- For Information of group members Minutes of the Meeting of Action Group on Nutrition, MOHFW 29th July 2011 Nirman Bhawan, New Delhi 1. AMessage 1 of 1 , Apr 2, 2012View Source
For Information of group members
Minutes of the Meeting of Action Group on Nutrition, MOHFW
29th July 2011
Nirman Bhawan, New Delhi
1. A meeting of the Action Group on Nutrition was organised on 29th July 2011 at Nirman Bhawan under the Chairmanship of Dr. Umesh Kapil, Professor Department of Human Nutrition at AIIMS and Co chaired by Dr. Ajay Khera, Deputy Commissioner (CH & I). The purpose of the meeting was to discuss current interventions (under GOI programmes) for prevention and management of malnutrition, with special reference to SAM. It was proposed that interventions suggested by the expert group should be ‘doable’ and within the mandate and control of MOHFW.
2. Progress: It was pointed out that between NFHS 2 and 3, stunting has declined by 6%. There has been an average reduction of 0.9% /year in stunting while country like Thailand has achieved a rate of 2-3 % /year. Nutrition is linked to development and factors like 100% female literacy, community ownership, strong political commitment, leadership and resources ‘ad lib’ could have made a difference. In India, ICDS was supposed to bring about a similar change but could not make a significant dent.
3. Programmatic issues: While the nutrition interventions are relatively well understood, the challenge basically is effective operationalisation of the programme.
Nutrition requires both biomedical and social interventions. While biomedical interventions are understood, social interventions need to be understood further and evidence generated for behaviour change component.
A basket of interventions which are cost effective and known to make a difference should be included.
The interventions must be thought about carefully to understand if they are aimed at reducing overall morbidity and mortality or increasing body anthropometry. An economic review through cost benefit analysis is also required.
4. IYCF: Since the problem of under nutrition starts even before birth and soon thereafter, 75% of the problem can be tackled by focussing on first 6 months of life.
There are now new opportunities available with NRHM, which can be capitalised. With substantial increase in institutional delivery, early initiation of breastfeeding in health facilities must be promoted. 10 points for successful breastfeeding should be followed in health facilities.
VHND is an existing platform where the two ministries, MOHFW and MWCD, come together but this opportunity has largely remained unutilised. Experts emphasise that breastfeeding and IYCF practices is more about behaviour change and practices and therefore VHND can serve as a good platform for this purpose. In addition a sustained Behaviour Change Campaign is required, which goes beyond ASHA and AWW, and sets the momentum for a larger change in social norms around breastfeeding.
It is also required that IYCF be made part of Home Visits, outcomes measured and incentivised.
Nutrition Counselling Corners can be established at health facilities to promote IYCF practices and support breastfeeding among mothers who attend outpatient services with their children.
Reviving an accreditation process for Baby Friendly Hospital Initiative would be another important step.
IYCF should be emphasised in medical education, nursing and ANM colleges.
5. Growth Monitoring: Growth monitoring as an intervention by itself does not improve nutrition status; it just makes it visible and helps identify children who need extra care.
For growth monitoring to make a difference, it should be part of a comprehensive set of interventions that include family level counselling, community level counselling and training in IYCF. While growth is being monitored in some cases, counselling is not taking place under programmatic conditions.
ANMs and ASHA have to be trained in use of MCP cards, as the field level experience shows that certain terminologies are not clear to them. A clear training plan for MCP cards should be developed.
6. Aanemia: The understanding regarding what works in preventing and treating anaemia requires to be further deliberated. The causes of anaemia among children in India should be further studied as B12, folate and other deficiencies may exist.
A systematic review (to be published shortly) shows that 80% coverage by IFA supplementation, which is the only known intervention in the short term, can reduce prevalence of iron deficiency anaemia by 38-50%. However coverage with IFA as a prophylactic is quite low as this concept is not well understood by health providers.
Operational guideline for Iron Folic Acid Supplementation is required.
In order to increase coverage of IFA, the possibility of initiating it during the Biannual Rounds for Vitamin A supplementation could be considered and may require an operational research to see if this strategy works. However Vitamin A supplementation during Biannual rounds as a strategy does not exist across all states.
The supply scenario has improved with availability of IFA syrup; the supply of dispersible paediatric tablets should be considered. However supply is irregular; compliance and availability of paediatric IFA tablets/syrup is an issue. The quality of IFA tablets supplied and the bioavailability of iron must also be ensured.
Deworming as an intervention has no benefit in terms of nutrition status, minor benefit on haemoglobin level is possible.
For long terms impact on anaemia, other approaches should be thought about.
7. LBW: Intrauterine and Antenatal period being critical in terms of birth weight and first two years of life in terms of growth, special emphasis should be given to interventions that can be made during this period.
LBW babies can grow well if necessary support is provided by the health system. IYCF counsellors can be placed at Newborn facilities, so that babies born with LBW can be followed up and supported to grow optimally. All children born in facilities with newborn care units can be counselled (by nutrition counsellors) as also mothers with children in outpatient services.
For long terms impact, maternal malnutrition should be tackled so as to reduce the incidence of low birth weight babies.
8. SAM: Management of children with SAM is primarily the responsibility of MOHFW.
Since there are an estimated 8 million children with SAM, NRCs may not be the answer. Community based management is required to reach this large number of children.
Presently identification of SAM takes place at community level, but providers should also be sensitised to detect it also at health facility level.
For management of SAM, RUTF vs Home Based food is an ongoing discussion. The research channel is progressing, with in 1st stage listing of proposals already done by SAM Alliance (MOHFW, Department of Health Research, Department of Biotechnology). Currently there is no evidence to straightaway recommend RUTF for managing SAM. Local diet can be used till further evidence is available.
Medical colleges (Departments of Paediatrics and Community Medicine) can play a role in management of SAM, by sensitising doctors, launching field initiatives, monitoring and follow up.
9. Monitoring: Presently there is no mechanism to assess regular progress of nutrition interventions and is mainly dependent on results from national surveys. An M and E system that is an integral part of the operational plan is required; monitoring tools have to be developed.
The best option would be to get nutrition monitoring institutionalised in the HMIS.
10. Institutional mechanisms: Many alliances, groups and CSOs are working in field of nutrition; new initiatives should be coordinated by MOHFW.
In order to draw high level attention, nutrition could be set up as a coordination unit or a separate department, headed by a Secretary level official. It can also be constituted as an overseeing authority under the Prime Minister’s Council.
Coordination within and between Ministries, Ministries and Planning Commission is important.
11. Dissemination of technical guidelines: Technical and operational guidelines should percolate down the system. Pre-placement training institutions should be provided with technical guidelines so that they are updated regarding new developments.
12. Convergence: NRHM and ICDS should consider developing a Unified District Action Plan so that the Ministries of Health and Woman & Child come together to review and fund it. Block should be taken as the primary unit for planning.
Goals and targets can be set at departmental level, roles of ground functionaries clarified so that they held accountable for respective outputs.
Nutrition should be a mandated topic for discussions held by various ministries and in the TRGs for Maternal, Child & Adolescent Health.
13. Over nutrition/Obesity: While undernutrition has become almost synonymous with malnutrition, the focus on obesity (an impending epidemic) is equally important.
National Policy on Non Communicable Diseases does not find mention about age group of 0-2 years and should be included as there is a connection between child health and NCD.
14. Other interventions: Single most important intervention which can impact nutrition status of children is to increase the age at marriage to 19 years. Conditional cash incentives are already there, they should also be linked to age at marriage.
The (UNICEF) conceptual framework for addressing malnutrition comprehensively should be brought back into programming. Food, water, safe drinking water, sanitation are public health interventions that need to be addressed in order to make a change to nutrition status of children.
Resources for ensuring food security are under consideration by Planning Commission. MOHFW must add to the advocacy efforts in order to see resources being secured for this purpose.
15. HR: Human resources, training and interventions in first two years of life remain the key issues for addressing nutrition. Worker: Family Ratio and capacity to counsel mothers are important issues in terms of coverage of nutrition interventions as is shown from experiences from Thailand.
More human resources are also required at central level (MOHFW) to deal with nutrition.
16. Forward steps: While advice and recommendations are valuable, it is important to describe how each of them can be put into implementation. Therefore, the key suggestions made during the meeting are bulleted in the section below (Annexure A) and the experts are requested to delineate specific details and indicate timelines for the same.
Key recommendations made by members of the Action Group on Nutrition
1. Existing platform of JSY, VHND, and VHSNC should be used for promoting IYCF and addressing nutrition issues.
2. Dedicated, focussed IEC, BCC strategy and campaign is required on nutrition.
3. Rapid coverage with IFA while ensuring the quality of Iron folic acid supplies is required to address anaemia.
4. Special attention to low birth babies is required; guidelines may be developed for quick reference by ANMs.
5. Monitoring of nutrition interventions should be made a part of institutional mechanism (HMIS).
6. Growth monitoring is screening process, but importantly it should be linked with action.
7. Human resources in terms of ‘Health Worker: Population Ratio’ should be taken into account; besides optimising human resources /team at block level. A gaps and situation analysis can be done at district level.
8. Policy on NCD should include children 0-2 years.
9. Malnutrition implies both under nutrition and obesity and should be taken into account in all future plans.
10. Food, water and sanitation have to be addressed as part of a comprehensive strategy to impact nutrition status.
11. Technical guidelines issued by the Ministry should be disseminated to training institutions, ANM training centres, medical and nursing colleges.
12. Nutrition Counselling Centres may be established in health facilities to support and counsel mothers/caregivers.
13. Nutrition should be an integral part of all discussions across ministries.
14. Unified District Action Plan can be developed, while considering district as one comprehensive unit.
15. Human resources at central level may be enhanced in terms of numbers
16. Setting up a National Technical support unit for nutrition (on similar lines as for HIV) can be considered.
17. Home visit for IYCF can be introduced and linked to cash incentives.
18. Group counselling should be undertaken for increasing breastfeeding rates (through VHND and any other available platform)
19. Role clarity of frontline workers is required.
20. Weight recording requires necessary logistics to be in place and the role of a logistics agency can be considered.
21. Ten steps for promotion of breastfeeding should be followed in health facilities.
22. Research priorities for nutrition must be identified.
23. Maternal malnutrition must be addressed to reduce child malnutrition.
List of participants
Chaired by: Dr. Umesh Kapil, Department of Human Nutrition, AIIMS, New Delhi
Co-Chaired by: Dr. Ajay Khera, Deputy Commissioner, CH&I
1. Dr. Pavitra Mohan, UNICEF
2. Dr. Kajali Paintal, UNICEF
3. Dr.Paul Francis, WHO India office
4. Dr. Nidhi Choudhary, WHO India Office
5. Dr. Rajiv Tandon, Save the Children