Posts Tagged ‘infant mortality’

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.

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.