How an innovative, holistic model of nutrition is working in Nandurbar district of Maharashtra
Minal Karanwal | February 12, 2024
When I sit and look back at data-driven policy, it makes me content and makes me uncomfortable at the same time. Content? Why? Because data would ultimately help me target the problem in a better manner, design solutions in a manner that is relevant. However, reducing a human being to just numbers, whether it be eyeing only for 2.6 kg birth (as 2.5 is low birth weight) or reducing severe acute malnutrition (SAM)/ moderate acute malnutrition (MAM) to zero as they are the least, we can expect for a ‘healthy child’ population.
Nandurbar district of Maharashtra reduced its SAM and MAM numbers by 1,500 and 3,500, respectively, in the screening drive in May-June 2023. While on one hand, it elated everybody, but on the other hand, we knew we have still close to 1,500 SAM and 11,000 MAM to tackle.
This article is not about these numbers, but it’s a holistic model of nutrition that Nandurbar tried to establish. In a span of two and a half years, we not only tried to change the narrative that we aren’t aiming for a 2.6 kg birth, or a zero SAM/MAM zone, but we struck nutrition at it’s very base: ‘The idea of protein.’ This eventually solves the data problem, that is essentially consequential to protein intake, whether it be mother’s milk or an egg. How we did it? By building the ‘protein’ idea from within the system and from the outside. (The attempt made in Nandurbar was not towards a successful fructification, but a big enough beginning for changing the lenses through which we view malnutrition.)
Changing the technique
Any policy/programme given to me, as an administrator, boils down to its technique. I can monitor all that I want to, but I cannot make a change if the technique is faulty at the outset. Maybe, this is the reason that we reel with problems of malnutrition or lower learning standards continuously and then blame the fieldworker or the standards themselves.
When we in Nandurbar got exposed to the ‘Health Spoken Tutorials’ of IIT Bombay, we realised that they were some sort of mechanical engineering on breastfeeding and how to intake protein of adequate amounts. [For more on that, read: https://www.governancenow.com/views/columns/exclusive-breastfeeding-yes] ‘Hold the child in a way that there is maximum milk transfer and efficient latching’ or ‘Take protein amounts approximately equivalent to your body weight’. Me being a non-doctor, non-science person, an action-oriented model appealed at the very outset. The trainings were embedded in free-source, local language modules on YouTube and hence revisions and audio-visual learnings became guaranteed.
As we moved ahead with the project, outcomes started to pour in. A growth of one kilogram per month of many babies after birth and many nicely complementary fed children. The link to outcome and the response of our field workforce convinced us for the techniques.
Another technique that came to the fore with the team of IIT Bombay was to change the way in which the home-based neo-natal care (HBNC) was being carried out. What Nandurbar tried was to convert it into a Learning and Action Protocol. With every visit of the healthcare worker scheduled to the mother, we gave a target weight gain. For example, on the seventh day, the weight of a baby girl child should be 100 grams more than the birth and on the 14th day, 500 grams more than the birth. This extended up to one year of the child’s growth period. This not only ensured a visit, but also gave our field force an idea of what ‘exactly’ to do on a home visit. Every visit was now outlined with a set of guidelines on what Health Spoken Tutorials to show on a visit and what weight of the baby to expect. If the weight gain was not consequent to the targets, a revision of the technique with the mother was expected. An app was introduced to not only monitor these LAP visits but also to direct the field force to the exact portion of the HST video on YouTube where that problem could be addressed.
Building the capacity of the health system
We realised in the very beginning that it’s important that the system learns and builds on its own, rather than having an external systemised input all the time. That is heavy on the exchequer and it also kills the self-learning and innovation drive of the fieldworkers who ultimately deliver the service to the people.
Hence, we organised a training session of our health and ICDS workforce and made sure that each fieldworker had an access to YouTube, in case they forgot what was being taught in the training session we also ensured that in every monthly and bi-monthly meet, they were revised briefly. We obviously couldn’t guarantee a 100% seepage, but what we saw was the health work-force learning and re-learning on their own.
Exact learning material
The action model also applies to this area. Once the IEC material that is designed is of ‘subjective’ quality, meaning thereby that it doesn’t objectively direct or prohibit what to do/not do, it loses its relevance and is reduced to the drawer/cupboard.
IIT Bombay provided us with learning material that was not only exact and objective but also action oriented. For example, a diet chart for a pregnant mother not only delineated that she is supposed to have milk, but two glasses of milk were shown pictographically to guide the same. An egg was not only written on the diet chart but four eggs were shown pictographically on the learning material that we provided.
Attack from outside the system
This was probably the most important part of the program. The belief that slowly developed was that a community level awakening on the right techniques of nutrition would eventually resolve the question at the root: all before a child is born. Trying to fine-tune the community through the system was challenging. Hence, we started to aim at two institutions: panchayats and self-help groups, both of which are excellently actualised on the field in Maharashtra. We trained the women of the SHGs and the sarpanches on a very basic do’s/don’ts of the techniques of breastfeeding and protein. For example, every woman in the SHG now knows how to calculate her protein count by mere addition of the content she intakes in breakfast, lunch and dinner. Every member of the SHG knows how to hold a child during breastfeeding for effective milk transfer.
The expectation was that it reaches the ‘mother’ through a different and more recurring route and the same happened. One nurse in the district hospital encountered a woman already knowing the cross-cradle hold and that was the beginning of our realisation that the work on the institutions not part of the health or the ICDS system could also help us bring change at the community level.
The attempt this entire while has been to make the system stand on its own feet when it comes to knowing the right technique and the holistic idea of nutrition. The attempt was to also see the system as part of the community that leaves and takes information between the home, society and the office. The attempt was to not just bring down the ‘numbers’ but to work on an idea that would stay in and beyond the system.
Minal Karanwal is 2019 batch IAS officer. She is currently CEO, Zila Parishad, Nanded.
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