Community management of acute malnutrition in Rajasthan, India
This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Daya Krishna Mangal and Shobana Sivaraman.
Daya Krishan Mangal is Professor and Dean of Research at the IIHMR University, Jaipur.
Shobana Sivaraman is Senior Research Officer for IIHMR University, Jaipur.
GAIN, UNICEF and other development partners supported the Community Management of Acute Malnutrition (CMAM) approach in Rajasthan. The authors would like to acknowledge Dr Abner Elkan Daniel, Child Development and Nutrition specialist, UNICEF India and Deepti Gulati, Head of Programmes, GAIN India for providing insight and technical expertise during the implementation of the CMAM programme described here.
Malnutrition in India
Despite economic growth in recent years, it is estimated that half of the world’s wasted children live in India and that malnutrition is the underlying cause of two thirds of child deaths. Latest national estimates suggest that 38% of children under five years of age are stunted and 21% are wasted. In the northwestern state of Rajasthan, rates of wasting have substantially increased from 11.7% in 1999 to 23% in 2016, making it a high-priority state for nutrition interventions.
India’s nutrition policy, developed in 1993, adopts a multi-sector approach to tackle malnutrition. Most recently, the Proactive and Optimum care of children through Social-Household Approach for Nutrition (POSHAN Abhiyaan) programme has been implemented by the Government of India (GoI). This is a multi-ministerial convergence mission to integrate all nutrition-specific and nutrition-sensitive interventions with the vision of eliminating malnutrition in India by 2022.
Treatment strategies to address severe acute malnutrition in India
The growth of children under five years is regularly monitored by frontline health workers across India. These include auxiliary nurse midwives (ANMs), posted at sub-centres and primary health centres, and community-level Anganwadi workers (AWWs). Children identified as having severe acute malnutrition (SAM), with or without medical complications, are referred to the nearest malnutrition treatment centre (MTC) or nutrition rehabilitation centre (NRC) for medical care and nutrition therapy. Limitations of this system include low coverage, the high costs of providing and accessing facility-based management of SAM and the acceptability of inpatient facilities in remote, rural populations. Steps have therefore been taken to test the utility of a community management of acute malnutrition (CMAM)1 approach in India.
CMAM in India
CMAM was introduced in India in 1999 by Médecins Sans Frontières as an emergency response. The programme demonstrated low mortality rates (0.8%) and high cure rates (57.4%) for non-defaulting children. In 2015, the Government of Rajasthan (GoR) National Health Mission (NHM), in partnership with UNICEF, Children’s Investment Fund Foundation (CIFF), Global Alliance for Improved Nutrition (GAIN) and Action Against Hunger (ACF), implemented CMAM through the POSHAN strategy. POSHAN I was implemented between 2015 and 2016 across 10 high-priority districts and three tribal districts of Rajasthan. Of the 6 to 59 month old children identified with SAM, 88% recovered after eight to 12 weeks of treatment. As a result, the CMAM approach (now called ‘integrated management of acute malnutrition’ (IMAM)) was scaled up under POSHAN II across 20 districts with high burdens of acute malnutrition in Rajasthan from November 2018. This was again implemented by the GoR NHM, in collaboration with UNICEF, CIFF, GAIN, ACF and Tata trusts.
POSHAN II implementation and outcomes
Screening and identification of SAM
In POSHAN II, CMAM services were provided through health sub-centres (POSHAN centres) through quality-trained ANMs and accredited social health activists (ASHAs, known as ‘POSHAN praharis’). POSHAN praharis used active case finding to screen 6 to 59 month old children in all households. Mid-upper arm circumference (MUAC) was measured and children identified with a MUAC of <12.5 cm were taken to the nearest POSHAN centre for weight, height/length and MUAC measurements. Children were also checked for bilateral pedal oedema and any medical complications, as well as given an appetite assessment using an energy dense nutritional supplement (EDNS). If a child had bilateral pedal oedema and/or any medical complication and/or failed the appetite test, he/she was referred to the nearest MTC, irrespective of anthropometric measurements. If the child’s weight-for-height z-score (WHZ) was <-3 SD and/or MUAC <11.5 cm, the child was identified as having SAM. SAM children without medical complications and with adequate appetite were enrolled in POSHAN II for management.
Community management of SAM
All enrolled SAM children were given a dose of albendazole for deworming, amoxicillin (a broad-spectrum antibiotic) and a weekly supply of EDNS according to their weight. The mother/caregiver was advised to feed the child the prescribed daily dose of EDNS, along with regular home-based food. The child’s weight, height and MUAC were assessed during a weekly visit to their nearest POSHAN centre and EDNS packets provided to their primary caregiver. Caregivers also received counselling on the use of EDNS and breastfeeding (children ≤24 months) practices, minimum meal frequency, handwashing practices, immunisations and healthcare seeking. POSHAN praharis provided daily household visits to SAM children in the treatment programme to ensure regular consumption of EDNS and to further counsel the mother/caregiver on adequate dietary intake and hygiene practices.
Children were followed up until they maintained discharge criteria (MUAC ≥12.5 cm and/or WHZ ≥-2 SD) for one week. Those who did not deteriorate during this time were categorised as cured and discharged from the programme. Children who did not recover after 12 weeks of treatment were referred to their nearest MTC for further investigation.
Of the 375,533 children aged 6 to 59 months screened during home visits, 10,344 were identified as having uncomplicated SAM and enrolled for treatment. After eight weeks, both default (10.6%) and death (0.1%) rates were low. Approximately 46% of children had not recovered by week eight and continued treatment from nine to 12 weeks. Mean weight gain of enrolled children after eight weeks (3.2 g/kg/day) was lower than international standards, as well as most other programmes in India. After 12 weeks, 70.2% of enrolled children had been discharged, 12.2% had defaulted, 17.2% had been referred for further treatment and 0.1% had died.
Independent impact evaluation of POSHAN II
An independent evaluation of POSHAN II was conducted by IIHMR between December 2018 and February 2019. A cohort of 1,322 SAM children aged 6 to 59 months was enrolled in the study from 70 POSHAN centres in five of the 20 programme districts. At baseline, 69.1% of children were enrolled in POSHAN II with WHZ <-3 SD, 16.2% with both WHZ <-3 SD and MUAC <11.5cm and 14.7% with MUAC <11.5cm. At eight weeks (midline assessment), 42.4% of children were cured, 4.1% had defaulted and 53.5% had not recovered and continued treatment. After 12 weeks (endline assessment), 66.9% of children were cured, 8.1% had defaulted and 25% had not recovered. Cure rates achieved after 12 weeks of treatment were favourable compared with international standards and other similar Indian studies.
Socio-cultural study of POSHAN II
The local context and cultural practices that may have influenced POSHAN II outcomes in SAM children were explored in a qualitative socio-cultural study. During focus group discussions and in-depth interviews with mothers, no differences in socio-demographic characteristics of cured, defaulted and non-recovered children were identified. There were also no patterns observed in the household food baskets between outcome groups and dietary diversity ranged substantially between households.
All SAM children had experienced a troubled medical history (e.g., vomiting, lack of appetite, diarrhoea and fever) and/or low birth weight (LBW) and lack of appetite from birth. Notably, some mothers of non-cured and defaulted SAM children reported extremely low levels of haemoglobin (as low as 5.5 g/dL) during pregnancy. However, most did not believe that they were undernourished and were not aware that their nutrition during pregnancy and lactation could impact on their child.
Potential for the scale-up of CMAM in India
POSHAN II is the first large-scale CMAM programme of its kind in India. Programme outcomes suggest that SAM children without medical complications can be treated successfully in the community using EDNS. While the daily average weight gain was lower than international targets, this may reflect the Indian context. Improvements may be achieved through better counselling and supportive supervision of mothers to improve compliance with feeding advice. The programme has been well integrated within existing health systems, eliminating the need for a new cadre of health workers.
Given the expense of EDNS supplies, a significant challenge to scale-up is the sustainability of funding. However, based on the findings of the evaluation study, the IIHMR recommends that the GoR NHM adopts the CMAM strategy in Rajasthan to address the high prevalence of SAM in the medium term while the long-term cost benefit is being studied. Success of such a programme will require a robust management information system, training of the healthcare workforce, a recording and reporting mechanism and significant resources and supply chain management for EDNS. Findings from the socio-cultural study suggest that poor maternal nutrition and LBW are important drivers of SAM that must be tackled. Linkages with other government programmes and development partners to address this should be explored.
National scale-up of CMAM is also recommended and should be promoted through the Nutrition Mission and the release of updated national CMAM guidance. Following this, CMAM should be integrated into the training curriculum for medical professionals, nutritionists and frontline/community health workers.
POSHAN II in Rajasthan is the first large-scale CMAM/IMAM programme in India to be implemented for the treatment of severely malnourished children in the community. The success of the programme, and the CMAM approach, in this context has been demonstrated and provides reassurance that locally produced EDNS is safe, acceptable and facilitates rapid improvements in the nutritional status of severely malnourished children. The CMAM programme should therefore be integrated within primary healthcare services in Rajasthan and beyond. Success of implementation will depend on a high level of political commitment and collaboration with partner agencies to provide technical and financial assistance.
For more information, please contact Daya Krishna Mangal.
1 CMAM is an approach to the management of child wasting that includes the management of medically uncomplicated cases in the community.
More like this
FEX: Community management of acute malnutrition in Rajasthan, India
View this article as a pdf Lisez cet article en français ici By Daya Krishna Mangal and Shobana Sivaraman Daya Krishan Mangal is Professor and Dean of Research at the...
FEX: Treatment of severe acute malnutrition through the Integrated Child Development Scheme in Jharkand State, India
By Grana Pu Selvi and Colleen Emary View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with the authors on the ENN...
NEX: Managing acute malnutrition with scarce resources in Pakistan
Dr. Mubina Agboatwalla, HOPE Pakistan Dr. Mubina Agboatwalla is a pediatrician and chairperson of HOPE. She has worked extensively on maternal and child health programmes...
FEX: Prise en charge communautaire de la malnutrition aiguë au Rajasthan, Inde
Read an English version of this article here Par Daya Krishna Mangal et Shobana Sivaraman Daya Krishan Mangal est professeur et doyen de la recherche à l'Institut...
FEX: Substandard discharge rules in current severe acute malnutrition management protocols: An overlooked source of ineffectiveness for programmes?
View this article as a pdf Lisez cet article en français ici By Benjamin Guesdon and Dominique Roberfroid Benjamin Guesdon is a nutrition and health research advisor...
FEX: Testing an adapted severe acute malnutrition treatment protocol in Somalia
View this article as a pdf Lisez cet article en français ici Summary of research1 By Naoko Kozuki, Jama Mohamud Ahmed, Mukhtar Sirat and Muna Abdirizak Jama Naoko...
FEX: Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition
Summary of research Bhandari N, Mohan SB, Bose A, et al. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition:...
FEX: Development and use of alternative nutrient-dense foods for management of acute malnutrition in India
View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Raja Sriswan Mamidi, N Arlappa, Khyati Tiwari, Shivani Rohatgi, G Sarika, Dripta Roy...
FEX: Managing severe acute malnutrition in India: prospects and Challenges
By Biraj Patnaik Biraj Patnaik is the Principal Adviser to the Commissioners of the Supreme Court of India in the right to food case. He is also associated with the Right to...
en-net: replacement for Plumpy net
Dear colleges, Greeting from Nini Thanks for your kind answer for my previous question about CMAM guideline. Here again, I have another urgent question. We are having the...
FEX: Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India
Summary of research1 Location: India What we know: The caseload of severe acute malnutrition in India is significant. Access to treatment is challenging in rural settings;...
FEX: Integration of management of children with severe acute malnutrition in paediatric inpatient facilities in India
View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Virendra Kumar, Sila Deb, Arpita Pal, Keya Chatterjee, Rajesh Kumar Sinha and Sanjay...
FEX: Community-based management of severe malnutrition: SAM and SUW in children under five in the Melghat tribal area, central India
By Dr Vibhavari Dani, Dr Ashish Satav, Mrs Jayashri Pendharkar, Dr Kavita Satav, Dr Ajay Sadanshiv, Dr Ambadas S Adhav and Dr Bharat S Thakare Dr. Vibhavari Dani is a...
FEX: Cost effectiveness of CMAM in Malawi
Government of Malawi guidelines Summary of published research1 A recent study assessed the cost-effectiveness of community-based management of acute malnutrition (CMAM) to...
FEX: Institutionalising quality of care in inpatient facilities for the management of severe acute malnutrition in India
View this article as a pdf Lisez cet article en français ici By Meeta Mathur, Naveen Jain, Shivangi Kaushik and Aakanksha Pandey Meeta Mathur is Head of Programmes...
FEX: Barriers to access for SAM treatment services in Pakistan and Ethiopia: a comparative qualitative analysis
Summary of research1 Location: Ethiopia and Pakistan What we know: Community-based sensitisation can overcome lack of awareness that impedes access to SAM treatment, but is...
View this article as a pdf Lisez cet article en français ici A warm welcome to our 63rd edition of Field Exchange, focused on child wasting in South Asia. The idea for...
Blog post: Nutrition in Jharkhand - A new beginning
Greetings! I am Dr Charulatha Banerjee, one of ENN's Regional KM specialists working in Asia. On the 9th of January I visited the Indian state of Jharkhand to meet...
FEX: Determining predictors for severe acute malnutrition: Causal analysis within a SQUEAC assessment in Chad
By Ruwan Ratnayake, Casie Tesfai and Mark Myatt Ruwan Ratnayake is the Epidemiology Technical Advisor with the International Rescue Committee based in New York. He supports...
FEX: Integrating nutrition services into mobile health teams: Bringing comprehensive services to an underserved population in Afghanistan
View this article as a pdf Lisez cet article en français ici By Ahmad Nawid Qarizada, Maureen L. Gallagher, Abdul Qadir Baqakhil and Michele Goergen Ahmad Nawid...
Reference this page
Community management of acute malnutrition in Rajasthan, India. FEX 63 digest , January 2021. www.ennonline.net/fexdigest/63/communitymanagementrajasthan