Monthly Archives: September 2016

[This is the second of a series of posts which Seva Setu shall publish during the National Nutrition Week (1-7 September)]

September 1-7 has been declared as the National Nutrition Week in India. As highlighted in our previous post, Seva Setu takes this opportunity to convey to a larger audience some notes on how we have engaged in this fight against malnutrition.

NRCs – how to empower them

In our previous post, we spoke of the challenges in the functioning of the Nutrition Rehabilitation Centers. We discussed four key challenges in its functioning –

• Location
• Capacity and utilization
• Relapse, and
• Social concerns

All four issues, when looked at closely, hint at a common root – a sense of unfamiliarity which an inaccessible service breeds. If it were a service being provided right next door, one wouldn’t have to bother about operational worries such as having to travel and stay at an unknown site while not having a grip of one’s home. From what we have seen, we strongly believe that if the whole NRC model is decentralized and if location and accessibility is preferred to capacity, it would make this one very compelling model of change. For instance, dedicating one ward (containing around 5-10 beds) in each Primary Health Center (PHC)(which is located in every block – a block being a collection of 10-15 panchayats) could be a first step into having a practical solution for these concerns. This way, parents could be given an option of visiting the clinic everyday for an hour or so after the first two-three days of getting them to stay over at the clinic. Such a model would hopefully ensure a higher utilization of this service and will also be easily marketable to the residents of nearby panchayats.

Dedicate a 5-10 bed ward at each PHC to handle cases of malnutrition instead of having one clinic per district. A dedicated clinic should not handle all cases of diagnosis and care. Instead, have them for only specialized treatment and tertiary care.

As far as the matter of relapse is concerned, the problem of such a monitoring mechanism reeks of a technology-based intervention. Having a phone-based monitoring system is a sure step towards ensuring beneficiaries of this program are kept in touch with and monitored closely. Having such a system will also act as a forcing function to ensure patient-data is available in a format where such electronic tracking is made possible. Skeptics might call this far-fetched, saying it would be just another useful sounding system on paper. To prove them wrong, we at Seva Setu embraced technology in such monitoring and intervention tasks long ago! Our mother care program has a fully automated system that anyone can be a part of which helps young, pregnant mothers in rural India enjoy a safe motherhood. Check out the nifty system here!

Have a technology-driven monitoring system. This will force the system to have digitized data, making it amenable for further monitoring and analysis. Seva Setu has set up one such system in its Mother Care program.

Related programs

Community Management of Acute Malnutrition

We aren’t the first to be enlightened by these simple yet effective interventions at ensuring the existing system works better. The concept of decentralizing the role of the NRCs has been acknowledged even by Doctors without borders (Médecins Sans Frontières) in Bihar’s Darbhanga district. Referred to as the Community Management of Acute Malnutrition model, the program shifts the onus of primary care for malnutrition to the PHCs and ensures that there’s more door-to-door monitoring that happens to avoid relapse. They don’t adopt a technology approach towards relapse prevention – a step which can easily be integrated into their current model. Go through their full study here.

Sneha Shivirs

This idea has also been embraced by the bureaucrats who have designed Bihar’s Integrated Child Development Service’s Program implementation plan for the year 2015-2016. Recognizing the problem at hand and with an aim to fast-track bringing down the malnutrition rate in Bihar below the 30% mark, the government had in 2014 instituted the Bal Kuposhan Mukt Bihar (BKMB) campaign. As part of the 2015-16 efforts, the government has planned on implementing Sneha Shivirs (nutrition camps). One such camp would be setup for every 4-5 Anganwadi centers and will run for a period of 30 days – the first 12 days would involve feeding the malnourished kids along with sensitizing the residents of the issue, which would be followed by 18 days of door to door monitoring of children’s health. This promises to result in close to 40,000 such camps being organized throughout Bihar. The idea again is to make such care and service localized and accessible. The success to such camps would be its execution month on month for a good period of time, which does not seem to be part of this year’s implementation strategy. This year’s plan speaks of only one such camp being held at the centers with a proposal to scale operations up based on the results of the pilot. Read the year’s implementation plan here.

Role of the media

While having mentioned these suggestions and tweaks to existing programs, one must not forget the role of the media in directing a nation’s conscience towards this pressing matter. We have seen media campaigns go viral in the past (e.g. the Pulse Polio campaign) which have made topics of importance a household name. Even if the layman does not understand the nuts and bolts of what an issue is all about, the fact that it plays on every TV screen and is the “trending topic” usually brings it into the realm of coffee table conversations. Unfortunately for us, the media has failed to pick up malnutrition as one such topic. What the nation seemingly wants to know this week is how rains have inconvenienced a visiting dignitary or how the vision of digital India is being fulfilled by a telecom operator. Debates and discussions around malnutrition, which the nation ought to know about, are missing. When we looked around, we found very few mentions of it in the popular media, most covering vegetable carving ceremonies to mark the national nutrition week! [link] If this is the seriousness with which this dialogue is carried forward, we are simply a long way away from being anything close to a nation conscious of a problem destroying its infants.

Addendum: The Times of India has carried out a piece on 6 September 2016 on the seriousness and extent of malnutrition plaguing our country. This was the only piece we could find which covered this issue.

Up next

In our subsequent post, we shall talk about other programs by the government and the prevention mechanisms which can help in addressing this issue in the long run. Help spread the word and stay tuned until then!

[This is the first of a series of posts which Seva Setu shall publish during the National Nutrition Week (1-7 September)]

September 1-7 has been declared as the National Nutrition Week in India. Dedicating a week to direct the nation’s conscience towards nutrition stems from a few disturbing facts – India has one of the highest number of children suffering from malnutrition [1]. This means roughly 50% Indian kids less than 2-3 years of age suffer from hunger and lack of a nutritious diet. Our government has put in place a number of measures to combat this situation – introducing the midday meal scheme (in the mid ’90s), establishing the Integrated Child Development Scheme (in the mid ’70s) wherein the concept of Anganwadi (pre-schools for kids in the 1-5 years’ age group) took birth and other such initiatives which got associated with the more recent National Rural Health Mission’s key performance indicators.

With this as a backdrop, we at Seva Setu present a perspective of our fight against malnutrition in Bihar for the last 3 years. We began operating in this space in two districts – Vaishali and Patna and have covered close to 40 panchayats in all till date. There were two questions we asked ourselves at the beginning of this exercise – a. what can be done towards its treatment and rehabilitation? .b. what can be done to prevent this condition?We started out with the former since that was more immediate in changing the situation. During the course of our work, we have also taken steps to address the latter. We first begin with our observations on the infrastructure to treat this condition.

Treatment and Rehabilitation

There have been several measures put in place by the government which help in treating malnutrition. We list here some of the popular programs and against each, list out positives and shortcomings of these efforts. This is not an exposition of our views – just a snippet which can sensitize and inform a layman to the kind of challenges that one faces on ground in the implementation of these programs.

In this post, we focus on the Nutrition Rehabilitation Centers (NRCs) which the government has setup. In subsequent posts, we shall showcase other such schemes by the government and chalk out some pros and cons.

Nutrition Rehabilitation Centers
These are excellent clinics to help children overcome malnutrition. It requires the affected kid and his/her mother to get admitted for 15-20 days, during which time they’re fed nutritious food. They’re also paid a daily stipend for staying over at the clinic in an attempt to compensate for their loss in daily earnings. The clinics also pay the family for the expenses incurred during the travel to and from the clinics.

This being a great program on paper, we see it constantly plagued by the following issues –

Location
One major concern regarding these centers is its location. There are close to 40 clinics spread across the whole of Bihar, wherein one clinic is allotted per district! (that’s one in a 50 square kilometer area!). For instance, the NRC in Patna district, which used to be located near Patna city (marked in blue) until recently, has now been moved to Mashauri (marked in orange), towards one end of the district. Someone wanting to travel to the NRC from the eastern edge of the district would have to travel more than a hundred kilometers! Adding to these woes, the NRC was closed for the last three months in Patna. With our efforts to highlight this issue through the media and the Lokshikayat center, we finally got it up and running! We had a separate post on this.

Capacity and utilization
Each of these clinics is supported with 20-beds. It takes 15 days on an average to pull a kid out of malnutrition and get him/her in shape. This means that the clinic can treat (365/15)x20 kids in total in an entire year. That’s close to 480 kids a year. In a previous post, we had analyzed RTIs we’d initiated and shown that only 10 beds on an average are usually utilized in these NRCs! In spite of there being just 30-odd NRCs in the whole of Bihar and close to 5 million malnourished kids, we still have NRCs operating at less than 50% of its full capacity!

This hints at a massive problem in the outreach mechanism which the NRCs have. Unable to connect supply with a pressing demand suggests a failure in its customer acquisition mechanism, a core problem which every enterprise invests heavily in. Enterprises generally have marketing teams or customer/client acquisition teams which crack this problem of getting people to use its products and services. The current mechanism of an Anganwadi Sahiyka (in-charge of an Anganwadi center) suggesting a family to visit the nearest NRC on spotting malnutrition in a kid is simply not enough.

Relapse
The NRCs provide no panacea to cure malnutrition. In fact, there isn’t any medicinal intervention which is provided to the kids at all. What is provided is simple, home-cooked meals which follow a certain diet and recipe plan. In essence, these interventions can easily be administered even at one’s home. In spite of this, one of the biggest threats to this program is the easy relapse of the condition. The kids recover and are cured fairly well during their stay at the clinics. But on being discharged, we find 30-40% of the families we work with suffer a relapse! Post-discharge monitoring is absoutely essential to the success of the interventions provided by these clinics. The government scheme also recognizes this aspect in that they financially compensate the families’ follow-up travel to the NRCs. However, the policies are too passive – there’s no active effort in ensuring those discharged are monitored.

Social concerns
A major concern we constantly face on the field, which trumps all the above mentioned concerns, is a strong social hesitance to be a part of this program. We are constantly faced with reasons, some genuine and most a form of hesitance and acceptance, which make getting families admitted to these programs a deal-breaker! We are audience to ‘strong’ reasons like “She is a mother of three kids. If the mother and one kid is away at the hospital, who will take care of the other two kids” or to some mellower ones like “Please come back tomorrow. We will need to discuss this” – which then never sees closure. The distance from one’s village, a lack of support for existing family members, the fact that this needs to be done alone and other such “soft” reasons usually collude to form a strong reluctance in getting admitted at these clinics. Also, since these are generally from families which do not have any reliable, robust source of income, the fact that the condition does not affect the major breadwinner of the home pulls down the severity of the situation in their eyes.

She is a mother of three kids. If the mother and one kid is away at the clinic, who will take care of the other two kids

Our recommendations

In our subsequent post, we shall talk about recommendations and minor policy interventions which can help strengthen the functioning of the NRCs. We shall also talk about other programs like the popular program by Doctors without Borders (MSF) called the Community Management of Acute Malnutrition (CMAM) in Darbhanga district of Bihar. Stay tuned.

In this while, if you have thoughts based on what you’ve read here, feel free to comment, like, share our post on FB or drop a line to comments@sevasetu.org. We will be happy to engage!

Part-2 of this series

Click here to read the next part in this series.

[1] National Family Health Survey, 2015; Link: http://rchiips.org/nfhs/nfhs4.shtml