frontline workers on malnutrition identification, treatment, and prevention.

Use criterion for detection, as recommended by WHO updated guidelines

Use the MUAC tape and checking of nutritional oedema for community screening and the MUAC, WHZ and oedema criterion for admission and discharge at the OTP and NRC. Make provisions for measuring boards, weighing machines, and MUAC Tapes at all AWCs and with all ASHAs such that detection of SAM is early and easy.

Therapeutic Feeding programs

Ensure all feeding programs – PDS, Anganwadis and State programs that address malnutrition - are well coordinated in order to ensure that food and care reach the most needy children.

Production, procurement and approval upon the use of adapted therapeutic foods matching with WHO specifications, for acutely malnourished children will ensure that SAM children without medical complications could be treated at community level and SAM children with medical complications will receive appropriate therapeutic milk when hospitalized in the MTCs.

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Contact us:

ACF-India (Action Against Hunger)

Thomas Gonnet, Executive Director Email: tgonnet@actioncontrelafaim.org

Dr. Rajiv Tandon, Deputy DirectorEmail: deputycd@in.missions-acf.org

Le Minh Tram, Head of Nutrition & Health DepartmentEmail: cmn@in.missions-acf.org

Address: D-14, 3rd Floor, Lajpat Nagar II, New Delhi 110 024

Website: www.actioncontrelafaim.org/en

Action Against Hunger | ACF International is a humanitarian organization committed to ending world hunger.

Recognized as a leader in the fight against malnutrition, Action Against Hunger | ACF International saves the lives of malnourished children while providing communities with access to safe water and sustainable solutions to hunger. With 35 years of expertise in emergency situations of conflict, natural disaster, and chronic food insecurity, ACF intervenes in over 40 countries benefiting seven million people each year.

ACF's 5,000+ professionals worldwide carry out innovative, life-saving programs in nutrition, food security & livelihoods, health, water, sanitation and hygiene through direct assistance and capacity building programs, in collaboration with government ministries and other Civil Society Organizations. Committed to principled humanitarian action, ACF restores dignity, self-sufficiency and independence to vulnerable populations around the world.

For more information, visit us at: www.actioncontrelafaim.org/en

Document written by: Kavita AyyagariPhoto credits - ACF India