Greetings! I am Dr Charulatha Banerjee, one of ENN’s Regional KM specialists working in Asia. 

On the 9th of January I visited the Indian state of Jharkhand to meet stakeholders working in nutrition. Jharkhand is a very recent "member state" of the Scaling Up Nutrition (SUN) Movement, joining in September 2016, it is the 3rd Indian state to sign on to this global initiative. Jharkhand joins the states of Uttar Pradesh and Maharashtra, and 58 national governments in Asia, Africa and Latin America that have committed to working towards reducing their high burden of malnutrition. 

Jharkhand is a relatively new state; it was carved out of the state of Bihar less than 2 decades ago. It has a population of 32 million people, 37%of which are living below the poverty line. According to the latest survey¹nearly half of all the children below the age of 5 are stunted (47.4%) and 3.7% of children (close to 250,000) in this age group suffer from Severe Acute Malnutrition (SAM).  

The Jharkhand State Nutrition Mission (JSNM) is the State Government entity leading on nutrition programming. The Mission kicked off 2017 by calling a Round Table meeting of development partners and other civil society actors working on nutrition issues in the State with the purpose of formulating action plans for pilots to address Community based Management of SAM. 

Till date, treatment of SAM children in India has been only through facilities called Nutritional Rehabilitation Centres (NRCs) across the country, known as Malnutrition Treatment Centres (MTCs) in Jharkhand-  which are established within health facilities at the block level (sub district level administrative units). In this current model coverage is limited. Barriers to inpatient treatment (which requires a minimum of 2 weeks) are similar to those identified in other locations such as the household burden of work, mothers unable to leave siblings at home, wage loss and a failure to recognise the need for urgent attention unless the child became visibly ill. Many children do not reach centres even after identification and there is a high defaulter rate of those who do manage to reach.  

Community Management of Acute Malnutrition (CMAM) in India has not been implemented at scale and the evidence for CMAM has been mostly through research studies.  Opposition to the use of Ready-to-use Therapeutic Food (RUTF) which was strident a few years ago, has petered down and states have, with assistance of development partners, rolled out CMAM pilots. The absence of a National Guideline has resulted in a variety of different operational models emerging, all following the global CMAM technical guidelines. Keeping in mind the diverse geographical and social context across India, a non-uniform operational model might well be the most suitable approach. The Government of India has tasked UNICEF with setting up CMAM pilots in 13 blocks in 13 states, including Jharkhand. An important step taken by the Jharkhand state is the creation of a cadre of Nutrition Counsellors (till date 6000) or Poshan Sakhis who are spread across 6 high prevalence districts. It can be expected that with appropriate training these workers will work closely with the Anganwadi centres to improve Nutrition practice. Anganwadi centres are part of a nationwide programme called the Integrated Child Development Scheme (ICDS) which provides basic health and nutrition services to children in the 0-6 age group and to pregnant and lactating women.  

At the Round Table in Ranchi in early January, World Vision, MSF and UNICEF presented detailed plans to start pilot initiatives for CMAM in high prevalence districts.   UNICEF and World Vision propose to deliver CMAM through the Anganwadi centres which are located in every village. As in its previous programme in the state of Bihar, MSF will deliver CMAM through health centres. The Anganwadi centre situated in every village seems to be the natural choice of vehicle for the delivery of CMAM, however, given the requirement of the Anganwadi workers to cope with the additional responsibility of correctly measuring and identifying children means the success of this approach is yet to be seen.  It is expected that lessons from these pilots will point in the direction of the vehicle most suited to deliver CMAM on the ground.

A debate that came up during the Round Table was whether to use MUAC or WHZ score to identify SAM children. Data presented by MSF (collected through a SMART survey done in one block) showed that Global Acute Malnutrition (GAM) levels were twice the WHO defined emergency threshold but with nil mortality. This discordance between high prevalence of acute malnutrition and mortality has been noted in few other sites in India also and is in sharp contrast to findings from Africa. Possible reasons for this are the existence of a safety net which allows children to hang in there in India-  a safety net composed of a healthcare network of unqualified practitioners who provide primary care (albeit imperfectly) at all times in addition to public provision schemes such as Mahatma Gandhi National Rural Employment Guarantee Scheme (MNREGS) and the  Public Distribution System (PDS) which function to a lesser or greater extent. Simply put, children live but do not thrive.  

Lastly, there was discussion at the Round Table about whether a therapeutic approach would completely dominate nutrition programming overshadowing preventive programmes; such concerns deserve to be given due cognisance. Jharkhand was in 16th place on the State Hunger Index out of the 17 states in a recent assessment. We also know that sanitation, another key determinant of nutritional status, is dismal with only 15% of the population having access to a sanitary facility and that there are low rates of exclusive breast feeding, poor dietary diversity and improper complementary feeding which all need urgent attention to prevent children from becoming severely malnourished in the first place. If these determinants are not addressed as part of the State’s efforts to scale up nutrition, the potential gains from scaling up treatment approaches will be short lived for the individual child and the community at large.  

There is work to be done at all levels in this state - identification of Nutrition sensitive programmes within all sectors, clear articulation of implementation plans, reallocation of resources towards nutrition actions and establishing a monitoring and accountability mechanism. It is here that the coordinating and convening role of the State Nutrition Mission will be critical. Additionally, it is essential that the Mission recognises and harnesses the capacities of local NGOs working on Nutrition in the state who are well connected with the communities. At the Round Table meeting, the Mission formed a Technical Assistance Group with all partners implementing interventions to address SAM -I will continue to follow the work of this group in my capacity as an ENN Knowledge Management Specialist and will support documentation and facilitation of exchange and learning with others in the sector. It is hoped that with the high political will and commitment to render Jharkhand free of malnutrition, the state will leverage its late mover advantage to ensure a better future for its children. Watch this space. 

(To understand more about the evolution of the Nutrition Mission including work done so far and plans for the future please see this video interview with Ms Mridula Sinha Director General of the Jharkhand State Nutrition Mission)

¹ (WHZ score <-2sd - 32.7% MUAC<125mms 9.6%)