1. POSHAN Community based Management of Children with Acute Malnutrition in Rajasthan

2. What Acute Malnutrition Means for A Child

3. Diagnostic Criteria for SAM in Children aged 6 – 59 months
Indicator
Measure
Cut-off
Severe Wasting
Weight-for-Height
<-3 SD
MUAC
< 115mm
Bilateral oedema
Clinical Sign

4. Present Scenario Prevalence of children with SAM (NFHS-3, 2005-06).
India 6.4%
Rajasthan 7.3%
Children with SAM in Rajasthan (6.5 lacs)
Children with SAM with complications (15%) 1.0 lacs
Children with SAM without complications (85%) 5.5 lacs

5. Why CMAM in Rajasthan ??
Global Evidence Suggests :
SAM can be identified in the community before the onset of medical complications
Of the total SAM population 10-15% need Hospitalization
Uncomplicated forms of SAM ( up to 90%) can be treated at home with Medical Nutrition Therapy
Community/home-based management of SAM with MNT has a major public health impact
Facility based management of SAM (hospitalization) has limited capacity (only for complicated SAM )
In Rajasthan there are 40 MTC’s(10 beds) MTC’s (6 Beds) = 1042 SAM can be treated at a time. Therefore around 25,000 SAM can be treated in a Year.
By implementing CMAM in Rajasthan the coverage will increase from few thousands half million

6. Key Milestones in CMAM Planning
Intra-State and Inter-State Exposure Visits
CMAM Advocacy Meet
Meeting on 11 September 2014 under the chairmanship of MD NHM to discuss CMAM
Government concern to tackle load of SAM
Intrastate exposure visit - ARTH- Udaipur on 4-6th November 2014
First Field Visit to Study the model
Interstate Visit- Maharashtra – Sion Hospital, SNEHA, Nutrition Mission
Second Field Visit to Study the model
Sept 2014
Nov 2014
Jan 2015

7. Conception of “Poshan”
Based on the scenario
Hon’ble CM of Rajasthan
in her
budget speech ( ) announced that
10,000 children with SAM of
10 HPDs and 3 Tribal districts
will be treated at
community level

8. Tripartite MoU Signing Ceremony between NHM, UNICEF and GAIN

9. Key Milestones in CMAM Planning
MoU Signed
MoU Signed
MoU Signed
To implement CMAM in 5 Districts of Rajasthan
MOU signed between NHM and ACF to implement CMAM in 5 Districts of Rajasthan
Capacity Building in production of EDNS
Technology Transfer MoU signed between DBT and NHM
Procurement of Poshan Amrit
MoU signed between NHM and RDPL for the efficient supply of EDNS
25 May 2015
September 2015
September 2015

10. Selection of Implementation Districts
Identified 10 High Priority Districts and 3 Tribal Districts for CMAM as these are high focus areas
41 Blocks selected from these 13 Districts
Cluster of villages from these blocks to implement CMAM
Rajasthan

11. Capacity Building Total 5889 No Training Officials Number of Batch
Number of Participants 1
State Level Orientation
RCHO,DPM,UHPC,DD ICDS, DAC, BCMO, MTC Incharges
One
122 2
State Level TOT
RCHO,DPM,UHPC,DAC, Trainer, State Resource Person
Three 91 3
District Level Training
MOIC, CDPO, BHS, MTC Incharges
Two
487 4
Block Level Training
ANM, ASHA and Lady Supervisor
4500 5
Video Conference
RCHO,DPM,UHPC,DAC, BCMO 93 6
ANM Samwad
BCMO, ANM
596
Total
5889

12. POSHAN Strategy 1 Month(12 Sep to 11 Oct 15)
20 Days (12 Oct to 31 Oct 15)
7 days ( 11 Dec Dec 15)
2 Months
(22 Dec 15 – 15 Feb 16)
4 Months
( 16 Feb 16 to 15 June 16

13. 2. Screening
Screening Process at Community Level by ASHA using MUAC (< 11.5cm) or bipedal oedema .

14. 3. Identification:
Identified SAM will be further assessed by ANM at Sub- Center Level
Incentive to ASHA (on identification) Rs 100/ child given by ANM at Sub Center

15. 4. Enroll in POSHAN Program- POSHAN PRAHARI
Counseling to Caretaker, Family Members of SAM child by using BCC tools.
MNT Kit given to the family for a week and same trend followed till 8 weeks
Follow up home visits by Poshan Prahari to access the improvement in Child health

16. What is MNT Kit ? MNT KIT Medical Nutrition Therapy
Poshan Amrit [Energy Dense Nutritional Supplement (EDNS)]
Antibiotics and Deworming tablets
Counseling Kit
Pictorial guide for care of children with SAM – calendar, Journey Book, a jar with sealing clip

17. 5. Two Phases of Program Phase 1- Community based treatment
From enrollment to 2 months, Daily home visit by POSHAN Prahari to Children with SAM
Review of appetite, general health and hygiene practices
Incentives: Rs 250/ child after completing first month, Rs 500/ child after completing second month
Phase 2- Post Treatment Follow up
After treatment from 2 months to 6 months.
Once/week visit in 3rd Month
Fortnightly Visit in 4th & 5th Month
One Visit by the end of 6 months
Review height and weight of Child
Performance Based Incentive : After the end of 6 Months Rs 500 /child

18. For celebration of POSHAN DAY – Rs 300-600/Sub Center
6. POSHAN DAY – SUB CENTER
Every Sunday Celebration of POSHAN DAY to do the anthropometric and clinical assessment of children with SAM
For celebration of POSHAN DAY – Rs /Sub Center
Transportation allowance Rs 100 given to parents /caretaker for bringing child to Poshan Center

19. Committees for monitoring the process of POSHAN
Technical Advisory Committee
Technical Sub Committee
Product Approval Committee
State Review Committee

20. Status till today……..
Sl. No.
District
No. of Blocks
No. of SCs
No. of Villages
No. of Children identified
No. of Pohan Prahari
Children Referred to MTC
Children referred to AWC
Screened
as SAM in Screening (MUAC <11.5 cm)
As SAM in Anthro. Examination (By MUAC &
Z-Score both) 1
Banswara 4 65
223
27959
1478
1228
295
115
1080 2
Baran 24 57
8064
537
118 58
1093 3
Barmer 86
158
38588
1673
1344
348 14
1391
Bundi 25 61
7199
648
489
125 11 88 5
Dholpur 30
9568
501
256 90 36
724 6
Dungarpur 50
150
22325
899
611
172
3148 7
Jaisalmer 45
7340
193 41 8
Jalore 48 72
18210
762
179
1179 9
Karauli 35
130
16497
826
745 20
114 10
Rajsamand 81
8780
602
543
122 42
131
Pratapgarh 26 98
10602
379
337
111
471 12
Sirohi 56
116
24815
645
580
184 22
733 13
Udaipur 60
341
34457
1879
1667
371
149
2207
 Total
555
1620
234404
11052
9178 *
2328
606 *
12654 *
* - Figures yet not Finalised as there are 1874 children who have again been exposed to Anthropometric examination at the time of Enrolment who can be identified as SAM / MAM or may be referred to MTC.

21. Steps…. Treatment Phase Follow up Phase
Screening by MUAC Tape
Anthropometric Test at Sub centres
MUAC Test
Counselling of parents
Appetite test and Enrolment
Treatment Phase
22 Dec. 15 to 15 Feb. 16
Follow up Phase
16 Feb. 16 to 15 June 16

22. PC- Poshan Centre PP- Poshan Prahari
Formats in POSHAN MIS
Phases
Screening at community
Enrolment at PCs
Treatment Phase at Poshan Diwas
Follow-up Phase at Poshan Diwas
Forms
Form 1
Form 3
Form 7
To be filled by
ASHA
ANM
ANM/PP
PC – Poshan Centres, PP – Poshan Prahari
PC- Poshan Centre PP- Poshan Prahari

23. Data flow – where, when & by whom?
At Sub-Centre
On weekly basis
By logistic assistant
Data collection
At Block/PHC
On Weekly basis
By data entry operator
Data entry
Data analysis
At District/ At State
By DPM (NHM), State officials

24. New Concept…. Partnership of State govt with UNICEF, GAIN and ACF
Weekly monitoring and MIS analysis
Poshan Prahari- to watch daily progress
Adverse Reaction Protocol defined
Roles and Responsibilities were defined from State level officials to Parents.
Consent form from Parents / Guardian; Poshan Prahari; ANM

25. Poshan Amrit

26. MNT Kit
Journey Book
Bag
Jar with sealing clip
Medicines
Calendar

27. A4 laminated sheets

28. Posters

29. Flip Book for ANM and Poshan Prahari

30. Poshan Guidelines

31. Poshan Prahari Brochure

32. Launch of POSHAN – 22nd December 2015

33. POSHAN Program Roll out
At Facility – Poshan Centre (PHC/CHC/Sub centre )

34. 1. Poshan Day Celebration

35. 2. Measurement of Length

36. 3. Measurement of Weight

37. 4. Measurement of MUAC

38. 5. Hand washing

39. 6. Appetite Test

40. 7. Transportation allowance (Rs 100 ) to parents

41. At Community – field monitoring by Poshan Prahari

42. 1. Filling of Journey Book

43. Filled Journey Book

44. 2. Observation of one feed

45. 3. Counselling to parents

46. 4. Home observation

47. Journey will continue ……… Thank you