Hamlets in four states show how community efforts can combat malnutrition among children. Funds for the initiative, however, are drying up
As the trees and bushes give way to Bada Doomartoli, a hamlet of Singhpur village in Nagri block of Ranchi, one can see a bunch of children running around playfully in the verandah of the first house. Their screeching can be heard from a distance. The younger children sit in a semicircle on a mat and sing poems, rolling their hands as they imitate each other. The house owner no longer lives here, and has rented the place to an NGO. It is now the ‘khaddeedpa’, a house for the kids in the Kurukh language of the Oraon tribe. The NGO calls it a crèche under their Action Against Malnutrition (AAM) programme.
The AAM is an initiative by a conglomeration of five NGOs in seven blocks of four states – Jharkhand, Chhattisgarh, Odisha and Bihar – that joined hands to fight malnutrition among the most marginalised and vulnerable populations. They run crèches for children below the age of three in remote villages in these states, preferring to feed them locally produced and cooked nutritious food at regular intervals throughout the day.
The children at the Bada Doomartoli are getting khichdi today. Like the poems, the children remember the daily routine. They patiently get their green bibs tied and line up next to the buckets of clean water to get their hands and face washed with soap. A sleepy one hangs on the back of a crèche worker who is sweeping the floor. The steaming hot khichdi with a spoonful of oil on top is served to them in clean plates. On other days, children get daal, saag, roti, poori and sattu – a nutritious mixture of chana, wheat, rice and ragi. They also get eggs twice a week.
The crèche has a full house today. Its Sunday noon and the children older than three years have also come to visit with their younger siblings. “All these kids grew up here with us,” says Anita Tikri, a crèche worker, pointing at the older children, with a satisfied smile on her face. She is entitled to that mother-hen smile as the children have turned out relatively healthy. Ten-month-old Khushi learnt crawling and sitting here at the crèche, she tells me proudly.
Anita, who earns Rs 3,000 a month, belongs to the hamlet and has been working at the crèche since it started in February 2013. She along with her colleagues Shobha Tikri and Taranani Kashyap fill an intricate gap in this place where access to most other public services is rare and difficult. The hamlet has no anganwadi centre; a sub centre is two kilometres away – and it is not functional, forcing the villagers to travel 18 km to reach the community health centre to find doctors. The nearest nutritional rehabilitation centre (NRC), where severely malnourished children are kept under observation for 15-20 days and fed a calorie-rich diet of potatoes, sugar, milk, fruits and oil, is 40 km away. The crèche workers have, hence, become the first point of contact for most women in this hamlet to discuss issues of health, hygiene and diet.
For the children in the hamlet, the crèche is like their second home. They spend their days with the crèche workers while their mothers go out for daily labour. They play with them, feed them and keep tabs on their physical growth: weighing them every month and measuring their height every six months.
This much-needed attention given to these young ones will go a long way, say childcare experts. “Many scientific studies have shown that the first 1,000 days of a child are crucial because this is when the brain develop rapidly. A child’s understanding, rationality and emotional stability are developed during this period. Sixty percent of the brain develops in the first year, but this aspect of childcare is least understood,” says Devika Singh, co-founder, Mobile Crèches, a Delhi-based non-profit organisation that provided training assistance to the AAM programme. “The right interventions during this period are important. Regular monitoring, care and feeding of children for the first three years can prevent them from being malnourished,” she adds.
The NGOs participating in the AAM programme stress that simply by following basic hygiene and ensuring that children eat at regular intervals has had a drastic improvement in their nutritional profile. Illnesses are diagnosed early and the children are provided timely treatment from the nearest government health centre. Severely malnourished children are referred to the NRCs, saving many lives, says Sanjeev Ghosh, district manager, Ekjut NGO which runs 60 crèches in Saharpada and Thakurmunda blocks of Odisha and Kundpani block of Jharkhand.
“In Bihar before the crèches started, five to six children used to die due to malnutrition in every village. It has now come down to about two cases, that too because the children migrate with their parents and cannot be constantly monitored by the crèches,” says Digvijay Kumar, director, Institute for Developmental Education and Action (IDEA), AAM’s Bihar partner that runs 15 crèches in Turkulia block.
Child In Need Institute (CINI), another partner operating 26 crèches in four villages of Gola block of Jharkhand estimates that out of 300 kids in their crèches, 60 to 70 children used to be in the ‘red category’ on the growth chart, indicating severe malnourishment, and 100 children used to be in yellow, which means moderate malnourishment. “Now only 30 kids are in red [in all 26 crèches],” says Sabina Khatun, a coordinator with CINI.
But as the new year dawns, these crèches may cease to function. The financial support of Rs 13 crore for the programme was provided by Jamsetji Tata Trust for three years from June 2012 to May 2015 which has come to an end. The NGOs are now searching for alternative donors, which are hard to come by.
In early November at the community ground at Namkum in Ranchi, a celebration is on: mothers have arrived with their infants tucked along; crèche workers, NGO coordinators and most of those associated with the AAM project have gathered to share the success stories from their villages through songs and skits prepared by themselves. However, their disheartenment is palpable; they know that the AAM programme is coming to an end.
“We will have to shut the crèches down by February or March,” says Sulakshana Nandi from Chaupal NGO that runs crèches in Chhattisgarh under the programme.
What AAM is and why it matters
The project started with the NGOs conducting baseline surveys in the villages with higher tribal or scheduled caste populations which had paltry access to other government services, if at all. These villages also had high prevalence of wasting (low weight for height) and stunting (low height for age) among children. The NGO workers held meetings with women in these villages and explained to them what a crèche is and how it will help their children. “The idea was to have a support system for women where they can leave their children in safe hands while they go out to work so that the children are given frequent meals,” says Rajesh Sriwastawa, programme coordinator, Public Health Resource Network (PHRN), Jharkhand, which runs crèches in Jharkhand. If the women agreed, they were asked to select the crèche workers among themselves with one worker literate so that she can help in documentation work.
“In Bihar, it was observed that in the dalit and minorities communities there is more malnutrition. These are mostly resource-less communities where men migrate to cities in search of work and women earn about Rs 50-100 a day through labour. They get work for barely 100 days in a year and that too during the harvesting and plantation seasons. If they take their babies to fields, the landlords don’t give them work as it is not safe to have babies in the fields,” explains Kumar. Their survey showed that mid upper arm circle (MUAC), one of the signs of malnutrition, was below nine cm in most children, indicating severe muscle wasting. The NGO decided to set up five out of 15 crèches in villages with high population of extremely backward Musahar caste.
For the nine hours the crèches function, between 8 am and 4 pm, two workers per 15 children prepare food with locally available vegetables and grains spending just Rs 12 per child per day. The children’s height and weight indicate whether their nutritional status is improving or deteriorating. The programme also emphasises on using the existing services of health care facilities and anganwadi centres, cutting the cost drastically.
In the three years of operation, 139 AAM crèches across four states have taken over 4,304 children under their wings. They are filling the gap in the rural areas that the government health and childcare development programmes have left unaddressed. The union government’s integrated child development services (ICDS) scheme, which operates anganwadi centres and gives ready-to-eat nutritious supplement packets once a week to children under three, has no provision where these children can be given complementary hot-cooked food. “The biggest programme in the country for children [ICDS] has no provision of ‘care’”, laments Singh.
The ready-to-eat nutritious supplement packets have failed to make any impressive impact on malnutrition in children. As per the last national family health survey (NFHS) data available for 2005-06, 48 percent of children under-five years of age are stunted, 43 percent are underweight and 20 percent are wasted.
The AAM crèches, meanwhile, with their experiment of community-based management of malnutrition locating the crèches within the villages and involving the villagers, show an alternative. “Many women donated vegetables and toys; mothers who stay at home help at the crèche at times,” says Ghosh.
Child health and nutrition specialists Vandana Prasad and Dipa Sinha write in the August issue of International Journal of Child Health and Nutrition how AAM is different from other programmes in addressing malnutrition. While “most programmes for malnutrition in India have focused exclusively on the treatment of children with SAM [severe acute malnutrition], and ignored others who may well be at risk of becoming severely malnourished”, the AAM focuses on preventing children from slipping into malnutrition and pulling out those who are already malnourished.
Prasad and Sinha analyse the data on height and weight of 587 children, who visited the crèches between May-July 2013 and November 2013 to track the changes in their growth and malnutrition status. They found that during the period of the study, the number of severely malnourished children decreased from 45 to 24 – a four percent drop. Out of the 45 children, five received treatment from the NRCs as well besides constant monitoring at the crèche. Twenty-six of them weighed 15 percent more than their weight during the baseline survey.
Among the moderately wasted children, 26 percent showed no improvement, seven percent became severely wasted and 67 percent became normal. Overall, 84 percent children either improved from their current status or maintained it and severely underweight children were reduced from 24 percent to 17 percent. There was, however, no change in the status of stunting during this period. Stunting indicates chronic malnutrition. It takes longer, sometimes even a generation, to show any change in it, explains Sinha.
The numbers in the study give us a glimpse of what a community-driven low-cost programme on malnutrition is capable of achieving. The funding for the project may stop, but the AAM workers are confident the behavioural change that the communities have seen over three years will go a long way in prevention of malnutrition in the future.
“Mothers started asking questions from the anganwadi workers,” Dildar Hussain, a crèche coordinator, Nagri block, Jharkhand, points this as the biggest achievement of the AAM programme. The crèche workers involved women in checking the growth of their children. They taught women how to fill and read growth charts and what each colour on the chart indicates.
There were several myths in the communities; women used to believe that if their children are weighed regularly, their weight will drop, says Suman Devi, a crèche worker from Hetha village of Ratu block, Jharkhand. When the women in the village saw regular weight monitoring at crèches and its benefits, they demanded the same from the anganwadi centres. “To show fewer malnourished cases, the anganwadi workers were marking malnourished children’s weight in green column instead of red on the growth charts,” says Hussain. But after women understood the consequence of this, they started demanding answers.
“Mothers now want additional [take home] ration if their child is malnourished,” he says. Also, there are villages where the anganwadi workers approached the crèche workers to learn how to fill the growth charts correctly, says Baleshwar Bawri, a crèche coordinator, Gola block, Jharkhand.
Weight is the most sensitive indicator, explains Shampa Roy, programme coordinator, PHRN, Jharkhand. “Children may be stunted, and not wasted. In that case their MUAC will not be as low, which can be misleading. The crèche workers are sensitised on these matters and can track each and every child for stunting, wasting and underweight,” she adds.
It was also noticed in the villages where AAM was operational that severely malnourished children were seldom referred to the NRCs. “When we insisted that all severely malnourished children be taken to the NRCs, families were hesitant at first. But once a beginning was made, women saw children recovering and understood the benefits,” says Ghosh. On August 1, 2013, first two children were referred to an NRC from one of their crèches. “They are now model kids in the village,” he adds. Out of 2,473 children registered with the crèches, 78 were referred to NRCs over a period of 1.5 years.
Once the younger children were taken care of, the elder siblings could continue school and the mothers saw a rise in earnings, as highlighted by Prasad and Sinha in their paper. “The mothers used to leave the younger children with the elder ones when going to the forest to collect firewood or water. The elder children had to miss school. Once the crèches started, the older children could be regular at school,” says Suman. A woman is now taking stitching classes by leaving children at the crèche, says Roy.
“The programme has reached 60,000 to 80,000 women through outreach activities,” says Prasad, which is another aspect of the AAM programme. The programme also ensured that commercial packaged foods are kept out of the crèches, and from homes. “People used to think that the child will grow healthy if he or she is given Horlics and Cerelac. But now they understand that giving them fruits is a better option,” says Khatun.
NGO workers told women about simple techniques like keeping salt covered to preserve iodine, she adds. Women have bought a small bowl and a spoon, and feed children at home the way they are fed at the crèche. Some families have started backyard poultry farming for regular supply of eggs.
The AAM programme shows an effective alternative to medical interventions in tackling malnutrition, says Sinha. “In treating severely malnourished children only institutionally, the relapse rates can be high and there is no follow-up. Also, it can only be provided to a few children as not all need nor can access inpatient care. A community-based approach using local foods may provide better access, sustainability and continuity of care at lower costs. The results may be relatively slower, but there will be greater adherence,” she says.
“After six months of exclusive breastfeeding, complementary feeding for children has to start. What is served to them is important,” says Prasad. The AAM crèches take care of this element in the process of childcare. It takes only Rs 1 lakh per crèche per year to run it in its current state, yet no state is willing to come forward and institutionalise the concept, she adds.
There is little possibility of Jamsetji Tata Trust continuing funding. “The results of this project will have to be shown to the trustees. We are not committing anything now,” says Nilesh Yadav, programme associate, health, Tata Trusts. “Government has the power and actual finances, they should take this up,” he adds.
The crèches, meanwhile, are preparing for the end-line survey for the AAM programme which will be conducted by March. It will show the overall impact of the three-year programme and may bring in new donors. The effort to convince state governments to invest in crèches and adopt the AAM programme has so far brought no concrete results.
The states, meanwhile, have announced other initiatives to tackle malnutrition, but even those are at a nascent stage.
The Bihar government wishes to have 4,000 crèches in the state but it neither has funds, nor manpower. The proposal may be withdrawn, informs Kumar.
Jharkhand’s minister for department of social welfare and women and child development Louis Marandi announced in November at Namkum that the state is in the process of adding special staff at anganwadi centres called ‘kuposhan sakhi’. “It is a proposal now and we are considering this option but I cannot make any commitments,” she said.
Referring to the AAM project, Jharkhand’s minister for food, public distribution and consumer affairs Sarju Rai said, “These efforts are a drop in the ocean. The benefits of such programmes should reach all those who need it and advocacy for this should be done at the centre and the states will follow. The government should cut funds from various departments, which will be a substantial amount, and put it to nutrition.”
“Real infrastructures of a country are the children,” says Kumar, “But government wants roads.”
(The story appears in the January 16-31, 2016 issue)