combating malnutrition & under-5 mortality in nagaon district of assam - dr.p.ashok babu, ias...

COMBATING MALNUTRITION &UNDER-5 MORTALITY

IN

NAGAON DISTRICT OF ASSAM

- Dr.P.Ashok Babu, IAS Deputy Commissioner

Date of Discharge: 15.03.13Discharge weight- 6.05kgMUAC- 12.8 cm

Date of Admission:28.02.13SAM NO.: AS-N-10-06-0001Weight – 5.25 kgMUAC – 11.5 cm

Patient’s Name : Abdulla HussainAge: 1 year 7 months

Farjina Khatun,22 monthsAdmission date- 29.06.2013

Weight – 5.230 kgMUAC: 10.6 cm

Discharged Date-08.07.2013Weight- 6.370 kgMUAC: 12.6 cm

Mohor Ali2 years 2 Months

Dhing

Date of Admission: 14.05.13SAM NO : AS-N-10-06-0027Weight: 6.585 kgMUAC: 10.5 cm

Date of Discharge : 28.05.13Weight : 7.665 kgMUAC : 12.8 cm

Nagaon District of AssamApprox 30,00,000 population, density 711/sq.Km

Approx 55% Muslims, 42% Hindus, etc

Under nutrition is described by World

Health Organisation BOTH

as a Medical

and Social disorder,

as it is seen

predominantly in low

income groups.

Malnutrition is a major contributor to under -5 mortality rate as it reflects as Measles, Pneumonia, Diarrohea, Heart Disorders etc and can kill a child.(World Health Organisation Report)-a Giant Killer of the district ??

Malnutrition is a condition that develops when body DOES NOT get the right amount of required nutrients such as… i) Carbohydrates ii) Proteins iii) Vitamins iv)Minerals etc.

Effects of Malnutrition

Diseases and Morbidity

Medical Treatment Cost – More into Poverty

Poor Learni

ng Ability

Death

Malnutrition & Under-5 Mortality

Social Support

SOCIAL

WELFARE

DEPARTMENT

Medical Support

HEALTH

DEPARTMENT

(NRHM)

Extent of the Malnutrition Problem in Assam

• UNICEF : 48% of Under-5 Children

• NFHS-3 : 48% of Under-5 Children

• Department of Social Welfare : Conservative figures (about 2%)

• Assam: 83.3 deaths/ 1000 live births (NFHS-3)

• India : 64/1000 (SRS-2009)

Under-5 Deaths

The Statistics of Malnutrition and Under-5 Mortality…Issues

• Huge variation• MEASURED- Tries to measure quantum of the

problem alone• NOT MEASURED - How many suffered have return

back to normal health AND how many died because of malnutrition – indicator for Government efforts

• NEEDED - Real Time Dynamic Data Base - Measures Government efforts AND Inter Departmental synergy

GOVERNMENT EFFORTS

• All issues required to address the problem are identified in ICDS Programme & Assam State Annual Programme Implementation Plan (APIP) for 2011-12

• Interdepartmental synergy is planned with Health Department, PHED, SSA etc.

• Sufficient funds are provided

GOVERNMENT EFFORTS

1. The

Supplementary

Nutrition

(SNP)

2. Measurement of Weig

ht

3. Maintenance of Grow

th Chart

s

4. Healt

h Check Ups at

VHND

(Village

Health &

Nutrition

Day)

5. Skill

Developme

nt throu

gh IMNC

I ( Integrate

d Management of Neonatal and

Childhood Illnes

s)

6. Immunisati

on

7. Moth

er and

Child Protection Cards (MCP

s)

8. Refer

ral Servic

es etc.

Why the rates of Malnutrition and Under-5 Mortality are High…

• The Government Efforts are covering all the issues

• Sufficient fund, Strong organizational support , PRIs, 10,500 employees per district

(AWW, AWH, CDPOS, Supervisors, DC Office etc)

• BUT, the cutting edge at the field level has been found to be BLUNT

• The field level implementation has to be sharpened.

Field Level Issues…

Field level Issues…

Field level issues…

• Malnutrition and addressing the problem are NOT issues at the Anganwadi Centres

(3-5 in each Centre)

• Huge under reporting• Registered children are always higher than actual

attendance (double recording, absenteeism (difference 20 %- 95%).

(Registration is more important because severly malnourished is disease hit more often, and will be in the house)

• Mothers/parents passive


• Weighment of the kids to ascertain early grade of malnutrition is not regularly done and rarely done.

Not even in a single Centre, it is observed all children being weighed monthly. Either it is lack of weighing machines, ANM not cooperating etc, but not a single solid reason.

Field level issues…The Growth Charts either not made OR made in a cursory manner

Rahul Rabha (Severe Grade Malnutrition with dental infections, skin infections, cirrhosis and ascites) and his Growth Chart


The ASHA and Anganwadi Worker appear not working together

* Though VHNDs which have to be conducted in Anganwadi Centres only.

* The ASHA and ANM should have reported and followed the malnourished kid to the Hospital and ensured treatment. But the follow up by NRHM functionaries is not observed.

* The first level interaction with a doctor for a malnourished kid appears ONLY when parents take the child to doctor when the kid gets some disease and by that time kid could be immune-compromised.

* The recovery of the child if identified at this stage could be fatal.


• Poor Supervision by Supervisors and CDPOs• Mandatory visits are not followed• Training in identification of malnourished

child, Awareness is required in Anganwadi Workers

• About 20% Anganwadi Workers are trained in Ka Shreni Training by SSA.

Field level issues… MOTHERS

• The Mothers of Malnourished kids appear passively watching decline of the child.

• The Mothers must be made part of Government efforts.

• At least mother should be made to ensure the malnourished son/daughter eat proper food at house and at Anganwadi Centre and the kid under a medical supervision through ASHA or ANM or Doctor.

Combating Malnutrition & Under-5 Mortality

By following the principles of …

• Linking Child with Anganwadi Worker, Supervisor and CDPO

• Separate monitoring of each child and ensuring his health

• Addressing lacunae of field performance • Automatic performance studies of field performers • Synchronising Social Welfare and Health Department

efforts through a monitorable prtotcol • Involvement of Parents

Training on Malnutration & U-5 Mortality to Supervisors, Anganwadi

Workers and ASHA

Inauguration of Project on Combating Malnutrition and U-5 Mortality by

Hon’ble Minister Social Welfare Sjt. Akan Bora.

Sample Data Collection Sheet

Field Visit Of Anganwadi Centre

Field Visit Of Anganwadi Centre with UNICEF Officials

Verification of Data at AWC with UNICEF Officials

Combating Malnutrition and Under-5 Mortality through - Growth Tracking and

Field level Protocol for inter Departmental synchronisation

The Child Registration before entry into the Anganwadi Centre is done in a systematic and simple manner

Every child is registered with photograph with Mother and with one Unique ID number.

The ID number of the child is generated based on the code of CDPO, Supervisor, Anganwadi Worker.

Thus the Service Provider and the child are linked.

The Details of CDPO, Supervisor, Anganwadi Worker, Child Name, His/her Photograph with mother, Weight, Height etc address are registered.

Example of digital Growth Chart

Performance Study of District,On real time basis

October’2013

Performance Study of CDPO Blockon real time basis

Dolonghat Block, October’2013

Performance Study of Anganwadi Worker

# Once the child is medically normal, if he/she continues to be malnourished action has to be initiated on AWW/

Supervisor/ CDPO

# # If the child has not received treatment action has to be initiated on

ASHA/ ANM

Monitoring of Malnourished ChildrenModerately Malnourished

Monitoring of Malnourished ChildrenSeverly Malnourished

Review of Project on Combating Malnutrition & U-5 Mortality

By Hon’ble Minister , Social Welfare Sjt. Akan Bora.

Letter to Parents

Involvement of Mothers

Involvement of MothersBringing the sense of involvement of Mother and

Government TOGETHER, to keep the child away from Malnutrition.

1) The photograph of the child to be taken

always with the mother, during registration.

2) Matritva Sahay Gut (Mothers

Committee) for involvement

3) Weight Measurement is

done in a fixed day of the month in

front of mothers.

4) Immediate communication through a letter automatically

generated to the mother as soon the

child is detected with malnutrition.

Benefits Received so farParameter Before the Project After the Project

1 Measuring malnutrition: Plotting of malnutrition in the district on real time basis.

Vague, Summary Monthly progress reports from CDPOs existed showing rounded off percentages varying from 2-10%.

Real time, dynamic data of malnutrition with precision which gets updated monthly is now available. Malnutrition is plotted quantitatively and geographically.

2 Identification of children with malnutrition: Children identified with moderate/ severe grades of malnutrition individually case by case basis.

Individual child identification reports were not available. Summary percentages indicating very low malnutrition cases reported. Fear/ apprehension among field officials and Anganwadi Workers existed that reporting malnutrition will be viewed as under performance and consequential punitive actions. They apprehend that it would invite more scrutiny on to the Anganwadi Centre if malnutrition is reported.

Large number of cases of moderate grade malnutrition, cases of severe grade malnutrition are identified. Presently, Anganwadi Workers report malnutrition and work for solving the problem. Approximately 3,00,000 Growth Charts a month are electronically prepared through a software to bring out reality without errors. Presently, there are 44,887 moderately malnourished & 11,043 severely malnourished children in the district.

3 Improved service delivery time:Time for contact of malnourished child from Anganwadi Centre of Social Welfare department with Health department for medical care, a measure of inter departmental synergy.

Previously the contact used to happen, when parents take the weak child to a doctor after kid gets some disease like typhoid, diarrhea etc, with underlying cause being malnutrition. By this time, the child could be immuno-compromised which may lead to fatal outcome.

In the present system, the detection and intimation of malnutrition to health care worker happens automatically and immediately. Hence, the service delivery has become fast.

Benefits Received so far..Parameter Before the Project After the Project

4

Improved service delivery:Malnourished children referred to Doctor/ Nutrition Counseling/ Nutrition Rehabilitation Centres.

There is no figure maintained by Social Welfare Department though synergy with Health department is planned in the Annual Program Implementation Plans (APIP).

So far in the present system, all the malnourished children have come into contact with ASHA/ ANM and 97,294 children are referred for medical advice preventing from fatal outcome.

5

Enhanced Transparency: Reduction in duplicacy.

There is no standard system of registering the children to further follow up. The names of the children are just entered in the attendance registers of respective 5,646 Anganwadi Centres.

The Anganwadi Workers have to register each and every child with Unique ID number. The ID number links Service Seeker (the child) with Service providers (Anganwadi Worker, Supervisor and CDPO) The ICDS child beneficiaries reduced by about 43,000 in one year.

6

Increased efficiency: Performance plotting of Anganwadi Centres.

There is no organized system to review performance of Anganwadi Centres, Supervisors, CDPOs based on existing malnutrition problem in their area.

The performance of each and every Anganwadi Centre / Supervisor / CDPO is revealed through a Pie diagram every month.

Benefits Received so far…Parameter Before the Project After the Project

7

Concept of model Anganwadi Centres:

As flag bearers of good work culture.

The Anganwadi Centres structurally (hygienic and child friendly environment) and functionally working towards addressing problem of malnutrition are not reported.

The concept of Model Anganwadi Centres in each CDPO Block started, which are flag bearers in good work culture and every month the number is increased. The number started as 20 Centres, now reached 3,529 out of 5,646 Anganwadi Centres.

8

Involvement of stakeholders:

Involvement of Mothers/ Mothers Groups.

The parents of the malnourished child appear relatively silent and not acting on malnutrition till the child gets hit by some disease such as diarrhoea, pneumonia etc. They are silently watching decline of the child as first contact point ie., ASHA/ Anganwadi Workers are not coming forward to show a simple, reliable, inexpensive way out to deal with their weak child.

The mothers/ Mothers Group are playing important role. Mothers group (Matritva Sahay gut) checks the food, weight measurement, expenditure of fund etc. The mothers are intimated from Deputy Commissioner’s office through a letter when the child is severely malnourished to be more active.

9

Improvement of service delivery:

Prioritization of malnutrition at Anganwadi Centre level.

Malnourishment was never an issue felt to be addressed by the Anganwadi Centre. Just providing some nutrition to those kids who attend the Centre is deemed as work.

Regular weight measurement with 85-90% weighing efficiency among the registered children is reported from Anganwadi Centres. The malnourishment cases are taken care and immediately informed to healthcare worker for further follow up.


INNAGAON DISTRICT OF ASSAM

• Sustainability: The project is of very low cost and with Rs. 5 lakhs entire hardware and software requirements can be set up. The IEC efforts optional. The system uses existing manpower of ICDS system. The data entry operators (5-8 members) are only engaged on contractual basis. Hence, it is easily sustainable.

• Replicability: Government of Assam included this model for replicating in four more districts of Assam in the Annual Project implementation Plan (APIP) of Social Welfare Department for the year 2013-14.

UNICEF Assam’s study of the Project (Anthro-2011)

• Regular monitoring and counselling have positive effect

• Faster reductions in severely malnourished possible

• Lesser age groups are more amenable to change

• Boys are suffering more malnutrition than girls in the district

THANK YOU

combating malnutrition & under-5 mortality in nagaon district of assam - dr.p.ashok babu, ias...

Documents

malnutrition problem

combating malnutrition

field level implementation

rates of malnutrition

malnutrition indicator

statistics of malnutrition

field level issuesthe

discharge weight