India

Project Background:  

RMF's Childhood Malnutrition Eradication Initiative has the largest field presence of any NGO working in malnutrition in the region, a result of strong partnerships with government, NGOs, business, and most importantly, local communities. Into its second year, our program continues stronger than ever.  Our team of 75 Community Nutrition Educators (CNEs) is covering enormous ground every week across 5 districts and 600 villages in Madhya Pradesh.  Madhya Pradesh carries India's highest malnutrition burden, with 60% of its children under 5 malnourished – approximately 6 million children whose futures are at risk.  Our strategy continues to be closing the gap between the resources available and the families who need them by focusing on the basics of malnutrition awareness, identification, treatment, and prevention and inserting simple, but innovative technologies and practices. 

In Year Three of this program, RMF does not just act as a catalyst mobilizing communities to the resources available, but also works on a more intimate level with government health and nutrition workers and Village Health and Sanitation Committees to help build their capacity towards social mobilization, referrals, and provision of effective nutrition counseling.  Throughout this year RMF will gradually transfer the responsibilities of our CNEs to government supervisors and Anganwadi workers, helping integrate RMF’s work into the government framework to ensure long-term sustainability.

Project Objectives during this reporting period:

• Continue to identify new SAM and MAM cases, refer complicated cases to the NRC and provide home-based counseling for all malnourished children
• Review all program data and make necessary changes in program reporting system
• Refer 1,000 SAM children to government centers for treatment with a 50% success rate
• Conduct 2,500 Community Nutrition Meetings
• Conduct 9,000 individual Family Counseling Sessions
• Send CNEs to NRCs to help counsel families present
• Continue to develop linkages with government health and nutrition services

Results and/or accomplishments achieved during this reporting period:

During the Second Quarter of 2012, RMF’s Malnutrition Eradication Program continued to be a strong presence in Madhya Pradesh(MP). The CNEs are continuing their day-to-day activities of counseling, identification and referrals, while RMF staff work to improve the rollout of Madhya Pradesh’s Atal Bal Mission state nutrition mission (ABM). By collecting feedback on the implementation of the ABM in our 5 target districts, and presenting our findings to policymakers in Bhopal, RMF is integrating field level observation with our model to change the landscape of malnutrition treatment in MP.  

Commcare by Dimagi

On May 17-20, 2012, RMF trained all 60 CNEs on the use of mobile phones with Commcare. Over three days, the CNEs familiarized themselves with the new technology and began collecting information on children and referrals in the community.

After one month of data collection with the phones, the CNEs had entered data on over 3,300 children with SAM and MAM in their communities. Information on each of these children isinstantly available on Commcare HQ for download and analysis, and gives RMF management up to date information oneverychild in the RMF program, the CNE covering that child, their location, any referrals to NRCs and where, the child’s complication and immunization history, and the topics they have been counseled on. With this information, RMF can mobilize resources better to children more in need.

In addition, Commcare HQ provides better supervision of RMF CNEs, giving instant information on the amount of time each CNE spends counseling, which topics they cover, and the follow up rate with each case. These indicators give us hard dataon individual staff performance, and allow RMF to train, communicate, and adjust staff with more information and guidance.

CMAM Pilot

In parallel, RMF management staff also worked diligently towards securing the permissions required for the upcoming CMAM (Community Based Management of Acute Malnutrition) pilot using Ready to Use Therapeutic Food for community based treatment of malnutrition in our target villages. 

In consultation with officials from the MP government and academic partner, the Indian Institute of Health Management Research (IIHMR), RMF revised our sample size calculations to include more children. This larger sample size will ensure that the results of RMF’s pilot will hold up under scrutiny, and make a stronger case for adaptation of RMF recommendations. Based on the new sample size, IIHMR’s ethical review board met in May and approved these changes.

On June 2, 2012, RMF participated in a roundtable discussion with officials from the Government of Madhya Pradesh, UNICEF, the UK’s Department for International Development (DFID), Valid International, and Action Against Hunger. During this meeting it was agreed that RUTF for use in this study should be procured from MPAGRO, the state food production company, rather than a private manufacturer. Two CMAM pilots have been accepted by the Government of MP using this new RUTF, RMF and Valid International, and are currently waiting on timelines of availability for state produced RUTF (estimated for March 2013).

After a successful demonstration of CMAM with RUTF, RMF hopes to change the landscape of SAM treatment in India. Previous programs using RUTFin Africa and other Asian countries have shown that, with proper counseling and monitoring, the use of RUTF in CMAM programs has a success rate as high as 80%

During this quarter the program:

• Identified 688 children suffering from SAM and gave counseling to the caregivers of each of these children
• Saw an improvement from SAM to MAM in 484children
• Identified 1,275 children with MAM and provided one on one counseling to the caregivers of these children
• Saw an improvement from MAM to normal in 974 children
• Successfully ensured the 14 day treatment of 205of the most serious cases at local Nutrition Rehabilitation Centers
• Conducted 1,116 village nutrition training sessions, with over 7,050 people in attendance
• Conducted 12,025 family counseling sessions

Impact this project has on the community (who is benefiting and how):

Since our program began in 2010 this program directly impacted: 

• 1,931 children who have received lifesaving treatment
• 22,206 children who have improved directly through our intervention
• 276,110 individuals from rural villages who have received training on malnutrition awareness and prevention in their villages
• The families of the 68 women RMF employs as part of this initiative, many of whom are from the intervention villages themselves and use their salary from RMF to support their children’s education and to improving the lives of their families.

Success story(s) highlighting project impact:

Jitendra is an 8 month old boy from the village of Nani Badwani in Barwani district. When he was born, his anus was not big enough, so doctors at Barwani Hospital performed an operation to dilate, but were unsuccessful. A hard mass had formed in his abdomen.

With these serious complications and Jitendra falling in the SAM category according to his MUAC, previous admissions to the NRC had failed to resolve either his malnutrition or his other complications.

Following up closely on the case, RMF Program Manager Pratik Phadkule coordinated with the doctors in Barwani and agreed to help take the child to a pediatric surgeon in MY Hospital, a higher care facility in the large city of Indore, 4 hours away. 

On the 19^th of June, Jitendra was taken to Maharaja Yeshwantrao (MY) Hospital but the pediatric surgeon was on leave. After consultation with another pediatrician, Jitendra was advised dilation (of the anal opening) with a dilation kit and gel, 4 times a day for 15 days to see if the mass would resolve non-surgically. A follow up visit was scheduled 15 days later to see the surgeon. Jitendra also needed to be cared for his malnutrition, and was advised to stay in the NRC in Barwani.

15 days later, Jitendra, his family, and RMF staff traveled to MY hospital in Indore again to follow up with the pediatric surgeon. The surgeon checked the child and confirmed that corrective surgery was required. Jitendra and his family came back to Barwani as they needed time to plan for further treatment.

For many families like Jitendra’s this is a difficult time for health problems. In Barwani and RMF’s other districts in Madhya Pradesh, most families rely on seasonal agriculture for their livelihood. Their economic cycle at home centers around one important event: the arrival of the annual monsoon. Typically, most of these families begin to prepare for the rainy season in early June by sowing and planting their fields. When the rains arrive in late June or early July, there is a lot of maintenance to ensure that the crop succeeds. For many families, this one crop is the best chance they have all year of earning cash at home. In short, this is a bad time for a child to get sick.

Because of their obligations at home and the family’s other children, it was difficult for them to get away. Jitendra’s stay at the hospital for surgery was going to take at least 5 days, but with his malnutrition and the flood of patients at MY Hospital, one of the busiest hospitals in the region, it was difficult to predict. The family was willing to go, and they wanted to do everything for Jitendra, but the timing was horrible.

On July 25^th, after diligent follow up by RMF CNEs and planning from the family, Jitendra was finally admitted to MY hospital for his surgery. Although he will need some additional time to gain strength before general anesthesia, his family is ready to stay there as long as it takes. Surgeons at MY hospital have a plan, and once Jitendra has gained some strength and with support, he can begin his road to recovery.