Malnutrition: Lack of management or lack of scientific knowledge?

Tuesday, 3 June 2014 01:06 - - {{hitsCtrl.values.hits}}

By Visakha Tillekeratne Much has been written about the topic of malnutrition in Sri Lanka. Many are the reports that have been produced and multiple opinions that have been exchanged. In fact the Medical Research Institute over the past few years has produced more reports of surveys than ever before. The number of directorates that have a role for nutrition within the Ministry of Health is mind boggling. Furthermore, with the advent of the National Nutrition Secretariat housed within the President’s office, the responsibilities for improving malnutrition have been extended across as many as 16 ministries as part of the multi sectoral approach to achieve a ‘Well Nourished Nation by 2016’. The writer after deliberating and operating for well over a decade at national level as part of various development agencies, albeit as a programmer and policy stakeholder and not as a researcher, is attempting to give a rather dispassionate view in what is presented below. This opinion is from a ‘community development management’ perspective. The writer also has the fortune of currently looking at two unit approaches in development – at Divisional level, by being engaged in a community food security improvement initiative and in a District level engagement in reducing child vulnerability to a form of abuse, which is child labour. The opinion expressed is that in the case of children or even families and communities, vulnerability, both from the economic and social aspects, needs to be ‘managed’ There is plenty of knowledge around the table. However Sri Lanka is very poor at managing the resources found in plenty, both human and material. Furthermore monitoring and evaluation, which is the key to management review, is very weak and communication from top to bottom and bottom to top is disjointed. Managing vulnerability is a wide topic. So let us talk about food and nutrition vulnerability and doing better in managing resources, strengthening monitoring and evaluation and effective communication. The writer is involved in driving a food security initiative, mainly through local government at Divisional level. The community, mainly women were trained in doing their own food security and basic dietary intake assessment as part of a partnership with the local council and an NGO. It is interesting to note that the assessment which was made very user friendly and error absorbing matched very well with a ‘real professional food security assessment’ done by UN Agencies and a Ministry in the same geographical area. A near scientific assessment by the people is a good starting point for ‘their’ empowerment based on ‘their own’ evidence. Managing resources – Human and material The idea of a community driven, no frills, no nonsense assessment, was with the objective of empowering the people to collect their own information and to act upon the findings, to the extent possible, to achieve their own food security. However where the community exhausts its potential, the state needs to kick into action. The survey had a number of sections on food security, dietary diversity, knowledge, attitudes and practice (KAP) and an analysis on gaps in services received. With the findings, the community could and would act in many ways, eg: demand that the full package of services from the government be delivered whether it is agriculture, Samurdhi, livestock rearing or housing. Improving housing means that nutrition and health will be improved with better kitchens, toilets and ventilation, which are the determinants of disease and malnutrition. The community would also demand that NGOs deliver their programs in a focused and effective manner to the most needy. Act, could also mean the community deciding to innovate models, tools, campaigns, recipes to suit the local situation using local resources, during the different seasons. This part is now left to them, post assessment and after a very basic training on food security and nutrition, which was delivered in a participatory and fun manner. The community played, cooked, laughed, and talked their way through the training. They even cooked their own meals during the training. Pre and post group evaluation was actually an eye opener. Knowledge of ‘connecting food groups to nutrients to formulate menus which are low cost, nutritious, fuel efficient, space efficient, tasty, attractive’ was extremely poor. At the end of the cooked meal which met all this criteria, there was excitement. “Yes, we can eat good food even if we are day labourers” – This is a simple demonstration of managing people to manage resources. Building the available types of food as part of food groups was also a realisation. To them it was unimaginable that in Sri Lanka one has the bounty of over 250 varieties of green leaves, over 60 different fruits, over 75 vegetables! Over 30 different yams! The concept checking one’s diets for inclusion of the various food groups was alien. Hence low dietary diversity! Even health personnel who attended the training as observers did not know the difference between cereals, legumes and oilseeds. Knowledge is power. However beyond that the state needs to act. For example in the survey above, it was found that severe food insecurity in that Division was 57%! This calls for subsidies, supplements, seed plans and seed supply, water supply, training, agriculture land management including zoning, home garden prototypes and a host of other inputs which the people may not gain access, just because they are empowered. Their cries must be heard and not suppressed. Scoring vulnerability for early prevention of problems In the District approach to eliminate child labour, a Vulnerability Score Card is being used, to identify children who are vulnerable to a gamut of abuses. A child who is vulnerable to abuse or neglect is often malnourished as well. Malnutrition too is an abuse regardless of whether it happens because of parental neglect or lack of affordability or availability of food. A scale has been developed together with the community on reasons for abuse for which weightage has been given from 100 points. As an example, all communities in this particular district felt that based on what they saw and experienced, poverty was the highest contributing factor to child labour or any other type of abuse. The community also strongly felt that alcoholism, lack of knowledge and fragmented families were other high probability factors which increase child vulnerability. So marks have been allocated accordingly. The Score Card is used for the most vulnerable older children and for all newborns. If the score is high, action needs to be taken immediately to prevent all types of abuse. As actions are implemented and targeted towards the child, the scoring needs to be done at least at two month intervals to monitor if vulnerability of the child is being reduced. Monitoring and evaluation: This part is not written based only on the Division or District initiatives, but rather the experience of being a programmer of food and nutrition. The following is essential and should be done uniformly across the country.

Take the Medical Officer of Health (MOH) or DS Division and its Public Health Midwife (PHM) areas or Grama Niladhari (GN) Divisions as the units of disaggregation.
Strengthen the excellent work done by the Ministry of Health’s Nutrition Coordination Division in nutrition surveillance. Pick up the trends of nutrition status and act locally first, nationally second.
Separate the malnourished children for special attention and counseling. One size interventions will not fit all. Especially in the case of supplementary feeding, standard rations will not work.

Be child specific. What is the improvement of anthropometry (body size measurement) required for that particular child? The child needs tracking, so does the family. Is there family sharing the supplementary food issued, what are their problems at a household level? Here the multisectoral interventions need to kick in. What can agriculture do beyond food handouts, what can Samurdhi do to empower mothers to stand up against the abuse of a drunken husband? What can NGOs do to build family unity? Interestingly in the Divisional assessment mentioned above, it showed that in a sample of 863 families, there were 100 children under 2 years. Of these 35% were underweight. Of the 35 children underweight, 71% or around 25 children were also growth-faltering. So there chances of improving their weight were unlikely unless close attention was paid to their specific situation. Questions for the community and professionals to ask are how long have the child been faltering? What is the causal analysis? Not only the PHM, but the community too has a role to play in this analysis and propose their own solutions.

Look at the family units contributing to malnutrition at the GN level and see what reasons are common to all the families, what is specific to a family?
Together with the people of the area fix targets for improvement in indicators. This would be the basis for formulating community action for a common achievement.
What about the adults in a malnourished household? Do they deserve attention or not? Should they not be monitored? How would a weak adult support the family?
A Divisional Food and Nutrition Improvement Plan should be formulated together with the government, NGOs, development agencies, grassroots organisations such as Women’s Rural Development Societies (WRDSs) and Mothers’ Groups. The different stakeholders need to take on what they can do viz a viz this plan and have a self monitoring system. This plan also ensures communication at different levels.

Once a country hits 20% to 25% of malnutrition indeces, one needs to look at poverty alleviation and creative approaches which provide focused attention to the malnourished. Population wide, one size fits all will not fit all. The fact that the country has not gone into specific management of malnutrition, has been proven in its stagnant low birth weight prevalence – 16.6% for 10 years, as well as wasting of children under 5 years at around 15%, that has persisted in the same level for the past 30 years. While having common interventions, ‘zoom’ into the needy families and children and act ‘specifically’ like drug receptors. (The writer is a Freelance Consultant and Member, Technical Advisory Committee on Nutrition of the National Nutrition Secretariat and Vice President, Nutrition Society of Sri Lanka. The article’s content is the individual view of the writer and not of any other entity.)