India: Progress Report for Malnutrition Initiative

September 15, 2010

Caitlin McQuilling

Year to date Progress Report: January through August 31st, 2010

As we approach the 9th month of our Malnutrition Eradication program, this progress report serves to summarize the incredible achievements of this initiative in such a short time. 

This project seeks to empower communities through health literacy and connects rural communities with existing government health and nutrition services locally available, thus reducing the prevalence of malnutrition. We employ 55 tribal women as Community Nutrition Educators, covering 500 villages across 5 of the districts hardest hit by malnutrition in Madhya Pradesh.

After the first two quarters the ambitious baseline stage of the program was completed, and the Community Nutrition Educators have been able to move into the intervention stage of the Childhood Malnutrition Eradication Program. Our staff have been incredibly well received by the communities and are getting recognition from local government.

During the first 8 months of this program, 2,841 village level nutrition training sessions have been conducted, with almost 30,000 local men and women in attendance. Our staff have individually counseled 38,821 families of malnourished children during one to one counseling sessions in their homes and have seen 6,070 SAM and MAM kids improve because of their interventions. Through our referrals to Nutrition Rehabilitation Centers, 225 children with the most severe cases have been successfully treated to date.

Summary of our accomplishments this year:

• Chose 500 intervention villages, based on input from government, NGO, and local community assessments as to where the intervention was most needed
• Recruited, hired, and trained 55 staff members
• Completed baseline assessments in the targeted villages
• Compiled “Rapid Assessment” Data to identify number of cases of Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) captured
• Calculated total cases of SAM and MAM by village and district and total number in all five districts; identify priority villages based on case load
• Referred all children, especially those with SAM/MAM to anganwadi centers for additional assessment, supplementary food, growth monitoring, and immunizations
• Referred cases of complicated SAM identified to Nutrition Rehabilitation Centers (NRC) for treatment
• Tracked progress of patients referred to NRC and follow up with defaulters and successfully treated patients in their villages
• Established relationships between District Coordinators and their counterparts in the NRCs for better follow up, referral and general trouble-shooting of care for patients with SAM
• Began intervention phase of the program, including community meetings in villages and one-on-one family counseling with SAM and MAM children identified in the baselines by Community Nutrition Educators (CNEs)
• Completed one of the most extensive door to door baseline surveys ever conducted in Southwest Madhya Pradesh, covering all 500 intervention villages and reaching 37,141 families (refer to ANNEX I for complete baseline report)
• Performed Mid Upper Arm Circumference (MUAC) tests on 65,876 children in the villages
• Compiled family data on over 37,141 families to assess their socio-economic and health status
• Identified 6,070 children suffering from SAM and gave counseling to the caregivers of each of these 6,070 children
• Identified 16,516 children with MAM and provided one on one counseling to the caregivers of these 16,516 children
• Successfully ensured the 14 day treatment of 225 of the most serious cases at local Nutrition Rehabilitation Centers
• Saw an 25% improvement rate in SAM children counseled and a 24% rate in MAM children counseled, 5,545 children whose nutritional status improved directly from our intervention
• Conducted 2,841 village nutrition training sessions, with over 29,897 people in attendance
• Conducted 38,821 one on one counseling sessions in the month of August
• Continued to identify new children after the baseline and into the day to day intervention, finding 6,708 new children from June through August as migrants returned during the monsoon
• Our dedicated staff is already receiving recognition for their hard work and excellent rapport with the communities in which they work. Representatives from the district and state government health and women and child departments have praised their work and have now expressed a desire to work more closely with RMF. NGOs such as DFID, Action Against Hunger, UNICEF and Clinton Foundation have come to SW MP to see our work in the field and learn from our approaches and have been continually impressed
• Introduced the “Eradicate Malnutrition” Program and team to local government officials in each District. One of the primary goals of the program is to strengthen existing government facilities and schemes, therefore building these relationships is vital for the success of the program. Permissions were obtained from each District Collector, Women and Child Development (WCD) Head and Chief Medical Officer (CMO).


Intervention Phase:

Once the baseline assessments were completed in the first two quarters, the CNEs were able to begin the actual intervention phase of the program. Each CNE has been assigned ten villages and, with the information captured by the assessments, knows which children are malnourished in these villages and where their families live. With this information, the CNE can visit with the family twice a month to counsel them on nutritious food, proper preparation of food, hygiene, proper breastfeeding and the importance of supplemental feeding after 6 months, and what health services are available to them for treatment of malnutrition. In addition to the family counseling, the CNEs began their community meetings in each village to give the entire community, not just the families of malnourished children, lessons on the importance of good nutrition in children under five, providing awareness of malnutrition. The CNEs have also been coordinating with the government village health worker, the Anganwadi, on referrals, feedings, and follow up with cases of MAM at their homes. When anganwadi centers haven’t been delivering the services they have promised, RMF’s team has intervened with supervisors and District Program Officers in order to address these gaps in service delivery.

In addition to the counseling aspect, the CNEs also referred cases of complicated SAM to NRCs for treatment. The referrals are usually done by the village Anganwadi worker, who receives compensation for every child admitted into the NRC, as a means of strengthening government structures and providing sustainability to the program. In Madhya Pradesh, SAM is treated on an in-patient basis at the NRC over 14 days with each child receiving supervised, regular feedings of therapeutic food. In addition to the feedings, the mothers are also given education similar to what our CNEs provide. Over the course of the 14 day treatment, RMF’s District Coordinators follow up with the families of our referrals and verify that they are still in treatment, that the child is recovering, and to follow up with any of the family’s needs. So far 225 children have been successfully referred, treated, and received follow up visits from our staff.

During this time our CNEs have developed a relationship with the communities they work with. This bond is the most important part of our program, as we want the communities to see our CNEs as part of the community rather than workers coming to visit. Most of the CNEs are locals and live close to the villages, so establishing that bond comes naturally to them, however, some communities are reluctant at first. Slowly, with each success story, our CNEs are becoming trusted members of the community. The communities have started to come to the CNEs with nutrition questions, rather than our workers having to seek out SAM cases. Furthermore, as they get to know the communities better, each CNE can track the progress of individual children, and asses their health and family in a more familiar way.

The training and employment of 55 local, previously unemployed women has already had a secondary empowering benefit. Many of the training and capacity building exercises for the staff centered around team-building and empowerment and helped the CNEs and DCs become confident, knowledgeable leaders. With 55 village women empowered with knowledge about malnutrition identification, treatment, and prevention, we already have 55 families who won’t have malnourished kids.

Challenges Faced


Southwestern Madhya Pradesh includes some of the most remote and poor areas in all of India. Many development indicators are similar to sub-Saharan Africa, and education levels in the districts are generally low. Qualified staff, both for the CNE and DC positions, were difficult to locate, particularly in Khandwa district, which lengthened the interview and hiring process more than expected. This was overcome by coordinating with established NGOs already working in the areas and using local networks to locate qualified women.

Khandwa district, where the malnutrition problem is most acute and the need for intervention is greatest, presents many challenges. Education in the area, particularly in the remote villages, is extremely low. Furthermore, the connectivity to the remotest villages is extremely poor, often requiring a round trip of over three hours from Khandwa town. In order to best serve the needs of the community, locally based village women were engaged as CNEs. The advantage of the local women is their familiarity with the areas in which they are working, their proximity to targeted communities, and fluency in local tribal dialects. However, locating qualified women in the remote areas was extremely difficult, and the capacity building and training period was longer than expected. Khandwa district is also going to require the most supervision and assistance from more experienced RMF staff.

In addition to the challenge of locating qualified staff and training them, the beginning of the scheduled Baseline Survey period unfortunately coincided with the local festival period in the area. Holi, a national festival and holiday, cost our workers two days in the field. Besides Holi, the local tribal communities in SW MP celebrate a festival called “Bagoria” where the men of the community travel to other villages to collect their new brides. Even though the mood is celebratory and festive, there is a large amount of alcohol consumption and rowdiness, which may have exposed the CNEs to some danger. Besides the danger, the results of the surveys conducted during this period would have been skewed because many of the families where not in their homes or native villages. Overall, the holidays cost the team 8 days.

During the monsoon we again had connectivity problems, with flooding cutting off some villages and the height of corn and other crops making walking through villages more time consuming.

NRC Referrals

One of the largest challenges facing our CNEs, and the treatment of SAM in MP in general, is getting children requiring treatment to the NRC. Even after successful referrals, the rate of defaulters is very high as many of the women cannot stay with their children for the entire 14 day course of the treatment. Each child must have a caretaker stay with them for the entire course of treatment. However, many of the women are not able to stay that long, or even go at all, because of family pressure, household responsibilities such as cooking or agricultural work, or the presence of other small children in the household with no other caretaker.

The CNEs and coordinators try to solve this with a variety of techniques, including:
• Increased counseling in the field about the NRC treatment and why it is important
• Follow up with successful referrals by our coordinators
• Coordination with NRC workers by our coordinators to address problems specific to our referrals
• Follow up with defaulters in the field by our CNEs
• Suggestions for other caretakers, such as grandparents or siblings
• Increased communication about the need and specifics of treatment, such as why it takes 14 days

Goals for next reporting period

• All 50 CNEs regularly visiting their 10 villages at least twice a month and conducting group training sessions, one on one counseling sessions, job trainings for anganwadis and referring serious cases to NRCs
• Refer 1,000 SAM children to government centers for treatment with a 50% success rate
• 90% follow up rate for all children discharged from NRCs
• Conduct 3000 Community Nutrition Meetings (500x2x3 months)
• Hold at least 3000 meetings with anganwadi, giving them on the job support
• Conduct 9000 individual Family counseling sessions
• Ensure timely and accurate reporting from all staff
• Send CNEs to NRCs to help counsel families present
• Continue to develop linkages with government health and nutrition services

• Continue to develop linkages with government health and nutrition services

Baby William: Success Story

Today, we went on a field visit to the village of Devigrah where our nutrition coordinators, along with the village liaison, were able to identify one village child whose condition suggested treatment at the Nutrition Rehabilitation Center (NRC).

The child was one-year old Baby William whose mother reported that he had been sick and vomiting recently, complications that can lead to malnutrition and can prove fatal for a child already weak or acutely malnourished. Baby William’s glossy eyes and lack of energy suggested malnutrition even at a glance. Using the Mid-Upper Arm Circumference (MUAC) evaluation, Baby William was diagnosed on the spot and with an upper arm circumference of only 11.1 CM. The one-year old was not only malnourished, but was suffering Severe Acute Malnutrition (SAM) and needed immediate treatment.

The Community Nutrition Educator, Soniya, counseled the mother about the severity of William’s condition being careful to mention that his illness was most likely the cause. While SAM is a serious and potentially deadly condition, weakening the immune system and often leading to infections such as respiratory illness or diarrhea in young children, our team has been trained to remain sensitive to the feelings of the mother when explaining their child’s condition and to make sure that mothers do not feel accused of failing to take care of their children.
By being sensitive to the feelings of the families as a whole, we have found that there is an increased openness for further education about malnutrition, especially when it comes to the importance of taking their children to Nutrition Rehabilitation Centers (NRC) for more thorough evaluation and immediate treatment.

Mother and baby arrived at the NRC in Jhabua the next day and William was put on a 14 day treatment schedule. In the course of his stay, Baby William underwent a comprehensive physical assessment which evaluated blood sugar and electrolyte levels; vital signs; signs and symptoms of infection, including eye drainage, mouth sores, extremely low or high temperatures; and the presence of shock or severe dehydration.

This successful referral ensured that Baby William received required feedings essential in his health recovery. With the support of regular visits by Soniya to the NRC and follow up, Baby William and his mother spent the full 14 days in the NRC and William gained over 1 kilo. His infections were gone and he was starting to play again. His mother received daily counseling on how she could best care for William and at discharged said that she felt that she had learned the necessary skills to ensure that her child would not relapse into malnutrition.

He is one example of success, one child at a time, in the efforts of Real Medicine Foundation to eradicate malnutrition in the impoverished villages of Madhya Pradesh through education and treatment.


Country Page: India Initiative Page: Childhood Malnutrition Eradication Program