SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.

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Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper – http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30363-1/abstract

Time for a Relook at India’s flagship programs

The findings of the Global Burden of Disease 2015 study are truly depressing. The results, published in The Lancet, lists the main factors behind illness, death and disability in countries.

While deaths of children under five years has gone down between 1990-2015 from 12.1 million to 5.8 million, India still tops the number of child deaths at 1.3 million in 2015.

India is followed by Nigeria, which has over seven lakh deaths, and Pakistan with three lakh deaths. Bangladesh has done better. There were 7663 maternal deaths in 2015 in Bangladesh, which is a dramatic improvement from 21,789 in 1990. Maternal deaths in India dropped by half to 63,861 in 2015 from 1,32,239 in 1990

Neonatal mortality, which is death in the first 30 days of life, remains high. While deaths under five years have reduced, it still remains way lower than the MDG goal.

Some of the main causes given in the study are pre-term birth complications, trauma and respiratory infections. Diarrhea-related diseases are the fourth leading cause.

The study says that while government schemes like Janani Suraksha Yojana have been successful in improving access to institutional births, the reach remains patchy with large parts of rural India unable to access the services. This is the demography that remains most vulnerable. A reality we encounter everyday in news reports of pregnant women dying on their way to hospitals.

Clearly, it is time to step back and take a close, hard look at our flagship programs like JSY and the integrated child development scheme, ICDS. The ICDS was launched in 1975 and is one of the world’s oldest nutrition programs. If after 41 years of ICDS, we are still failing so many hundreds of thousands of children, something is clearly going very wrong.

 

Time to End the Shame Around Breastfeeding

Last week, protests were witnessed across Argentina by groups of women who breastfed their babies in public. They were agitating against the police’s move to throw out a mother from a square in Buenos Aires for nursing her infant in public.

Carrying signboards that said, “Nursing is not up for discussion” and “My breasts, My rights”, over 500 women took to the streets in different parts of the country demanding respect for mother’s rights.

Breastfeeding is a simple, no-cost intervention that boosts the health of children and women substantially, in rich and poor countries. Yet there is little awareness about this. And as we get set to observe World Breastfeeding Week (August 1-7) around the world, experts are calling for programs that encourage ideal breastfeeding practices.

Studies in The Lancet point out that increasing breastfeeding to optimum levels could save over 800, 000 lives every year, most of them children under six months. Also, nearly half of all diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries could be prevented.

Babies who get no breast milk at all are seven times more likely to die from infections than those who get some in their first six months.

Children who are breastfed also do better at intelligence tests, are less likely to be overweight and less likely to get diabetes later in life. The benefits to mothers are also huge. They show lower risk of developing breast and ovarian cancers.

The awareness is especially abysmal in low-income countries, like India. And it does not help that the government has not aggressively promoted breastfeeding. The focus on bringing down maternal and child deaths has been heavily directed towards promoting institutional deliveries, antenatal check-ups and neonatal care.

There are many barriers that come in the way of early breastfeeding in India and this helps explain why signs of childhood malnutrition like stunting (45%) and wasting (20%), that depend significantly on early breastfeeding, remain high.

According to studies, only one in four mothers are able to start breastfeeding within one hour of giving birth and less than half of all mothers are able to exclusively breastfeed their babies for the first six months after birth.

Supportive health-care systems, workplace interventions, counseling and educational programs are needed to improve breastfeeding. The government’s recent moves to bring changes to the Maternity Benefit Act of 1961 are welcome steps.

There is also a need to break the wider social shame that exists around breastfeeding in public, something the UN has also acknowledged by backing the social trend of belfies – mothers sharing pictures of themselves breastfeeding. It is a welcome step towards ending that stigma and spreading the word about the importance of a mother’s milk.

 

 

 

Addressing the nutrition challenge

Just how poor nutrition levels are among Indian children has been highlighted yet again; this time in IMRB’s recent survey across ten Indian cities.

According to the report, one in three children in these cities misses school for about 50 days a year due to persistent health issues, ranging from cold, cough or skin irritation – a telling sign of poor immunity levels.

The children surveyed were between the ages of 6 to 14 years. Many had even missed exams due to a nagging health issue.

Apart from the health concerns, the findings throw light on the financial implications. Three out of ten mothers said they went to the doctor at least once a month to get their child treated and spent about Rs 850 a month on medicines.

This comes just a few months after The Lancet published a report on how despite its economic progress, India continues to do poorly across health indicators. The report rated India’s performance as the worst among the BRICS nations (Brazil, Russia, India, China and South Africa). Not just that, it is far behind poor countries like Nepal and Bangladesh.

The Lancet report specifically highlighted how low body weight and stunting remains a serious concern in India.

Lack of awareness about what the link between nutrition and immunity levels is a big part of the problem. Parents, in both middle class and lower middle class homes, rely on processed foods, unaware of just how harmful they are for health. Consumption of fruits and vegetables is practically non-existent. There is emphasis on the quantity eaten, rather than quality.

All this points to a need to implement programs like AAHAR aggressively on a national scale. Under this program started by SNEHA, yearly camps are conducted across Mumbai slums where counsellors talk to mothers and grandmothers in the community about why cooking food fresh and fruits and vegetables matter. Healthy cooking practices are also demonstrated.

Given the low level of understanding of nutrition and the attractive, overwhelming presence of junk food, there is a need to find creative ways to address the nutrition challenge effectively.

Even rich countries are battling this, even if its from a different spectrum. In the US, for instance, no less than First Lady Michelle Obama has taken up the nutrition challenge, demonstrating cooking methods and exercise techniques on TV and social media. Her goal, is specifically children and the youth. Its high time India’s leadership showed similar commitment to the health of our children.