Download a PDF of this issue - Field Exchange - Emergency ...

Field Article
(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.
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
Valid International, India
Anganwadi worker with Members of Anganwadi
or Janch Committee, Kalahandi district
Table 2: Best performing states with regard to trend in
child malnutrition (weight for age) prevalence
(NFHS 2 & NFHS 3)
NFHS 2
(1998-99)
% of U3s child
malnutrition
NFHS 3
(2005-06)
% of U3s child
malnutrition
Orissa 54.4 44.0 10.4
Maharashtra 49.6 39.7 9.9
Chhattisgarh 60.8 52.1 8.7
Himachal 43.6 36.2 7.4
Pradesh
Rajasthan 50.6 44.0 6.6
Note: Based on NCHS references for comparative purposes
% decline in
U3s child
malnutrition
Table 3: Worst performing states with regard to trend in
child malnutrition (weight for age) prevalence
(NFHS 2 & NFHS 3)
NFHS 2
(1998-99)
% of U3s child
malnutrition
NFHS 3
(2005-06)
% of U3s child
malnutrition
Assam 36 40.4 4.4
Jharkhand 54.3 59.2 4.9
Madhya 53.5 60.3 6.8
Pradesh
Haryana 34.6 41.9 7.3
Note: Based on NCHS references for comparative purposes
Box 1: Definition of SAM (WHO/UNICEF)
% increase
in U3s child
malnutrition
The “criteria for severe acute malnutrition in children
aged 6 to 60 months include any of the following:
(i) weight for height below –3 standard deviation (SD
or Z scores) of the median WHO growth reference
(2006),
(ii) visible severe wasting,
(iii) presence of bipedal oedema and
(iv) mid upper arm circumference (MUAC) below 115mm”.
Figure 2: Prevalence of child wasting in India
(0-59 months old)
Percentage
25
20
15
10
5
0
19.8
wasting
(W/H