OPINION: States lead the way in community management of acute malnutrition

Community management of malnutrition has yet to be included in POSHAN guidelines

46-Vikrampur Bridging the gap: File picture of children eating meals served under the Supplementary Nutrition Programme in Vikrampur | Sravani Sarkar

India is a heterogeneous and diverse country, due to which states require a granular approach while combating developmental challenges. Malnutrition is one such problem that, historically, has impacted the country at large. Despite several nutrition programmes, malnutrition, stunting and wasting remain roadblocks to development for various state governments. 

Each state has tried to deal with it in its unique manner and has had varied experiences. While the problem persists, some have been more successful than others allowing states to learn from each other. 

One such state is Rajasthan which, as per Niti Ayog’s national health index, has emerged as one of the top two states that have made the most progress on healthcare indicators between 2015-16 and 2017-18. Rajasthan has seen a drop in death rates of newborns and children under five years of age, a reduction share of low-birthweight babies and a rise in immunisation rates. A reading of all these indicators points to an overall improvement in child health. 

Similarly, Rajasthan has also been making headway in dealing with malnutrition by implementing community management of malnutrition (CMAM). Traditionally, in India, children with severe acute malnutrition (SAM) have been treated in a facility (hospital-based) setting. SAM children are treated and stabilized through the facility-based protocol following a clinical regime that includes medical and therapeutic treatment. However, the facility-based management has certain limitations since many people are usually reluctant to bring malnourished children to the facilities (also known as Malnutrition Treatment Center or MTCs). This reluctance increased during COVID-19 due to lockdowns and fear of contracting the virus.

Children with SAM have nine times more risk of dying than well-nourished children, and the Rajasthan government rightly made SAM a priority for targeted intervention. Community management of malnutrition has essentially decentralized the management of SAM, making it easier to reach and treat children in their communities. It involves early detection of children with SAM, outpatient treatment in communities (a strategy similar to the Directly Observed Therapy that is used for Tuberculosis), timely referral to inpatient care for those who develop or have complications, and subsequent follow-ups in the community.

Rajasthan’s tryst with community management of malnutrition started in 2015 when it first implemented this as a part of the National Nutrition Mission (AKA POSHAN) in 10 districts. The success was tremendous, with around 88 per cent of SAM children recovering in just about 8-12 weeks of treatment. Encouraged by the pilot program’s success, Rajasthan scaled up its community management programme under POSHAN-II across 20 districts of Rajasthan involving 10,000 SAM children. This has been hailed as one of the largest CMAM projects in the country. The children were provided energy-dense nutrition supplement (EDNS) for two months resulting in a recovery rate of 75 per cent and around 95 per cent retained nutrition levels even after the stoppage of these supplements. 

This suggests that SAM children without medical complications can be treated successfully using supplements in the community and do not require inpatient treatment at Malnutrition Treatment Centres. There is also common consensus among stakeholders that these centres are not enough to bear the burden of SAM cases. Treatment of SAM children without medical complications through CMAM programs enables tackling the malnutrition problem at a larger scale than what is possible through only patient treatment of SAM children, which is concentrated in certain areas. Treatment centres are not a very scalable solutino as they require infrastructural investment. With CMAMs, Asha workers and Anganwadis can be engaged.

Apart from Rajasthan, even states like Madhya Pradesh and Gujarat have had some significant experience with CMAM. All states that have adopted CMAM have benefited in terms of their nutrition outcomes. Concurrently, there seems to be some acknowledgment towards CMAM from the Central government, considering that sensitization for community management has been included in Poshan-MAAH (the government’s flagship programme for improving nutritional outcomes for children, pregnant women and lactating mothers ) activities for this year. 

However, the Central Government has still not made CMAM a part of the POSHAN guidelines. Without the Central Government’s mandate, CMAM cannot be implemented at the national level. 

Governments ought to recognize that malnutrition has serious repercussions on human capital, poverty alleviation, and equity promotion. It also keeps people from reaching their potential and reduces the nation’s economic growth. Malnourished children underperform in school, limiting their future job opportunities.

On the one hand, we regularly find state governments holding investment summits to attract capital, while on the other hand, investment in health continues to be sub-optimal. Therefore, for states to truly emerge as attractive investment destinations, efforts towards improving the ease of doing business need to be complemented with improvements in health indicators like malnutrition. A sustained reduction in malnutrition will contribute significantly to poverty reduction and increased government budgetary savings.

Dr K. Madan Gopal is Senior Consultant, Health, NITI Aayog

The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.