Chandni Patle placed Bau Pawara, a feeble-looking 17-month-old baby, on an electronic weighing machine. The child, with bony limbs, was quiet and inactive – unusual for toddlers his age. It was early September, and this was his fourth check-up in two months at the nutrition rehabilitation centre in Dhadgaon, in Maharashtra’s Nandurbar district. Patle, a nurse, noted his weight and shook her head in disapproval. He weighed 5 kg; for his age, the normal range is between 8 kg and 13 kg.

She held up a chart that tracked the child’s weight over the preceding few months. “His weight has fallen by 300 grams in two weeks,” Patle told his parents. She advised them to admit him to the nutrition rehabilitation centre.

The centre, which is attached to a rural hospital, is a health facility for children who suffer from severe acute malnourishment. They are usually referred to these centres from anganwadis – once admitted, they are treated for medical complications they might have, such as diarrhoea and fever, and are given nutrition supplements to increase their weight.

The idea for such centres originated several decades ago in Africa. The concept was replicated in India, beginning with Madhya Pradesh in 2007. Their number has fluctuated in recent years – from 800 nutrition rehabilitation centres in 2014, up to 1,151 in 2018 and down to 1,073 in 2021.

In 2019-’20, 2.25 lakh children were admitted to these centres; this number fell to 1.04 lakh in 2020-’21. According to health experts, this decline occurred because of the pandemic, during which only critical cases were being referred to the centres.

Bau’s was one such critical case. His problems began within a few months of his birth in April 2021. He was admitted to the Dhadgaon centre last year, and, when his health did not improve, he was referred to a larger centre in Nandurbar city. This year, on June 17, he was admitted again to the Dhadgaon centre. After 18 days, during which he was fed nutritious food every few hours, his weight rose by 700 grams, from 4.7 to 5.4 kgs.

Jadiya and Sangita Pawara have admitted their son Bau to a nutritional rehabilitation centre twice in one year. Despite receiving treatment at them, the child remains underweight. Photos: Tabassum Barnagarwala

His parents, Jadiya and Sangita Pawara, said they did everything that the doctors and local anganwadi worker advised. During Bau’s stays at the centres, they left their two other children in the care of an uncle so they could be with the baby. During that time, they were not able to work on their farmland. After Bau’s stay in June, they visited the centre for a follow-up every fortnight, spending Rs 100 on each trip from the village of Amala, 30 km away.

So when, despite all these efforts, Bau’s weight dropped to 5 kg, they were dismayed.

Other families in the district have faced even greater hardships.

In August, the Bombay High Court took cognisance of a report submitted by activist Bandu Sampatrao Sane, which claimed that 411 children younger than five have died in Nandurbar district this year. The court criticised the district officials of Nandurbar for these deaths and ordered the collector to appear before it in September and submit a report on the problem.

The same month, the chief secretary took note of the problem at a quarterly meeting held to review the affairs of districts with sizeable tribal populations. According to two officials present at the meeting, also attended by the heads of various government departments, and representatives of NGOs, the chief secretary raised concerns about the poor performance of nutrition rehabilitation centres, especially in Nandurbar, and their failure to pull children out of severe malnourishment. visited three centres in Nandurbar’s Taloda, Dhadgaon and Molgi regions, and found that most children had not gained the target weight specified under the guidelines of the National Health Mission. According to these guidelines, between the time of admission and discharge, the weight of a child must increase by 15%. Further, like Bau, many had slipped back into malnourishment after being discharged.

Data sourced from the district health office confirmed this trend. Across the four nutrition rehabilitation centres in Nandurbar, of 1,233 children who were admitted since 2021, only 471, or 38%, gained the targeted weight. Molgi nutrition rehabilitation centre, located on an isolated hill north of Nandurbar, saw the worst outcomes – only 51 of 280 children admitted to the centre, or 18%, gained the required weight.

Rajalakshmi Nair, nutrition specialist at UNICEF, noted that a complex web of factors was to blame for poor weight gain at the centres, including whether the child had suffered prolonged malnutrition, whether it had had a low birth weight, and the feeding practices that were followed at its home. “All these factors contribute to how much weight gain a child can have at an NRC,” she said.

The National Family Health Survey-5 of 2019-’21 found that Nandurbar had the second-highest percentage of underweight children under five years of age in the country, behind only Jharkhand’s Paschimi Singhbhum. While in Paschimi Singhbhum, 62.4% of the children were found to be underweight, 57.2% were underweight in Nandurbar, up from the 55.4% found underweight in the NFHS-4, conducted in 2015-’16.

Sane said that beyond a child’s health, there were other factors at play as well. “Policies are not being implemented properly, be it in anganwadis or in health centres,” he said. “As a result, a child continues to remain malnourished.”

The district’s civil surgeon, Dr Charudatta Shinde, told that since he had joined, earlier this year, he had been seeking to ensure that the centres reported weight gain accurately, and did not manipulate numbers to show that they were achieving targets. “Hence the high numbers,” he said.

He added that migration was a key challenge in ensuring that children received the nutrition they needed. “These children go out of our monitoring system once they migrate,” he said

Seventeen-month-old Bau Pawara was admitted for 18 days in June and July this year to this nutrition rehabilitation centre in Dhadgaon. This followed a stay last year at a centre in Nandurbar city.

Poor policy implementation

Back in the Dhadgaon centre, Bau’s parents, both lean and sun-burnt, were reluctant to readmit their child. Sangita Pawara was pregnant with a fourth child, and another stay in the centre would be difficult, she said. The couple have limited savings, and depend heavily on their daily earnings from agricultural work.

But there were other reasons too. The couple pointed out that Bau’s weight had not increased much over the last two admissions and that, therefore, they weren’t sure another stay would prove effective. Besides, Jadiya Pawara said, stepping aside and whispering, “The centre also told us we will be paid Rs 300 for each day. But we haven’t got any money.”

He was referring to a scheme under the National Health Mission, under which one parent of a severely acute malnourished child is paid Rs 300 per day as wage compensation for staying at the centre. Once a child is admitted, the minimum stay mandated by the National Health Mission is 14 days – they can stay up to 21 days, or when the targeted weight gain is achieved, whichever occurs sooner. The payment for parents is an incentive for people like Jadiya Pawara, who lose several days of farm work to get their child treated. As per the guidelines of the National Health Mission, on the day of the child’s discharge, the centre is required to pay wage compensation for all the days of admission.

Jadiya Pawara showed this reporter the discharge card for his son, which stated that for an 18-day stay at the centre between June 17 and July 5, the father was entitled to receive Rs 5,400. He made several visits to the centre in July and August, but did not get any money. When this reporter enquired in September about the payment with the medical officer of the rural hospital to which the centre is attached, he immediately instructed a clerk to make the payment. The payment was made in cash the same day, two months after it was due. For last year’s admission, Jadiya Pawara said, he was yet to receive wage compensation from the Nandurbar centre.

Jadiya Pawara’s payments are far from the only ones that are delayed. When Lalit, aged a year and half, was discharged on September 5 from the Dhadgaon centre, his mother, Kavita Pawara, did not receive Rs 4,500 as wage compensation for the 15 days that she had stayed with him. Neither did Rumaliya Pawara, whose son Aakash was also discharged that day. Rupsa Krishna, whose eight-month-old son, Anush, was admitted to a centre in Taloda, 43 km from Dhadgaon, said the centre’s staff did not even tell her about the wage compensation scheme.

District data shows that of the 1,233 children who were admitted to the centres in Nandurbar since 2021, wages of 22% of parents remain pending. But’s reporting suggests that there may be flaws in this data: in the Nandurbar nutrition rehabilitation centre, for instance, data shows that parents of all 276 admitted children in 2021-’22 received wage compensation. But Bau was admitted in Nandurbar centre last year and his father is yet to receive wage compensation for that stay.

The delays impact the programme’s functioning. In Dhadgaon’s Son village, Pramila Valvi, an anganwadi worker, said people become distrustful when wages are promised and not given. “In my anganwadi, there is a child who requires NRC admission,” she said. “But his mother has refused to go.”

Valvi showed this reporter her register, which had details of this child, whose name was Ditya Vasave. The record showed that Vasave was a 10-month-old who weighed 6 kg and needed urgent admission. His elder sister, Manisha, was three years old and suffered from moderate acute malnourishment, although she did not yet need to be admitted to a nutrition centre. Their father migrates out of Nandurbar for work for most months of the year, leaving only their mother, Hathu Vasave, to take care of them. “Hathu works on farms to earn a daily wage,” Valvi said. “I told her the NRC will pay her, but she does not believe me.”

Delays are not the only hurdle when it comes to payments, Valvi added. Payments are often held up because parents need to furnish their Aadhaar card to avail of wage compensation. Dr Sulochana Bagul, resident medical officer in Nandurbar Civil Hospital, said that payments could not be processed without an Aadhaar number.

On the ground, however, found that different nutrition rehabilitation centres follow different protocols. Some, like the Dhadgaon centre, register parents for wage compensation payment even if they don’t have an Aadhaar card, while some, like the centre in Taloda, demand Aadhaar for the process.

Rajib Dasgupta, professor, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, said that in regions like Nandurbar, where food security concerns are common, and the incidence of malnutrition is high, an insistence on Aadhaar and delays in wage compensation payments can deter people from admitting their children.

“People are caught up in trying to get their wages,” he said. This occupies their energy rather than “ensuring their child gains weight in two weeks. It is difficult to achieve this,” he added.

Mothers feed a special feed, prepared at the nutrition rehabilitation centre, to their children. A parent who stays with a child at a centre is entitled to payment of wage compensation from the government.

Lack of funds and staff

According to the Central government’s guidelines, each nutrition centre must have a number of staff, including a dietician to prepare the diet chart, a nurse to monitor the child, and a paediatrician to treat medical complications. The three centres that visited had no paediatricians posted in them.

In the Molgi centre, where only 18% children gained the required 15% weight by the time of discharge, a staffer pointed out that several children who visit the centre have diarrhoea, high fever and a loss of appetite, and that it typically first takes around three or four days to clinically treat them, before staff can focus on nutrition. “If there is no paediatrician, managing them clinically becomes difficult,” the staffer said. “Nutrition alone cannot help.”

Where there are no paediatricians, “critical children are referred to the civil hospital,” said Dr Bagul. She added that the district administration had attempted to appoint paediatricians to different regions of Nandurbar in the past, but that few doctors are willing to work in relatively remote centres that cater largely to tribal people.

The centres don’t just suffer from a shortage of personnel, but also of funds. In June, Taloda rural hospital, which runs a nutrition rehabilitation centre, raised concerns over the dearth of funds to buy food supplements for children. In each centre, every child is given one litre of milk per day and two special feeds, called F75 and F100. The feeds both have, in different proportions, cereal, milk powder, sugar and coconut oil. A child is usually given food 12 times a day for the first week; this is slowly reduced to eight portions per day in the second week if the child’s weight improves.

For this, the Taloda centre requires an average of Rs 15,000 per month for 10 children, a senior doctor at the hospital said. “Vendors started pressing for payments,” the doctor explained. “We reached a point where we thought they could stop supply any day. We got funds after two months, in August.” The doctor added that the fund crunch had also delayed payment of wage compensation to parents.

Children admitted to a nutrition rehabilitation centre are given two feeds, F75 and F100. These have, in different proportions, cereal, milk powder, sugar and coconut oil.

Staffers also pointed out that centres are often short of space. The Dhadgaon centre, for instance, has 10 beds. During the monsoons, when diarrhoea cases rise, the number of malnourished children admitted at any given point often rises above 15. “We have to spread mattresses on the floor, make two children share a cot,” a staffer said.

Holistic measures needed

Their flaws notwithstanding, many argue that the centres serve an essential function.

At the Molgi centre, dietician Varsha Pawara did a round of the centre with a register in hand, halting by each cot to talk with mothers cradling their children. She inquired about problems such as loose stools, vomiting and fever, and then counseled the mothers on what to feed the child at home.

“This kind of quality conversation can’t happen if they treat their child at home,” she said. She added that though the centre had been unable to ensure that children gained the desired weight, it had been able to prevent deaths by intervening and stabilising them early, through the provision of nutritious food.

Dr Gulrukh Hashmi, an independent consultant in community medicine who has researched nutrition rehabilitation centres in Karnataka’s Kalaburagi district, said that the work of the centres needed to be supplemented by other initiatives. She explained that it was always difficult to convince a parent, usually the mother, to leave some children at home, stop her daily labour work and spend at leasts two weeks at a centre. “Therefore, NRCs should be the last option for only critical kids in need of clinical management,” she said. “Others must be managed at community level with therapeutic feeding.”

The interventions Hashmi was referring to included ensuring the provision of proper meals at anganwadis, counselling parents about children and regularly monitoring children’s weight. In her research, she has found that these measures are crucial to preventing malnutrition in the long run. In any case, she explained about children’s stay at the centres, “two weeks is also a short duration to see improvement in a child”

Health activist Sane said that once a child is discharged, anganwadis had to ensure the continued progress of their health. “Anganwadi must continue to provide proper meals so that the weight gain continues,” he said.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.