Sector Wide Approach to Strengthening Health ( SWASTH )

Bihar Technical Assistance Support Team (BTAST)
Government of Bihar initiative supported by Department for International Development, UK


Community-based management helps fight severe acute malnutrition in Purnea, Bihar

The success of community-based management of acute malnutrition (CMAM) depends on community mobilisation and early case finding in vulnerable areas.

COMMUNITY-based management of acute malnutrition (CMAM) has been gaining acceptance worldwide. The importance of CMAM can be gauged from the fact that about 80 per cent of the severely acute malnourished (SAM) children are treatable at the community level.The success of CMAM depends on community mobilisation and early case finding in the vulnerable areas. While the community-based care is for SAM children with uncomplicated severe acute malnutrition, in-patient-therapeutic-care is extended to children with medical complications. Earlier, every child suffering from SAM used to be sent to a Nutritional Rehabilitation Centre (NRC), however, evidence shows that a majority of the affected children can be treated at home by therapeutic care with the help of community-based workers like Accredited Social Health Activist (ASHA) /Auxiliary Nurse Midwife (ANM), as per the World Health Organisation protocol.As per WHO and UNICEF, in children aged 6–59 months, a Mid-Upper Arm Circumference (MUAC) measure of less than 110 mm indicates severe malnutrition, and requires urgent treatment. Community health workers can also be trained to recognise nutritional oedema of the feet, which is another sign of this condition. Once children are identified as suffering from severe acute malnutrition, they need to be seen by a health worker who has the skills to fully assess them following the Integrated Management of Childhood Illness (IMCI) approach. The health worker should then determine whether they can be treated in the community with regular visits to the health centre, or whether referral to in-patient care is required.The Government of Bihar, too, is following this approach. In Bihar, CMAM initiative is a convergent effort of the Health Department and Integrated Child Development Services (ICDS), which is a government-run welfare programme for providing food, pre-school education and primary healthcare to children. 

At the state level, both ICDS and State Health Society, Bihar have issued relevant orders to streamline the implementation. This ensured participation of ANMs, Anganwadi Workers (AWWs) and other Frontline Health Works (FLWs). Valid International, a technical resource agency, is extending technical assistance in the form of cascade training and capacity building of FLWs and creating a pool of master trainers. Purnea, which is predominantly rural with a majority of people depending on agriculture for livelihood, was chosen as the first intervention area for CMAM. Purnea’s population of about 32 lakh includes 5.5 lakh under-5 children. As per NFHS 4 (2015-2016), Purnea’s population includes 5% SAM children. While ICDS scheme is the nodal agency, health department and Valid international are key stakeholders driving the implementation of CMAM in Purnea. Since the leadership of CMAM implementation rests with the district collector, coordination meetings take place periodically. With the continued commitment at the district level for the implementation of CMAM, it is being hoped that SAM deaths and the under-five mortality rate will gradually decline in the district.The implementation of CMAM in Purnea was made possible by providing relevant training to FLWs as well as experts like AWWs, ANMs, ASHAs, Medical Officers, and Lady Supervisors. The CMAM interventions are being done through MUAC tape measuring children with SAM above 6 months to 59 months. The State Health Society, Bihar including district level health officials facilitated supply of 7,000 MUAC tapes to Purnea and distributed them through the office of Civil Surgeon in the district. To support the implementation of this approach, the first government-run Nutritional Rehabilitation Centre (NRC was set up and made functional in Purnea in November, 2015. AWWs started the screening process for children with SAM in eight blocks of Purnea in which seven blocks are being covered by Gram Varta (Village Dialogue), which on its part spreads awareness among women on health, nutrition, water, sanitation and hygiene.

Gram Varta is an initiative under the Sector Wide Approach to Strengthening Health (SWASTH), which is supported by DFID-UK, and it works through Self Help Groups and participatory learning and action meetings cycle to encourage communities to increase their knowledge and awareness and thereby change their behaviour. About 1,59,653 children in the district have been covered through mass screening activities carried out during the monthly Village Health Sanitation and Nutrition Days (VHSNDs), and also through home visits in just two months.It was followed up with mass screening of 5,594 SAM children, who were identified due to this programme. And these identified children were linked with Supplementary Nutrition Programme. After this, further treatment of children started and community started addressing those children. While almost 309 were found medically ill and referred to a Primary Health Centre (PHC) for further treatment, more than 200 children were cured at the PHC. Some children were referred to NRC. The early results and learning from this approach show that CMAM could be a promising intervention that helps communities to actively participate in improving the nutrition levels of their own children. The need of the hour is to support communities to take ownership of such initiatives. 


The Sector Wide Approach to Strengthening Health (SWASTH) programme aims to improve the health and nutritional status of people of Bihar by increasing access to better quality health, nutrition, and water and sanitation services, particularly for the underserved groups. The focus of this programme is to strengthen the systems through better planning, organisational strengthening and human resource management, decentralisation and convergence among key departments. The programme also uses community level processes to manage, demand and monitor services.
This story was written by Vijeta Sinha at OneWorld Foundation India.
Disclaimer: SWASTH is supported by the Department for International Development (DFID)-UK and implemented by the Government of Bihar, in collaboration with the Bihar Technical Assistance Support Team. However, the views expressed in this report do not necessarily reflect either DFID’s or Govt. of Bihar’s official policies or views.