Managing severe acute malnutrition in India: prospects and Challenges

By Biraj Patnaik

Biraj Patnaik is the Principal Adviser to the Commissioners of the Supreme Court of India in the right to food case. He is also associated with the Right to Food Campaign in India. This paper reflects his personal views.

This article is based on a case study and presentation delivered by Biraj Patnaik for the Addis Ababa Conference on CMAM scale up in November 2011. He describes the scale of nutritional problems in India, current institutional mechanisms, and challenges in addressing the SAM burden in particular. Jamie Lee and Bernadette Feeney (Valid International) were invited by the India delegation to describe a number of developments in India since the conference around CMAM that are shared in a postscript.

The context

Self Help Group outsde their facility for making blended food for children under 3 years

Despite being the second fastest growing economy in the world, India continues to harbour some of the worst social sector indicators. India has the highest burden of child malnutrition in the world, with 42.7% of children under 5 years of age (U5s) classified as underweight (low weight for age). Twenty per cent of children under five years of age are wasted (low weight for height). The child prevalence of malnutrition in India is twice that of Sub-Saharan Africa and more than one third of the world’s children who are wasted live in India. Forty eight per cent of U5s (61 million children) are (low height for age) due to chronic undernutrition, accounting for more than 3 out of every 10 stunted children in the world¹.

According to the most recent National Family Health Survey (NFHS 3, 2005-06), one third of children are born with a low birth weight. The percentage of under three year olds (U3s) who are anaemic has actually increased from 74.2 per cent to 79.2 per cent and immunisation coverage has decreased slightly from 26.9 per cent to 26.2 per cent. A recent survey by the National Nutrition Monitoring Bureau (NNMB 2007) shows that there is a daily deficit of over 500 calories in the intakes of children in the age group of 1-3 years and about 700 calories in children in the age group 3-6 years.

The fact that these figures are the most "updated" and that data on malnutrition is not compiled more regularly, is in itself reflective of the failure of the country’s policymakers to appreciate the seriousness and scale of the problem of child malnutrition in India. What is even more worrying is the lack of progress in tackling child malnutrition. In 1999, NFHS 2 had estimated the child malnutrition rate at 47%. Only a one percent reduction in the intervening six years, between NFHS 2 and NFHS 3, points to a serious crisis in tackling malnutrition. Table 1 (NFHS 3) reflects the indicators at the national level on a range of nutritional indicators.

While the problem of malnutrition is endemic across the country, some states bear a more than disproportionate burden of hunger and malnutrition. Figure 1 (IFPRI, Global Hunger Index, 2010) classifies all the states/union territories with respect to three indicators of child malnutrition, infant mortality and percentage of persons consuming less than 1700 calories per day. The map demonstrates how the regional distribution of malnutrition in the country varies widely, with Madhya Pradesh having the highest proportion of malnourished U3 children (60%) and Mizoram with the lowest percentage (19.9%).

There has been uneven progress in the reduction of malnutrition in India, in terms of regional variations. Table 2 summarises the performance of the best performing States between the two NFHS surveys (1999 and 2006). Sixteen states reported a reduction in child malnutrition between 1999 and 2006. However, 13 states reported an increase in child malnutrition, in the corresponding period. Even Kerala, which is also by far the best state in India with respect to most social indicators, showed a marginal increase in child malnutrition rates. Table 3 summarises the worst performing states. Ironically, some states with the highest per capita income in country, including Punjab, Haryana and Gujarat, showed an increase in the child malnutrition rates.

Note: Based on NCHS references for comparative purposes

Note: Based on NCHS references for comparative purposes

The causes of malnutrition in India are due to a variety of factors, including low birth weight of babies, early marriage and pregnancy, low status of women and lack of access to quality health care at the primary level. India has the highest rate of open defecation in the world (58% of the global total), poor access to potable drinking water and cultural practices that inhibit early initiation of breastfeeding. Young children also do not have access to quality foods when they are introduced to complementary foods and consume foods that have low nutrient inputs. Programmatic interventions for preventing malnutrition are therefore likely only to succeed if they are multi-dimensional and are focused as much around prevention as around dealing with the consequences of malnutrition.

The burden of SAM in India

While there is some consensus on what constitutes severe acute malnutrition (SAM), there is still considerable debate in India as to the extent of SAM in India. The Indian Association of Paediatrics (IAP) has accepted the definition of SAM adopted by WHO and UNICEF (see Box 1). The IAP’s recommended diagnostic criteria (2007), adapted from the earlier WHO guidelines, are weight for height/length below 70 per cent or 3SD of NCHS median and/or visible severe wasting and/or bipedal oedema. Mid upper arm circumference (MUAC) criteria may also be used for identifying severe wasting.

The NFHS 3 data shows 19.8 per cent of Indian U5s children as wasted and 6.4 per cent of U5s children as severely wasted. In terms of numbers this would translate to almost astounding 8 million children in India who are severely wasted out of the 25 million children who are wasted (See Figure 3).

The burden of SAM in India is disproportionate to the population and this is evident from the fact that with just 16 per cent of the world’s population, India has close to 42 per cent of the severely wasted children of the world. Even for the number of children who are wasted, India compares very badly with Sub-Saharan Africa. The number of children below the age of five is roughly around 125 million both in India and in Sub-Saharan Africa. However, the number of children who are wasted is 11 million for Sub-Saharan Africa and 25 million for India.

Anganwadi worker with Members of Anganwadi or Janch Committee, Kalahandi district

In terms of the regional variation within India, the burden of SAM is most prominent in those states which also have a high burden of poverty and malnutrition, as reflected in the regional desegregation of the Global Hunger Index given above. The states of Uttar Pradesh, Madhya Pradesh and Bihar are the three states with the highest burden of SAM in India. In some states, a disproportionate number of girls are affected as compared to boys (58 per cent and 67 per cent respectively in Madhya Pradesh and Bihar). These figures are particularly stark, given the already adverse sex ratios in these states.

SAM surveillance

The NFHS (conducted once every five years) collects data on severely wasted children. However routine surveillance for malnutrition undertaken by state governments does not collect any data whatsoever on the prevalence on SAM -MUAC and data on heights are not part of the routine data collected at the Integrated Child Development Services (ICDS) centres run by the Government.

The ICDS (which is the only institutionalised mechanism for dealing with child malnutrition in the country) show severe under-reporting of children who are severely wasted (of child malnutrition in general), as compared to the data compiled by NFHS.

ICDS in practice

The ICDS was initiated more than three decades ago in 1975 and is the only institutional mechanism of the state for addressing issues affecting children under six years of age. Following a Supreme Court Order in 2011 the service guarantees universal coverage to 160 million children under the age of six years through delivery of six essential services (including supplementary feeding) through a network of 1.5 million centres.

Problems with the ICDS include excessive focus on the age-group of 3-6 years and not 0- 2 years, the age when malnutrition manifests itself the most. The system also lacks a regular nutritional surveillance system and does not collect data on severe wasting. It is plagued with problems of understaffing (one worker per centre) which does not allow for nutritional counselling, pre-school education or effective community management of acute malnutrition and has no convergence with health programmes run by the government.

The Supreme Court of India set calorie and cost norms for the supplementary feeding element of the service for children from 6 months -3 years, 3-6 years, pregnant and nursing women, and adolescent girls. Crucially, it also banned the role of the private sector in all supplementary feeding programmes due to prevalent widespread corruption. It re-iterated the order banning all private contractors from ICDS in 2006 and 2009 and monitored the removal of contractors from the system. Insistence of the Supreme Court on the removal of the private sector has had a role in the prevention of the spread of privately manufactured Ready to Use Therapeutic Food (RUTF) for the treatment of SAM and has been widely used by civil society to push for local production of calorie-rich, energy dense foods in the public sector at an appropriately decentralised level, especially through community groups and public institutions.

The ICDS is perceived by many in official policy circles as having failed to tackle the problem of child malnutrition. Yet, the experience in the field has been varied. In many states, where it has been allowed to grow to its full potential (it is a centrally funded scheme implemented by the state governments), it has managed to achieve its original objectives. However, many key issues at the programme level remain inadequately addressed in the ICDS.

Universal coverage of beneficiaries

The instructions of the Supreme Court have been categorical to ensure the coverage of all children below six years, all pregnant and lactating mothers and adolescent girls in all rural habitations and urban slums with all nutritional and health services of the ICDS in a phased manner by December, 2008 at the latest.

Although the coverage of children under six under the Supplementary Nutrition Programme (SNP) of the ICDS increased between 2007-08, less than 60% of the under 6 population are identified by the ICDS centres (anganwadis (AWC)) in the country. The NFHS-3 data show that 81 per cent children under 6 years of age were living in an area served by an AWC. About 20 per cent children have not even been covered by the AWC survey and can be assumed to be left out of any of the AWC benefits. Therefore, only about 46 per cent of children are covered by the SNP services of the ICDS.

Universal coverage of habitations

The Supreme Court in various orders directed the Government of India and the State/UT governments to ensure that there is an AWC in every habitation.

While most of the states have made good progress in the operationalisation of sanctioned AWC, Jammu and Kashmir is yet to operationalise more than 30% of the AWCs. In Chhattisgarh and Maharashtra, about 10-15% of the AWCs are yet to be operationalised (see Figure 5).

Finances

ICDS is a centrally-sponsored scheme implemented through the state governments/UT administrations with 100% financial assistance for inputs other than supplementary nutrition which the States should provide out of their own resources. From 2005-06, it has been decided to extend support to States up to 50% of the financial norms or 50% of expenditure incurred by them on supplementary nutrition, whichever is less.

The cost of supplementary nutrition varies depending upon recipes and prevailing prices. However, the central government issues guidelines regarding cost norms from time to time. The Government of India issued new guidelines in November 2008 that were to be effective from 2009-10 (see Box 2).

Analysis shows that at an all India level, Rs. 1.78 was spent on each beneficiary per day in 2007-08 (beneficiaries include both pregnant and lactating mothers and children under six years). The states that spent less than Rs. 2 per beneficiary per day are Assam, Orissa, Jammu and Kashmir, Delhi, West Bengal, Gujarat, Uttar Pradesh, Rajasthan, Maharashtra and Chhattisgarh. States spending less than Rs 1.50 per beneficiary per day are Gujarat, West Bengal, Delhi, Jammu and Kashmir, Orissa and Assam (see Figure 6).

Severe undernutrition (or wasting)

The main objective of ICDS scheme is to tackle malnutrition among children under six years. The NFHS that are conducted at regular intervals give an estimate of the proportion of undernutrition in different states in the country. Table 4 shows the proportion of children U3 who are severely underweight based on NFHS in 1998-99 and 2005-06. It demonstrates that according to the latest survey, 15.8% of children are severely underweight in the country and that this has decreased by only 2.2 per cent in the seven year period between the two rounds of the NFHS surveys. Further, in some states, the percentage of children who are severely underweight has actually increased in this period.

*Based on NCHS to facilitate comparison

However, the data maintained at the AWCs shows gross under-reporting of severely (grade III and IV²) malnourished children. According to a report prepared by NIPPCD (National Institute of Public Cooperation and Child Development) for the Ministry, the percentage of Grade III and Grade IV as per state government records is now only 1 per cent in 2006. In cases of children between 3 and 5 years of age, the percentage of children in Grade III & IV has reduced to 0.8 per cent (2006). These figures are totally at variance with the NFHS-3 figures of 15.8 per cent children being severely malnourished³.

The two critical gaps in the ICDS across the country on which there remains considerable consensus is that the programme focuses on the age group of children in the age group of 3-6 years, whereas much of child malnutrition in the country affects children before the age of two years. It is now widely acknowledged that this wasted ‘window of opportunity’ should become a corner-stone for recasting the programmatic priorities of the ICDS. The other major problem that has also been clearly identified is the lack of adequate staff at the ICDS centres. The lone ICDS worker in the Centre is clearly unable to cope with the multiple demands that are made on her time. As a result the outreach services for breastfeeding and complementary feeding counselling and the pre-school education are virtually non-existent in most ICDS centres in the country.

Members of Self Help Group making blended cood for children under 3 years, Kalahandi district

India has been very slow at initiating the community based management of acute malnutrition (CMAM) model. In 2006/7, there were discussions around the role of RUTF in community based therapeutic care for SAM. Consensus in civil society was difficult to achieve since treatment of SAM using RUTF was perceived by donors as a ‘magic bullet’ with little emphasis on the continuum of care for all children, including the prevention of malnutrition. There was particular concern about the programme being product driven without a strong community component. Civil society kept raising the fundamental issues of looking at CMAM not as a magic bullet with RUTF as the only solution but as merely one component of a larger continuum of care, including preventative activities with links to social protection.

There were some initial experiments with CMAM (implemented by UNICEF) using imported RUTF. However, the UNICEF project was closed by the Government of India on grounds of lack of permission to use imported RUTF in 2009. Since then, there have been a number of smaller scale pilot projects initiated by community groups using local foods (JSS in Chhattisgarh and CINI-ASHA in multiple sites). Simultaneously many states have initiated institutional treatment of SAM (through Nutritional Rehabilitation Centres) and states like Madhya Pradesh have included the protocol for CMAM as part of the official missions to tackle malnutrition.

A key milestone was a consensus workshop on the treatment protocol for SAM for India (2009) which brought together a wide range of stake-holders. There is now more consensus, especially in State Governments like Orissa and Madhya Pradesh, on what needs to be done to move forward, even though some groups in civil society continue to harbour reservations. This consensus converges around the need for evidence of impact of community based management of acute malnutrition, the role of the public sector in production, involvement and ownership of local communities in line with recommendations by the Supreme Court, and eliminating the role of the private sector.

Evidence based scale-up will require the following:

• Trials to compare approaches that do not use RUTF with those that use local foods.
• Clear distinction between therapeutic treatment and infant and young child feeding.
• Locating treatment of SAM in an integrated continuum of care that promotes good practices (such as exclusive breastfeeding).
• Impact monitoring, particularly coverage and scale.

There remain many concerns about the role of the private sector. In particular:

• Absence of a comprehensive governance framework for the private sector.
• Regulatory standards used by donors often used as a alibi for creating entry barriers for local producers.
• Historical monopolies created for proprietary products.
• Competitive advantage given to companies in developed countries through discriminatory procurement procedures.

Where are we now (November 2011)

Yet in spite of all these concerns and the need for greater evidence, the need for a new model for SAM treatment is clear. In Madhya Pradesh, there is a dramatic under capacity for treatment of SAM using the model of institutional care alone. Treatment capacity is for approximately 70,000 cases but the case load is an estimated 830,000. There is now a state strategy for integrated management of SAM (IMSAM) using facility and community based interventions. This is due to be piloted first in four districts and then scaled up to the entire state. However, the effort required to train and secure the commitment of frontline service providers is quite daunting.

The numbers of local staff who need to be trained in the community management of SAM are 90,000 ICDS workers, 50,000 community health volunteers, 20,000 health workers and 52,000 village health, sanitation and nutrition committees.

Recent efforts in Madhya Pradesh have focused on the creation of capacity in the public sector to produce therapeutic food. Similarly in Orissa, the treatment of SAM is being approached, like in MP, as a continuum of care, and not revolving around the delivery of the therapeutic product. Orissa is also attempting to innovate in the production of therapeutic food by using self help groups of women, who are currently producing complementary food, to produce therapeutic foods.

Even while the federal government in India continues to dither on dealing with the problem of child malnutrition, State Governments, including Madhya Pradesh and Orissa, have seized the initiative to take the treatment of SAM forward.

For more information, contact: Biraj Patnaik, email: biraj.patnaik@gmail.com

¹Source of prevalence figures: UNICEF, accessed June 2012 http://www.unicef.org/india/nutrition.html

²Grade III: <60% weight for age and Grade IV: <50% weight for age

³See also a recent paper Prasad et al, 2012. Falling Between Two Stools: Operational Inconsistencies between ICDS and NRHM in the Management of Severe Malnutrition. Indian Paediatrics. Vol 49. March 2012. http://www.righttofoodindia.org/data/icds/March_2012_falling_between_two_stools_ operational_inconsistencies_icds_nrhm_severe_malnutrition_vprasad_dsinha_sridhar _indian_pediatrics_16 _march_2012.pdf