BackThe failing health of Delhi’s nutritional rehabilitation centres
From dirty linen to wandering dogs, a visit to the five functional nutritional rehab centres in Delhi presents a bleak picture
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New Delhi: The mother wanted to know what her five-year-old child was ailing from. If it wasn’t life threatening, why had the family been put in an isolation room where hardly anyone came to check on them?
She could have been told that Room 513 in the Sanjay Gandhi Memorial Hospital in Delhi’s Mangolpuri area is where doctors treat children under five years of age suffering from severe acute malnutrition (SAM) as they are at nine times higher risk of dying of common childhood diseases than well-nourished children.
Even though there’s no label, the room is what the medical profession calls a nutritional rehabilitation centre (NRC).
The 2005-06 National Family Health Survey (NFHS), the third in a series, and containing the most recent official data on malnutrition, states that 47.9% of Indian children under age 5 are stunted—they are too short for their age. The data indicates that nearly half the country’s children may be chronically malnourished, with all manner of implications for their development as well as health as adults.
Another nearly 20% of children under five years of age in the country have low weight for height (wasting). A joint study by the United Nations Children’s Fund (Unicef) and the ministry of women and child development—the 2013-14 Rapid Survey on Children (RSOC), conducted in 2013—was submitted to the government in June this year, but has not been put out in the public domain.
Two reports on malnutrition were released on 13 November—one by the International Food Policy Research Institute (IFPRI) and the other by the World Bank. IFPRI’s Global Nutrition Report states that India has reduced by 9% the number of stunted children in the last eight years and drastically improved its exclusive breastfeeding numbers. It mentions the RSOC study, stating that currently under-5 stunting is 38.8% (down by 9.1% since NFHS-3) and under-5 wasting is 15% (down by 5%).
“Reliable national statistics on child health and nutrition go back to 2005-06, a gap of nearly 10 years. By contrast, neighbouring countries like Bangladesh and Nepal conduct regular national health and nutrition surveys. This statistical vacuum in India is itself a telling symptom of the fact that child nutrition is not a political priority," says economist Jean Dreze.
Severe acute malnutrition
Room 513 has two beds with dirty linen on them and a table laced with dust in one corner. Posters with information on malnourishment are stuck on its white walls. “What has happened to my daughter?" the 27-year-old mother of four asks Dr Kritika, (who prefers to use a single name), the medical officer for pediatrics with additional charge of NRC.
“Don’t worry," the doctor replies. “It’s a hospital and children with all sorts of diseases come here. Your child is very weak and we do not want her to get an infection."
The child’s face is pale with scattered white patches, her hair has turned brown, the arms are broomstick-thin and the folds of skin in her legs show wasting. She was losing weight and had no appetite. It was the unusual weight loss and non-stop loose motions that alarmed the mother. “Diseases have names…It can’t just be weakness. It must have a name if we are put in this secluded room," the mother wonders.
Technically, a child is said to suffer from SAM when he or she has a very low weight-for-height ratio Z score—below minus 3 SD (Z scores reflect how much a child’s weight or height deviates from the standard for healthy child growth set by the World Health Organization (WHO). The closer a child’s Z score is to zero, the closer he or she is to the median of the international growth reference standard). Or when the circumference of the child’s mid-upper arm is less than 115mm or if the child suffers from oedema—swellings caused by the accumulation of fluids.
A separate room is allocated to an NRC to treat children suffering from SAM and protein energy malnutrition (PEM). They are kept under 24-hour watch, treated for medical complications, and provided sensory stimulation and emotional care. NRCs are also supposed to focus on improving mothers’ skills in childcare and feeding practices so that the child continues to receive adequate care at home when he or she is discharged. Low birth weight (about 30% of the children are born with low birth weight), poverty and poor feeding practices are all linked to high levels of malnutrition in India. District-level household survey for 2007-08 shows only 40.5% children were breastfed within one hour of birth.
The World Bank nutrition report Nutrition in India states that even among the wealthiest Indians—the top third of the wealth distribution—only about 7% children between 6 months and 24 months receive adequate feeding, healthcare and environmental health, these being the three key determinants that are critical for good nutrition. The report finds that stunting rates in children with adequate feeding, healthcare and environmental health are half those with none of these in adequate measure—23% against 52% in children who have inadequacies in all dimensions.
A silent emergency
The five-year-old’s report, lying among several at the nursing station of Sanjay Gandhi Memorial Hospital reads: failure to thrive, cough, mild grade loss of appetite, diarrhoea, wasting, keratomalacia, and PEM grade 4.
Even though NRC in the hospital is secluded, there is no 24-hour monitoring or any special care given to the child, as prescribed by the National Rural Health Mission (NRHM) in guidelines issued in 2011.
An estimated 8.1 million under-5 children in India are affected by SAM, which accounts for 0.6 million deaths and 24.6 million DALYs (disability-adjusted life years). Nearly 70-80 million under-5 children in India suffer from PEM, and nearly 4 million suffer from severe forms of PEM—like marasmus (characterised by severe wasting of fat and muscle), kwashiorkor (severe oedema) and marasmic kwashiorkor (presence of both wasting and bilateral pitting oedema).
Levels of malnutrition are high in almost all states, especially Madhya Pradesh, Bihar and Jharkhand, but the disease is nearly absent in six states— Goa, Kerala, Manipur, Mizoram, Punjab and Sikkim. Unlike other diseases, malnutrition is what the World Bank calls a “silent emergency" and so, very often, mothers don’t think it is a matter of concern. When mothers do bring their children to the hospital, it is mostly because of subsequent complications, not malnutrition per se.
Realizing that children with SAM, when managed in specialized units with skilled attendants and adequate nutrition rehabilitation have high rates of survival, authorities introduced NRCs under NRHM—first in Madhya Pradesh in 2005. NRCs provide SAM patients with a 14-21-day treatment consisting of regular feeding with micronutrient-rich food and antibiotics if needed to treat infections as
well as treatment of underlying illnesses.
Purnima Menon, senior fellow at IFPRI, says even though NRCs are a key component of an overall continuum of care approach for malnourished children with complications, these are not in any way the solutions to malnutrition. “NRC is an important component of the system, but it is the end-of-line treatment for malnutrition. We haven’t quite figured out everything coming before it," she adds.
Menon says India needs to focus on making malnutrition a visible mark of development, just like the economy. “After every two-three years, data should be collected on malnutrition. We have all the set policies. What we need to do is translate them into action, and deliver a package of interventions to every woman and every child," she adds.
Currently, there are 875 NRCs in 23 states, offering a total of 9,763 beds. Rajiv Tandon, senior adviser (maternal, newborn, child health and nutrition) at Global Alliance for Improved Nutrition in Delhi, says demanding an NRC has become “fashionable", but strangely the concept is still a mystery—even to experts in the field of health, even in the National Capital.
A bleak picture
In Delhi, there are 11 NRCs on paper, but only five are functional—those in Guru Gobind Singh Government Hospital, Kalawati Saran Hospital, Sanjay Gandhi Memorial Hospital, Kasturba Gandhi Hospital and Hindu Rao Hospital.
Out of a total of 1,420 SAM children admitted in all the functional five NRCs in Delhi, 25 died from April 2012 to March 2014, according to information received through RTI responses sent to an NGO, Matri Sudha, a partner of Child Rights and You, an NGO working on child rights. The maximum admissions at 547 were in Hindu Rao Hospital, which also saw the maximum number of deaths (16).
A visit to these NRCs presents a bleak picture.
Hardly any of them follow all NRHM guidelines, and most complain of lack of funds or space. “We have a dearth of staff. When patients with complications come, we treat those complications. For the rehabilitation part, we need round-the-clock staff nurses. NRHM was supposed to provide us all the staff. We are doing as much as can be done with the resources we have," says Indermeet Singh, head of paediatrics at Sanjay Gandhi Memorial Hospital. NRHM guidelines say hospitals are given a one-time capital cost of ₹ 2 lakh and ₹ 7.80 lakh as a recurring annual expenditure.
The ministry of health and family welfare denies that lack of funds is the reason for the “unsatisfactory" performance of these NRCs. “There is no shortage of funds. Every year the ministry releases funds. Other states are performing so well. The condition in Delhi is not at all satisfactory. The budget in Delhi is not channelized properly by the hospitals. We are planning a rapid assessment of NRCs. We need to," says Sila Deb, deputy commissioner (child health), ministry of health and family welfare.
Instead of a referral system and information sharing from anganwadi workers, public health centres, sub centers, as prescribed by NRHM guidelines, most NRC beds are occupied by children who come for regular check-ups in the out patient department (OPD) or are admitted to the emergency.
Every morning during OPD, at the Kasturba Gandhi Hospital located in the densely populated Old Delhi region (area) of the National Capital, children are screened for weight and height. The prescriptions have small boxes for SAM and PEM, which a staff nurse at the waiting section ticks as and when required. Children are admitted as per the defined admission criteria—weight/height ratio is the indicator of choice for the detection of acute malnutrition.
Once the children are admitted, principles of management of SAM are based on three phases: stabilization, transition and rehabilitation.
In the stabilization phase, which lasts one-two days, children with SAM without an adequate appetite with a major complication are stabilized in an in-patient facility. The transition phase aims to ensure that the child is clinically stable and can tolerate an increased energy and protein intake. In the rehabilitation phase, the aim is to promote rapid weight gain, stimulate emotional and physical development, and prepare the child for normal feeding at home. For discharge from an NRC, WHO and Unicef jointly recommend 15% weight gain as criteria.
Different names, same stories
The four-bed NRC in Kasturba Gandhi Hospital has four staff nurses from NRHM, a dietician and a nodal officer. It is part of the children’s ward, and has a play mat for children with toys on it and posters of some cartoon characters. In the last two-and-a-half years of its existence, this NRC has had 180 admissions.
“We have shortage of space and so in situations like a dengue epidemic, we need to discharge these patients to adjust dengue patients on these beds," says NRC’s nodal officer Anuradha Govil.
Kalawati Saran Hospital, on the other hand, has a properly running NRC irrespective of the fact that it is also a room carved out of the critical care ward. It has 12 beds, a consultant, a doctor, four staff nurses and a social worker. In addition to the usual treatment, this NRC, which opened in 2012, has had 229 admissions, of whom five children have died.
In this room, the stories are the same as in any NRC—just with different names.
Mostly the tiny patient has a line of siblings before or after them. Most were admitted with diarrhoea, dysentery, dehydration. All are underweight. Some have severe, some moderate wasting. Vishal is a nine-month-old from Palwal village in Haryana. On admission, his weight was 3.25kg. He was admitted with a distended abdomen, fever, vomiting and dysentery. His oldest sibling is 15 years old, followed by five others aged 12, 10, 8, 5 and 2. Father Sarjeet Singh, 42, earns ₹ 3,000 per month. Faulty feeding is the reason for Vishal’s condition.
Even though NRHM guidelines stress hygiene, it is a big problem with NRCs. “How do we keep the beds clean? Look at these children. These patients belong to a certain socio-economic strata," says Govil of Kasturba Gandhi hospital. The centre in Hindu Rao hospital, which is considered the best of the five NRCs in Delhi, had a dog wandering around inside the huge room allocated to the facility.
In Guru Gobind Singh hospital, which is cleaner, NRC is a cubicle stuffed with four beds. The occupancy, like in most NRCs, shoots up during June-July and goes down in the winters. There is a staff nurse for SAM patients, a nutritionist, two specialists and a medical officer by NRHM.
Even though NRHM guidelines state: “NRCs should have a cheerful, stimulating environment. Walls can be brightly coloured. For a 10 bedded unit, there should be one medical officer, four nursing staffs, one nutrition counsellor, a cook-cum care taker, two attendants/cleaners, one medical social worker."
Chief medical officer Sangeeta Rani says the hospital is working towards making the centre better.
She says even though the idea behind starting NRCs is noble, the government should prioritize timely monitoring of children’s growth. “The ‘why’ should be focused on. Why do children become malnourished? Intervention should be done at the time growth faltering occurs, not when the child lands up in malnutrition," says Rani.
India needs a comprehensive model to tackle malnutrition that combines prevention and cure, says Vandana Prasad, a founding member and national convener of the Public Health Resource Network, a national-level initiative to build district- level capacities for achieving NRHM goals.
“Primarily, malnutrition is a problem of socio-economics rather than health. There is a failure of root analysis. The concept of NRCs is not wrong, but it is an incomplete approach," Prasad adds.
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