COMBATING MALNUTRITION & UNDER-5 MORTALITY

1. COMBATING MALNUTRITION &UNDER-5 MORTALITY INNAGAON DISTRICT OF ASSAM- Dr.P.AshokBabu, IAS Deputy Commissioner

2. COMBATING MALNUTRITION &UNDER-5 MORTALITY

3. Patient’s Name : Abdulla Hussain Age: 1 year 7 months Date of Admission:28.02.13 SAM NO.: AS-N-10-06-0001 Weight – 5.25 kg MUAC – 11.5 cm Date of Discharge: 15.03.13 Discharge weight- 6.05kg MUAC- 12.8 cm

4. Farjina Khatun,22 months Admission date- 29.06.2013 Weight – 5.230 kg MUAC: 10.6 cm Discharged Date-08.07.2013 Weight- 6.370 kg MUAC: 12.6 cm

5. Mohor Ali2 years 2 MonthsDhing Date of Admission: 14.05.13 SAM NO : AS-N-10-06-0027 Weight: 6.585 kg MUAC: 10.5 cm Date of Discharge : 28.05.13 Weight : 7.665 kg MUAC : 12.8 cm

6. Nagaon District of AssamApprox 30,00,000 population, density 711/sq.KmApprox 55% Muslims, 42% Hindus, etc

7. Malnutrition is a major contributor to under -5 mortality rate as it reflects as Measles, Pneumonia, Diarrohea, Heart Disorders etc and can kill a child. (World Health Organisation Report) -a Giant Killer of the district ??

8. Malnutrition is a condition that develops when body DOES NOT get the right amount of required nutrients such as… i) Carbohydrates ii) Proteins iii) Vitamins iv)Minerals etc.

9. Effects of Malnutrition

10. Malnutrition & Under-5 Mortality

11. Extent of the Malnutrition Problem in Assam • UNICEF : 48% of Under-5 Children • NFHS-3 : 48% of Under-5 Children • Department of Social Welfare : Conservative figures (about 2%) • Assam: 83.3 deaths/ 1000 live births (NFHS-3) • India : 64/1000 (SRS-2009) Under-5 Deaths

12. The Statistics of Malnutrition and Under-5 Mortality…Issues • Huge variation • MEASURED- Tries to measure quantum of the problem alone • NOT MEASURED - How many suffered have return back to normal health AND how many died because of malnutrition – indicator for Government efforts • NEEDED - Real Time Dynamic Data Base - Measures Government efforts AND Inter Departmental synergy

13. GOVERNMENT EFFORTS • All issues required to address the problem are identified in ICDS Programme & Assam State Annual Programme Implementation Plan (APIP) for 2011-12 • Interdepartmental synergy is planned with Health Department, PHED, SSA etc. • Sufficient funds are provided

14. GOVERNMENT EFFORTS

15. Why the rates of Malnutrition and Under-5 Mortality are High… • The Government Efforts are covering all the issues • Sufficient fund, Strong organizational support , PRIs, 10,500 employees per district (AWW, AWH, CDPOS, Supervisors, DC Office etc) • BUT, the cutting edge at the field level has been found to be BLUNT • The field level implementation has to be sharpened.

16. Field Level Issues…

17. Field level Issues…

18. Field level issues… • Malnutrition and addressing the problem are NOT issues at the AnganwadiCentres (3-5 in each Centre) • Huge under reporting • Registered children are always higher than actual attendance (double recording, absenteeism (difference 20 %- 95%). (Registration is more important because severly malnourished is disease hit more often, and will be in the house) • Mothers/parents passive

19. Field level issues… • Weighment of the kids to ascertain early grade of malnutrition is not regularly done and rarely done. Not even in a single Centre, it is observed all children being weighed monthly. Either it is lack of weighing machines, ANM not cooperating etc, but not a single solid reason.

20. Field level issues… The Growth Charts either not made OR made in a cursory manner RahulRabha(Severe Grade Malnutrition with dental infections, skin infections, cirrhosis and ascites) and his Growth Chart

21. Field level issues… The ASHA and Anganwadi Worker appear not working together * Though VHNDs which have to be conducted in Anganwadi Centres only. * The ASHA and ANM should have reported and followed the malnourished kid to the Hospital and ensured treatment. But the follow up by NRHM functionaries is not observed. * The first level interaction with a doctor for a malnourished kid appears ONLY when parents take the child to doctor when the kid gets some disease and by that time kid could be immune-compromised. * The recovery of the child if identified at this stage could be fatal.

22. Field level issues… • Poor Supervision by Supervisors and CDPOs • Mandatory visits are not followed • Training in identification of malnourished child, Awareness is required in Anganwadi Workers • About 20% Anganwadi Workers are trained in Ka Shreni Training by SSA.

23. Field level issues… MOTHERS • The Mothers of Malnourished kids appear passively watching decline of the child. • The Mothers must be made part of Government efforts. • At least mother should be made to ensure the malnourished son/daughter eat proper food at house and at Anganwadi Centre and the kid under a medical supervision through ASHA or ANM or Doctor.

24. Combating Malnutrition & Under-5 Mortality By following the principles of … • Linking Child with Anganwadi Worker, Supervisor and CDPO • Separate monitoring of each child and ensuring his health • Addressing lacunae of field performance • Automatic performance studies of field performers • Synchronising Social Welfare and Health Department efforts through a monitorableprtotcol • Involvement of Parents

25. Training on Malnutration & U-5 Mortality to Supervisors, Anganwadi Workers and ASHA

26. Training on Malnutration & U-5 Mortality to Supervisors, Anganwadi Workers and ASHA

27. Training on Malnutration & U-5 Mortality to Supervisors, Anganwadi Workers and ASHA

28. Training on Malnutration & U-5 Mortality to Supervisors, Anganwadi Workers and ASHA

29. Inauguration of Project on Combating Malnutrition and U-5 Mortality by Hon’ble Minister Social Welfare Sjt. Akan Bora.

30. Inauguration of Project on Combating Malnutrition and U-5 Mortality by Hon’ble Minister Social Welfare Sjt. Akan Bora.

31. Sample Data Collection Sheet

32. Field Visit Of Anganwadi Centre

33. Field Visit Of Anganwadi Centre with UNICEF Officials

34. Field Visit Of Anganwadi Centre with UNICEF Officials

35. Verification of Data at AWC with UNICEF Officials

36. Combating Malnutrition and Under-5 Mortality through - Growth Tracking and Field level Protocol for inter Departmental synchronisation

37. The Child Registration before entry into the Anganwadi Centre is done in a systematic and simple manner

38. Every child is registered with photograph with Mother and with one Unique ID number. The ID number of the child is generated based on the code of CDPO, Supervisor, Anganwadi Worker. Thus the Service Provider and the child are linked.

39. The Details of CDPO, Supervisor, Anganwadi Worker, Child Name, His/her Photograph with mother, Weight, Height etc address are registered.

40. Example of digital Growth Chart

41. Performance Study of District,On real time basisDecember’2013

42. Performance Study of CDPO Blockon real time basisDolonghat Block, December’2013

43. Performance Study of Anganwadi Worker

44. # Once the child is medically normal, if he/she continues to be malnourished action has to be initiated on AWW/ Supervisor/ CDPO# # If the child has not received treatment action has to be initiated on ASHA/ ANM

45. Monitoring of Malnourished Children Moderately Malnourished

46. Monitoring of Malnourished Children Severly Malnourished

47. Review of Project on Combating Malnutrition & U-5 MortalityBy Hon’ble Minister , Social Welfare Sjt. Akan Bora.

48. Review of Project on Combating Malnutrition & U-5 MortalityBy Hon’ble Minister , Social Welfare Sjt. Akan Bora.

49. Review of Project on Combating Malnutrition & U-5 MortalityBy Hon’ble Minister , Social Welfare Sjt. Akan Bora.

50. Letter to Parents