Case study Analysis: Reducing Child Malnutrition in Maharashtra, India

Submitted by: Jaya Sharma

Roll No: EGMP45066

Introduction

This case study on reducing child malnutrition in Maharashtra, India, establishes what it takes to
address a chronic, intergenerational public health issue. It explores the factors behind the reduction
of malnutrition in Maharashtra State, India, from 2001–2013. It also examines UNICEF India’s efforts
to address stunting at the national and subnational levels. It reflects the extent to which the country
programme and related plans support the effective implementation of programme actions at the
national and subnational levels, and the alignment & achievement of outputs to improve nutrition.
Also, the case examines the strategies and management decisions of leaders of the government-
established Rajmata Jijau Mother-Child Health and Nutrition Mission as they worked to reduce the
incidence of malnutrition in children and women through a multi-sectoral collaborative approach.

Malnutrition- A Curse

The prevalence of malnutrition encompassing both undernutrition and over nutrition is an important
indicator of a country's health. Those who are either undernourished or are obese are physically
restricted and tend to underperform in various aspects of life, missing out on opportunities to live a
fulfilling life.

Malnutrition in under-5 children is an important concern for the healthcare authorities over the
world. Approximately 156 million of the world’s children under the age of 5 are stunted, with an
estimated 80% of these children concentrated in only 14 countries like Afghanistan, Bangladesh,
Bhutan, Maldives, India, Nepal, Pakistan etc. Stunting threatens child survival and development by
contributing to child mortality, morbidity, and disability, including impaired or non-optimal physical
growth and cognitive development. In recent years, the global nutrition community has increased its
focus on stunting. There is a causal relationship between stunting and short-term childhood
development, as well as with long-term intergenerational effects on families. These relationships
highlight the critical importance of nutrition during the first 1,000 days between a woman’s
pregnancy and her child’s 2nd birthday, a period associated with risks of irreversible effects.

Undernutrition In India

India being home to the second largest population in the world is among those countries with the
highest recorded numbers of undernourished. Although India has experienced rapid economic
growth, inequalities in the distribution of new wealth and existing poverty persist. The nation is
vulnerable to droughts, flash floods, severe thunderstorms, and earthquakes. It faces several
environmental and health challenges associated. As a result of the huge national population
combined with inequalities among disadvantaged groups and environmental vulnerabilities, India
faces several complex development challenges. India as the country aspires to fulfil its economic and
social development goals; malnutrition is one area which needs to be dealt with utmost attention.
Malnutrition is a serious problem for India, and the government has taken some significant steps to
combat the issue. Some of the key initiatives by the government are national rural health mission to
improve access to healthcare services, implementing Integrated Child Development Services (ICDS)
Scheme and Rajiv Gandhi Scheme for Adolescent Girls i.e. SABLA. While ICDS covers the nutritional
needs of children of 6 months- 6 years age, pregnant and lactating mothers, RGSAG Scheme covers
the nutritional and non-nutritional components for adolescent girls. Under these schemes, age
appropriate Supplementary Nutrition is provided to the beneficiaries at the Anagnwadi Centres
spread across the country. With these efforts in place, there is still a need of further
experimentation that can bring us closer to understanding how this serious problem can be fixed
efficiently and permanently.

Maharashtra: Tackling Malnutrition

The Indian state of Maharashtra is one of the most prominent examples of a populous state
achieving a rapid and significant decline in undernutrition amongst children. The state has made big
strides in reducing child malnutrition, a problem India has been struggling to overcome for years.
Between 2006 and 2012 the prevalence of child undernutrition dropped dramatically from 39% to
22.8%. Childhood stunting (low height for age – a key measure of chronic developmental difficulties)
fell considerably. This was a decline of nearly 3 percentage points per year. This puts Maharashtra
amongst the most successful states to have tackled childhood undernutrition.

One factor that has contributed significantly in achieving this feat is better coordination between
different government departments of health & nutrition. To increase coordination between
departments, Maharashtra was also assisted by a special mission set up by the state government in
2005 to focus on improving childhood and maternal nutrition. Known as the Rajmata Jijau Mother-
Child Health (RJMCH) and Nutrition Mission, this body gets monetary and technical help from
UNICEF. It helped monitor workers in villages and suggests changes in government policy.
Improvement in the work of grassroots workers in villagers thru funding and training by National
Rural health mission was another prominent factor that helped considerably. As per Mr. Victor
Aguayo, chief nutritionist at UNICEF India, a few important developments in maternal and child care
have accelerated Maharashtra’s “much faster decline” in malnutrition rates. Educating pregnant
mothers about the importance of breastfeeding, more visits by anganwadi workers, community
nutrition counsellors, medical officers to check on the health of pregnant mothers in rural areas,
immunization, timely vaccination of children between 0-3 years of age, improvements in other
facilities, such as sanitation and the availability of nutritious food are some of the key initiatives that
have helped prominently.

UNICEF as well has played an important role in dealing with this grave issue. It has catalysed the
movement to bring together the government, civil society, businesses and various other
stakeholders in a collective effort to improve nutrition. Support on initiatives like Marathwada or
malnutrition removal campaign, technical & financial support and establishment of Rajmata Jijau
Mother-Child Health and Nutrition Mission to prevent malnutrition in children below 6 years of age
in rural and urban areas, had been of utmost importance in bringing down malnutrition in
Maharashtra.
Now the second phase of the special nutrition mission’s work in Maharashtra will focus on providing
better healthcare and nutrition to expectant mothers and children under the age of two.

Though the role of government & UNICEF has been quite substantial in reducing malnutrition in the
state of Maharashtra, we can also say that the government of India could have garnered the support
of corporations in fighting against malnutrition.

The Tata Corporation’s funding initiative for Maharashtra’s alliance against malnutrition clearly
connotes that private sector can also play an important role in these support initiatives.

Healthcare services in India: The Present scenario

India has a universal health care system run by respective state governments. Government hospitals,
some of which are among the best hospitals in India, provide treatment at taxpayer expense.
Essential drugs are provided free of cost to all patients in these hospitals. Government hospitals
provide treatment either free or at minimal charges. For example, an outpatient card at AIIMS (one
of the best hospitals in India) costs a onetime fee of rupees 10 (around 20 cents US) and thereafter
outpatient medical advice is free. Treatment costs in these hospitals depend on financial condition
of the patient and facilities utilised by him, however, these are usually much less than the private
sector. For instance, a patient is waived full treatment costs if he is below poverty line while another
patient may seek for an air-conditioned room, if he is willing to pay extra for it. The cost for basic in-
hospital treatment and other diagnostics are much less in public hospitals as compared to the
private hospitals. The cost for these subsidies, come from annual budget allocations from the Central
and State Governments. In addition to public and private hospitals, there are charitable healthcare
providers, many of which provide treatment and facilities parallel to those provided by private
hospitals at highly discounted rates or in some cases free of costs to needy population.

That being said, there is great dissimilarity in the quality and coverage of medical treatment in India.
Healthcare between states and rural and urban areas can be significantly different. Rural areas often
suffer from physician shortages, and disparities between states mean that residents of the poorest
states, like Bihar, often have less access to adequate healthcare than residents of relatively more
affluent states, reason being the frail state of public health sector in India due to the minimal
funding that’s allocated to public health institutions. A recent example of the weak public health
facilities is, at least 386 children were reported to have died at a public hospital in the north Indian
city of Gorakhpur in Uttar Pradesh. This sudden rise in fatalities at the Baba Raghav Das (BRD)
Hospital placed India's healthcare system under scrutiny. Authorities attributed the increase to a
seasonal encephalitis outbreak, but others have placed the blame on corruption within India's public
healthcare system.

In comparison to newly industrialized nations and even the BRICS countries, India’s per capita
spends on health care is dismal. India’s annual per capita spends on healthcare is estimated at about
USD 75. According to the World Health Organization (WHO), most of the healthcare expenditure in
India - which averages $75 per capita - comes from the private spending of households. While China
has the per capital expenditure of USD 420, South Africa of USD 570, Russia of USD 893, and Brazil
of USD 947 and the difference is substantial.
Lack of funding leads to non-availability of adequate healthcare services and facilities due to which
many Indians turn to private healthcare providers, although this as an option is generally
inaccessible to the poor. Insurance is often provided by employers to help pay for healthcare costs,
but most Indians lack health insurance, and hence out-of-pocket costs make up a large portion of the
spending on medical treatment. In India, private healthcare services are indeed exorbitant and cost
about 800 percent the expenditure a patient is likely to incur in a public hospital or medical centre.
Despite this, people across rural and urban sectors prefer to seek out private practitioners and
medical services. For Indians, the cost of private healthcare is about four times greater than the
country's public healthcare. About 72 percent of residents of rural areas and 79 percent of residents
of urban areas use private healthcare services

When it comes to India’s private health care sector, it is not well regulated. Private health care
providers deliver an array of outpatient services in solo practices ranging from those not registered
with the relevant medical council to trained medical practitioners to small nursing homes and
multispecialty clinics. An estimated 40 percent of private care is provided by unqualified
practitioners

The private hospital sector has expanded rapidly, and government-sponsored health schemes also
rely on private hospitals as a part of public–private partnerships. From 2002 to 2010, the private
sector created more than 70 percent of new beds, contributing 63 percent of total hospital beds.
Private hospitals currently provide about 80 percent of outpatient care and 60 percent of inpatient
care.

Private Healthcare providers like Narayana Hrudyalaya (NH), operating on a model for accessible and
affordable healthcare for all, play a very significant role in Indian healthcare system. As per Dr.
Shetty of NH, the health care industry needs more process innovation than product innovation. The
industry “does not need a magic pill or the fastest scanner or a new procedure,” he states, but
instead requires improvements that lower the cost of medical attention and make it more widely
available. Shetty’s premise of economies of scale is not radical; in fact, the doctor describes his way
as “the Walmart approach.”

Is Privatisation The Answer?

National Institution for transforming India and the Ministry for health and family
welfare proposed to increase the participation of private business in public health system, and
sharing state-run hospitals' ambulance services, blood blank, physiotherapy services, mortuary
services, in-patient payment counters and hospital security. It also had further decided to privatize
medical facilities and hospitals in Tier I and Tier II cities. This will allow the hospitals to charge the
patients for all treatments not covered by government health schemes.

Privatisation of healthcare will certainly bring in better facilities, management and infrastructure.
Better and advanced medical equipment, trained and qualified professionals and individualized care
will accompany privatisation. That’s why, privatising the sector is vital. Private hospitals serve a
better management mainly to maintain an image and (earn huge profits obviously) because if
something goes wrong, their income will be affected. Better quality of service and availability of
latest technology is the major reason why despite they charge 4 times more than the government
hospitals, people prefer to get treated in private hospitals. It would also lead to quick and easy
access to treatment that means people will have to face less waiting hours.

Lack of funds and investment is one of the major reasons why the healthcare is lagging behind. The
public sector has failed to increase investment; the private players have stepped and have brought
along with them truckloads of money and funds, but, with an eye for profits. More privatisation
means more investments and fewer burdens on the state to spend that money on healthcare. Big
private players like Tatas, Max India, Fortis can generate more funds by the way of financial aids
from banks, top industrialists, pharmaceuticals and so on. As per a PWC report, private health
spending in India was more than double the government’s expenditure in 2014. So if the
government spent 1.4% of the GDP, the private sector spent 3.3%.

However, as per Drèze, whose research interests include rural development, elementary education,
child nutrition and healthcare, says public-private partnerships are not the solution to the
problem. “The private contribution is bound to be driven by the profit motive, which does not work
very well in the field of healthcare; it also tends to become a way of putting public resources at the
service of private gain”, “This is not to deny that some public-private partnerships may work, but the
overarching responsibility for funding, planning and managing public health centres must remain
with public authorities,” says Drèze.

Keeping in mind the above mentioned points, Privatisation might do good to the healthcare industry
provided the government doesn’t give up full control of the sector, as complete privatisation might
do more harm than good. Whether privatization would shorten waiting lists by creating more
facilities is arguable. What it would certainly do is change who would be waiting. Access would come
to be more about money than medical need. Money diverted to the private system would not buy
the same health care as it would in the public system.

In that case, Public private partnerships can be explored to increase the efficacy of the sector.
Partnership with the private sector has emerged as a new avenue of reforms, in part due to resource
constraints in the public sector of governments. There is indeed a possibility that public and private
sectors in health can potentially gain from one another. While reviewing the health sector in India,
the World Bank (2001) and the National Commission on Macroeconomics in Health (2003, 2005)
strongly advocated harnessing the private sector s energy and countering its failures by making both
public and private sectors more accountable.

In this scenario, there can be an effective implementation of initiative like Rajamat Jijau Mother-
Child Health and Nutrition Mission. Certain advantages that are out rightly visible are higher quality
and timely provision of services, private sector’s expertise and efficiencies can be utilised in PPP
project and faster completion of projects can be expected. Some of the successful Public Private
Partnerships (PPP) involves laboratory services (pathology, radiology, CT scan, MRI etc.), mobile
medical units, PHC management, telemedicine services and hospital maintenance. The models that
have been experimented with the states are: contracting out, contracting in, lease, service
agreements (outsourcing), buying of a product/ service, joint venture company, social marketing and
franchising. In addition, service delivery through telemedicine, high end tertiary care; innovative
models for delivery in rural areas, community insurance schemes are other opportunities where
private sector will need to participate. Modicare, the govt. policy can also emerge as a great example
of PPP on certain stages when implemented effectively. The Modicare health insurance scheme will
lure more investments into private healthcare sector and drive down cost of treatment at private
hospitals in near future, estimates NITI Aayog.

"It's about making choices, focus on particular areas. One of them is PPPs and you will continue
seeing Philips dominating that space. We love PPPs. PPP is a great way to create access, to lower
cost, to bring healthcare to tier II and III cities in the country," Says Daniel Mazon MD, Phillips, Indian
subcontinent.

Participation of public and private sector will provide competition between service providers and
choice to beneficiaries. Given choice, patients will gravitate towards the best care providers. Over
time, revenue will become a marker of quality. Public and private facilities should be remunerated at
par. From being cost centres, public health facilities will evolve into revenue streams. A self-
financing mechanism may emerge to revitalise the public healthcare system.

The Role Of Civil Society In Nutrition For All

It is very clear that government can’t deal with this humungous problem of malnutrition alone.
There is a significant role that is played by our civil society in nutrition for all. Civil society has helped
to shape the Scaling Up Nutrition (SUN) Movement at global level and helped to deliver improved
nutrition at country level. Civil society organizations work closely in, and with, communities, and
have experience in implementing multi-sectoral programs. They are uniquely positioned to advocate
for greater attention to hunger and malnutrition. By engaging national governments, civil society can
play an important role in elevating nutrition as a priority for the next set of goals. A thorough
involvement of civil society organizations (including NGOs, social movements and community-based
organizations), especially those representing the sectors of the population that are most vulnerable
to hunger and malnutrition is key to ensure coordination, ownership, effectiveness and
accountability of initiatives aimed at improving nutrition. A proactive effort to stimulate the
participation of civil society representatives so as to have a balanced representation in terms of
constituencies, type of organization, geographic distribution, gender and age is of crucial
importance.

Conclusion

All sectors must work together for this common goal. Private companies, civil society, knowledge
institutions and government need to agree upon finding effective and efficient policies, sustainable
practices and food solutions to reach the underserved consumer. At the same time agro-food
solutions are required that provide foods which are nutritious, healthy and respond to consumer
demand.

Sources

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http://international.commonwealthfund.org/countries/india/

https://www.forbes.com/sites/suparnadutt/2017/09/12/despite-a-booming-economy-indias-public-
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