Multiple Commitments for Multi-Sector Nutrition Initiatives in Nepal

This blog post introduces Multi Sectoral Nutrition Initiatives in Nepal, the current provisions, barriers to effective implementation and the way forward.

Introduction

The National Planning Commission (NPC), on behalf of the Government of Nepal, had developed the Multi Sector Nutrition Plan in 2012 jointly with the Ministry of Agriculture and Development, Ministry of Education, Ministry of Federal Affairs and Local Development, Ministry of Health and Population and the Ministry of Urban Development. This involved a series of consultative meetings involving the National Nutrition and Food Security Steering Committee and Coordination Committee members, government line agencies, technical working groups, sector reference groups, experts and consultants, and representatives from various development partners including donors and civil society organizations.

This plan offers a package of a set of focused interventions to attain priority strategic objectives for each of the key sectors that over five years, should all contribute to a reduction of more than 20 per cent of currently prevalent rates of chronic malnutrition. The plan includes actions to enhance inter-sector collaboration and coordination, strengthen multi-sector monitoring and evaluation mechanisms to track progress, and financial and human resources. It also helps to identify the gaps and future needs to ensure the commitment and capacity to implement it in a sustainable manner.

The long-term vision of the multi-sector nutrition plan, over the next ten years, is to lead the country toward significantly reducing chronic malnutrition so that it no longer becomes an impediment to improving human capital and for overall socio-economic development. The goal, over the next five years, is to improve maternal and child nutrition, which will result in the reduction of Maternal Infant and Young Child (MIYC) under-nutrition, in terms of maternal BMI and child stunting, by one third. The main purpose is to strengthen capacity of the NPC and the key ministries to promote and steer the multi-sector nutrition program for improved maternal and child nutrition at all levels of society.

Status of Nutrition in Nepal

Addressing chronic malnutrition among children is the basic foundation for all social and economic development, and for the accelerated achievement of all Millennium Development Goals. It is one of the best predictor of human capital in developing countries. Unfortunately about forty-one per cent of Nepalese children suffer from chronic malnutrition, according to Demographic and Health Survey (DHS, 2011). It revealed that the process of stunting occurs between conception and two years of age, and is an irreversible process. Furthermore, the population of Nepal, especially women and children, are affected by major micronutrient deficiencies. Malnutrition increases the risk of mortality in the early stages of infancy and childhood, impairs cognitive function of those who survive, and hinders efforts to enhance national social and economic development goals and the attainment of Millennium Development Goals (MDGs).

The cost of mineral and micronutrient deficiencies alone in Nepal is estimated at two to three per cent of GDP, which is equivalent to US$250 to 375 million annually according to the World Bank. For each baby born with a low birth weight and that survives, the lifetime losses in earnings are conservatively estimated to be at least US $500 leading to the perpetuation of inter-generational poverty.

The immediate causes of chronic malnutrition in Nepal include poor feeding and care practices, insufficient nutrient intake, high rate of infection and teenage pregnancy. Less than half (about 46 percent) of babies are initiated with breastfeeding and although 70 per cent are exclusively breastfed at six months, only 66 per cent are introduced to complementary foods at 6-8 months. Most importantly, complementary feeding is infrequent, and inadequate in terms of quality, quantity and safety. Only one-fourth of children (24 per cent) are fed with the recommended Infant and Young Child Feeding practices. Almost a quarter of mothers (23 per cent) give birth before 18 years of age, while about half give birth by 20 years of age .They are often involved in heavy manual work including farming, immediately after delivery, plus 13 per cent of these women smoke, and 18 per cent of women of reproductive age are thin or undernourished. Furthermore, maternal and infant infections are very common, intestinal parasites constitute one of the major public health problems, prevalence of fevers (19 per cent) are as common as diarrheal diseases (14 per cent), while Acute Respiratory Infections affects five per cent of children which causes children's deaths and malnourishment.

With regards to the underlying causes of chronic malnutrition, there have been some encouraging improvements over the years towards reducing poverty levels in Nepal, but 25 percent of the population is still below the poverty line according to Nepal Living Standards Survey (NLSS, 2011). In addition to that, ensuring food security for an estimated 3.5 million people in food deficit areas throughout the year is a difficult task.

Access to health services has improved, including child immunisation, contraceptive prevalence rates, and maternal care practices – both antenatal and postnatal. However, there is still a large gap in sanitation services; 38 per cent of the population still defecates in the open according to DHS. More than one quarter of the population (33 per cent) lives in single-roomed dwellings, and over half of all households (66 per cent) use earth and sand as flooring material. Open fires are still common for cooking and heating; 71 per cent of households cook inside the house and the majority (75 per cent) use solid fuels (including coal/lignite, charcoal, wood/straw/shrub/ grass, agricultural crops and dung). Second hand smoking is another serious concern; 40 per cent of households are exposed to second hand smoke on a daily basis. Significant improvements have also been made in infrastructure including roads, schools and health centers. But, there is increasing inequity. Some of the discriminatory and exclusionary practices based on gender, caste, class, religion, ethnicity or regions still persist. However, development actors and agencies have significantly improved their orientation on social inclusion and gender in recent years.

Key Principles and Approaches

The multi-sector nutrition plan will be guided by the following key principles and approaches:

a) Alignment with government policies: MSNP will be the basis for the implementation of the Three-year Plan as a GoN program to improve nutrition. It will be designed and implemented in compliance with the present constitution and the related regulations (until new policy & legislation are in place.)

b) Rights-oriented inclusiveness and gender equity: MSNP will support socially inclusive and gender and child friendly approaches in the design and implementation of its programs. Affirmative action policies will be introduced in favor of the poor, women, and disadvantaged communities to maximize their participation in, and to benefit from the program’s interventions. Leadership and managerial skills of women and disadvantaged communities (Dalit, Janajatis and others) will be improved through capacity building that leads to their empowerment. The plan will also seek to ensure that their voices are heard in key decision-making processes at the local level, including, to the extent possible, by mainstreaming and institutionalizing their participation in such institutions.

c) Adoption of flexible and process-oriented approach: The program will work to translate GoN’s commitments to improve nutrition, state restructuring and the engagement of local agencies with communities, with the aim to improving the delivery of public goods and services at the local level. Thus, support to line agencies and local bodies will be flexible and process-oriented. This includes consideration of innovative and flexible ways to ensure that the primary program outcome of responsive, inclusive and accountable governance through participatory development is attained. Procedures for working with communities and for targeting the poorest and most disadvantaged segments of these communities will be rationalized and harmonized in order to ensure greater equity and efficiency, and to reduce transaction costs for the communities themselves.

d) Peace building: The program will follow a conflict sensitive implementation approach, promoting factors in support of reconciliation and peace building and avoiding those that inhibit peace or stimulate conflict/violence at the local level.

e) Transparency and accountability: The MSNP will ensure transparency in all its operations and budgets, decision-making processes, and communication to all actors, coordination among line agencies and non-state agencies, and in reaching remote areas to focus on the tangible benefits of the program. The program will delineate roles and responsibilities of all the actors and use a systemic program implementation approach to increase accountability at all levels.

Key Outcomes and Results of MSNP

MSNP will contribute to attaining its long-term vision and mid-term goal by achieving three major outcomes:

Outcome 1: Policies, plans and multi-sector coordination improved at national and local levels.

This outcome specifically aims to increase multi-sector nutrition commitments and resources for nutrition, strengthen nutritional information management and data analysis, and establish a protocol for multi-sector nutrition profiles (as a basis for planning) at central and local level.

Outcome 2: Practices that promote optimal use of nutrition ‘specific’ and nutrition ‘sensitive’ services improved, ultimately leading to an enhanced maternal and child nutritional status.

This outcome will strengthen/maintain the key existing nutrition ‘specific’ interventions that are already being carried out on a large scale through the health sector, including: Biannual Vitamin A supplementation and de-worming for all children aged 6-59 and 12-59 months respectively; Iron Folic Acid (IFA) supplementation with de-worming for all pregnant and lactating women; zinc in management of diarrhea together with new ORS and increased feeding; and universal salt iodization.

Outcome 3: Strengthened capacity of central and local governments on nutrition to provide basic services in an inclusive and equitable manner.

This outcome aims to strengthen nutrition related capacities of NPC and MSNP implementing agencies to integrate nutrition into central and local planning and monitoring. It also intends to strengthen collaboration between central level sector agencies and local bodies. Capacity development is needed at the policy and implementation level in order to create a better understanding of the importance of “life-cycle” dimensions of nutrition in development, across the various sectors that need to become actively involved, if the reduction of maternal and child under-nutrition is to be accelerated.

Related Policies and Acts

Children's Act, 2048 (1992)
Maternity Regulation in Nepal Regulation Collection (2063)
Nepal Breast Milk Substitute Act, (1992)
Nepal Breast Milk Substitute Regulation, (1994)
Nepal Food Act, (1967)
Nepal Food Regulation, (1970)
Nepal Iodized Salt (Production, Sale and Distribution) Act, (1999)
National Nutrition Policy and Strategy (2004)
National Agriculture Policy (2061)
National Nutrition Policy and Strategy (2004)
National Health Policy, 2071 (2014)

Barriers to Effective Implementation of MSNP

Establishing a truly multi-sectoral program, particularly for a complex issue like nutrition, is difficult at best. In Nepal, there is historical precedent of difficulty with the joint nutrition support program. The MSNP acknowledges this in a list of risks and assumptions that focuses on barriers to intra-government collaboration, including competing priorities and resource availability and allocation. The high level National Food Service Security Council includes sector representation at the Secretary level. While this provides high level representation of the sector, most Secretaries have limited background in nutrition and other more pressing sector responsibilities making it difficult to prioritize MSNP activities for their sector. Sector nutrition capacity at all levels is limited, and needs to be strengthened.

In addition, the variety of funding mechanisms and timelines between donors and the governments complicate the ability of the government to implement a unified nutrition policy. The MSNP calls for implementation decentralized to the district level and below, but the decentralization process is just beginning in Nepal. It will be difficult for districts to implement the MSNP without support from the central level, since districts do not yet have full autonomy over budget flow, program prioritization, sector coordination, or capacity building and training.

Nepal’s political instability resulted in more frequent than usual staff changes for key posts within each sector. At the same time, the political fluctuation at the district level has affected the ability of district staff to capitalize on the trend toward decentralization, including work planning and budget management. Like many other national policies, implementation of the MSNP has faced challenges in development of a timely M&E system.

Way Forward

Developing and implementing a multi-sectoral nutrition strategy is challenging, and successful models are limited. Nepal has undertaken this effort with the development of a clear and comprehensive Multi-sectoral Nutrition Plan and has already established an ‘architecture’ for its implementation, and has started implementing in several districts. The complexity of this effort has resulted in understandable delays, but with the establishment of functioning committees and solid government and donor support, the effort is moving ahead.is a complex and inter-wined task to say the least.

The 2009 Nutrition Assessment and Gap Analysis outlined the key recommendations to step up progress on nutrition within the country, with a call to establish the national nutrition architecture and to mobilize all the key sectors to tackle the high prevailing rates of malnutrition in a sustained manner through a multi-sector approach. The National Planning Commission (NPC) revitalized the national nutrition steering committee and the National Nutrition Seminar was held in October 2010, where the need for a multi-sector nutrition plan was reiterated, and a technical working group to oversee the development of the plan was formed by the NPC.

It is the need of the hour that all relevant sectors come forward and take a combined ownership to take the nutrition agenda forward in a collaborative fashion.