Community management of acute malnutrition in Rajasthan, India

This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Daya Krishna Mangal and Shobana Sivaraman.

Daya Krishan Mangal is Professor and Dean of Research at the IIHMR University, Jaipur.

Shobana Sivaraman is Senior Research Officer for IIHMR University, Jaipur.

GAIN, UNICEF and other development partners supported the Community Management of Acute Malnutrition (CMAM) approach in Rajasthan. The authors would like to acknowledge Dr Abner Elkan Daniel, Child Development and Nutrition specialist, UNICEF India and Deepti Gulati, Head of Programmes, GAIN India for providing insight and technical expertise during the implementation of the CMAM programme described here.

Background

Malnutrition in India

Despite economic growth in recent years, it is estimated that half of the world’s wasted children live in India and that malnutrition is the underlying cause of two thirds of child deaths. Latest national estimates suggest that 38% of children under five years of age are stunted and 21% are wasted. In the northwestern state of Rajasthan, rates of wasting have substantially increased from 11.7% in 1999 to 23% in 2016, making it a high-priority state for nutrition interventions.

India’s nutrition policy, developed in 1993, adopts a multi-sector approach to tackle malnutrition. Most recently, the Proactive and Optimum care of children through Social-Household Approach for Nutrition (POSHAN Abhiyaan) programme has been implemented by the Government of India (GoI). This is a multi-ministerial convergence mission to integrate all nutrition-specific and nutrition-sensitive interventions with the vision of eliminating malnutrition in India by 2022.

Treatment strategies to address severe acute malnutrition in India

The growth of children under five years is regularly monitored by frontline health workers across India. These include auxiliary nurse midwives (ANMs), posted at sub-centres and primary health centres, and community-level Anganwadi workers (AWWs). Children identified as having severe acute malnutrition (SAM), with or without medical complications, are referred to the nearest malnutrition treatment centre (MTC) or nutrition rehabilitation centre (NRC) for medical care and nutrition therapy. Limitations of this system include low coverage, the high costs of providing and accessing facility-based management of SAM and the acceptability of inpatient facilities in remote, rural populations. Steps have therefore been taken to test the utility of a community management of acute malnutrition (CMAM)¹ approach in India.

CMAM in India

CMAM was introduced in India in 1999 by Médecins Sans Frontières as an emergency response. The programme demonstrated low mortality rates (0.8%) and high cure rates (57.4%) for non-defaulting children. In 2015, the Government of Rajasthan (GoR) National Health Mission (NHM), in partnership with UNICEF, Children’s Investment Fund Foundation (CIFF), Global Alliance for Improved Nutrition (GAIN) and Action Against Hunger (ACF), implemented CMAM through the POSHAN strategy. POSHAN I was implemented between 2015 and 2016 across 10 high-priority districts and three tribal districts of Rajasthan. Of the 6 to 59 month old children identified with SAM, 88% recovered after eight to 12 weeks of treatment. As a result, the CMAM approach (now called ‘integrated management of acute malnutrition’ (IMAM)) was scaled up under POSHAN II across 20 districts with high burdens of acute malnutrition in Rajasthan from November 2018. This was again implemented by the GoR NHM, in collaboration with UNICEF, CIFF, GAIN, ACF and Tata trusts.

POSHAN II implementation and outcomes

Screening and identification of SAM

In POSHAN II, CMAM services were provided through health sub-centres (POSHAN centres) through quality-trained ANMs and accredited social health activists (ASHAs, known as ‘POSHAN praharis’). POSHAN praharis used active case finding to screen 6 to 59 month old children in all households. Mid-upper arm circumference (MUAC) was measured and children identified with a MUAC of <12.5 cm were taken to the nearest POSHAN centre for weight, height/length and MUAC measurements. Children were also checked for bilateral pedal oedema and any medical complications, as well as given an appetite assessment using an energy dense nutritional supplement (EDNS). If a child had bilateral pedal oedema and/or any medical complication and/or failed the appetite test, he/she was referred to the nearest MTC, irrespective of anthropometric measurements. If the child’s weight-for-height z-score (WHZ) was <-3 SD and/or MUAC <11.5 cm, the child was identified as having SAM. SAM children without medical complications and with adequate appetite were enrolled in POSHAN II for management.

Community management of SAM

All enrolled SAM children were given a dose of albendazole for deworming, amoxicillin (a broad-spectrum antibiotic) and a weekly supply of EDNS according to their weight. The mother/caregiver was advised to feed the child the prescribed daily dose of EDNS, along with regular home-based food. The child’s weight, height and MUAC were assessed during a weekly visit to their nearest POSHAN centre and EDNS packets provided to their primary caregiver. Caregivers also received counselling on the use of EDNS and breastfeeding (children ≤24 months) practices, minimum meal frequency, handwashing practices, immunisations and healthcare seeking. POSHAN praharis provided daily household visits to SAM children in the treatment programme to ensure regular consumption of EDNS and to further counsel the mother/caregiver on adequate dietary intake and hygiene practices.

Children were followed up until they maintained discharge criteria (MUAC ≥12.5 cm and/or WHZ ≥-2 SD) for one week. Those who did not deteriorate during this time were categorised as cured and discharged from the programme. Children who did not recover after 12 weeks of treatment were referred to their nearest MTC for further investigation.

Programme outcomes

Of the 375,533 children aged 6 to 59 months screened during home visits, 10,344 were identified as having uncomplicated SAM and enrolled for treatment. After eight weeks, both default (10.6%) and death (0.1%) rates were low. Approximately 46% of children had not recovered by week eight and continued treatment from nine to 12 weeks. Mean weight gain of enrolled children after eight weeks (3.2 g/kg/day) was lower than international standards, as well as most other programmes in India. After 12 weeks, 70.2% of enrolled children had been discharged, 12.2% had defaulted, 17.2% had been referred for further treatment and 0.1% had died.

Independent impact evaluation of POSHAN II

An independent evaluation of POSHAN II was conducted by IIHMR between December 2018 and February 2019. A cohort of 1,322 SAM children aged 6 to 59 months was enrolled in the study from 70 POSHAN centres in five of the 20 programme districts. At baseline, 69.1% of children were enrolled in POSHAN II with WHZ <-3 SD, 16.2% with both WHZ <-3 SD and MUAC <11.5cm and 14.7% with MUAC <11.5cm. At eight weeks (midline assessment), 42.4% of children were cured, 4.1% had defaulted and 53.5% had not recovered and continued treatment. After 12 weeks (endline assessment), 66.9% of children were cured, 8.1% had defaulted and 25% had not recovered. Cure rates achieved after 12 weeks of treatment were favourable compared with international standards and other similar Indian studies.

Socio-cultural study of POSHAN II

The local context and cultural practices that may have influenced POSHAN II outcomes in SAM children were explored in a qualitative socio-cultural study. During focus group discussions and in-depth interviews with mothers, no differences in socio-demographic characteristics of cured, defaulted and non-recovered children were identified. There were also no patterns observed in the household food baskets between outcome groups and dietary diversity ranged substantially between households.

All SAM children had experienced a troubled medical history (e.g., vomiting, lack of appetite, diarrhoea and fever) and/or low birth weight (LBW) and lack of appetite from birth. Notably, some mothers of non-cured and defaulted SAM children reported extremely low levels of haemoglobin (as low as 5.5 g/dL) during pregnancy. However, most did not believe that they were undernourished and were not aware that their nutrition during pregnancy and lactation could impact on their child.  

Potential for the scale-up of CMAM in India

POSHAN II is the first large-scale CMAM programme of its kind in India. Programme outcomes suggest that SAM children without medical complications can be treated successfully in the community using EDNS. While the daily average weight gain was lower than international targets, this may reflect the Indian context. Improvements may be achieved through better counselling and supportive supervision of mothers to improve compliance with feeding advice. The programme has been well integrated within existing health systems, eliminating the need for a new cadre of health workers.

Given the expense of EDNS supplies, a significant challenge to scale-up is the sustainability of funding. However, based on the findings of the evaluation study, the IIHMR recommends that the GoR NHM adopts the CMAM strategy in Rajasthan to address the high prevalence of SAM in the medium term while the long-term cost benefit is being studied. Success of such a programme will require a robust management information system, training of the healthcare workforce, a recording and reporting mechanism and significant resources and supply chain management for EDNS. Findings from the socio-cultural study suggest that poor maternal nutrition and LBW are important drivers of SAM that must be tackled. Linkages with other government programmes and development partners to address this should be explored.

National scale-up of CMAM is also recommended and should be promoted through the Nutrition Mission and the release of updated national CMAM guidance. Following this, CMAM should be integrated into the training curriculum for medical professionals, nutritionists and frontline/community health workers.

Conclusion

POSHAN II in Rajasthan is the first large-scale CMAM/IMAM programme in India to be implemented for the treatment of severely malnourished children in the community. The success of the programme, and the CMAM approach, in this context has been demonstrated and provides reassurance that locally produced EDNS is safe, acceptable and facilitates rapid improvements in the nutritional status of severely malnourished children. The CMAM programme should therefore be integrated within primary healthcare services in Rajasthan and beyond. Success of implementation will depend on a high level of political commitment and collaboration with partner agencies to provide technical and financial assistance.

For more information, please contact Daya Krishna Mangal.