here are all-round efforts to tackle childhood
undernutrition in India . An estimated 8.1 million under-five
children in India are affected, and 0.6 million deaths and 24.6 million
DALYs (Disability Adjusted Life Years) are attributed to severe acute
malnutrition [2,3]. The Nutritional Rehabilitation Center (NRC) was
designed several decades back in Africa for clinical management of
severe malnutrition. While there are community (both in emergency and
non-emergency settings) and facility-based options for management of
SAM, the latter has emerged as a state-promoted and dominant model in
NRCs were first launched as an innovative scheme,
Bal Shakti Yojana, under the National Rural Health Mission (NRHM) in
Madhya Pradesh (MP). Since its inception, 36,538 SAM children out of the
targeted 39,840 have been treated through the 258 NRCs set up throughout
the state . Following the example of Madhya Pradesh, many states have
set up similar network of NRCs.
Bergeron and Castleman  used inter-country data to
classify countries by their prevalence of each condition expressed in
tercile (low, medium, and high) and showed that wasting and stunting
generally coexist within populations. India has uniquely high prevalence
of both stunting and wasting, implying that both SAM and severe chronic
malnutrition (SCM) co-exist. Severe chronic malnutrition (SCM) in
children is characterized by stunted growth and defined as child’s
height-for-age < –3 z-score of the median, according to WHO growth
standards . While the median under-five case-fatality rate for
untreated SAM ranges from 30-50%, children with SCM are considered to
have a potentially less serious but continual form of malnutrition.
Prasad, et al.  pointed to the inadequacies
in the criteria for identification, admission, referral and discharge in
NRCs; the lack of clarity in management of sick versus hungry
children. Our earlier work, based on anthropometric survey data of 1,879
children (aged 6 months to 3 years) had pointed to the limited
usefulness of measuring mid-upper-arm-circumference (MUAC) as a
screening tool used by frontline health workers to identify SAM .
This was hypothesized to be on account of high levels of chronic
undernutrition/stunting in these communities in contrast to the
epidemiologic profile of acute undernutrition in African child
What really have been the outcome and the experience
of the NRC model? The NRC model was designed to treat children with SAM;
epidemiologic profiling suggests higher prevalence of SCM among children
in societies with chronic poverty in India. This report is an
exploration to deconstruct whether the intervention (NRC) is suited to
address the epidemiologic profile and priorities in settings where the
prevalence of chronic poverty and SCM are known to be high. Outcome
indicators of the program have thus been used as a lens to deconstruct
the programmatic approach.
Study Settings and Methodological Approach
In a spatial analysis of distribution of rural
poverty, the proportion of those who were very poor was noted to be
largest in South Western MP, Southern Uttar Pradesh, Southern Orissa,
Inland Central Maharashtra, Southern Bihar, Northern Bihar and Central
Uttar Pradesh. These seven regions had 26% to 42% of their population in
severe poverty and had a squared poverty gap (takes into account not
only the distance separating the poor from the poverty line, the poverty
gap, but also the inequality among the poor) ranging from 5 to 9.7; this
near-contiguous cluster of districts has been termed the ‘poverty square
of India’ [9,10]. Eastern districts of MP have been identified as
suffering from ‘high levels of deprivation’ (Balaghat, in our case) and
some of the districts bordering Maharashtra (Khandwa, in our case – that
borders Melghat in Maharashtra also marked by high prevalence of
undernutrition and starvation deaths) . Both these districts
belonged to the fourth quintile – this pattern holds both for human
development indices as well as the Achievements of Babies and Children
(ABC) index computed by the authors. The NFHS-3 recorded that 40% of
children (under age 3 years) were stunted in MP and 33% wasted,
indicating a high prevalence of SAM among children with SCM .
Six NRCs were studied in Khandwa and Balaghat
Districts, MP; one NRC each at District Hospital level and two NRCs each
at peripheral (CHC/PHC) levels. Interviews were held with various
categories of care-providers and institutional data analyzed. Patient
data was collected for a period of 6-7 months preceding the period of
survey; facility and observational checklists represent single cross
sectional data. Assessments of the facilities were made through
structured check lists, drawn up in accordance with the operational
manuals. We stratified patient data from the two levels of NRCs (1,000
at the peripheral NRCs and 746 at the District hospital level).
E-interviews of key experts at national and state levels were conducted
following the guidelines of Mann and Stewart .
Anthropometric data from the earlier baseline surveys
among populations served by the peripheral NRCs of both districts were
as follows: (i) wasting 29% and stunting 64.9% in Khandwa and (ii))
wasting 26.7% and stunting 52.1% in Balaghat. This corresponded well
with National Institute of Nutrition survey data in these districts and
conformed to the typology of Bergeron and Castleman .
Infrastructure at the facilities was assessed as per
the NRHM Operational Manual for infrastructural parameters: building,
available rooms, kitchens, play areas, toilets, counseling area, staff
position, clinical equipment, kitchen equipment and pharmacy supplies.
Items on observational checklists included hand washing, general
hygiene, laundry, waste disposal, feed preparation and weighing .
Knowledge levels of admission, monitoring and discharge criteria were
also assessed. They were found to be adequate and functional at both
district and peripheral NRCs; differences in treatment outcomes would
thus be independent of facility-level factors.
We summarize key findings from our analysis of
treatment data from NRCs in these two districts as follows.
1. Two kinds of registers were observed; one
which had columns to record weight gains for 14 days and the other
for 21 days. Children were typically admitted for 14 days and
discharged (on the 14th
day) irrespective of their attaining/not attaining target weights;
this accounted for about 90% of admissions. In very few cases of
inadequate weight gain they stayed for few days more. Default
typically occurred during the first week with a range of stay of
about 4-7 days (about 10% of admissions).
2. Triage criteria for facility/hospital
admission: pitting edema, failure of appetite test and complicating
medical illness was about 10-15% [14,15].
3. The critical parameters defined by the program
manual were: (i) recovery rate (number of children discharged
for recovery/total number of exits); (ii) cure rate (number
of children who have reached the discharge criteria [15% of weight
gain]/total number of exits; and (iii) defaulter rate (number
of true defaulter in the program/ total number of exits) .
4. A far higher proportion of children are
getting ‘cured’ [attaining target weight; i.e. 15% of the weight at
admission] at district hospital level NRCs than the peripheral NRCs.
(a) With relatively few children being
referred from the peripheral to the district hospital level
NRCs, most of the admissions at district hospitals are from
areas closer to the district town.
(b) Referrals from district hospital
to medical colleges are far more than referrals from peripheral
NRCs to the district level.
(c) The cure rates, as per the state
program guidelines (which include a follow up period of eight
weeks, during which the child is only on home-based, and not
therapeutic foods) are nearly double at the district hospital
level NRCs (52.3%) compared to the peripheral ones (37.1%).
(d) The average weight gain of those
cured is 11.2 g/kg/day at the best performing district hospital
level NRC and is somewhat lower, 9.6 g/kg/day, at the best
performing peripheral NRC.
5. The proportion of non-responders is at least
twice or more in peripheral NRCs
(a) Non-responder rates at peripheral
NRCs were two-and-half times at district-level NRCs (average of
13.7% at district level; 34.9% in peripheral NRCs)
(b) There is no follow-up of the
non-responders, at either level, despite the operational manual
having an algorithm for it.
6. There were hardly any deaths at peripheral
NRCs, at least in part due to complicated cases being referred to
higher-level institutions. There were no deaths recorded at
peripheral level NRCs, and also deaths at district hospital level
NRCs were not more than 1-2% of all admissions.
7. The program guidelines for detecting secondary
failure, not gaining >5 g/kg/day weight for three successive days
after feeding freely on catch-up diet is not being followed and
reported . Computing from raw data at the best performing
district hospital level NRC, we obtained secondary failure rate of
up to 15%.
8. WHO-UNICEF Joint Statement recommends 15%
weight gain as discharge criterion for all infants and children
admitted to therapeutic feeding programs; but when weight-for-height
is used as an admission criterion (which is the case in our study),
"it is advisable to continue to discharge children at
weight-for-height > –1SD" . Several of our experts opined that
-2SD is a reasonable target to aim at and achieve, and that is the
position of the IAP Consensus Statement .
(a) Applying the –2SD criteria, cure
was nearly 90% at the district hospital level NRCs, and about
50% at –1SD.
(b) At peripheral NRCs the cure rates
for –2SD and –1SD were 64.4% and 6.7%, respectively.
The reference manual for NRCs in MP benchmark
‘acceptable’ recovery rate and defaulter rate at >75% and <15%,
respectively; <50% and >25% are considered to be ‘alarming’. Recovery
rates in our district hospital level NRCs reached acceptable levels
whereas the peripheral NRCs (where large numbers are being treated) were
in the alarming category. Despite an overall low cure rate, average
weight gain of those cured was above the acceptable range of
³8 g/kg/d. Defaulter
rates were in the alarming category with most NRCs recording >25% .
A review of the rate of weight gain in 170 patients
in Ethiopia found it to be much lower than International minimum
standards . In another prospective cohort study conducted in a
squatter settlement of Karachi, out of the total of 24 children included
in the study, 45.8% reached –1SD at the end of 3 months while 41.6% took
4 months ; 91.6% were at the median weight-for-height by the end of
5 months . Similar overlaps have been reported from Bangladesh,
Pakistan and Kenya .
We have reviewed patient data of a fairly large
sample. Applying the International criteria for cure at -1SD, not more
than 50% of children admitted at district hospital level would be able
to achieve it, while only 6.7% would do so at the peripheral levels.
This is a significant pointer to the high prevalence of SCM in these
child populations, particularly in peripheral locales, and argues in
favor of community level rehabilitation. It is pertinent to recall here
that only about 15% of those admitted fulfill criteria for facility
Restricted public health approach towards SAM
management in societies with high levels of chronic undernutrition has
been questioned earlier. It has been argued that a large proportion of
children with SAM require additional management for SCM .
Co-existing wasting and stunting is the consequence of inadequate and
sustained poor dietary intake . WHO considered SCM to be the
consequence of long-term nutritional deficiency due to poverty, poor
housing, inadequate water and sanitation, unemployment and illiteracy
The NRC model (in MP as in other states) is focused
on managing ‘SAM’; contrary to ‘SAM outcomes’, mortality is very low
(despite ‘alarming’ low recovery rates in peripheral NRCs) and little
complicating medical illnesses. We interpret this apparent paradox on
account of high prevalence of predominantly SCM, particularly in
populations served by peripheral NRCs. This is further strengthened by
very low rates of pitting edema and failed appetite test as admission
criteria (markers of SAM). An adverse fallout of less sick children is
the minimal engagement of doctors who perceive NRCs as yet another
‘feeding program’. Further, low weight gains (in the two/three weeks of
hospital stay) do not lead to visible and perceptible changes in
children leading to parents questioning the efficacy of the intervention
. Taneja, et al.  reviewed data of 100 admitted
children in NRCs in MP and found that a high proportion of the children
(>40%) continued to remain in the high risk category at the time of
discharge and concluded that it would require approximately 15.5 years
to treat all SAM children of the state.
The labeling of all severe undernutrition as SAM has
lead to an exceedingly clinical response with sharp standard operating
procedures as designed, implemented and sustained by humanitarian and
development organizations as well as by government health services .
In contrast, programs aimed at correcting SCM (the dominant entity)
require well-rounded multi-sectoral approaches that promote adoption of
practices to improve the quality of local diets, improving child feeding
practices, and reducing exposure to illnesses and also wider issues such
as sustaining livelihood of mothers as well as addressing her time
issues through crèche and day care models [24-26]. Put differently,
while SAM management typically requires a vertical approach (exemplified
in the NRC model), SCM mitigation calls for sustained horizontal
strategies including support from frontline health workers as well as
community mobilization and putting mothers’ issues center stage . SAM
has the opportunity of being treated or reversed through swift
medicalized treatment; the approach to SCM cannot nurture similar goals;
indeed, it requires multi-pronged action towards prevention with little
scope for ‘cure’. MP is in the process of piloting community-based
management models; the results of these experiments shall be keenly
awaited. The caveat: with chronically malnourished children
(non-responders) gaining little weight even with two weeks of
therapeutic diet (at NRCs), it would take sustained therapeutic feeding
through community level interventions to achieve target weights.
The NRC has emerged as a quasi-vertical model with
emphasis on identifying and referring undernourished children from
villages to institutions (health workers reported to the investigators,
pressures from the highest quarters of the administration). There is a
failure to recognize SCM as an epidemiological entity and gear
wide-ranging programmatic and social interventions. The need for
convergent actions towards better health and correcting chronic
undernutrition cannot be over-emphasized and involves sectoral as well
as cross-cutting action. In order to carve out a roadmap, the Planning
Commission considered two models: (i) "Whole of Government" (WoG)
– inter-sectoral coordination for policy and program development at
national and state levels; and (ii) "Whole of Society" (WoS) –
rendition of trans-sectoral harmonization at the point of implementation
for convergence in true spirit through involvement of all key
We recognize the sincere efforts of well-meaning
health personnel in reaching out to children under difficult
circumstances. The alarming(ly) low cure rates and high non-responder
rates in these districts of the poverty square are pathognomonic of a
basic flaw in the approach itself and not a marker of poor
implementation. This is a wake-up call to our own selves for a re-think
lest it be a slow peaceful journey to nowhere!
Acknowledgements: Sincere thanks and
appreciation for support in the field activities are due to: Sachin
Jain, Vikas Samvad, Bhopal; Prakash Michael, Spandan, Khandwa; Ammen
Kumar Charles, Community Development Centre, Balaghat; Haldhar Mahato,
PHRN Jharkhand; Dipa Sinha; Dr. Vandana Prasad and Dr Ganapathy Murugan,
PHRN, New Delhi. The authors acknowledge the insightful comments to the
manuscript by Dr N K Arora, INCLEN & CHNRI.
Contributors: RD conceptualized and led the
study. All authors participated in data collection, analysis, manuscript
writing and approved the final draft.
Funding: Indian Council of Medical Research;
Competing interests: None stated.
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