The burden of undernutrition is high in India. One-fourth of India’s children are born with low birth weight, 35.7 percent of children under five are underweight, 38.4 percent are stunted and 21 percent are wasted. Iron deficiency is wide spread, exists across income quintiles and age groups (over 53 per cent of women of child bearing and over 58 per cent of children under five are anaemic, NFHS 4).
The immediate determinants of malnutrition at the individual level (inadequate dietary intake and disease) are products of underlying causes at the family or household level (insufficient access to food, inadequate maternal and child practices, poor water and sanitation, and inadequate access to quality health services) as depicted by 1990 UNICEF framework. Malnutrition manifested in the form of stunting, wasting, underweight, anaemia and low BMI in women are influenced by a set of immediate causes (nutrition specific) and underlying causes (nutrition sensitive) intervention. Dietary intake and disease status, immediate causes of malnutrition, can be addressed through nutrition specific interventions. The underlying causes of malnutrition i.e. food security, care and feeding practices for mothers and children and health services and healthy environment can be addressed through nutrition sensitive interventions. Both the nutrition specific and nutrition sensitive interventions are further influenced by interventions which improve socio economic status of women, domestic violence, and education status.
Multisectoral interventions address the underlying and basic determinants of malnutrition. Whennutrition programs emphasize water, sanitation, and hygiene—and WASH programs emphasize hand washing before preparing food, feeding a child, and elimination of open defecation—both programs can maximize impact.
Research in India has shown that increased crop diversification improves dietary diversification in the home and helps children recover from growth faltering. When education programs invest in nutrition, it improves academic achievement. One example is school feeding programs, which can improve learning and academic performance. Students participating in school feeding and take-home ration programs have improved cognition.
These programs yield the greatest impact when coupled with other programs like deworming, micronutrient supplementation, and fortification. Integrating nutrition programs into school curriculum initiates life-long healthy behaviours.
By engaging multiple sectors, partners can leverage knowledge, expertise, reach, and resources, benefiting from their combined and varied strengths as they work toward the shared goal of producing better Nutrition and health outcomes.
Multisectoral Approach helps in addressing the issues in a focused way as it helps in pooling the resources and formulating the common objectives. One of the major advantages is optimization of usage of resources by avoiding duplication of inputs and activities which tremendously improve program effectiveness and efficiency.
Strong leadership and mandate at the policy level are necessary to plan and execute the successful multisectoral coordination. All the major stakeholders require sharing the common vision and perspective. Developing institutional mechanism is of utmost importance as it will standardize the processes of inter- sectoral coordination.
The POSHAN Abhiyan has undertaken the multisectoral approach to address malnutrition, the output of which is a multisectoral district nutrition action plan.
This multisectoral plan will ensure strong nutrition focus through institutional and programmatic convergence by integrating it in the planning, implementation and supervision process in all relevant direct and in-direct interventions and programs.
The key recommendations that emerged from various consultation on multisectoral convergence for improved nutrition are strengthening and promoting Village Health Sanitation and Nutrition Day (VHSND) as a platform for multisectoral convergence at village level, local food mapping and promotion of kitchen garden to ensure nutritional security at household kitchens, priorities home visits but the FLWs, inter personal counselling (IPC), infrastructure development of health facilities to ensure privacy for antenatal check-ups and child care etc.
Severe Acute Malnutrition (SAM) is defined by a very low weight for height with medical complications are treated at Nutritional Rehabilitation Centres (NRC) / Malnutrition Nutrition Centre (MTC) while the SAM without medical complications are provided energy and nutrient dense foods at household level. Intensive follow-up of cases at household / community level as well as in the NRC are crucial as per the CMAM review in India. Many studies indicated that maximum cases reported were in the age-group 6-24 months probably because the complementary food starts at 6 months and inappropriate complementary feeding and lack of breastfeeding after 6 months are the possible reasons. Some of the issues found were low bed occupancy rate, poor appetite and weakness in most of the admitted children. The number of follow up visit tends to reduce in the third and fourth follow up. Hence there is a need to strengthen NRC / MTC in terms of infrastructure, effective counselling and incentivising follow up visits.
There is a need of national CMAM guidelines to makes the scale up of SAM treatment. It is also felt that the implementation of an effective public health approach for addressing SAM requires a significant investment by policy& program leaders to develop need-specific sustainable as well as effective models of care that build joint capacity to treat the burden of children with SAM. This can happen only by a more holistic approach that incorporates preventive measures such as – Timely screening of all the children before development of complications, maximum coverage, integration with other programs including health, ICDS, WASH, hygiene promotion, clean water, prevention of prenatal macronutrient and micronutrient deficiencies, and the promotion of age-appropriate foods and feeding practices for infants and young children, provision of regular THR, effective VHSND, growth monitoring: monthly weight & quarterly height, community events / Jan Andolan, collating quality information / data for immediate corrective measures, etc.
Dr Sujeet Ranjan is Executive Director, The Coalition for Food and Nutrition Security based in Delhi.