Health Wednesday: How convergence between Health & WCD can curb malnutrition

Background

The district of Mahasamund faces severe challenges in the health & nutrition sector, with 7.96% children marked as Severely Acutely Malnourished (SAM) and 25.2% children marked as Moderately Acutely Malnourished (MAM). This is striking when compared with the all-India average figure of 25.7%.

Initially, the Health department & WCD were working in a disaggregated way to tackle malnutrition. The Health department was in-charge of running the NRC, and was checking children for the presence of malnutrition. Despite that, the occupancy of NRC was less than 25% in NRC-Saraipali, while the occupancy was around 95% at NRC-District Hospital. Similarly, the WCD was monitoring the height & weight of children, but did not have access to remedial measures.

The District Collector decided to bring about convergence of these two initiatives to bring about an outcome-focused approach for tackling malnutrition. There was a natural need to create an organic linkage between these departments, wherein the output of one department (WCD) acts as input for the other (Health). As there were a number of schemes running to tackle malnutrition from different angles, there was an urgent need to reduce duplication & channelize the energy & efforts in a focused manner. Due to the practical limitation of making the health experts move to the malnourished children, it was decided to create a channel for creating a movement to bring about the children to the health experts. Similarly, it was necessary to rope in the resources of all the AWCs & PHC/CHCs to ensure maximum coverage. And all of this was to be done by limiting the financial burden, & ensuring optimum resource usage.

Intervention

1. The 'Health Wednesday' is an initiative by the district administration of Mahasamund in the state of Chhattisgarh to reduce the prevalence of Severe Acute Malnourishment (SAM) present among children in the district. This has been achieved by ensuring convergence between the efforts of the Health department and the Women and Child Development department.
2. The initiative channelizes the resources, available under ICDS, to shortlist SAM children & for providing medicines. The Health Department functionaries provide facilities like free health checkup at the CHC/PHC, & shortlist children for the Nutrition and Rehabilitation Center (NRC). At the NRC, the children are further prioritized on the basis of various parameters like Nutritional Edema, MUAC. The SAM children are admitted at Nutrition and Rehabilitation Centres (NRCs) by Anganwadi workers using funds from 'Mukyamantri Bal Sandarbh Yojana.' Free food is provided to all the children visiting the DH/CHC/PHC, which is funded by the Jeewan Deep Samiti, which is funded by the District Mineral Fund.
3. Under this initiative, it has been decided to create an organic linkage between the identification of SAM children at the Anganwadi Center (AWC) to their enrollment at the Nutrition Rehabilitation Center (NRC). The Anganwadi Worker (AWW), working under the tutelage of WCD, measures the height, weight, and Mid-Upper Arm Circumference (MUAC) of all the children in the age group of 6 months to 5 years. This is done every month so as to track the progress of all the children monthly. WCD uses the World Health Organization's age-growth chart to categorize the children, as per their development, into the following three categories: Red, Yellow, & Green.
4. The children marked as 'Red' and Yellow are categorized as SAM, and they are taken by the AWW to their nearest Primary Health Center (PHC). At the PHC, the child's height, weight, and MUAC is again measured by a team led by a doctor. The PHC, then, analyzes the child on the basis of Standard Deviation (SD) between weight/height, and children are prioritized on the basis of the level of malnourishment.
5. Based on these scientific indicators, the children are then referred them to NRC. The Mahasamund district has two functional NRCs at the District Hospital and at Saraipalli. Both of them have a combined monthly capacity to rehabilitate 60 children per month. A third NRC to be established at Baagbahara block with a capacity of 30 child under the District Mineral Fund.
6. The children are taken to the NRC by the AWW as per the roster decided by WCD. At the NRC, besides measuring the height, weight, & MUAC, the children are prioritized on the basis of Nutritional Edema, MUAC development, Developmental Delays and, then, SD from the ideal weight/height ratio.
7. The objective of NRC is to increase the weight by 15% or achieve an increase of 8 grams per kilogram per day increase in weight.
   1. Multiple investigations done in the NRC are shown in the Table 1, which is available at page 2 of the supporting document.
   2. Multiple services provided in the NRC are shown in the Table 2, which is available at page 3 of the supporting document.
8. At the NRC, the admitted children are kept under observation for 15 days. During this time, they are provided with a balanced diet consisting of lentils, vegetables, milk, eggs etc. The diet is prepared at the NRC in a systematically controlled environment by a trained supervisor. The funding for the food is provided by the Jeewan Deep Samiti. The initiative provides for a follow up on the NRC-released children in 15 days to assess the sustainability of the initiative in overcoming malnourishment. This programme directly affected the Bed occupancy rate of Nutritional Rehabilitation centre (NRC), which has been increased regularly, especially at NRC-Saraipali.
9. The mothers, whose children are admitted in NRC, are being given daily wages at the rate of Rs. 150 per day.
10. Based on learnings, the district is working on identifying the various causes of malnourishment which cannot be treated in NRC, and then, devising strategies for resolving them. There is a future plan to provide vaccination services during this initiative, so as to improve the vaccination percentage in the district. The mission-mode approach of the Health Wednesday initiative has renewed vigour in the approach to eradicate malnutrition in the district.

Impact

1. Reducing Infant Mortality Rate (IMR): This Programme significantly contributes to reduction of under-five mortality as undernourished children have increased susceptibility to infections and, hence, frequent episodes of diarrhea, acute respiratory infections, malaria and measles were reduced.
2. Reducing malnutrition: Malnourished children are directly examined by Medical Officer/Assistant Medical Officer. The Mild Malnourished children were treated at the health facility, which has directly resulted in the reduction of Severe Malnutrition.
3. Changing knowledge, attitude, and habits: The SAM children are transferred to NRC for intensive feeding so as to recover lost weight, development of emotional & physical stimulation, capacity building of the primary caregivers of the child is improved through sustained counselling and continuous behavioral change activities. Thus, the HEALTH WEDNESDAY is intended to function as a bridge between NRC & home care.
4. Reducing out-of-pocket expenditure: The SAM children are treated free of cost at the NRC, and the government also provides for transport.
5. Improving awareness: The children who have benefited from NRC and their mothers, who have learned about cleanliness and nutritious diet, act as force multipliers in spreading awareness.
6. Motivating field staff: The focused approach of the program serves as a motivating factor for the field staff. At each stage of treatment, there is a presence of trained and dedicated health personnel.
7. Improving governance: The increased faith in governance has led the people to demand more and efficient services. This has made the departments respond to the needs of the needy.
8. Improved tracking: By using an online portal for maintaining data, tracking has been made easy.
9. Improving inter-departmental coordination

Key Takeaways

What have we learnt?

1. The main takeaway point is that the only way to tackle malnutrition comprehensively is by forging convergence between the Health Department & WCD.
2. The initiative has to be sustainable in nature. Institutionalization of the initiative will help in ensuring that the initiative will be able to survive benign neglect.
3. Ensuring optimum financial viability is vital for the success of initiative
4. Motivating field-level functionary is a must.
5. Outcome-based monitoring is necessary not only for the monitoring of the initiative by the DC, but also for motivating the staff at cutting-edge.
6. Infusing technology helps in improved data management, & helps the concerned managers in taking data-driven decisions.
7. Cross-checking of data helps in improving the authenticity of data collected.
8. Transparent implementation helps in building consensus and ensuring motivation.
9. Regular monitoring by the managers is necessary to promote efficiency, find bottlenecks, & resolving operational issues.

Health Wednesday - Dist. Mahasamund Chhattisgarh

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Source : NITI Aayog