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[AHRC Forwarded Open Letter] INDIA: The treatment of Severe Acute Malnutrition (SAM) children in Madhya Pradesh – Suggestions for the policy

Dear friends,

The Asian Human Rights Commission (AHRC) wishes to forward to you the following open letter from Right to Food Campaign Madhya Pradesh Support Group.

Asian Human Rights Commission
Hong Kong

June 9, 2009

An Open Letter from Right to Food Campaign Madhya Pradesh Support Group forwarded by the Asian Human Rights Commission (AHRC)

Mrs. Tinoo Joshi
Principal Secretary
Department of Women and Child Development
Government of Madhya Pradesh
Ballabh Bhawan, Bhopal
Madhya Pradesh

Respected Principal Secretary,

Re: INDIA: The treatment of Severe Acute Malnutrition (SAM) children in Madhya Pradesh – Suggestions for the policy

Greetings from Right to Food Campaign Madhya Pradesh Group!

Right to Food Campaign Madhya Pradesh Support Group is an alliance of civil society organizations and people’s organizations working across the country for ensuring right to food with dignity and future security, especially for the most marginalized and excluded.

This with specific reference to the issue of Severe Acute Malnutrition (SAM) and its treatment strategies, we would like to communicate and share our stand in the present scenario.

We believe that millions of children under the age of six years in Madhya Pradesh facing the life long disadvantages due the severe acute malnutrition, many of them even die, mostly due to preventable conditions.

Use of Ready to Use Therapeutic Food (RUTF) in SAM treatment - We would like to begin with our agreement with the fact that we also accept the need of High Energy Therapeutic Food (that may be called RUTF) for the treatment of Severely Malnourished Children and it should be provided to them with a protocol. We also feel that SAM must be seen in the broader context of Malnutrition prevention and Management and rights of Children under age of six. Further that RUTF should be seen as one component on the protocol for SAM. Yes, there is a need to provide energy dense food and easily digestible food for the treatment of SAM.

In continuation to this we also express our concerns for diversity (like cultural acceptability among different communities) and decentralization in production of RUTF along with the comprehensive package of services (services for Nutrition, Health, Protection and Inclusion). The provision and use of RUTF in isolation will not take us to the expected target, elimination of Malnutrition in the society. There is a need to adopt a holistic approach to eliminate the malnutrition and make children grow well.

The Madhya Pradesh experience (in Khandwa district, where we also followed with curiosity to see the impact of RUTF) shows that there is a pressing need for strong follow-up and monitoring of RUTF as an essential component. That was a case of use of RUTF in an emergency situation, so some important aspects were neglected, but in the context of a long term strategy we surly need a protocol of RUTF. So, clearly we need to work on a protocol for the use of RUTF, as one of the strategies for the treatment of SAM in Madhya Pradesh.

No-Commercialization of RUTF - The group working for Children’s right to food also in favor of local and decentralized production of RUTF and it should be made sure that it does not turn into commercial interests of any kind. In fact, indirect processes or sub-contracting will also not be a good strategy.

In very initial phase we, immediately should move ahead with setting up a unit under the public sector undertaking or institution like SANCHI Cooperative Group!!

You may also be aware that National Institute of Nutrition (NIN) is the apex body to provide knowledge and guidance with authority. We suggest the services of NIN should seriously be involved in the process.

RUTF vs. RUF - Having heard on various forums, we are also concerned about the conversion of RUTF into RUF. While making the guidelines and protocol, we hope state government will also take necessary steps to prevent this possible conversion. In a sense
Department may clearly define its stand in its Nutrition Policy that the orders of the Apex Court on provision and availability of Hot-Cooked Supplementary Nutrition will, in all conditions, be implemented. For this purpose SHGs, Community Groups, Mahila Mandals will be involved.

Roles and Responsibilities - There is a point, emerging again and again, relating to roles and responsibilities. We have seen Women and Child Development Department has a limited role to play in the treatment of SAM. The Health Department has to play a central role in it, but the issues of convergence and coordination is still un-answered. We feel Health institutions may provide treatment in the institutions with F75/F100 formulas or with RUTF, but their network (ASHAs and ANMs) should also be part of counseling processes, even after the child is back to community.

And on the other side, Integrated Child Development System (ICDS) bodies should also be a part of SAM treatment and their capacities should also be built to monitor the children with SAM. Also they could be the most important factor in counseling and rehabilitation of children in the community.

In our policy, we need to address the point that how the SAM children will be treated, once they are back to the families after taking institutional treatment for SAM. Anganwadi centers (Child Care Centers) /Anganwadi workers could work as one of the important source to council the parents/community and keep an eye on SAM treated children. Growth monitoring (through growth charts) and pre-school education components under ICDS must be intensively promoted so as to keep a regular check on the growth of children.

An independent cell to monitor the implementation of nutrition program should be set up and it should be out of pressure or influence in any kind.

Our recent study on the operational parts of ICDS shows that growth monitoring is a neglected component of this integrated program. We suggest it should be considered a nonnegotiable component of the system. It will be great step, if the data about each and every child is (malnourished, severe malnourished and not malnourished) kept in public domain (at
Panchayat, district and state level)

Socio-Economic Protection - We cannot compete with SAM on technical grounds; it’s an outcome of socio-economic imbalance and chronic hunger. The group feels that, while making framework for the treatment of SAM children, we should also suggest that the families will be given protection through food and employment entitlement based schemes (like AAY, NREGS, Social Security Pension etc.). At this moment, these demands may look odd, but our analysis shows that social and economic security net is a fundamental requirement.

You must have data of breast feeding practices on record. The linkages of malnutrition with low breastfeeding are quite visible. In Madhya Pradesh also, malnutrition rises once cycle of breast feeding is broken. In SAM treatment protocol, promotion to breastfeeding practices should be targeted as a non-negotiable aspect.

There has to be a will to breast exclusive breast feeding for the children under the age of six months and the age group between 6-59 months should be provided with locally made and culturally accepted nutrition in sustained process. In our view Malnutrition is a complex problem, so the solution and efforts to address this problem has to be planned in a larger framework by addressing the issues of Access to quality institutional Services, Capacities of persons (like ANM, AWW, MPW, ASHA etc.), Quality of Services, Accountability in the System, Community involvement and Counseling etc. The clinical treatment and nutritional care for the SAM children will be a serious component of that larger framework; this can not be addressed in isolation.

There is a need to ensure the system at 3 levels – 1) Community (before treatment and for referrals), 2) at NRC level (once they are brought to the institution), 3) at ICDS level or in the community again. We strongly suggest that the network of NRCs and its relations with ICDS centers and community needs to be more operational and functional with no strings attached. We should make sure that no service delivery section (individual or institution) is giving an argument that mothers or parents of the child don’t want to get their child treated, They themselves go back to home, what government can do? Do we really understand the limitations of these deprived families; we need to internalize their situation, when they find themselves in such a position and make sacrifices!

We insist on adequate management of SAM through NRCs with the milk based F75 / F100 and community management with somewhat as good ready mixes.

SAM children need nutrition and care protection net, complexed with Home and community based institutions and services. ICDS services should be straightened for the protection of SAM children. Along with that SAM children with complications need to be provided proper institution (Nutritional Rehabilitation Centers and Primary Health Centers) based services.

We must have some alternate arrangements also to reach the community if they cannot afford, due to any circumstances, to come to health institutions for the treatment of their malnourished children.

At the end of our letter we would like to repeat the views on SAM treatment and the use of RUTF as the SAM treatment strategies. We express our consensus that Energy dense digestible Food (like RUTF) is a need and should be adopted in SAM treatment, BUT it should be produced in a decentralized system with non-commercial interests and should be culturally accepted among the communities. There should be a protocol for SAM treatment with the use of RUTF, and make sure that it does not get converted in to the RUF strategies. You will agree with the fact that our system in ICDS and Child Health services require revolutionary changes, and then only various SAM treatment strategies will be able to show their impact. Otherwise it will be a work half hearted done!!! Let us strengthen our ICDS centers and the huge network of Anganwadi centers for the implementation of these strategies.

We hope, while preparing strategies, you will definitely refer to our views and expressions.


Right to Food Campaign Madhya Pradesh Support Group

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