Pune District’s Efforts To Reduce Child Malnutrition Bear Fruits

During a health screening in 2022, Waghule realised that Shivani was malnourished. “We started to feed her nutritious food like upma/finger millet dosa, finger millet dessert, lunch of chapati and vegetable curry. We fed her six times a day in the anganwadi, and asked her mother Alka to feed her twice, in the morning and evening,” says Waghule. “Her weight started to increase within two months and now she is out of the malnourished category.”

Shivani’s mother Alka Waghule says she was unable to take proper care of her daughter as she had to go to the farm to work. “I would leave my kids with my in-laws, who are old. Now I feed them with food given by the anganwadi didi.”

Shivani is not alone. The Zila Parishad, Pune (ZP) in April 2020 launched the Mission Malnutrition-Free Pune drive to reduce malnutrition across the rural areas of the district. Though Covid-19 hampered its pace, the Parishad smoothened out the process after January 2022, they say.

Through extensive health screening, nutrition interventions and medical care, Pune has reduced the number of malnourished children from 2,118 in January 2022 to 346 in June 2023, which includes 302 children with ‘severe acute malnutrition’ (SAM) and 44 with MAM, Jaising Girase, deputy chief executive officer of the Integrated Child Development Services (ICDS) in Pune, told IndiaSpend. In addition, 153 kids underwent surgeries supported by the government; of these, 44 children had heart ailments that were successfully resolved.

What the data say

Of 56 million children under five years tracked across India in February 2023 through the Poshan Tracker, an ICT application for monitoring services delivery under Mission Poshan, 7.7% were in the ‘malnourished’ category, as per information provided to the Lok Sabha by Smriti Irani, Union minister for women and child development.

Overall, data from the fifth National Family Health Survey (NFHS) show that in 2019-21, 35.5% of children in India under five years were stunted (short for their age), 32.1% were underweight (low weight for age), 19.3% were wasted (low weight for height) and 7.7% were severely wasted.

In Pune district, NFHS data show that 30.7% of children under five years were stunted in 2019-21, 32.7% were underweight, 31.4% were wasted and 14% were severely wasted.

The Pune ZP tracks severe and moderate malnourishment, which are sub categories of wasting. The World Health Organization (WHO) defines SAM as severe wasting or weight for height three standard deviations below the average. MAM is moderate wasting, when weight-for-height z-scores are two or three standard deviations below the average or mid-upper arm circumference (MUAC) is between 115 millimetres and <125 millimetres.

Malnutrition increased during the Covid-19 pandemic, says Girase, but was brought under control after 2022.

The data from the Pune ZP and the NFHS do not match, as the Pune ZP data are only for the rural area of Pune and excludes areas under the Pune Municipal Corporation and Pimpri Chinchwad Municipal Corporation, said Girase. The difference is also because the NFHS is a sample survey while the ZP tries to screen all children under six years of age, he added.

We have reached out to officials from the Union Ministry of Women and Child Development, as well as to the International Institute of Population Sciences that oversees the NFHS, to understand why there is a difference in the data from the Zila Parishad and the NFHS, and will update the story when we receive a response.

How Pune reduced malnutrition

Girase said the government appointed Taluka Health Officers (THO) and Child Protection Development Officers (CPDO) in each block. They in turn created teams consisting of existing healthcare workers: an auxiliary nurse midwife (ANM), a community health officer, an accredited social health activist (ASHA), and anganwadi workers (AWW). These teams were tasked with carrying out health checks of children, 0-6 years, in the anganwadis in their jurisdiction.

Girase said that the ZP Pune working with the Maharashtra Emergency Medical Services has developed a special web-based application, called Child Health Tracking System (CHTS). The app tracks 32 parameters, which teams of ANM, ASHA and AWW fill in the app after the child’s health check-up. If a kid had rashes in the eyes, for instance, the app has an option to register that.

A nutrition corner at Chandkhed anganwadi in rural Pune district, showcasing food made from local produce, fruits etc. Pune Zila Parishad is trying to reduce malnutrition through several interventions, including nutritious food at anganwadis.

Officials then analyse the collected data, marking how many fall in the SAM or MAM categories, and how many require medical treatment. Generally, they have found that kids needing treatment suffer from issues such as multivitamin deficiencies, skin diseases and heart ailments. These are referred to doctors at the district level at the Dr D Y Patil Hospital, Pune and the Sassoon General Hospital, Pune for specialised treatment.

“ZP Pune, working from September 2021 to January 2022, collected data of all 331,392 children in the age group 0-6 years in the rural area of Pune district,“ said Girase. “We have found issues with 4,603 kids including 1,724 MAM, 394 SAM, and the remaining with various health issues. One hundred and fifty three kids had critical diseases like Tetralogy of Fallot [a birth defect impacting blood flow] and needed surgical intervention. We connected these kids with hospitals that are under Rashtriya Bal Swasthya Karyakram (RBSK).”

RBSK, which is a Union government scheme, involves screening children from birth to 18 years of age for ‘4 Ds’--defects at birth, diseases, deficiencies and development delays--spanning 32 common health conditions for early detection and free treatment and management, including surgeries at the tertiary level.

Ailments detected during health screening for malnutrition

Since four-year-old Shreyas Bokade underwent surgery for his multiple heart disorder in May 2023, he has been active, enthusiastic and happy. Before surgery, he would get exhausted easily, not attend school and would not mix with other children in the anganwadi in Gahunje village, 28 km away from Pune city. His lips and palms would turn black, said Meena Tikhe, an anganwadi worker, as his heart was too weak to pump blood. He was malnourished and fell in the severe acute malnutrition category. His weight was 9.4 kg before surgery; post surgery, it is a healthy 14 kg.

During health screening at the anganwadi, doctors realised that Shreyas had Tetralogy of Fallot. Meena Tikhe said they realised that his mother Sangita, 35, and father Popat, 37, were aware of his heart ailment. But as both of them are daily wage labourers, they were unable to follow the doctor’s advice to perform surgery costing Rs 10 lakh.

The Pune ZP, with funds under a government scheme, arranged for Shreyas to have surgery at the Kokilaben Dhirubhai Ambani Hospital in Mumbai. He still has to undergo one more surgery, but already he is fit, and able to participate in active play with his peers.

“He has had problems since birth,” said Shreyas’s mother Sangita, “and doctors had told us that without surgery, he would not survive. But we had no money. Thanks to anganwadi for arranging the surgery. Now I feel happy as my son has recovered.”

Village Child Development Centres

Children at Gahunje anganwadi sing songs with anganwadi workers.

Five-year-old Rhitik Bhalerao plays on a red-coloured bench, one of several along a wall painted with colourful flowers and animals. His sister Rutuja, 4, plays with toys on a mat on the floor of the anganwadi in Chandanwadi hamlet of Chandkhed village, 30 km from Pune city. Anganwadi worker Shobha Thorat calls the children over for a treat--nachni laddu (finger millet dessert) at 4 p.m.

Both Rhitik and Rutuja are malnourished, falling in the category of moderate acute malnourishment. The Pune ZP runs a Village Child Development Centre (VCDC) at the anganwadi to treat malnourished kids till 6 p.m. daily.

“We have three kids who fall in the MAM category in our VCDC,” Throat said. “We give medicines prescribed by doctors and nutritious food as prescribed by health experts to kids six times a day, every two hours from 8 a.m. till 6 p.m. SAM and MAM kids stay here till 6 p.m. unlike healthy kids who go home at 2.30 p.m.” Girase says that during the anti-malnutrition drive, the ZP ran 288 such VCDCs.

Parents whose kids are admitted to anganwadis are often daily wage workers who work from dawn to dusk and are unable to give nutritious food to their children. The majority of the population at Chandkhed are Thakurs, classified as Scheduled Tribes.

Hygiene is a major issue. “You will see goats and chickens in the same room where kids play and sleep,” said Thorat. “We had a hard time counselling parents to maintain hygiene and give nutritious food to kids. Earlier, no clean drinking water was available here. We have convinced the gram panchayat to supply clean drinking water to the hamlet.”

“Food is not covered during cooking, which causes loss of nutrients through steam evaporation. Babies should be exclusively breast-fed, but that too is not followed,” says Ayush Prasad, CEO of Pune ZP. He explains that the malnutrition drive was carried out by implementing various existing schemes of the Union and state governments, and did not require an additional budget.

Jyoti Bhalerao, Rhitik’s mother, said she leaves her children with her ageing in-laws as she and her husband have to work. “I used to try to give good food to the children, but that was not always possible. But now the anganwadis regularly send food packets, rations to feed children in the evenings. If I don’t visit them, they come home to check how we are taking care of the children at home.”

“Rhitik and Rutuja were in the SAM category during a check-up done in January 2022,” said Thorat. “As per norms, they had to be put in the Nutrition Rehabilitation Centre (NRC) at the District Hospital in Aundh, in Pune. Jyoti, their mother, was not ready to do this as she could not afford to miss work. We arranged food for the family for two weeks, during which the children were being treated. It was only then that Jyoti and her husband agreed to admit the children.”

“Children in the SAM category generally vomit or experience diarrhoea when they first start getting good food, as their bodies are not used to it. Once they are treated with medicines and nutritious food in an NRC, their bodies start accepting healthy food without health issues,” says Manisha Govande, Tehsil Medical Officer, Maval block, Pune.

Vinod Shende, a nutrition expert, lauded the Pune ZP’s efforts to make hot local food available to children through the VCDC. “The state generally distributes packs of dry rations to families with kids. But the Pune ZP made hot and local food available to kids at anganwadis through VCDCs. That has made a difference. Besides, not stopping at health screening for ailments but treating kids at tertiary care hospitals has also proved beneficial.”

Consistent efforts needed to fight malnutrition

“Efforts by the Zila Parishad to reduce malnourished cases are praiseworthy,” said Abhijit More, social activist with the Jan Swasthya Abhiyan, adding that efforts should be consistent to prevent a rise in malnutrition. “The reasons for malnourishment are social, such as poverty, lack of health education among parents, and poor access to the health system. When government agencies intervene in various ways, like regularly monitoring the weight of children, providing nutritious food, and creating awareness among parents by explaining healthy feeding practices, it always results in the reduction of such cases.”

Vikas Raskar, a teacher at a local school in Chandkhed, points out that AWWs often go to houses of kids if they are not present. “I see AWWs counselling parents regularly. They feed kids with their hands. They take care of kids in the absence of their parents. They have managed funds to paint anganwadis so that kids find it attractive. Many organisations provide fruits and vegetables to anganwadis, due to honest efforts by the workers, and visible results.”

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