Posts Tagged ‘child nutrition’

17 Aug

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

Posted by vramani in health & nutrition, political economy, public affairs, public policy. Tagged: , , , , , , .

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/17/himalayan-blunders-in-healthcare-gorakhpur-and-beyond/

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped. Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulverma08) based on the replies to a Right To Information (RTI) query of 2011.

image 1 principal BRD Medical college RTI.png

Reply from the office of the Principal, B.R.D. Medical College, to an RTI application.

The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the non-functioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.

image 2 staffin shortage.png

Staffing shortages in medical and nursing personnel (Jan 2012)

The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 40% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.

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Status of equipment and machinery in PICU and NICU.

But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir Nagar, Siddharth Nagar, Maharajganj, Kushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care, medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per 1000 live births and of infants (0-1 year) from 62 to 87 per 1000 live births, with 80% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over 10% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.

gorakhpur tragedy hospital doctors watermark.png

The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons – especially children – constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confrères but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors – man-made and natural – have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”

10 Nov

Palghar – lessons for Maharashtra (and other states)

Posted by vramani in government, health & nutrition, public policy. Tagged: , , , .

It was that time of the year again…the rains came and, with them, the sense of déjà vu that stories of child deaths in tribal areas of Maharashtra evoke in the public mind. The procession seems endless: Melghat in the 1990s, then Nandurbar in the first decade of this century and now Palghar in the second decade of the twenty first century. The political and administrative actors have changed in the intervening years, economic and social changes have taken place in town and countryside but the same problem seems to return to haunt us with a recurring, almost numbing regularity. Opposition politicians (who seem to forget that they were in power for a decade and a half till very recently) are ready with their criticism of the first two years of the present ruling dispensation. The usual knee-jerk reactions are on full display, with Ministers of the concerned departments undertaking flying visits to the affected areas and attempts being made to rope in the medical fraternity, nonprofits and civil society to tackle the problem. Unfortunately, there is no well thought out strategy to tackle the problem of child malnutrition on a long-term basis, whether it be in Maharashtra or in any other state in India. It might, therefore, be apposite to outline what should not be the focus of public policy in the immediate future — both short and medium-term — and what strategy could yield handsome dividends in the next few years.

What is definitely a losing proposition is the obsessive focus on the centralised supply of nutrition to affected mothers and children. There seems to be a misconceived notion (at various levels of government, nonprofits and civil society) that augmenting supplementary nutrition to mothers and children through the existing channels of the Integrated Child Development Services (ICDS) system will help matters. The past (and more recent) history of state-directed and centralised nutrition provision through the ICDS system has been controversial, with repeated attempts (across many states) to circumvent the Supreme Court-directed policy of empowering local communities and families to meet the nutrition requirements of their mothers and children. The experience, over the last one year, of the Abdul Kalam Amrut Aahar Yojana in Maharashtra, aimed at providing one hot cooked meal to pregnant mothers and to nursing mothers in the first three months after delivery, has not been very heartening either, given the less than enthusiastic involvement of the ICDS machinery and the glitches in timely fund allocation to local committees tasked with provision of the nutritious meal. Since the National Food Security Act, 2013 has mandated a cash maternity entitlement of Rs. 6000 to mothers, in addition to access to food supplies through the Public Distribution System and through specific nutrition programmes for pregnant and nursing mothers, the possibility of cash transfer of the entire entitlement to women through Aadhaar-linked bank accounts needs to be closely looked at. This would not only check programme leakages but also reduce wasteful expenditure on overheads on state-run programmes. However, this requires a separate study, so the issue will not be further pursued here.

Reducing chronic malnutrition in under-5 (“U5”) children is a process that involves factors like accelerated economic development and the behavioural changes that rising income levels bring. But, rather than passively waiting for economic development to reduce child malnutrition, governments (and their extensive machineries) can take proactive steps in the short-term to reduce acute malnutrition (and the accompanying mortality) in U5 children. This article focuses on these measures.

The first step is the use of real-time, accurate data, based on anthropomorphic indicators, to get a grip on the exact geographical regions (going right down to every individual anganwadi) where child malnutrition levels are highest, be they remote tribal hamlets or congested urban slums. Currently, monthly recording of weight for age (based on the WHO growth norms) is the only criterion used to assess child undernutrition in the ICDS. This exercise is carried out (if at all) perfunctorily in anganwadis in most states in India. In any case, no systematic analysis of this data, for policy planning and implementation purposes, is undertaken by any official of the departments or directorates/commissionerates tasked with improving the status of child nutrition in India. What is needed is a rigorous exercise to weigh all children in the state every month. If this is not done monthly for logistic reasons (although required as per the existing job chart of the anganwadi worker), weights of all U5 children should be scrupulously recorded at least once in two months. The Jatak software, already developed for use in some areas of Maharashtra, Kerala and West Bengal, would enable porting child weight data online through use of interactive voice response systems and obtaining immediate anganwadi-wise data on the number of severely underweight (SUW) U5 children.

Step number two would involve the lists of these SUW children (anganwadi-wise) being made available online (through a web-based health module linked to the Jatak SUW child data) to the Primary Health Centres (PHC) in whose area the anganwadi falls. The Auxiliary Nurse Midwives (ANMs) and Accredited Social Health Activists (ASHAs) working in a PHC area would then record the height/length and weight of each U5 SUW child in the health sub-centre area, with this data being subsequently ported into the health module. The software would automatically provide to the PHC, anganwadi-wise, the list of U5 children falling in the severe acute malnutrition (SAM) category.

Once the U5 SAM children are identified, they need to be medically examined to assess whether their condition requires them to be admitted to Nutrition Rehabilitation Centres, also termed as Child Treatment Centres (CTCs) and located in Primary Health Centres. Children suffering from environmentally induced diseases (tuberculosis, pneumonia, etc.) or congenital conditions (sickle cell anemia, heart disease, etc.) would be admitted to CTCs. Apart from children requiring treatment at specialist medical facilities, others would stay in the CTCs for a period of up to thirty days. The treatment protocol prescribed by the WHO would be followed to improve the health and nutrition status of these SAM children. It would also be desirable to provide health, hygiene and nutrition education to the caregivers (mostly mothers) who stay with the children in the CTCs, so that there is no relapse in the nutrition status of the children after their return home. Maharashtra had started the salutary practice of providing an allowance to the caregiver staying with the child in the CTC to compensate for loss in wages; this was an added incentive to ensure that children were admitted to and underwent the full course of treatment in the CTCs.  Monitoring of the health and nutrition status of these children by health workers needs to be done regularly for one year after their discharge from the CTC to ensure there is no relapse.

Children in the SAM category not requiring medical attention can, along with children in the moderate acute malnutrition (MAM) category, attend the Village Child Development Centres (VCDCs) at the local anganwadis to receive supplementary nutrition at two hour intervals in accordance with a laid-down nutrition protocol. As the pioneer in developing the VCDC concept, which has been internationally acclaimed, it is unfortunate that the Government of Maharashtra has not financially supported this initiative for the past three years.

Zeroing in on the geographical areas with the worst incidence of severe wasting (SAM) in U5 children would definitely reduce child mortality, given that SAM children have a mortality rate over nine times as high as children in the normal category. It would also check the impairment of cognitive and physical capabilities of U5 children, enabling them to lead fuller, more productive lives as adults. The tragedy lies in the failure of governments in India to systematically adopt the approach outlined above. My experience as Director General of Maharashtra’s Rajmata Jijau Health and Nutrition Mission is that, when U5 child mortality occurs, no attempt is made to trace the case history of such children: specifically, their nutrition and health status in the months before their death and whether any efforts were made to improve this status. A systematic use of real-time U5 children nutrition data to enable focused health and nutrition interventions followed by rigorous monitoring of treated children on an ongoing basis would help reduce mortality rates. Even using the current ICDS projectwise monthly progress reports (MPRs) on U5 children nutrition status (in terms of child weights) would give some idea of the areas in a state most prone to child malnutrition. If we examine the latest available ICDS MPR for Maharashtra for March 2016 (available at www.icds.gov.in), we observe that the ICDS projects with the highest percentages of severely underweight children are largely located in the tribal pockets in the districts of Palghar, Nandurbar, Amravati, Nasik and Gadchiroli, the very areas which have been at the centre of child death controversies for over two decades. If all the ten states of India with a percentage of SUW children over 10 percent of the U5 child population, as revealed by the 2013-14 Rapid Survey on Children (RSOC) data released by the Ministry of Women and Child Development, Government of India, were to rigorously monitor the monthly weights of children, they can put in place strategies to tackle SAM and reduce mortality in U5 children in the high burden areas.

India has the rather dubious distinction of being ranked 120 out of 130 countries in the prevalence of wasting in U5 children (Global Nutrition Report 2016). The 2015-16 National Family Health Survey (NFHS-4) shows that large states like Maharashtra and Madhya Pradesh have as many as 14 (out of 35) and 23 (out of 50) districts respectively with a severe wasting (SAM) rate of over 10 percent of the U5 child population, while U5 child mortality rates are as high as 58 and 65 (per 1000 live births) respectively for Bihar and Madhya Pradesh. So what holds our governance systems back from taking positive, proactive steps? Firstly, a complete absence of focus on what is the extent of the problem, where the problem exists and what policy measures are needed. Secondly, a failure to enforce accountability (in the ICDS and public health bureaucracies) for high rates of child malnutrition and mortality. And, finally, indifference to the debilitating consequences of child malnutrition, which society and the polity contribute to through inaction on a variety of fronts and a lack of compassion.

14 Oct

Improving child nutrition: the way ahead for Maharashtra

Posted by vramani in government, health & nutrition, public policy. Tagged: , , , .

The recently released National Family Health Survey (NFHS-4) data on maternal and child health and nutrition outcomes in Maharashtra provides sobering food for thought. This data does not provide the cheer that the 2012 UNICEF Comprehensive Survey on Nutrition in Maharashtra (CNSM 2012) brought to Maharashtra, with the showing of a stunning reduction in under-2 child stunting rates (between 2006 and 2012) from 39% to 23% and a corresponding reduction in under-2 child underweight rates from 30% to 22%. The NFHS-4 figures, which cover under-5 children, show a reduction in stunting from 46% to 34% and in underweight from 37% to just 36% over a ten-year period between 2005 and 2015. More tellingly, the NFHS-4 data reveals that high malnutrition rates are not a feature only in predominantly tribal districts; districts like Parbhani and Yavatmal (with tribal population percentages of 2.2% and 18.5% respectively) show stunting rates over 45%. As many as 13 districts in the state show underweight percentages in excess of 40%. What is disquieting is the fact that districts in Vidarbha, like Buldhana and Washim (apart from Yavatmal), and in Marathwada, like Jalna and Osmanabad (apart from Parbhani), show a high percentage of underweight children. Considering that the campaign to reduce child malnutrition in Maharashtra had its beginnings in Marathwada in 2002, the regression in performance of districts in this region indicates that the gains in child nutrition in the first ten years of this century seem to have been lost in the past few years.

Another noticeable feature of the NFHS-4 data for Maharashtra is the variance of its figures from the ICDS monthly progress reports (MPRs) of the corresponding period. Since the NFHS-4 survey was carried out in mid-2015, a comparison of district-wise under-5 children underweight percentages as shown in the June 2015 ICDS MPR was made with the district-wise figures of the NFHS-4 data. The analysis shows that as many as 20 districts showed ICDS MPR underweight percentages which were more than 25 percentage points below the corresponding NFHS-4 percentages (Table 1). Unless one wishes to contest the accuracy of the results of the NFHS-4 sample survey, the only conclusion that can be drawn is that the ICDS MPR figures are understated. My personal experience, as a former Director General of Maharashtra’s Rajmata Jijau Mother Child Health and Nutrition Mission (“the Mission”), is that there is generally a tendency, on the part of the ICDS machinery (not just in Maharashtra, but in most states) to underreport underweight numbers, both because of lack of emphasis on accurate growth monitoring, as also to avoid criticism.

TABLE 1: MAHARASHTRA – STATE AND DISTRICT VARIATIONS IN UNDERWEIGHT PERCENTAGES

 

District NFHS-4 Under-5 under-weight (%) ICDS MPR June 2015 figures (MUW+ SUW) (%) Variation between NFHS-4 and ICDS (%)
Ahmednagar 31.1 11.15 19.95
Akola 39.3 7.13 32.17
Amravati 33 16.02 16.98
Aurangabad 36 7.99 28.01
Bhandara 32.5 4.99 27.51
Beed 36.9 7.84 29.06
Buldhana 41.3 10.21 31.09
Chandrapur 40.3 16.06 24.24
Dhule 47.5 11.56 35.94
Gadchiroli 42.1 19.98 22.12
Gondia 40.1 7.42 32.68
Hingoli 36.9 9.82 27.08
Jalgaon 36.4 12.78 23.62
Jalna 43.6 7.50 36.10
Kolhapur 31.2 4.30 26.90
Latur 34.5 6.26 28.24
Mumbai 22.7 17.81 NA
Mumbai Suburban 28.9
Nagpur 33.6 11.83 21.77
Nanded 34.4 6.68 27.72
Nandurbar 55.4 31.05 24.35
Nashik 42.9 10.64 32.26
Osmanabad 44.5 8.80 35.70
Parbhani 42.3 7.37 34.93
Pune 25.6 8.64 16.96
Raigarh 38.6 6.01 32.59
Ratnagiri 28.9 8.24 20.66
Sangli 24.8 3.87 20.93
Satara 27.8 7.93 19.87
Sindhudurg 25.2 11.85 13.35
Solapur 34.6 6.58 28.02
Thane 40.3 17.21 23.09
Wardha 36.1 9.73 26.37
Washim 42.9 6.51 36.39
Yavatmal 49.1 8.79 40.31
Maharashtra State 36.0 10.55 25.45

Sources: NFHS-4 (2015-16) and Maharashtra ICDS MPR (June 2015)

 The above analysis becomes even more relevant in the context of the recent furore over child deaths in Palghar district (newly carved in 2014 out of the existing Thane district and comprising the predominantly tribal-populated talukas), attributed to the high child malnutrition rates in this tribal region. Why has this state of affairs come about in a state which, barely a few years ago, was in the forefront of efforts to reduce child malnutrition and whose achievements gained national and international recognition?

Over the last five years, during the second phase of the Mission, there was a move away from data monitoring at a disaggregated level ranging from the district down to the Anganwadi. The Mission focused on behavioural change processes at community and family levels and on pilot initiatives to promote nutrition-sensitive projects in association with corporates/nonprofits. While these yielded results at the micro-level, there was no specific focus on scaling up these initiatives or ensuring their sustainability. More importantly, the emphasis on strengthening health and nutrition systems at the cutting edge levels, a significant feature of the operations of the first phase of the Mission, was not stressed in the second phase. Neither was there systematic follow up of the under-5 child nutrition status at the ICDS project level, a measure which is crucial to monitor the high malnutrition burden areas. With little pressure on them to monitor or ensure achievement of key nutrition outcomes, the ICDS machinery at the Zilla Parishad level and below paid little attention to outcomes.

There was also a diminution in the role of the Mission in terms of coordinating the nutrition-specific and nutrition-sensitive activities of different government departments. Departments continued to function in their respective silos; even fundamental activities like the medical facility based treatment of severe acute malnutrition and the community management of acute malnutrition suffered setbacks on account of budgetary cuts and what can only be termed as the absence of a clear policy focus. The lack of coordination in the nutrition-sensitive/specific programmes of different departments is manifest even to date in the manner of implementation of the Abdul Kalam Amrut Aahar Yojana, a maternal nutrition scheme aimed at pregnant and nursing mothers. The ICDS machinery is yet to wholeheartedly take responsibility for making this programme a success; delayed fund transfers to the village level and failure to put in place effective monitoring systems continue to bedevil the programme even a full year after its commencement. Few systematic reviews of the child malnutrition position have been undertaken at the apex levels of the political and administrative hierarchies in recent years.

The need for a mission approach to tackling child malnutrition in Maharashtra arose in the early 2000s out of the perceived inability of the ICDS machinery to make a significant impact on reducing child malnutrition despite almost three decades of its existence: its overwhelming focus on supplementary nutrition, the lack of attention to under-3 children and the failure to adopt a data-based implementation strategy. Frequent transfers of officers at the helm of affairs of the ICDS and the Department of Women & Child Development (DWCD) and absence of accountability for outcomes have bred a “business as usual” approach. The situation on the ground has deteriorated to the extent that over 70% of posts of Child Development Project Officers, the lynchpin of the ICDS programme, lie vacant today, with the DWCD apparently unable to draw up a recruitment policy for this crucial post. The creation of the Mission was expected to engender a sense of purpose in the ICDS, improve its coordination of activities with other departments and enforce accountability for measurable outcomes. This approach, largely successful in the first phase of the Mission till 2010, has been diluted greatly in the second phase.

As matters stand, the government of the day, despite having in hand a clear proposal on the modalities for launching the third phase of the Mission, has not been able to take a decision for over eighteen months. Current thinking seems to be in favour of subsuming the operations of the Mission within the ICDS Commissionerate, a move that will make the Mission a toothless entity and, in effect, ensure a regression to the status quo prevailing prior to 2005.

Ultimately, any structure to tackle child malnutrition can only be effective if it is staffed with personnel with the passion and commitment to make a difference. The indifferent experience of a number of other states that launched Nutrition Missions based on the Maharashtra model is a clear indication that standard bureaucratic interventions will not work. Maharashtra is free to experiment with any governance structure for addressing the issue of child malnutrition. There are, however, certain fundamental steps that are a sine qua non for making a significant dent on the problem:

  • Accurate, real-time data has to be the basis for a strategic approach. Both the health department and the ICDS need to use technology to gather real-time data on maternal and child health and nutrition to strengthen systems to tackle underlying causes. Maharashtra made a beginning in 2011-2012 using the Janani and Jatak software systems for individual mother and child tracking to monitor maternal and child health and nutrition outcomes with a view to build service delivery capabilities of the health and ICDS systems. Unfortunately, both departments have not made use of these softwares, specifically customized for Maharashtra, to aid them in efficient service delivery.
  • A far greater sense of accountability needs to be enforced in the ICDS and public health systems, as well as in other departments with a role to play in reduction of child malnutrition and mortality, from the Secretariat to the village level. A clear political message needs to go out that the death of even one child or the continued prevalence of stunting, underweight and wasting in under-5 children will not be tolerated.
  • Whether as a Mission or as a high-level council under the Chief Minister, there needs to be an organisational structure that coordinates the activities of government departments/agencies, nonprofits and civil society organisations. This body would plan strategies for high incidence areas, garner financial and other resources for tackling malnutrition, help develop innovative, sustainable programmes and set time-bound, measurable goals.

 

 

 

 

 

 

 

 

1 Jun

The politics of infant mortality…and the tragedy

Posted by vramani in government, health & nutrition, public policy. Tagged: , , , , , .

“There are three kinds of lies – lies, damned lies and statistics”

(Mark Twain: Chapters from My Autobiography)

A recent comment by India’s Prime Minister (PM) during an election speech comparing the infant mortality rate (IMR) in the tribal areas of Kerala state with those in Somalia kicked up a furore. A wounded Chief Minister of Kerala (from the opposing political party) has threatened to sue the PM, though the exact nature of the offence is not clear. Now that the electoral battle in Kerala has been lost and won, it is time we dispassionately analysed the contention of the PM and the implications for health policy in India. Let us first get to the numbers; at 60 deaths per 1000 live births in the tribal areas of Northern and Eastern Kerala, he felt that the area was not lagging far behind the African country of Somalia, which, as per the number he had, registered 85 deaths per 1000 live births in 2015. This is where statistics can be dangerous, and it does not need a Mark Twain to convey this message. Firstly, there seems to be no basis for concluding that the tribal areas of Kerala have an IMR of 60: whether this covers just the tribal population or the districts with a larger proportion of tribal population is not clear. Secondly, the PM’s information feeders seem to have culled the magic number of 85 from the latest country wise estimates of infant mortality released by the UN Inter-agency Group for Child Mortality Estimation (www.childmortality.org). The problem, as with all statistics, lies in the level of confidence reposed by the estimators in their own estimates. In the present case, three sets of numbers are given for each country: low, median and high. While the variation in these three numbers in countries like the United Kingdom with excellent reporting systems is minimal (3.0 to 3.5 to 4.1) and reasonable for a country like India (34.1 to 37.9 to 41.8), the range from the low to high figure is from 53.3 to 143.3, with a median figure of 85, for a country like Somalia with underdeveloped reporting systems. The UNICEF State of the World’s Children Report 2015 gives an IMR of 108 for Somalia and the CIA Fact Book places it at 98, showing that there is no unanimity on the number. With such a vast range of uncertainty regarding the numbers, it would be hazardous to plump for a number like 85 with any degree of confidence. The matter is further complicated when we compare the tribal population of Kerala with that of Somalia – 0.49 million versus 34 million. A small population, especially when it is largely comprised of poor tribals, will display higher figures of mortality in infants, given the prevalence of poverty and the poor reach of essential health services. The law of averages operates as the sizes of populations increase. To give one graphic example: just two infant deaths in a village with a population of 1000 (with an annual population growth rate of 2%) imply an IMR of about 100 per 1000 live births: which is why mortality statistics are never calculated below the district level. As statistics combine disadvantaged with more prosperous areas, these numbers come down, in the case of Kerala state to 12 per 1000 live births, which compares very favourably with many developed country figures.

The tragedy lies in the lessons that are not learnt from areas in Kerala like Wayanad, Idukki and Attappady, Palakkad (in the news a couple of years ago for infant deaths in significant numbers) and the mistakes committed through apathy and misgovernance across much larger swathes of India. Politicians would do well to remember the adage “Those who live in glass houses shouldn’t throw stones”. Of the nine states that are at the top of the high child malnutrition pecking order, seven are presently ruled by the party whose PM has spoken disparagingly about IMR levels in the tribal areas of Kerala, and all nine, including his own state of Gujarat, have or have had BJP governments (either on their own or in alliance with other parties). Barring two states where the BJP has recently come to power, its governments have had ample time to tackle the menace of child malnutrition, which is attributed by experts to contribute at least 45% of child deaths in India (and probably an even greater percentage of infant deaths, given that an overwhelming majority of under-5 children die before they cross the age of one). And yet, it is precisely these states which are the greatest contributors to infant mortality and child malnutrition. Don’t get me wrong: I am not in any way absolving other political parties which have ruled these states for many years without making a significant difference to the problem. The fault, dear Brutus, lies not in our stars, but in ourselves: in our dysfunctional systems, our cavalier disregard of data, our failure to focus on key geographical areas with a high child malnutrition burden and our failure to evolve a coherent, time bound public policy to effectively tackle the problem.

Let us start with our dismal grasp of the magnitude of the problem. Growth monitoring has always been one of the main components of the ICDS strategy right from its inception. Unfortunately, the monthly exercise of weighing of all under-5 children by the Anganwadi Worker (AWW) has been treated mostly as a routine task, with little or no importance being given to the use of this massive body of raw data. In the absence of weighing scales, weighing is sometimes not carried out; where weighing is done, there is no analysis of the data to chart out a meaningful course of remedial action in case of underweight children at any level, whether the anganwadi, ICDS project, district or state. Almost no state posts aggregated data, ICDS project wise, on the nutritional status of children online and it is doubtful if any administrator, at the project, district or state level, pays any attention to this data.

This blissful neglect of valuable data leads to governmental failure to identify and focus attention on the geographical regions requiring urgent, sustained intervention, be they remote tribal areas or congested urban slums. Aggregated data of monthly weights of children helps identify the specific localities (villages, hamlets, slums, etc.) that need to be focused on to reduce the burden of child malnutrition. The common budgetary approach of allocating funds to areas on a child population basis, without weightage for high burden malnutrition areas, discriminates against the latter. Poor infrastructure and inadequate staff in tribal areas lead to underutilisation of even allocated budgets. Resources of different departments are generally not combined in an innovative manner to deliver the crucial health and nutrition (both nutrition-specific and nutrition-sensitive) services to children and women that can reduce undernutrition and mortality. The new methodology of untying central fund releases to states is likely to see even further diminution in fund allocations to politically weak tribal regions of states and to urban slums. Public nutrition and health services for mothers and children are in short supply in urban slums. There are no systematic efforts to reach out to urban communities to develop their capacities to self-manage their nutrition and health issues. This limited attention given to identified high burden geographical areas is likely to see a continuation of high child malnutrition and mortality rates in these areas.

Resource misallocation to this critical area is aggravated by the absence of a clear cut vision on how to most effectively tackle the problem in the short run. India’s policy makers refuse to use height/length of under-5 children as a measure of nutrition status, in addition to weight (which has been used for nearly four decades). This would enable an immediate estimation of wasting (weight/height) status for taking action to improve the health and nutrition status of children suffering from severe acute malnutrition. Software exists to record both anthropometric measures digitally so that the wasting status of any child can be immediately established (a pilot project in Attappady, Kerala has proven the feasibility of such a digital approach to recording data using IVRS technology). Tackling moderate and severe wasting in India’s children (which goes upto 25% in many states) through inpatient and outpatient methods would significantly reduce malnutrition. But India’s ICDS and public health departments are unconvinced that they need to make this programme a key step to reduce child malnutrition and mortality. Adequate international evidence linking child malnutrition (especially wasting) to a higher incidence of mortality has had little to no impact on the thinking processes of the bulk of India’s medical professionals. Governments (at central and state levels) have failed to make such a programme the cornerstone of efforts to reduce malnutrition/mortality. The ICDS Commissionerates/Directorates are obsessed with centralised, contractor-dominated food supplies (rather than child feeding practices and micronutrient interventions), a policy which has drawn much critical comment from the Supreme Court and High Courts (the reasons are not difficult to fathom!). The resultant haphazard, ill-directed programmes to manage malnutrition, with no systematic measurement of nutrition outcomes and no focus on geographical areas most in need of such programmes, are the reason for India’s dismal world ranking in child nutrition indicators.

Finally, there is gross underutilisation of one of the most extensive systems set up anywhere in the world to deal with the issue of maternal and child nutrition — the ICDS. With anywhere from 50,000 to over 100,000 AWWs in each state of India, spread over almost every habitation in the country, this valuable human resource could well be the underpinning for a revolutionary transformation of the child malnutrition scenario in India. Unfortunately, with the ICDS largely functioning as a khichdi kitchen, these workers have never been empowered with the knowledge, skills and resources necessary to fulfil their innate potential. My experience in the nutrition sector in Maharashtra opened my eyes to the fantastic work they can do given the right working environment — upgraded knowledge/skills, access to resources, appreciation for their good work and the development of self-esteem for the important tasks they are undertaking. Even the huge public health system has no specific focus on the preventive aspects of health and good nutrition that could develop a generation of healthy girls and mothers, leading ipso facto to the birth of healthy, normal weight children.

For a country on the cusp of economic power and a growing global presence, it reflects poorly on India that she takes her place among the league of failed and failing nations in indices of child/infant mortality and undernutrition, whenever the exercise of evaluating each country’s performance in these areas is taken up. Latin America and East Asia have left us behind, as they made significant strides over the past few decades. Our immediate southern neighbour, Sri Lanka, is an object lesson to us that improvement in human development indicators can be achieved. Even within India, states like Goa, Kerala, Maharashtra and Tamil Nadu have performed far better than their counterparts in Northern and Eastern India in reducing IMR, though they still need to reduce wasting rates in under-5 children. If “Make in India” is to have any real meaning, children born in India need to have the guarantee of a healthy, disease-free, long and productive life.

 

 

 

 

 

1 Dec

Reducing Child Malnutrition – Four D(o)s for governments

Posted by vramani in government, health & nutrition, public policy. Tagged: , .

Child malnutrition constitutes one of India’s biggest public health challenges. A look at international child nutrition rankings can be very sobering: India (with 44% of under-6 children underweight and 48% of under-6 children stunted) is in the same league as countries with far more pressing social, economic and political problems. The recently released Rapid Survey of Children carried out by the Ministry of Women & Child Development (MWCD), Government of India and UNICEF highlights the gap between better-performing and laggard states within India. The bulk of the poor performance on under-6 child nutrition (underweight and stunting) indicators is accounted for by just seven states: Bihar, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Meghalaya and Uttar Pradesh. This is in spite of India having one of the oldest programmes (since 1975) – the Integrated Child Development Services (ICDS) – dedicated to improving maternal and child health and nutrition. The problem clearly does not lie in the intent: it lies in the inability of governments at the national and state levels to adopt a systems approach to tackling this issue. This blog argues that there are four must-dos for governments in India (all coincidentally starting with the letter D) which will hopefully contribute to significant reductions in child malnutrition. These are based on my personal experience with Maharashtra’s Rajmata Jijau Mother-Child Health & Nutrition Mission (“the Maharashtra Mission”) which I headed from 2005 to 2010 and from the heartening statistics which show that stunting and underweight in under-2 children in Maharashtra fell by 41% and 24% respectively between 2006 and 2012, attributable, at least in part, to a more focused approach of the Government of Maharashtra towards tackling child malnutrition.

Data & Disaggregation

Government systems are noticeably reluctant to use data, especially disaggregated data, to inform public policy direction and the ICDS is no exception. The MWCD receives monthly progress reports online from all state governments detailing inter alia the under-6 child underweight status (as per the WHO classification) on an ICDS project wise basis at the sub-district level. Unfortunately, this data often arrives after a considerable time-lag (when it does arrive at all) and there is no insistence on timely, accurate reporting. In any case, no use has been, or is, made of this rich source of data by governments at the national and state levels to focus attention on specific geographical areas where the incidence of child malnutrition is severe. In all development indicators, some regions in the country will lag well behind others. In child nutrition outcome indicators, too, it is observed that some regions in specific districts of the country, particularly those inhabited by tribal populations, minority communities and other socially disadvantaged groups show markedly poorer performance. There is also the issue of child coverage under the ICDS: despite the orders of the Supreme Court over ten years ago, a significant proportion of under-6 children still do not receive the full range of health and nutrition services. The decennial Census of India gives figures of children in the 0-6 age group right down to the village and urban ward level. Using these figures as the denominator for action, as the Maharashtra Mission did from 2005 onwards, enables inclusive coverage of all 0-6 children. Ensuring that each and every one of these children are regularly weighed gives comprehensive monthly data on the nutrition status of children in each habitation and enables taking of corrective nutrition and health measures in a timely manner. The availability of disaggregated data, including nutrition outcome indicators, draws the attention of policymakers to the worst affected areas and enables concentration of financial and human resources in those areas. More recently, Geographic Information System (GIS) tools like Jatak (see www.issnip.jatak.org ) have been developed to track individual child nutrition status and take steps to improve the health and nutrition status of children. Using Interactive Voice Response Systems (IVRS), data on key child nutrition indicators are received from frontline nutrition workers as voice files and converted into data at a central facility. This data has a two-way flow: it goes downwards for initiation of timely action by field workers and also enables supervision of their activities by middle-level managers. Aggregated at sub-district and district levels, it also aids timely policy interventions.

Design & Delivery

As mentioned in the preceding section, the use of the latest census data on 0-6 child population allows firming up of the numbers of children to be covered by each anganwadi or a cluster of anganwadis in a revenue village or urban ward. The starting point has to be the provision of public health and nutrition services to the child based on an assessment of her nutrition status. Growth monitoring is one area where significant systemic weaknesses can be seen in nearly all states. Maintaining monthly weight records of under-6 children and monitoring their growth progress enables the anganwadi worker to refer children at risk to medical facilities for early treatment of childhood illnesses or congenital diseases. The focus in the ICDS system thus far has been only on under-6 child underweight status. However, extensive research has shown that stunting (height-related) and wasting (weight to height related) indicators are also crucial to the healthy development of the child. Till such time as government policy sanctions length/height measurement as an indicator, the appropriate strategy, as adopted by the Maharashtra Mission, would be to record the lengths/heights of all under-6 children listed as being severely (more than three standard deviations below normal) underweight as also of under-6 children with faltering growth patterns and determine children, especially in the under-2 age category, requiring urgent health and nutrition interventions to check severe acute malnutrition (SAM), which significantly increases infant and child mortality. This requires close coordination between the ICDS and health systems at village and health centre levels. The use of a system like Jatak would give an upto date list of severely underweight children and those displaying faltering growth patterns. The anganwadi worker would provide this list to the nearest health worker/ medical facility to record the lengths/heights of these children and determine those children failing in the SAM category. Such children would be admitted to medical facilities, with continued post-treatment monitoring by field workers at home subsequently. Children in the moderate acute malnutrition category can be attended to at the anganwadis or at home by anganwadi workers.

The focus on reducing moderate and severe underweight and wasting rates in under-6 children requires revamping of delivery systems in the ICDS sector through building up motivation, skills and knowledge in anganwadi workers, supervisors and Child Development Project Officers. The negative mentality of blaming field workers for high rates of child malnutrition has to give way to an appreciation of the severe constraints they operate under, moving, as the Maharashtra Mission termed it, from “a fault-finding to a fact-finding approach”. Anganwadi workers are paid a pittance (often after a delay of many months) for the devoted services they render to the community and are handicapped by a severe shortage of infrastructure and equipment essential to the effective performance of their duties, as well as voluminous reporting requirements and absence of on-the-job training. The awareness that they are contributing to the raising of the next generation needs to be imprinted in the minds of all ICDS functionaries. It is not that monetary incentives alone motivate people: non-monetary recognition, through an appreciation of work by those higher in the hierarchy and giving publicity to achievers, can be a major inspiration to workers. At the same time, senior officer levels in the ICDS need to take on team leadership – they should be available 24*7 for solving implementation problems and making available resources to frontline workers to enable them to give of their best. A large part of the Maharashtra Mission’s efforts went into establishing an easy rapport with ICDS staff, encouraging innovative approaches at their level, appreciating their efforts and resolving their operational and organizational problems with higher levels in the ICDS Commissioner’s office.

It’s not rocket science!

The above approach combines responsive governance with the intelligent use of data in a systematic, disciplined manner, adopting a standard operating protocol, which can yield rich dividends where improving child nutrition outcomes are concerned. Of course, there are very relevant issues like the nutrition and health status of adolescent girls, effective antenatal care for expecting mothers, behavioural changes in communities and families on issues of health, nutrition, education, sanitation and gender equality, not to mention the all-important aspect of tackling poverty and low incomes. Trying to tackle all these issues is beyond the capacity of any one agency or department, let alone the government; governments, corporates, nonprofits and civil society have to come together to evolve solutions to these problems. These will take time; till then, our emphasis has to be on the child, as poignantly penned by the poet Gabriela Mistral:

“Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer “Tomorrow”, his name is today.”