Dr. Rakesh Sarwal

Dr. Rakesh Sarwal

MBBS, MPH, DrPH (Johns Hopkins), Therapeutic Yoga Consultant

Professor, Community Medicine, Head, Integrated Health Clinic, ESIC Medical College & Hospital, Faridabad, India

Expertise

  • Lifestyle Medicine, Nutrition, Yoga
  • Health Systems for UHC
  • Public Health Policy

Posts by Collection

portfolio

publications

Geo-visualising Diet, Anthroprometric and Clinical Indicators for Children in India

Published in , 2020

Researchers from the Geographic Insights Lab at the Harvard Center for Population and Development Studies and the Institute of Economic Growth geo-visualised diet, anthropometric and clinical indicators for children across districts in India and provide a clear snapshot of high priority districts for targeting nutritional interventions among children in India.

Recommended citation: Sarwal, R. (2020). Geo-visualising Diet, Anthroprometric and Clinical Indicators for Children in India. https://doi.org/10.7910/DVN/ZSH8HR
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Lessons from Covid-19: A Plan for Action in Journal of the Harvard Club of India

Published in [], 2021

The need for a National Public Health Agency in India is of crucial relevance today. Along with a responsive public health system, we need to focus on preventive healthcare and the promotion of healthy lifestyles. The country, as it marks its 75th year of Independence, must remember that it is essential to bring in structural change for effective public health governance. (Pages 59-67)

Recommended citation: Sarwal, R. (2021). Lessons from Covid-19: A Plan for Action in Journal of the Harvard Club of India. []. https://doi.org/10.31219/osf.io/rj2bm
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MITIGATION AND MANAGEMENT OF COVID-19: PRACTICES FROM INDIA’S STATES & UNION TERRITORIES

Published in [], 2021

This compendium details information about various practices and initiativesimplemented by States, Districts and Cities in India for containing and managing theCOVID-19 outbreak. It is important to note that these initiatives are not being termedas ‘best practices’ by NITI Aayog as that would require a separate and comprehensiveevaluation exercise as well as longer term follow-up. Moreover, in a rapidly evolvingsituation, it can be challenging to consistently and fully correlate practices withoutcomes - a practice might yield good results for a certain period of time but cease todo so thereafter.An email was sent to all States and Union Territories (UTs) in July, 2020 requestingthem to share any practices or models that they believe had been useful for COVID-19mitigation and management. The email was followed up with phone calls to officials fromthe health departments in States and UTs. Ten States/UTs responded in writing to thisrequest for information. Additional information was provided by States telephonically aswell as during review meetings with Member (Health), NITI Aayog.Literature searches were conducted using various combinations of keywords inPubMed, ScienceDirect, Google and Google Scholar. Relevant case studies andpapers were also identified by searching the websites of State/UT Governments andthe National Disaster Management Authority (NDMA). The last literature search wasconducted on November 10, 2020.Only case studies/reports/papers published in English between 1 February-10November, 2020 were considered. While efforts have been made by all States and UTsto follow the broad guidelines issued by the Central Government pertaining to differentaspects of COVID containment and management, this review captures the specificpractices adopted by State and UT Governments to make the implementation of theCentral Guidelines effective and relevant to their local context.All case studies/reports/papers highlighting practices/interventions/models implementedby State or Sub-State Governments on their own or in collaboration with civil society,private sector, volunteers were included in this review. Case studies/reports/papersfocusing on interventions implemented by civil society organizations, private sectoror individuals independent of any partnership with State/Local Governments wereexcluded from this review.Practices have been categorized into the following broad themes: public health andclinical response, governance mechanisms, digital health, integrated models as well 10 Report on Mitigation and Management of COVID-19as welfare of migrants and other vulnerable groups. While governance and technologycut across several themes, they have been included separately to highlight certainpractices adopted by States which pertain primarily to putting in place governancemechanisms or leveraging technology for COVID containment and management.A summary of the relevant Government of India guidelines has been included for theaforementioned categories, wherever applicable. It is important to note that theseguidelines are continually revised based on the emerging scenario with respect to theCOVID-19 outbreak.

Recommended citation: Sarwal, R. (2021). MITIGATION AND MANAGEMENT OF COVID-19: PRACTICES FROM INDIA’S STATES & UNION TERRITORIES. []. https://doi.org/10.31219/osf.io/5uq6c
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NFHS Policy Tracker for Districts and Parliamentary Constituencies of India

Published in , 2021

The National Family and Health Survey (NFHS) is a nationally representative multi-round survey that has afforded sample sources of health and development data throughout India. This dataset includes district- and parliamentary constituency-level changes for 55 indicators that commonly appear in the fourth round (NFHS-4) and the fifth round of the NFHS (NFHS-5) factsheets.

Recommended citation: Sarwal, R. (2021). NFHS Policy Tracker for Districts and Parliamentary Constituencies of India. https://doi.org/10.7910/DVN/BL6NMM
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Precision mapping child undernutrition for nearly 600,000 inhabited census villages in India

Published in Proceedings of the National Academy of Sciences, 2021

There are emerging opportunities to assess health indicators at truly small areas with increasing availability of data geocoded to micro geographic units and advanced modeling techniques. The utility of such fine-grained data can be fully leveraged if linked to local governance units that are accountable for implementation of programs and interventions. We used data from the 2011 Indian Census for village-level demographic and amenities features and the 2016 Indian Demographic and Health Survey in a bias-corrected semisupervised regression framework to predict child anthropometric failures for all villages in India. Of the total geographic variation in predicted child anthropometric failure estimates, 54.2 to 72.3% were attributed to the village level followed by 20.6 to 39.5% to the state level. The mean predicted stunting was 37.9% (SD: 10.1%; IQR: 31.2 to 44.7%), and substantial variation was found across villages ranging from less than 5% for 691 villages to over 70% in 453 villages. Estimates at the village level can potentially shift the paradigm of policy discussion in India by enabling more informed prioritization and precise targeting. The proposed methodology can be adapted and applied to diverse population health indicators, and in other contexts, to reveal spatial heterogeneity at a finer geographic scale and identify local areas with the greatest needs and with direct implications for actions to take place.

Recommended citation: Sarwal, R. (2021). Precision mapping child undernutrition for nearly 600,000 inhabited census villages in India. Proceedings of the National Academy of Sciences. https://doi.org/10.1073/pnas.2025865118
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Trends in underweight, stunting, and wasting prevalence and inequality among children under three in Indian states, 1993–2016

Published in Scientific Reports, 2021

Abstract Child undernutrition remains high in India with far-reaching consequences for child health and development. Anthropometry reflects undernutrition. We examined the state-level trends in underweight, stunting, and wasting prevalence and inequality by living standards using four rounds of the National Family Health Surveys in 26 states in India, conducted in 1992–1993, 1998–1999, 2005–2006, and 2015–2016. The average annual reduction (AAR) for underweight ranged from 0.04 percentage points (pp) (95% CI − 0.12, 0.20) in Haryana to 1.05 pp (95% CI 0.88, 1.22) in West Bengal for underweight; 0.35 pp (95% CI 0.11, 0.59) in Manipur to 1.47 (95% CI 1.19, 1.75) in Himachal Pradesh for stunting; and − 0.65 pp (95% CI − 0.77, − 0.52) in Haryana to 0.36 pp (95% CI 0.22, 0.51) in Bihar & Jharkhand for wasting. We find that change in the pp difference between children with the poorest and richest household living standards varied by states: statistically significant decline (increase) was observed in 5 (3) states for underweight, 5 (4) states for stunting, and 2 (1) states for wasting. Prevalence of poor anthropometric outcomes as well as disparities by states and living standards remain a problem in India.

Recommended citation: Sarwal, R. (2021). Trends in underweight, stunting, and wasting prevalence and inequality among children under three in Indian states, 1993–2016. Scientific Reports. https://doi.org/10.1038/s41598-021-93493-1
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Analysis of Key Nutrition Indicators Based on National Family Health Survey, NFHS 4 (2015-16) and NFHS 5 (2019-2021)

Published in [], 2022

This analysis on key nutrition indicators from successive rounds of the NFHS (4 and 5) is based on all-India and State/UT level factsheet released by Ministry of Health and Family Welfare (MoHFW). The analysis includes: 1. National level trends from NFHS-3 (2005-06), NFHS-4 (2015-16) and NFHS-5 (2019-21) data for 44 indicators including outcomes, service delivery and key determinants of nutrition. 2. State level trends of same indicators- number of states showing improvement / worsening (± 0.1 percent point change), /no change for these indicators, spatial maps based on change in prevalence for these indicators; and charting State performance with respect to achieving Sustainable Development Goals (SDG 2030) targets. This presentation will be useful for policy makers, State administrators, public health experts, research scholars and research institutes in the area of maternal and child health & Nutrition.

Recommended citation: Sarwal, R. (2022). Analysis of Key Nutrition Indicators Based on National Family Health Survey, NFHS 4 (2015-16) and NFHS 5 (2019-2021). []. https://doi.org/10.31219/osf.io/r9ybf
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Dietary diversity as a sustainable approach towards micronutrient deficiencies in India.

Published in The Indian journal of medical research, 2022

The silent epidemic of micronutrient deficiencies (MNDs) continues to be a major public health challenge in the developing world, including India. The prevalence of iron, iodine, zinc, vitamin A and folate deficiencies is alarmingly high worldwide. India is additionally facing a high prevalence of vitamin D and B12 deficiencies. To combat the hidden epidemic of MNDs, various governments around the world have mostly relied on supplementation or fortification-based interventions. India launched salt iodization programme in 1962 and vitamin A and iron-folate supplementation programmes in 1970. Yet, even after decades of these programmes, MNDs are still widespread in the country. Due to slow progress in alleviating the burden of most MNDs, the Government of India aims to scale up fortification-based intervention programmes. However, there are safety and effectiveness concerns with such approaches. Hence, overdependence on supplementation and fortification alone may be counterproductive. Instead, food based dietary diversification approach can be the way forward. In this article, we list the common MNDs in India, evaluate major policy interventions, discuss concerns pertaining to fortification and suggest the need for a concurrent food-based approach, in particular dietary diversification, as a long-term and sustainable strategy to address population-based MNDs.

Recommended citation: Sarwal, R. (2022). Dietary diversity as a sustainable approach towards micronutrient deficiencies in India.. The Indian journal of medical research. https://doi.org/10.4103/ijmr.ijmr_3314_21
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Exit strategies from lockdowns due to COVID-19: a scoping review

Published in BMC Public Health, 2022

Abstract Introduction In response to the ongoing COVID-19 pandemic, countries have adopted various degrees of restrictive measures on people to reduce COVID-19 transmission. These measures have had significant social and economic costs. In the absence of therapeutics, and low vaccination coverage, strategies for a safe exit plan from a lockdown are required to mitigate the transmission and simultaneously re-open societies. Most countries have outlined or have implemented lockdown exit plans. The objective of this scoping review is to (a) identify and map the different strategies for exit from lockdowns, (b) document the effects of these exit strategies, and (c) discuss features of successful exit strategies based on the evidence. Methods A five-step approach was used in this scoping review: (a) identifying the research question and inclusion/exclusion criteria; (b) searching the literature using keywords within PubMed and WHO databases; (c) study selection; (d) data extraction; (e) collating results and qualitative synthesis of findings. Results Of the 406 unique studies found, 107 were kept for full-text review. Studies suggest the post-peak period as optimal timing for an exit, supplemented by other triggers such as sufficient health system capacity, and increased testing rate. A controlled and step-wise exit plan which is flexible and guided by information from surveillance systems is optimal. Studies recommend continued use of non-pharmaceutical interventions such as physical distancing, use of facemasks, and hygiene measures, in different combinations when exiting from a lockdown, even after optimal vaccination coverage has been attained. Conclusion Reviewed studies have suggested adopting a multi-pronged strategy consisting of different approaches depending on the context. Among the different exit strategies reviewed (phase-wise exit, hard exit, and constant cyclic patterns of lockdown), phase-wise exit appears to be the optimal exit strategy.

Recommended citation: Sarwal, R. (2022). Exit strategies from lockdowns due to COVID-19: a scoping review. BMC Public Health. https://doi.org/10.1186/s12889-022-12845-2
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Reducing childhood stunting in India: Insights from four subnational success cases

Published in Food Security, 2022

Abstract Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22–47%), and maternal factors (15–30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households.

Recommended citation: Sarwal, R. (2022). Reducing childhood stunting in India: Insights from four subnational success cases. Food Security. https://doi.org/10.1007/s12571-021-01252-x
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Small Area Variations in Dietary Diversity Among Children in India: A Multilevel Analysis of 6–23-Month-Old Children

Published in Frontiers in Nutrition, 2022

Dietary diversity is an important indicator of child malnutrition. However, little is known about the geographic variation of diet indicators across India, particularly within districts and across states. As such, the purpose of this paper was to elucidate the small area variations in diet indicators between clusters within districts of India. Overall, we found that clusters were the largest source of variation for children not eating grains, roots, and tubers, legumes and nuts, dairy, vitamin A-rich vegetables and fruits, and other vegetables and fruits. We also found positive correlations between the district percent and cluster standard deviations of children not breastfeeding or eating grains, roots, and tubers, but negative correlations between the district percent and cluster standard deviation for the remaining seven outcomes. These findings underscore the importance of targeting clusters to improve child dietary diversity.

Recommended citation: Sarwal, R. (2022). Small Area Variations in Dietary Diversity Among Children in India: A Multilevel Analysis of 6–23-Month-Old Children. Frontiers in Nutrition. https://doi.org/10.3389/fnut.2021.791509
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Take Home Ration-Good Practices Across the States/UTs

Published in [], 2022

POSHAN Abhiyaan, Government of India’s flagship programme, is a scheme under ICDS umbrella which converges with other programs and services delivering nutrition interventions during the first 1000-days period. One of its core interventions includes take-home rations, which aims to fill the calorie-protein-micronutrient gap among children and pregnant and lactating women in India. This THR report covers various improvisations adopted in the implementation of the THR value chain, from formulations to last-mile delivery, by the States and UTs. These practices can be taken up by state governments to leverage the existing services and strengthen THR implementation, increase the coverage, ensure better nutritional outcomes of children and pregnant & lactating women and hence reduce the prevalence of under nutrition in the country.

Recommended citation: Sarwal, R. (2022). Take Home Ration-Good Practices Across the States/UTs. []. https://doi.org/10.31219/osf.io/fhaqr
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White paper on Promoting Domestic Manufacturing of Medical Devices

Published in [], 2022

India’s medical device market is the fourth largest in India and one of the top 20 worldwide; however import dependence to the tunes of about 80 percent of overall sales is an impediment to achieve self-reliance vis-a-vis domestic manufacturing of medical devices and equipments. This high reliance on imports presents a grand opportunity to domestic manufacturers. An enabled ecosystem that promotes indigenous manufacturing of medical devices is crucial for the growth of the health care sector. The current white paper analyses various scenarios for manufacturing capability of different medical technologies and probable recommendations to augment and strengthen production within each scenario.The four scenarios described in the paper includes (1) those medical devices for which there is a high domestic demand that is fulfilled through imports even if domestic manufacturing capacity exists, implying low production in the country (2) relatively low-end technology medical devices for which there is domestic demand with high reliance on imports (3) high-end technology devices which are imported to satisfy domestic need and for which there is no domestic manufacturing capacity (4) medical devices which are being exported to rest of the World. The paper recommends for a comprehensive regulatory overhauls, review of existing taxation structure, calibrated customs duty, fixed term capital subsidy, extended coverage of PLI scheme, strengthening the research and innovation ecosystem, emphasis on technology transfer and building brand India as some of the measures that can potentially favour promotion of domestic manufacturing of medical devices and allow the India Med-Tech sector to grow into global champions.

Recommended citation: Sarwal, R. (2022). White paper on Promoting Domestic Manufacturing of Medical Devices. []. https://doi.org/10.31219/osf.io/6s4ta
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PARLIAMENTARY DISCOURSE ON NUTRITION: What motivates law makers to ask questions

Published in , 2023

The review of two decades of parliamentary questions on nutrition and associated topics revealed information on the topics of interest, themes covered, nature of discourse and what influenced the composition of questions. We found that a majority of the questions raised focused upon the national level implementation of key programmes such as the Integrated Child Development Services (ICDS), Mid-day Meal Scheme (MDMS), Public Distribution System (PDS), Supplementary Nutrition Programme (SNP), Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) and Poshan Abhiyaan. In terms of house-wise distribution of questions, Lok Sabha had a higher number of questions as compared to the Rajya Sabha. The peak years for number of questions raised in the Parliament were 2009, 2011 and 2020. Poshan Abhiyaan, launched in 2018, was identified as the likely stimulus for many questions. Other important events in the nutrition domain were not found to be linked to the number or type of questions raised. In terms of probable triggers, only 10.7% of the total questions had references to specific articles or publications. Other key findings include:` ` Out of a total of 52,698 questions, 2,005 questions (4%) were raised on nutrition and associated themes. The highest number of questions (233) were raised in 2021 and the lowest number in 2004 (38). The years 2009, 2010, 2011 and 2021 saw higher number of questions being raised` ` Considering the underlying themes of major nutrition programmes, nearly 891 (44%) questions were addressed to the Ministry of Women and Child Development (MoWCD), 532 (27%) questions were directed at the Ministry of Health and Family Welfare (MoHFW), followed by 230 (11%) questions at the Ministry of Consumer Affairs, Food and Public Distribution` ` Four broad categories of questions have emerged: Questions on the prevalence of malnutrition in the country; questions on nutrition programmes and interventions; questions on implementation of policies and plans of action; questions on institutional bodies including composition, roles and responsibilities and reports submitted by these institutions` ` The number and composition of questions were driven by critical events and probable triggers related to nutrition that had occurred in that particular year but not limited to a particular session (there are 3 sessions per year)` ` Majority of questions raised (74%) focused on the implementation of policies and programmes at the national level, whereas only 10% of the questions were concerned with the implementation of policies and programmes in specific States ` ` Five types of sources were cited in the Parliamentary Questions - newspaper articles, Global Hunger Index, Reports, reports published by the UNICEF, Supreme Court Orders and reports published by International and domestic organizations` ` Amongst all the sources, reports published by UNICEF have been referred to the highest number of times and constituted 37.5% of the total number of questions that had mentioned a reference (81/221)` ` The discourse on nutrition as evident from analysis appears to be repetitive and limited in scope. This is especially relevant in cases where sources or references were not stated clearly. Many questions leaned towards being outside the realm of discussion, thereby not suggesting any clear change in the policy, legal and institutional frameworks associated with nutrition.

Recommended citation: Sarwal, R. (2023). PARLIAMENTARY DISCOURSE ON NUTRITION: What motivates law makers to ask questions. https://doi.org/10.31219/osf.io/xb4n3
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Viewpoints from the national consultation on addressing acute malnutrition on mainstreaming community-based program for management of acute malnutrition in India

Published in Indian Journal of Community Medicine, 2023

Recommended citation: Sarwal, R. (2023). Viewpoints from the national consultation on addressing acute malnutrition on mainstreaming community-based program for management of acute malnutrition in India. Indian Journal of Community Medicine. https://doi.org/10.4103/ijcm.ijcm_205_22
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Integrated Health Clinic at ESIC,Faridabad

Published:

I shared the exprience of starating and manageing patients of chronic diseases at the Integargted Health Clinic. We have had over 2400 visits of over 1200 pateints, 95$of which report having benefitrted from following tehlifestule regiem taught at out clinic. See presentation at

teaching