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Assessment of Malnutrition Treatment Centres in Jharkhand and State Consultation

31st October 2013
Eight MTCS were visited in five districts of Ranchi to collect information against the indicators in the framework. These MTCs were located at Doranda (Ranchi), Mandar (Ranchi), Khunti (Sadar), Gola (Ramgarh),Gumla (Sadar), Reidh (Gumla), Bhandra (Lohardaga) ,Kuru (Lohardaga). The assessment was done in collaboration with CINI, world vision, right to food campaign, Ekjut, BPNI, PHRN, SCPCR and Vikas Bharati. The MTCs were assessed on the bases, which included location and infrastructure, human resources and training, and process and protocols. The recommendations include increasing accessibility and coverage, institution based facility should be supplemented with community based preventive management, addressing the institutional differences between ICDS and NRHM guidelines, improving compliance rate of follow up visits, increasing financial support for accompaniment etc. The State Consultation was organized on 31st October in collaboration with Viaks Bharti and CHILDLINE Nodal Ranchi (XISS). The State Consultation was attended by Chairperson, SCPCR, Director, MTCs, government of Jharkhand, former President India Medical Association, MOs of MTCs, Save the Children, world vision, representatives of relevant departments from Government of Jharkhand besides CSOs, academics, and media. The recommendations included policy demands, increased financial allocations, operational issues, facilities.
 
Ms. Roop Laxmi Munda, Chairperson SCPCR, pledged renewed efforts to make Jharkhand malnutrition free. She assured the support and commitment of SCPCR in the fight against malnutrition.
 
Dr. Ajeet, Malnutrition Treatment Center in-charge, Department of Health and Family Welfare, Govt. of Jharkhand, addressing the civil society organizations shared that there are 69 malnutrition treatment centers functional in Jharkhand amounting to capacity of 576 beds. Speaking about the number of children suffering from SAM, he shared that out if 35000 children identified as SAM, 17000 have been treated till now. 
 
Addressing the infrastructural gaps, Dr. Ajeet emphasized that malnutrition treatment centers were initiated in Jharkhand in 2009 with limited resources as a result of the emergency crisis of SAM which is one of the reasons for high child mortality. On the important component of nutrition education, he shared that the recruitment of nutritional counselor is in the process. The nutrition counselor will also promote use of locally available nutritious food among mothers to ensure sustainability of the treatment after discharge from malnutrition treatment centers. Speaking about community management of malnutrition, he shared about Jeevan Asha Programme launched by the government of Jharkhand. 
 
Dr. Ajeet speaking on the poor compliance of follow-up visits shared that the government has approved a sum of 150 Rs per follow-up to cover the travelling costs which will act as an encouragement to ensure timely follow-up visits. He informed the gathering that keeping in mind the current amount of daily wage compensation to mothers, the government has decided to increase the daily wage compensation from 100 Rs per day to 150 Rs per day.  
Responding to a query by Save the Children Jharkhand he emphasized that the civil society organization should not experiment by introducing any therapeutic feed in the community without due permission from the government. 
The consultation started with sharing the findings of snap assessment carried out by PAIRVI. Sharing the key findings of snap assessment carried out by PAIRVI, Ms. Richa spoke about the lack of nutrition education, poor accessibility to malnutrition treatment centers, low compliance rate, absence of regular growth monitoring and counselling at the AWCs, inaccessibility to safe drinking water and hygienic conditions and absence of community management of different grades of malnutrition as the major issues. 
 
Dr. Rakesh, Medical Officer In-charge of Malnutrition Treatment Center, Gumla, speaking on the low bed occupancy rate shared that there is reluctance on the part of mothers to avail treatment at MTCs because they cannot afford to lose their daily wages. He added that mothers also drop out before the child meets the discharge criteria due to lack of information about the issue and process of treatment and strong rooted belief in superstitious practices.  He attributed poor infant caring practices, lack of community management mechanism and poverty as the factors that influence the effectiveness of the treatment received in Malnutrition Treatment Centers.
 
Ms. Sheila, district social welfare officer, Ranchi, reiterated the difficulty faced in referral to MTCs due to reluctance expressed by mothers for the in-patient treatment of children. Highlighting the importance of counselling she said that though much is said about counselling on infant and young child care practices by Anganwadi Workers, there does not exists a protocol for the same. DSWO further spoke about better coordination between malnutrition treatment centers and anganwadi centers for follow-up of children discharged from the malnutrition treatment centers. Talking about the future plans of department of social welfare, women and child development to address malnutrition in the state, she shared that cr�ches would be introduced in every block to emphasize the importance of first 1000 days of life and anganwadi centers in every block would be shaped as model anganwadi centers in a phased manner. Addressing the findings of assessment by PAIRVI on absence of growth monitoring and subsequent recording on mother child progress card, she shared about the shortage of mother child progress card. DSWO also expressed the need for training for anganwadi workers on feed preparation being used in the MTCs to ensure follow-up at the community level.
 
Dr. Suranjeen, former state head of CINI-Jharkhand, brought attention to the fact that 50% children receiving treatment at the malnutrition treatment centers do not meet the discharge criteria of 15% weight gain. While much is discussed about accessibility to malnutrition treatment centers, emphasize should also be given on identifying the reasons for children not meeting the discharge criteria. According to him failure to identify and treat medical complications is a major reason of the inability to meet the discharge criteria. Speaking further on the issue, he shared that chest x-rays which is mandatory as per the guidelines to rule out any congenital heart disorder are not regularly done in all malnutrition treatment centers. Repeat chest x-ray before declaring children deem fit for discharge is a rare phenomenon. Dr. Suranjeen also spoke about the importance of daily medical examination of every child and its irregularity in malnutrition treatment centers in Jharkhand.
 
Dr. Ajay, former president-Indian Medical Association and vice president of Vikas Bharti, focused on the much needed coordination between department of health and family welfare and department of social welfare, women and child development. He put forth that promotion of literacy, hygiene and awareness among people are key to nutritional status of children.
 
Civil Society organizations namely Save the Children and Public Health Resource Organization shared their interventions to improve the nutritional status of children in Jharkhand. Save the Children shared about their programme in Gumla district which emphasizes on outpatient treatment of children with distribution of therapeutic feed. Save the Children’s proposal of making child friendly MTCs was not well received which questioned the cultural and local sensitivity of the proposal. Public Health Resource Organization shared about their intervention with children from 0-3 years and the importance of community mobilization in any such intervention to make it sustainable.
 
Recommendations:
  1. To ensure that the nurses appointed in malnutrition treatment centers are sensitive towards the issue and have minimum training.
  2. All malnutrition treatment centers should be installed with an exhaust fan to address the problem of poor ventilation. 
  3. Children accompanying their siblings to malnutrition treatment centers should also be screened.
  4. More number of MUAC tapes should be made available in the community. 
  5. The shortage of mother child progress card should be addressed on priority basis.
  6. The comparative malnutrition charts should be made available at the anganwadi centers
  7. The PRI members should be trained on their roles and responsibilities for better coordination with frontline health workers and also to create a sense of community ownership on the issue of malnutrition.
  8. Counselling of mothers in the community and MTCs should be ensured.
  9. Promotion of locally available nutritious food should be an important component of nutrition education.
  10. The discrepancies in screening and referral should be addressed. Weight for height should also be used as a screening criterion. 
  11. There is a need to adopt domiciliary approach for follow-up of children discharged from malnutrition treatment centers.
  12. A case book should be maintained for each child receiving treatment at MTCs for the convenience of anganwadi workers and also to trace defaulters and non-respondents.
  13. There should be specific focus on children suffering from HIV AIDS in the gambit of intervention to address malnutrition as they are at a higher risk.
 
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