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

Table 4: Proportion (%) severely underweight
children under three years of age
State
Weight for age
percentage of the
median < - 3SD*
% change
NFHS 2
(1998-99)
NFHS 3
(2005-6)
India 18 15.8 -2.2
Madhya Pradesh 24.3 27.3 +3
Gujarat 16.2 16.3 +0.1
Andhra Pradesh 10.3 9.9 -0.4
Bihar 25.5 24.1 -1.4
Delhi 10.1 8.7 -1.4
Assam 13.3 11.4 -1.9
Tamil Nadu 10.6 6.4 -4.2
West Bengal 16.3 11.1 -5.2
Rajasthan 20.8 15.3 -5.5
Uttar Pradesh 21.9 16.4 -5.5
Maharashtra 17.6 11.9 -5.7
Orissa 20.7 13.4 -7.3
*Based on NCHS to facilitate comparison
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
Valid International, India
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
Members of Self Help Group making blended cood
for children under 3 years, Kalahandi district
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
Postscript
CMAM in India: What happened next?
By Bernadette Feeney and James Lee
Bernadette Feeney is a Technical
Advisor with Valid International.
She is a nurse and public health
nutritionist and provides technical
support on implementation of
CMAM in both emergency and
non emergency contexts.
James Lee is a member of Valid
International’s management team
and is responsible for the organisation’s
work in India.
State-level actors in India have been quick to
use the momentum established at the
Community based Management of Acute
Malnutrition (CMAM) Conference in Addis
Ababa to take forward the severe acute malnutrition
(SAM) agenda. States have considerable autonomy
under India’s federal system and have a critical role
in service delivery. Consistent with the powerful
Indian civil society presence in Addis, next steps have
been orchestrated in a three-way discussion between
the NRHM 1 , the DWCD 2 (which oversees the ICDS 3 )
and India’s Right to Food movement, with additional
participation from UNICEF, donors and technical
advisors present at the Addis conference. An obvious
starting point for India CMAM planning has been the
agreement by all parties that an energy rich nutrient
dense therapeutic food formulated to meet the nutritional
needs of a child with SAM ]used in State
CMAM programmes must not be of foreign manufacture
or produced for-profit. With a lead time of at
least six months before alternative RUTF local manufacture
can begin, investigation of the manufacturing
options is proceeding in parallel with planning for
CMAM pilot programmes.
Two states, Odisha and Madhya Pradesh (both
represented in Addis), are currently in the process of
designing pilot programmes intended to furnish
1
National Rural Health Mission
2
Department of Women and Child Development
3
Integrated Child Development Services
88