Malnutrition is one of the leading causes of death and diseases in children under-5 years of age, globally. It adversely affects cognitive development and learning capacities among children, thereby resulting in decreased productivity in the booming years.

According to a study by Lancet, 68 per cent of the under-5 deaths in India can be attributed to malnutrition. Besides, India is home to nearly half of the world’s “wasted or acute malnourished” (low weight for height ratio) children in the world. Wasting is a critical health condition where a child is nine times more likely to die as compared to a healthy child.

According to National Family Health Survey (NFHS)-4 conducted in 2015-16, 21 per cent of children in India under-5 suffered from Moderate Acute Malnourishment (MAM) and 7.5 per cent suffered from Severe Acute Malnourishment (SAM). Despite the various targeted outreach and service delivery programmes run by the government such as POSHAN Abhiyaan, Supplementary Nutrition and Anaemia Mukt Bharat, to name a few, 16 out of the 22 States and union territories have still shown an increase in SAM, as per NFHS-5 conducted in 2019-20.

Covid queers the pitch

While the deteriorating facets of malnutrition continue to remain a matter of grave concern, the emergence of Covid-19 has only worsened it. The partial closure of Anganwadi Centres (AWCs) along with disruptions is supply chain due to subsequent lockdowns has resulted in halting of Mid-Day Meals scheme, reduced access to Take Home Ration (a nutritional measure to supplement some portion of a child’s calorie needs) and restricted mobility to health care services.

According to a study published in journal Global Health Science 2020 , the challenges induced by Covid-19 are expected to push another 4 million children into acute malnutrition. This is also evident from India’s poor ranking, an abysmal 94th out of 107 countries on the Global Hunger Index 2020.

Complex set of factors at play

Acute malnutrition is a complex socio-cultural problem that lies at the interplay of inequitable access to nutritious foods and health services, sub-optimal infant, and young child-feeding practices (IYCF) including breastfeeding, low maternal education, low capacities of field functionaries in detection malnutrition, poor access to clean water and sanitation, poor hygiene practices, food insecurity and unpreparedness for emergencies. And Covid-19 has significantly unravelled all these inefficiencies, therefore, bringing to the fore, the need to adopt sustainable solutions aimed at integrated management of acute malnutrition in tandem with mitigating the impact of Covid-19.

And the first step to reduce this burgeoning burden of acute malnutrition is to ensure early identification and treatment of SAM children to stop them from further slipping into the vicious cycle of Malnutrition.

Currently, in India, SAM children with complications are usually referred to the Nutrition Rehabilitation Centres (NRCs), mostly established in District Hospitals with a low ratio of hospital beds per population. While access to health infrastructure is a major thorn in the flesh, it is also a proven fact that 70-80 per cent of the children face no medical complication and need not required to be hospitalised.

Maharashtra’s success

Therefore, in such a scenario, it is feasible to adopt an approach that treats the uncomplicated SAM children more efficiently and “Community Management of Acute Malnutrition (CMAM)” works wonders in this regard. CMAM is recommended by both WHO and UNICEF and has shown positive results across many countries and some of the States and districts in India where it has been implemented as a pilot project. One such State that has fared well in CMAM is Maharashtra.

Taking cognisance of growing SAM children, in 2007, the Maharashtra government went on to implement CMAM at four different levels in the Nandurbar district.

The First Step involved community level screening, identification, and active case finding of SAM children by Anganwadi /ASHA workers.

The Second Step initiated treatment of SAM children without any complications at community level through Village Child Development Centre (VCDC) by using different centrally and locally produced therapeutic food. These energy-dense formulations are often at the core of nourishing the children since they are fortified with critical macro- and micro-nutrients. It ensures that the target population gains weight within a short span of 6 to 8 weeks.

The Third Step included treatment of children with complications at the NRCs.

And the Fourth Step involved following-up of children discharged from the CMAM programme to avoid relapse along with promotion of good IYCF practices, child stimulation for development, hygiene and other practices and services to prevent the further occurrence of SAM.

As a result, the district has witnessed a decline in SAM children, from 15.1 per cent in 2015-16 (NFHS-4) to 13.5 per cent in 2019-20 (NFHS-5). Nandurbar is a difficult terrain and if CMAM approach could achieve such favourable results in such a place, it has the potential to be scaled up anywhere in India.

Given the renewed political interest in nutrition through Poshan 2.0, CMAM must be given a serious thought if India plans to come anywhere close to meeting the stunting and wasting targets by 2025.

The writer is Sr. Advisor NRHM, UNICEF, and Ex-Vice Chancellor, Maharashtra University of Health Sciences

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