Recently food security provisions in India has improved and not surprisingly the country is operating one of the largest food safety nets in the World. However regarding figures related to malnutrition particularly chronic malnutrition, the country is at very poor level. There are many challenges in implementation of food security schemes which hinders achieving desired outcomes of reducing malnutrition and the benefits reaching the actual poor.
Link to Manoj’s blog in Global Food Security….Click here
e-learning course on Public Health Management 2015
After successfully managing three consecutive batches for the online course in Public Health Management (e-PHM), we kick started the fourth batch on 19th of August 2015. This batch brings along with it 31 amazing students from diverse backgrounds working across the country and internationally as well!
For the first time, we have five participants from Universitas of Gadjah Mada, Yogyakarta who are working in the department of public health. The diverse work backgrounds of the participants include UNICEF, National Institute of Epidemiology, St.John’s Research Institute, Bangalore Baptist Hospital, Department of Environmental Science and various NGOs like JANANI and SAATHI.
We also have participants who are pursuing their PG in the field of community medicine and hospital & healthcare management. The course consists of eight modules and each module consists of four units. Each unit will have one to two classrooms that is a PowerPoint presentation with audio recording and corresponding exercises. Each module ends with a final module test based on the content covered. The students are expected to complete these units and based on their completion we are presenting their progress. Based on the feedback provided, this new batch has new features to make the learning experience more interesting and fun. Keeping in mind the work backgrounds of our participants who have to travel constantly and have limited internet access, we have introduced a new feature called “Learn on the go”. This feature allows them to download MP3 versions of our classrooms and listen to them on the go! Out of 31 students, 30 have logged in and viewed our course. The number of students who have managed to complete Module – 1 are 19, which is about 61% of the total students.
We are currently in the process of identifying any challenges faced by the participants and address them as we move forward in the course. We look forward to providing a good learning experience to the participants!
In India, tuberculosis (TB) is still a major public health problem. In this blog, the author reflects on the stigma and discrimination faced by TB patients and how it affects their health seeking behaviour.
Link to Munegowda CM blog in BMJ can be found here
Many of us are aware that the importance of breastfeeding in child growth and nutrition.But have we ever wondered, in a developing country like India where many mothers are now into formal or informal work, why is it important to have a mother-friendly workplace. World Health Organisation recommends exclusive breastfeeding for the first six months of baby’s life and early initiation of breastfeeding for protecting the child from various types of malnutrition.But unfortunately, breastfeeding has never been a central agenda in long history of health reform in India. Results are obvious. India houses larger number of malnourished children , twice as large as of Sub-Saharan Africa and five times larger than our neighbor China. Here is a blog which discusses what barriers exist and what can be done to bring back good breastfeeding practices into the list of larger sustainable goals for the country.
Link to Manoj Pati’s blog in BioMed Central can be found here
In India, only 20% people with minor illness, and only 50% people with serious illness come to Government hospitals. Thus, there is a need to understand the reasons influencing health care seeking practices to generate demand for health programmes. Amongst rural and tribal communities in Madhya Pradesh, it has been generally noticed that the first point of contact for any illness is a private provider, many-a-times an untrained practitioner, since they are easily accessible. Literacy level is quite low in the state, particularly in rural and tribal communities, resulting in being unaware of the basic symptoms of Tuberculosis (TB) and availability of free treatment and diagnostics at Government health facilities. Some TB patients also discontinue treatment, due to lack of awareness. At times these people also get required medications from a local pharmacist, since they have low faith in Government health system and when condition worsens (both in terms of health as well as finances), they visit a Government health facility. Also these communities are generally dependent on daily labour, leading to delayed TB diagnosis and treatment, in fear of loss of wages. Alcoholism & tobacco use of all forms is predominant in these communities, thus affecting the treatment adherence.
Barriers & constraints
With reference to the programme delivery, a number of barriers play a role in influencing health care seeking behaviour of rural and tribal communities of Madhya Pradesh, such as unavailability of health staff, poor accessibility due to distance, unavailability of medicines and other requirements, to name a few. A major proportion of rural and tribal communities are residing far off from the Government health facilities, and thus even if the PHC is open and there are health staff providing services round the clock, it is difficult for a sick person to reach the PHC.
Beliefs influencing TB health seeking behaviour
Rural people in India and tribal populations in particular, have their own beliefs and practices regarding health. Some tribal groups still believe that a disease is always caused by hostile spirits or by the breach of some taboo. They therefore seek remedies through magic and religious practices.
Amongst tribals in Madhya Pradesh, evil spirits are attributed to be the cause of TB. The belief that TB occurs due to supernatural powers lead to the concept of seeking relief through magic, keeping the allopathic medical practitioner as a last resort. There are also beliefs that they cannot get TB, hence leading to delayed treatment seeking.
Lessons learnt and way forward
To summarize, there are many reasons for people to go to a particular health provider. Most important reasons include awareness, money, distance and availability of staff. These factors play a role in creating demand for any health programme, particularly the Revised National TB Control Programme (RNTCP). Hence, there is a need to address the issues that influence TB health seeking behavior such as improving the availability of trained staff at health facilities, enhance level of awareness amongst the community about TB – IEC activities to be increased, regular patient provider meetings to ensure treatment adherence as well as improved faith in Government health system. Also in RNTCP, there is a scope for involvement of NGOs in the programme – since most of the rural and tribal habitations are quite interior, Sputum collection centres can be established through NGOs nearer to these communities.
Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.
Acute malnutrition or wasting is a failure to gain weight or actual weight loss caused by inadequate food intake, incorrect feeding practices, infections or a combination of these. Considered both a medical and social disorder, Severe Acute Malnutrition (SAM) is defined by very low weight for height (Z-score below -3 SD of the median WHO child growth standards), or a mid-upper arm circumference <115 mm/<11.5cm, or by the presence of bipedal nutritional edema.
Case fatality rate of SAM children with complications can be reduced by 90% through standard case management protocol like specialized treatment and prevention interventions at NRCs (Nutritional Rehabilitation Centres). Under national health programme in India, SAM cases are divided into two categories – those with medical complications such as diarrhea, fever, and pneumonia, needing facility based care and those without complications who can be managed in the community. Not more than 10% of SAM children require facility based care, after which follow up in the community is required to prevent relapse.
Nutritional Rehabilitation Centres in Odisha
Odisha is an underprivileged state in Eastern India and is categorized as an Empowered Action Group (EAG) state. It means it is among the nine states of India characterized with relatively higher fertility and mortality and accounts for 48% of the country’s population. Infant Mortality Rate of Odisha is 56 and Under 5 mortality rate stands at 75 (AHS 2012 – 13). Under-nutrition is the underlying cause in 55% of all the under 5 deaths. In Odisha, severe wasting among under 5 children is 5.2%, whereas in non-EAG states it ranges from 2 -4%. Scheduled caste and tribes comprise 40% of the state’s population who are socio economically the most challenged community. Various data sources like NFHS-31,AHS- 20132, Census 20113 and DLHS-34 show that Odisha still has high poverty levels, low female literacy, high incidence of malaria and diarrhea and poor IYCF practices. All these contribute to the poor nutritional status including SAM among under fives.
NRCs have been started under the National Rural Health Mission (NRHM) in Odisha and so far, 44 have been established with uniform bed strength of 10 per NRC. Currently around 75% of children are discharged as cured.
Challenges faced
Data from 16 NRCs of Western Odisha from July to December 2014 reveals several challenges faced by the NRCs
1. Poor bed occupancy rate (just over 50%) – this is due to poor detection of SAM in the field due to low levels of use of Mid-Upper Arm Circumference (MUAC tape) and poor detection of SAM with complications even at the Community Health Centers (CHC).
2. Few admissions of SAM children with complications (from case sheets maintained at the NRCs. Data on fever, diarrhea and ARI are not captured in the NRC MIS). SAM children with complications are admitted to the pediatric ward in larger hospitals and not to the NRC though there is a pediatrician in charge to manage such children.
3. High default rate (12.5%). Undernutrition being so prevalent in the community, it is considered normal and many mothers think it is un-necessary to admit children for being “thin”, especially when they fail to recognize symptoms of complications. Other responsibilities at home, loss of wages, cost of transport to and from the centre – all contribute to the default rate as well as to poor follow-up after discharge.
4. Poor follow up after discharge (less than 10% attend 3 follow up visits after discharge)
Therefore NRCs in Odisha mostly manage children who were low birth weight and fail to gain weight even after two months; mothers following poor IYCF practices; non-breastfed children and SAM children without complications referred by ICDS (Integrated Child Development Services) workers and supervisors.
The perception of severe under-nutrition as an abnormal condition can only be changed through intense nutrition education of the community, regular weighing of children and discussion of weights with the parents, and through proper counseling at the NRCs. NRC activities also needs to be more interactive and engage mothers. SAM children with complications mostly come from remote and vulnerable tribal pockets. Pressure for livelihood generation and household management do not allow mothers to get admitted in NRCs along with their children. Hence, wage loss compensation for mothers admitted in NRC should be increased to the current minimum wage, along with increased attention to improve nutritional status of tribal women through life cycle approach. Innovative strategies like working with self-help groups (SHGs), and the National Rural Livelihoods Mission (NRLM) groups can also be adopted.
NRCs will reduce child mortality but will not improve the general nutritional status of children in the community. Therefore preventive and promotive efforts must be continued.Strengthening of community based mechanisms for identification, prevention and management of severe acute malnutrition is a must, in the absence of which NRCs will not be effective. Facility based approach may prevent some under 5 deaths, but will not be useful in addressing this problem in the community
1 National Family Health Survey, 2005-06.
2 Annual Health Survey, Odisha 2013, Registrar General of India.
3 Census 2011, Registrar General of India
4 District Level Health Survey 3, Registrar General of India
Disclaimer: IPH blogs provide a platform for ePHM students to share their reflections on different public health topics. The views expressed here are solely those of the authors and not necessarily represent the views of IPH.
Recently food security provisions in India has improved and not surprisingly the country is operating one of the largest food safety nets in the World. However regarding figures related to malnutrition particularly chronic malnutrition, the country is at very poor level. There are many challenges in implementation of food security schemes which hinders achieving desired outcomes of reducing malnutrition and the benefits reaching the actual poor.
s like JANANI and SAATHI.
ts
